Trinity Health Care Of Logan
Inspection history, citations, penalties and survey trends for this long-term care facility in Logan, West Virginia.
- Location
- 135 Bills Branch Road, Logan, West Virginia 25601
- CMS Provider Number
- 515140
- Inspections on file
- 21
- Latest survey
- February 10, 2026
- Citations (last 12 mo.)
- 23
Citation history
Health deficiencies cited at Trinity Health Care Of Logan during CMS and state inspections, most recent first.
A resident with a history of psychiatric illness and repeated aggression physically assaulted another resident, causing significant injuries including facial lacerations, a hematoma, and suspected brain bleed. Despite existing care plan interventions and staff training, the aggressive behavior was not prevented, leading to actual harm.
Staff continued to use a blue laundry detergent known to cause skin irritation and rashes among multiple residents when the hypoallergenic detergent was unavailable. Despite previous complaints and awareness of adverse effects, the blue detergent remained stored and in use, leading to confirmed outbreaks of skin issues.
A facility failed to protect residents from abuse, leading to immediate jeopardy situations. An LPN verbally abused a resident, causing fear among others, while two residents with dementia were involved in nonconsensual sexual contact. The facility did not properly assess consent or take immediate corrective action, placing all residents at risk.
The facility failed to secure hazardous materials by leaving the Central Supply room door open and the cabinet unlocked, exposing residents to dangerous items. Staff interviews revealed a lack of adherence to safety protocols. Additionally, the facility did not implement adequate fall prevention measures for a resident, as fall mats were obstructed and a bed alarm was not properly connected.
The facility failed to maintain resident dignity and proper meal service. A resident was improperly transported backwards in a Geri chair, a practice confirmed by a nurse aide and deemed inappropriate by an RN. Additionally, meal service delays were observed, with residents waiting up to 15 minutes for meals, and inconsistencies in serving residents simultaneously in shared rooms. Staff interviews acknowledged these issues and the need for correction.
The facility did not protect the privacy of residents' medical records when a medication computer screen was left unlocked and visible, displaying residents' pictures and names. An LPN acknowledged the oversight, and an RN confirmed the screen should have been locked.
A resident was administered Ziprasidone before showers to prevent combative behavior, despite recommendations to specify the diagnosis or discontinue the medication. The DON stated it was necessary to prevent harm, as the resident had a history of hitting and scratching staff.
The facility failed to properly investigate an alleged sexual abuse incident involving two residents. Staff witnessed the residents in a sexual position, but the investigation lacked interviews with the involved parties and witnesses. The social worker did not obtain statements until after surveyor intervention and assumed consent without assessing the resident's capacity. The facility concluded no abuse occurred without sufficient evidence.
The facility failed to implement care plans for three residents, leading to deficiencies in hydration, activity engagement, and fall prevention. A resident at risk for dehydration did not receive adequate fluids, another was not invited to preferred activities, and a third had ineffective fall prevention measures due to obstructed fall mats and an unconnected bed alarm.
The facility failed to follow physician's orders for medication administration for multiple residents, leading to missed doses, incorrect documentation, and late administration. An LPN did not document medication administration during system downtime, and another LPN prematurely checked off medication before administering it. Additionally, a resident did not receive the prescribed water flush before feeding, and several medications were administered late to another resident.
A resident was prescribed an antipsychotic medication, Ziprasidone, to be administered before showers due to combative behavior. Despite recommendations to specify the diagnosis or discontinue the medication, it was continued without exploring non-pharmacological interventions. The DON stated the medication was necessary to prevent harm during showers.
The facility failed to serve meals at safe and appetizing temperatures, as observed during an evening meal service. Staff delays and improper handling led to meals being served cold, with temperatures recorded below acceptable levels. Multiple residents reported dissatisfaction with the temperature of their meals, indicating a recurring issue with meal service.
The facility failed to maintain infection control standards during medication administration, linen disposal, and dinner service. A resident's dinner tray was placed back on the cart with clean trays after being contaminated, and an LPN did not use a barrier for a medicine cup. Soiled linen was found under sinks in two rooms, confirmed by staff as inappropriate.
The facility failed to report a bruise on a cognitively impaired resident and an allegation of verbal abuse by another resident. A nurse noticed a bruise on a resident who claimed to have bumped her eye, but the incident was not reported to authorities. Another resident accused a male staff member of making threats, but the social worker was unaware, and the allegation was not reported. The COO and Quality Assurance Director confirmed the need for reporting.
A facility failed to provide an accurate bed hold policy to a resident and their responsible party upon discharge to the hospital. The resident used three Medicaid bed hold days during an initial hospital stay. Upon a subsequent discharge, the facility incorrectly notified the responsible party that 12 bed hold days were available, while only nine days remained. The business office manager confirmed the error, noting the discrepancy between the verbal communication and the written notice.
A facility failed to maintain a resident's personal hygiene by not shaving chin hair, which was approximately 3 cm long. The resident expressed discomfort with the chin hair and noted her nails were only recently cut. A nurse aide mentioned the resident sometimes refused care but was unsure when the chin hair was last shaved. Records showed no refusals of care in the past 30 days and lacked a care plan for refusals. The DON confirmed the chin hair should have been shaved.
The facility failed to provide a legible activity program calendar, as observed by surveyors who noted it was written in bright colors that were difficult to read. A resident confirmed the issue, stating the colors were too bright to decipher, even with glasses. The Activity Director acknowledged the problem.
A resident at risk for dehydration did not receive adequate hydration due to the absence of a water pitcher in their room. Despite the care plan's focus on preventing dehydration, observations confirmed the lack of water access, and the DON acknowledged the issue without providing a solution.
The facility did not complete yearly performance evaluations for all nurse aides, with two evaluations found incomplete. One evaluation lacked a completion date, while another was missing selections in the characteristics portion and was also undated. The Nurse Aide Supervisor acknowledged these oversights as mistakes.
The facility failed to maintain accurate medical records for three residents. An LPN prematurely documented medication administration before it was given, and discrepancies were found in a resident's POST forms, including conflicting information and incomplete documentation. The DON acknowledged the errors, and a nurse was unaware of documentation requirements.
Resident-to-Resident Physical Abuse Resulting in Actual Harm
Penalty
Summary
A deficiency occurred when a resident with a documented history of psychiatric illness and repeated verbal and physical aggression physically assaulted another resident, resulting in actual physical injury. The aggressive resident's care plan included interventions such as redirection, coping skills encouragement, monitoring for triggers, and offering sensory tools, but these measures did not prevent the incident. On the day of the event, the aggressive resident struck another resident in the face twice with a closed fist after an altercation in the hallway, causing the victim to sustain superficial lacerations, a large hematoma, orbital fractures, and a suspected brain bleed. Prior to this incident, the aggressive resident had a pattern of similar behaviors, including striking staff, being involved in altercations with other residents, and requiring psychiatric interventions and medication adjustments. Despite these interventions and repeated staff in-services on abuse prevention and resident redirection, the resident continued to display aggressive behaviors, including pushing another resident and punching a roommate. The care plan was updated, and 1:1 supervision was initiated after previous incidents, but these actions were not sufficient to prevent the assault that resulted in significant harm. The facility's failure to ensure the safety of all residents and to prevent resident-to-resident abuse led to actual harm. The incident was reported to law enforcement, and the aggressive resident was ultimately removed from the facility. The deficiency was identified as past non-compliance, as the facility had already taken corrective actions prior to the survey.
Failure to Prevent Resident Skin Irritation from Laundry Detergent
Penalty
Summary
The facility failed to ensure that residents were protected from skin irritation and rashes associated with the use of a specific laundry detergent known to cause such reactions. During the survey, it was found that the blue detergent, which had previously caused outbreaks of rashes and itchiness among approximately half of the residents (from neck to feet, but not on hands or face), was still being stored and used in the facility. Record review and staff interviews confirmed that the hypoallergenic detergent was intended for use, but when it was unavailable, staff substituted the blue detergent, despite being aware of its adverse effects on residents. Observation in the laundry area revealed both the blue and a clear detergent present, with the blue detergent still accessible and connected for use. The laundry aide confirmed that the blue detergent was used as a backup and acknowledged that its use led to skin issues among residents. The administrator was unaware that the blue detergent remained in use, despite previous complaints and known skin-related concerns. This sequence of actions and inactions resulted in a substantiated deficiency affecting all residents reviewed during the survey.
Failure to Protect Residents from Abuse and Nonconsensual Contact
Penalty
Summary
The facility failed to protect two residents from abuse, resulting in immediate jeopardy situations. Resident #75 was subjected to verbal abuse by LPN #28, causing fear and anxiety among the residents. Witnesses reported that LPN #28 yelled and used inappropriate language towards Resident #75, discussing personal medical information in front of others. Despite multiple witness statements confirming the verbal abuse, the facility did not initially substantiate the report, and LPN #28 continued to work at the facility. Resident #91, who suffers from end-stage dementia and is rarely understood, was involved in a nonconsensual sexual contact incident with another resident, Resident #61. The facility's staff, including the social worker and DON, failed to assess Resident #91's ability to consent to sexual contact, relying instead on the resident's wandering behavior as a form of consent. The healthcare decision maker's approval was inappropriately used to justify the lack of investigation into the incident, and the facility's care plan included provisions for privacy during such encounters, which was inappropriate given the residents' inability to consent. The facility's inaction in both cases placed all residents at risk, as the staff failed to recognize and address the abuse and neglect. The lack of proper assessment and understanding of consent, combined with the failure to take immediate corrective action, resulted in a serious deficiency in the care and protection of the residents.
Removal Plan
- The administrator, Director of Nursing and Human Resources Director terminated employee #28. All staff were informed that all or any form of abuse or neglect toward a resident would result in immediate termination.
- All residents were interviewed by administrative staff to ensure that they felt safe and had never endured any type of abuse or neglect. Any residents unable to be interviewed were assessed for any visible signs of abuse or neglect with any corrective action immediately upon discovery.
- The Director of Nursing and Social Worker has begun in-servicing ALL staff about facility abuse and neglect zero tolerance policy and procedure and failure to comply resulting in immediate termination. All staff will be in-serviced prior to their next shift, and virtually if need be.
- The Administrator will ensure adherence to the Abuse and Neglect Policy and Procedure, ensure that any employee who commits any act of abuse or neglect will be terminated immediately. The Social Worker will complete the log attached for all reports of abuse and neglect and turn the log in to the Administrator each time a complaint is made so the Administrator can handle corrective action of the staff immediately. To ensure continued compliance, the monitoring log will be re-evaluated.
- The administrator assigned 1:1 staffing at all times for resident #91 to ensure she is free from non-consensual sexual acts. All staff were informed that all residents are to be kept free from non-consensual sexual harm despite their mental capacities.
- All residents were interviewed by administrative staff to ensure that they had never been subject to non-consensual acts of sexual nature with any corrective action immediately upon discovery.
- The Director of Nursing and Social Worker has begun in-servicing ALL staff about facility's policy and procedure about resident engaging in sexual acts and what is prohibited. All staff will be in-serviced prior to their next shift, and virtually if need be.
- The Administrator will ensure adherence to the Resident Sexual Acts Policy and Procedure, ensure that staff intervene prior to any non-consensual sexual acts occur between residents. All residents within the building will be evaluated for their capabilities to consent to sexual acts. A monitoring log will be completed to ensure that all residents are evaluated for their capabilities to consent to sexual acts upon admission, at any cognitive change, and/or quarterly thereafter. To ensure continued compliance, the monitoring log will be re-evaluated at the Quarterly and Quality Assurance meeting.
Facility Fails to Secure Hazardous Materials and Implement Fall Prevention
Penalty
Summary
The facility failed to maintain a safe environment by leaving the Central Supply room door open and the cabinet inside unlocked, exposing residents to potentially hazardous materials. During an observation, it was noted that the door to the Central Supply room was left open, and staff members did not take action to close it. Inside the room, various hazardous items such as disposable razors, rubbing alcohol, iodine prep solution, and syringes with needles were accessible to residents. This situation posed a significant risk to residents, particularly those identified as wanderers, who could potentially access these dangerous items. Interviews with staff revealed a lack of awareness and adherence to safety protocols. A nurse aide expressed uncertainty about whether the door was usually left open, while a licensed practical nurse suggested that maintenance might have left it open. The nurse also mentioned that the cabinet containing needles was likely left unlocked due to a nurse being distracted by other staff. This indicates a breakdown in communication and responsibility among staff members, contributing to the unsafe environment. Additionally, the facility failed to implement adequate fall prevention measures for a resident at risk of falls. Observations showed that fall mats were obstructed by furniture, and a bed alarm was not properly connected, rendering it ineffective. This oversight further highlights the facility's failure to ensure resident safety, as the necessary interventions to prevent falls were not consistently applied or monitored.
Removal Plan
- The administrator ensured that all razors, needles, scalpels, medicated powders, creams, and any other solution if consumed could be harmful was moved from the Central Supply Room to the East Wing Medication Room. All staff were informed that the items were relocated and even though those items are being placed elsewhere the Central Supply Room door is to remain closed at all times and locked.
- Video footage with full view of the Central Supply Room door was reviewed to ensure no residents entered the room for potential to have consumed any toxic substance with any corrective action immediately upon discovery.
- The administrator completed an in-service for all staff to ensure they are aware that the Central Supply Room door is to remain closed and locked at all times and the new location of the potentially harmful substances in the East Wing Medication Room. All staff will be in-serviced prior to their next shift, and virtually if need be.
- The Administrator will ensure adherence to the Keeping Residents Free from Potentially Harmful Substances and Items Policy and Procedure, ensure that staff keep all doors locked and all substances out of reach as appropriate. A monitoring log will be completed to ensure that all doors with locks are locked and all potentially harmful substances are kept in a safe area out of residents reach daily for 30 days, weekly for one month, and quarterly thereafter. To ensure continued compliance, the monitoring log will be re-evaluated at the Quarterly and Quality Assurance meeting.
Deficiencies in Resident Dignity and Meal Service
Penalty
Summary
The facility failed to treat residents with respect and dignity during the dining experience and by improperly transporting a resident. An observation revealed a nurse aide pulling a resident backwards in a Geri chair down a hallway, which was confirmed by the nurse aide as a regular practice. A registered nurse confirmed that staff should not be pulling residents backwards, indicating a lack of adherence to proper resident handling procedures. Additionally, during meal services, there were significant delays and inconsistencies in serving meals to residents. In the main dining room, 19 residents were left waiting for their meals while others were served, leading to a 15-minute delay. On the East Wing, residents were not served simultaneously within the same room, resulting in one resident waiting 13 minutes longer than their roommate for a meal. These observations were corroborated by staff interviews, which acknowledged the irregularities and the need for correction.
Failure to Safeguard Resident Medical Record Privacy
Penalty
Summary
The facility failed to maintain the privacy and confidentiality of residents' medical records in the [NAME] wing. During a tour, it was observed that the medication computer screen was left unlocked and visible to anyone passing by, displaying residents' pictures and names. This incident involved multiple residents, as indicated by the list of resident numbers provided. A Licensed Practical Nurse (LPN) acknowledged the oversight, stating they thought the screen was locked. A Registered Nurse (RN) was later informed of the situation and confirmed that the screen should have been locked, indicating awareness of the protocol that was not followed.
Failure to Ensure Resident is Free from Chemical Restraints
Penalty
Summary
The facility failed to ensure that a resident was free from chemical restraints, as evidenced by the administration of an antipsychotic medication, Ziprasidone, to a resident before showers. The medication was given to prevent the resident from becoming combative during the showering process. This practice was identified during a record review and staff interview, where it was noted that the medication was administered intramuscularly every Tuesday, Thursday, and Saturday, 20 minutes prior to the resident's shower. The medication regimen review from May 2023 recommended either specifying the diagnosis or discontinuing the medication, but the order remained unchanged. During an interview with the Director of Nursing, it was revealed that the medication was deemed necessary to manage the resident's combative behavior during showers, as the resident had a history of hitting and scratching staff, posing a risk of harm to herself and others. The facility's census at the time was 111, and this issue was identified for one resident reviewed for chemical restraints during the survey process.
Inadequate Investigation of Alleged Sexual Abuse Incident
Penalty
Summary
The facility failed to thoroughly investigate an allegation of sexual abuse involving two residents, identified as Resident #91 and Resident #61. The incident occurred when staff members witnessed the two residents in a sexual position in Resident #61's bed. Despite the presence of four staff members during the incident, the facility's investigation was inadequate, as it did not include interviews with the alleged victim, the alleged perpetrator, or any witnesses. The facility's five-day follow-up report lacked detailed summaries of interviews and failed to provide relevant information from the residents' clinical records or other documents. The social worker involved in the case did not take statements from the staff who witnessed the incident until after surveyor intervention. The social worker's rationale for not obtaining statements was based on a conversation with the healthcare decision maker, who indicated that the interaction was acceptable if consensual. However, the social worker did not assess whether Resident #91, who has dementia, was capable of giving consent. The social worker's actions and assumptions contributed to the deficiency in the investigation process. The facility's response to the incident was insufficient, as it did not verify or refute the allegation of abuse. The investigation lacked thoroughness, with no evidence collected to support or dismiss the claim. The facility's conclusion that there was no abuse or neglect was based on inadequate investigation and documentation, failing to address the seriousness of the situation and the potential vulnerability of the residents involved.
Deficiencies in Care Plan Implementation
Penalty
Summary
The facility failed to implement hydration interventions for a resident at risk for dehydration. The resident expressed that she did not receive juice and snacks as before, and no water pitcher was observed in her room during multiple visits. The care plan indicated the resident was at risk for dehydration and required encouragement to drink fluids, but these interventions were not implemented. The Director of Nursing acknowledged the absence of a water pitcher and was unsure about the need for adaptive equipment. Another resident expressed a desire to participate in activities such as singing, but was not invited to these events. The activity director confirmed that the resident was scheduled for in-room visits, but the care plan did not specify the frequency of these visits. The resident's activity notes indicated confusion and participation in some activities, but there was no clear plan for regular engagement in preferred activities. A third resident's fall prevention plan was not properly implemented. Observations revealed that fall mats were obstructed by furniture and equipment, and the bed alarm was not connected, rendering it ineffective. Despite the care plan's focus on fall prevention, these interventions were not consistently applied, as confirmed by staff during observations.
Medication Administration Deficiencies
Penalty
Summary
The facility failed to adhere to physician's orders for medication administration for five residents, as identified during the survey process. For Resident #15, the Medication Administration Record (MAR) for May 2024 was not initialed by the nurse, indicating that medications were not administered as ordered on multiple occasions. The Director of Nursing (DON) and Licensed Practical Nurses (LPNs) were unable to provide evidence of medication administration or documentation on downtime forms, suggesting a lapse in following protocol when electronic systems were unavailable. Resident #85 experienced a discrepancy in medication administration timing, where the MAR indicated medication was given before it was actually administered. Additionally, the LPN failed to check the resident's pulse before administering Toprol XL, as required by the physician's order. This oversight was acknowledged by the LPN, who attributed the error to prematurely checking off the medication due to the resident's request to smoke. For Resident #19, the LPN did not follow the physician's order for a 60-milliliter water flush before administering feeding and medications, instead using a portion of the 200-milliliter flush. Resident #57's medications were repeatedly administered outside the prescribed time frames, with delays ranging from over an hour to more than six hours. Lastly, Resident #361's MAR showed a blank space for a medication pass, with no documentation to confirm administration, and the DON could not provide additional evidence. These findings indicate a systemic issue with medication administration and documentation within the facility.
Unnecessary Use of Psychotropic Medication Before Showers
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free of unnecessary psychotropic medications. Specifically, an antipsychotic medication, Ziprasidone, was prescribed to a resident before showers. The medication was administered intramuscularly every Tuesday, Thursday, and Saturday, 20 minutes prior to the resident's shower. The recommendation from a medication regimen review in May 2023 suggested that the diagnosis should be more specific or the medication should be discontinued. Despite this, the medication was continued, and the resident received the injection on multiple occasions from May to July 2023. During an interview, the Director of Nursing (DON) explained that the medication was necessary to manage the resident's combative behavior during showers, as the resident would hit and scratch staff, posing a risk of harm to herself and others. This indicates that the facility did not explore or implement gradual dose reductions or non-pharmacological interventions as required, leading to the continued use of the psychotropic medication without sufficient justification.
Deficiency in Serving Palatable and Safe Temperature Meals
Penalty
Summary
The facility failed to serve food and drink that was palatable, attractive, and at a safe and appetizing temperature, as observed during an evening meal service. Staff were seen bringing trays into the dining room and placing them in a meal cart, which delayed the serving of meals to residents. When the last tray was served, the Certified Dietary Manager recorded temperatures that were below acceptable levels: chicken at 113.0 degrees Fahrenheit, mashed potatoes at 117.0 degrees Fahrenheit, and milk at 54.8 degrees Fahrenheit. These temperatures were confirmed to be outside the required range for safe consumption. Multiple residents expressed dissatisfaction with the temperature of their meals. One resident's meal was served without a cover, leading to contamination concerns, and was later reheated after the resident complained about it being cold. Other residents also reported that their food was often served cold, indicating a recurring issue with meal temperature. These observations and resident interviews highlight a systemic problem with meal service in the facility, affecting the quality of care provided to the residents.
Infection Control Deficiencies in Medication, Linen, and Meal Service
Penalty
Summary
The facility failed to maintain appropriate infection control standards in several areas, including medication administration, disposal of soiled linen, and dinner service. During a dinner service observation, a nurse aide placed a contaminated dinner tray back on the cart with clean trays after realizing it lacked a cover. This breach was confirmed by the Assistant Nurse Aide Supervisor and reported to the Licensed Practical Nurse and the Administrator. Additionally, during medication administration for a resident, an LPN failed to use a barrier before placing a medicine cup on the medication cart, acknowledging the oversight when notified. Further observations revealed issues with soiled linen management. A soiled towel was found under the sink in a resident's bedroom, and used bed linen was observed on the floor under the sink in another room during meal tray pass. Both instances were confirmed by staff members, including an LPN and the Administrator, who acknowledged that the linen should not have been left on the floor. These observations indicate lapses in infection control practices within the facility.
Failure to Report Allegations of Abuse and Injury
Penalty
Summary
The facility failed to report an allegation of verbal abuse for a resident and a bruise on another resident. In the first case, a nurse noticed a bruise under the eye of a resident who was severely cognitively impaired with a Brief Interview of Mental Status (BIMS) score of 3, indicating severe cognitive impairment. The resident claimed to have bumped her eye on a cabinet, and the nurse informed the emergency contact. However, the incident was not reported to the appropriate authorities as required, with the social worker and administrator stating it was not reported because it was not considered harm, and the nurse did not witness the incident. In the second case, a resident made an accusation against a male staff member, claiming he threatened her. The resident was noted to be agitated and talking to herself, with attempts at redirection being unsuccessful. The progress note documenting this was made by an LPN, but the social worker was unaware of the incident and questioned whether it should be reported. The Chief Operating Officer and Quality Assurance Director confirmed that the allegation should have been reported, but it was not. An interview with the resident did not yield further information as she denied any inappropriate behavior from staff.
Inaccurate Bed Hold Policy Notification
Penalty
Summary
The facility failed to provide an accurate bed hold policy to a resident and their responsible party upon discharge to the hospital. This deficiency was identified during a review of the medical records and staff interviews for a resident who was hospitalized. The resident initially went to the hospital and used three of her Medicaid bed hold days. Upon a subsequent discharge to the hospital, the facility issued a bed hold notice indicating the resident still had 12 Medicaid bed hold days available, which was incorrect. The business office manager confirmed that the resident only had nine bed hold days left at the time, and the discrepancy was due to the incorrect information on the bed hold notice, despite the correct number being communicated verbally.
Failure to Maintain Resident's Personal Hygiene
Penalty
Summary
The facility failed to provide adequate activities of daily living (ADL) care to a dependent resident, specifically in maintaining good personal hygiene. During an observation, it was noted that a resident had chin hair approximately 3 centimeters long, which covered most of her chin. The resident expressed that the chin hairs bothered her and mentioned that her nails were only recently cut. A nurse aide who provided care to the resident stated that the resident sometimes refused care, but was unsure when the chin hair was last shaved. A review of the resident's records showed no refusals of care for the past 30 days and no care plan addressing refusals of care. The Director of Nursing confirmed that the resident's chin hairs should have been shaved.
Illegible Activity Program Calendar
Penalty
Summary
The facility failed to provide an activity program calendar that was clearly visible and legible to residents. On June 3, 2024, at 1:04 PM, two surveyors observed that the May activity program calendar was displayed near the main dining room and activity office. The calendar was written in bright colors such as bright orange, lime green, hot pink, and purple, which made it difficult to read. This observation was confirmed during an interview with a resident at 1:30 PM, who stated that the colors were too bright to read, even with glasses. At 1:40 PM, the Activity Director acknowledged the issue, agreeing that the colors made the schedule hard to read.
Failure to Ensure Proper Hydration for a Resident
Penalty
Summary
The facility failed to ensure proper hydration for a resident, identified as Resident #27, during the survey process. The deficiency was identified through record review and interviews with the resident and staff. Resident #27 reported not receiving juice and snacks as before and expressed experiencing a dry mouth. Observations conducted on multiple occasions revealed the absence of a water pitcher in the resident's room, indicating a lack of access to water. The care plan for Resident #27 highlighted a risk for dehydration, with specific interventions to encourage fluid intake, yet these were not being implemented effectively. The Director of Nursing (DON) acknowledged the absence of a water pitcher in Resident #27's room during an observation. Despite the resident's care plan indicating a risk for dehydration, there were no adaptive equipment orders to address potential difficulties the resident might have in handling regular water pitchers. The DON was unable to provide an explanation for the absence of a water pitcher or adaptive equipment, indicating a lapse in ensuring the resident's hydration needs were met.
Incomplete Nurse Aide Performance Evaluations
Penalty
Summary
The facility failed to ensure that yearly performance evaluations were completed for each nurse aide, as evidenced by the review of nurse aide performance evaluations during the survey process. Specifically, two out of five nurse aide evaluations were found to be incomplete. The evaluation for one nurse aide was filled out but lacked a date indicating when it was completed. Another nurse aide's evaluation did not have a completed characteristics portion, with none of the options (unsatisfactory, satisfactory, good, excellent) selected, and it was also undated. During an interview, the Nurse Aide Supervisor acknowledged the incomplete evaluations and attributed them to a mistake.
Inaccurate Medical Records and Documentation Errors
Penalty
Summary
The facility failed to maintain accurate and complete medical records for three residents during the survey process. For one resident, a discrepancy was observed during medication administration. The resident requested their medication, and the LPN noted that the medication had already been documented as given in the Medication Administration Record (MAR), despite not having administered it. The LPN later realized they had prematurely checked off the medication as given before the resident went to smoke. This incident was reported to the Director of Nursing (DON), who acknowledged the discrepancy without further comment. Another resident's medical record review revealed inconsistencies in the Physician's Scope of Treatment (POST) forms. Two forms were found with conflicting information regarding the resident's wishes for a feeding tube. The DON confirmed that the physician's order was incorrect, as it did not reflect the most recent POST form. Additionally, the POST form for this resident was incomplete, lacking the section for the professional assisting in its completion, despite evidence that assistance was provided. A registered nurse confirmed they were unaware of the requirement to complete this section if the resident had capacity.
Latest citations in West Virginia
A deficiency occurred when a lunch tray on A Hall was found to be served below required hot-holding temperature standards. During a survey, a random tray containing mashed potatoes and gravy with steak was tested by the Traveling Dietary Manager in the presence of the Administrator, and both food items measured 110°F, which did not meet required serving temperatures. The Traveling Dietary Manager and the Administrator each confirmed that the food temperature was not at the required level, and the administrative team later acknowledged this deficiency.
Surveyors found that the facility failed to provide residents with consistent and accurate readily available menus reflecting their food preferences. The Traveling Dietary Manager reported that residents could choose from multiple egg preparations, but these options were not listed on the posted menu available to residents. Additionally, the “always available” menu used in the kitchen did not match the menu provided to residents, and this discrepancy was confirmed by the Traveling Dietary Manager. The issue was identified on all menus reviewed and had the potential to affect many residents in the facility.
The facility failed to follow its abuse reporting policy when a cognitively intact resident reported that two nurses were frequently sleeping on duty and later provided an audio recording of a nurse calling the resident a "jerk." The allegation was reported by the resident to an LPN and then to an RN Infection Preventionist, but the Administrator remained unaware until the survey, and the incident was not reported to authorities within the required 2-hour timeframe. In a separate case, another resident had a verbal abuse incident reported to the state, but the facility did not complete or submit the required 5-day follow-up report, and the Administrator confirmed there was no record of that follow-up.
A resident reported unknown charges on her debit card and alleged that a former roommate had used the card without permission, estimating losses of several hundred dollars. The facility documented initial steps such as notifying external agencies, involving law enforcement, cancelling the card, separating the roommates, and assisting the resident in obtaining bank statements. However, the facility did not maintain or retain key documentation, including copies of bank statements, the total amount of funds involved, or clear follow‑up on the status and outcome of the allegation. The resident reported not receiving updates, and the BOM acknowledged that the facility lacked the resident’s financial records because they had been turned over to law enforcement and were not requested or reviewed by facility staff until shortly before the survey, resulting in an incomplete internal investigation record of the alleged misappropriation.
A resident who was cognitively intact but lacked capacity for health care decisions left the facility after breakfast and morning meds. An activities assistant saw the resident walking outside and reported this to the Manager on Duty, but no effective action was taken to verify the resident’s whereabouts or initiate a search. Nursing staff later assumed the resident was in the bathroom or out smoking when he was not in his room at mid-morning and lunchtime. The facility did not recognize the resident as missing or begin search efforts until hours later, during which time the resident hitchhiked and accepted a ride from a stranger in the community. Surveyors determined that staff had witnessed the resident outside but failed to intervene or report effectively, and that the facility remained unaware of the resident’s absence for several hours, resulting in an Immediate Jeopardy finding for neglect.
A resident who is blind and requires specific instruction during ambulation was transferred from therapy to Restorative with documented recommendations to ambulate using a walker, gait belt, and a wheelchair behind her, along with ROM and strengthening exercises. Despite a physician’s order for a Restorative Nursing Program for ambulation and ROM and the therapy recommendations communicated via an Excel spreadsheet, Restorative staff ambulated the resident without a gait belt. The resident reported becoming tired while walking, with a wheelchair behind her but not close enough, and then falling hard. She and a PTA both stated that no gait belt was used. The fall resulted in fractures to the resident’s left distal femur and right distal femur/knee area, with osteopenia noted, and the DON acknowledged that therapy recommendations had not been carried over for Restorative staff to follow.
A resident experienced multiple leg fractures after a fall, resulting in a significant change in condition and non–weight-bearing status. Although the MDS reflected that it was important for the resident to participate in group activities, favorite pastimes, and church services, the activity care plan was not revised after the injury to address her new limitations. The existing plan listed numerous preferred activities such as resident council, food committee, religious services, music, gardening, and in-room pursuits, but no new individualized interventions were added, and documentation showed only two 1:1 visits after her return from the hospital. The resident reported she could no longer get into her wheelchair, attend council or church, or join groups she enjoyed, and stated that activity staff did not visit often, while the Director of Recreation confirmed she had not attended groups since the injury and that in-room social visits were not consistently documented, resulting in a decline in activity participation and social isolation.
A resident was discharged to a motel with home health services, a wheelchair, medications, and a follow‑up medical appointment arranged, and received education on medications, blood glucose monitoring, emergency response, and home health services. Discharge planning discussions and a referral to the Take Me Home program were documented, and the facility agreed to pay for an initial period of the motel stay. However, record review and staff interviews confirmed that the resident was not given the required 30‑day written discharge notice prior to leaving, limiting the resident’s ability to prepare for discharge and exercise discharge‑related rights.
A resident sustained multiple lower extremity fractures after a fall, resulting in hospitalization, non-weight-bearing status, and loss of prior functional abilities such as standing, pivoting, and walking with therapy. Before the fall, the resident actively participated in out-of-room activities including Resident Council, food committee, church, and socials, but after returning from the hospital she no longer attended group activities and had only two documented 1:1 visits. Despite an MDS indicating a significant change in status and clear changes in activity participation, the activity care plan—last revised months earlier—was not updated with new interventions to address her altered condition and in-room activity needs, as confirmed by record review and staff interviews.
A resident with intact cognition and a history of active participation in group activities, Resident Council, and church sustained bilateral lower-extremity fractures and returned from the hospital non–weight bearing. The MDS significant change assessment and the activity care plan documented that group involvement, church services, and various preferred activities were important to the resident, yet no new interventions were added to the care plan after the change in condition. Activity participation records showed that the resident had no out-of-room activities and only two documented 1:1 visits, while the Director of Recreation acknowledged that group attendance had stopped and that in-room social visits were not consistently documented. The resident reported feeling unable to attend her usual groups, Resident Council, or church and stated that activity staff did not visit often, leading surveyors to find that the facility failed to provide an activities program that met her needs and interests following her significant change.
Improper Hot Food Serving Temperatures During Lunch Service
Penalty
Summary
The facility failed to provide resident meals at proper serving temperature during a lunch meal service on A Hall. On 03/24/26 at approximately 12:10 PM, a surveyor had a random lunch tray on A Hall temperature-tested by the Traveling Dietary Manager, with the facility Administrator present. The tested items—mashed potatoes and gravy with steak—were both measured at 110°F. During an interview at approximately 12:15 PM, the Traveling Dietary Manager confirmed that the food did not meet the required serving temperature, and at approximately 12:16 PM, the Administrator also confirmed that the food did not meet the required serving temperature. This deficiency was acknowledged by the facility’s administrative team upon survey exit on 03/25/26 at approximately 4:00 PM. No additional resident-specific clinical information or conditions were provided in the report.
Inconsistent Readily Available Menus for Resident Food Preferences
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to provide residents with consistent and accurate information about readily available menu items that accommodate resident preferences. During document review and staff interviews, the Traveling Dietary Manager stated that residents could choose from several egg preparations (omelet, scrambled eggs, hard-boiled egg, or hard-fried egg) as part of the facility’s readily available items. However, the posted readily available menu accessible to residents did not list these egg options. Additionally, the “always available” menu used in the kitchen did not match the menu provided to residents, and the Traveling Dietary Manager confirmed that the readily available menus did not correlate. This inconsistency was found on 2 of 2 menus reviewed and had the potential to affect more than a limited number of residents in a facility with a census of 90. On a subsequent interview, the facility Administrator acknowledged the deficiency during the exit interview.
Failure to Timely Report Verbal Abuse Allegation and Submit Required 5-Day Follow-Up
Penalty
Summary
The facility failed to follow its abuse prohibition policy requiring that allegations of abuse be reported to the proper authorities within two hours of identification and that required follow-up reports be completed. The policy defined verbal abuse as the willful use of disparaging or derogatory language toward residents or within their hearing. A cognitively intact resident with a BIMS score of 15 reported that two nurses who worked Monday through Thursday were "always sleeping" and that, after he reported this to administration, one of the nurses called him a "jerk." The resident had an audio recording dated 03/11/26 capturing a staff member calling him a "jerk" and confirming this characterization when questioned by the resident. The resident stated he informed an LPN, who then reported it to the RN Infection Preventionist. The RN Infection Preventionist acknowledged awareness of a phone conversation in which someone called the resident a jerk but stated she did not know the full details and thought it might have been discussed in a care plan meeting. The Administrator reported being unaware of the situation until interviewed by the surveyor, at which time the incident had not been reported within the required two-hour timeframe. The facility also failed to complete and submit a required five-day follow-up report for a separate allegation of verbal abuse involving another resident. Record review showed that this resident had been admitted and later discharged to the hospital, and that a verbal abuse incident involving this resident had been reported to the state agency on 04/15/25. However, review of the facility’s list of reportable incidents for one year revealed no evidence that the corresponding five-day follow-up report was ever sent. The Administrator confirmed there was no record of that reportable incident or of a five-day follow-up. These failures were identified for two of two residents reviewed for abuse, with a facility census of 67.
Failure to Thoroughly Investigate and Document Alleged Financial Exploitation
Penalty
Summary
The deficiency involves the facility’s failure to ensure a thorough investigation and ongoing documentation of an allegation of misappropriation of resident property for one resident. Record review showed that the resident reported unknown charges on her debit card, and the facility initiated an investigation and notified OHFLAC, APS, the Ombudsman, and local law enforcement. Progress notes documented that law enforcement interviewed the resident, the resident cancelled her debit card, and she planned to obtain information from her bank. Notes also showed that the resident obtained bank statements, attempts were made to contact the investigating officer, and law enforcement later returned to obtain the resident’s banking information and ask additional questions. The facility’s 5‑day investigation report documented that the Administrator and DON reported the allegation, assisted the resident in obtaining bank statements, reviewed charges with her, identified the alleged perpetrator as the former roommate, separated the residents, and deactivated the debit card. The investigation was labeled inconclusive with law enforcement continuing the investigation, and a later Grand Jury subpoena was issued for the resident related to alleged fraudulent use of her debit card. Despite these initial steps, at the time of survey the facility was unable to provide additional documentation or evidence of follow‑up regarding the alleged misappropriation, including the total amount of funds involved, the outcome of the investigation, or any ongoing tracking of the allegation until requested by the State Agency. In interviews, the resident stated that her former roommate used her debit card without permission, estimated that approximately $800–$900 had been spent, and reported she had not received any updates about the situation. The BOM stated the facility did not have copies of the resident’s bank statements because they had been turned over to law enforcement and that law enforcement would not release information due to an ongoing investigation. In a follow‑up interview, the resident reported that no one from the facility had requested or attempted to review her bank statements, aside from law enforcement, until shortly before the interview when the BOM inquired, demonstrating that the facility did not maintain documentation necessary to determine the extent of the alleged misappropriation. A staff member later provided a written statement that they accompanied the resident to a Grand Jury proceeding related to fraudulent use of the debit card, but the facility still lacked internal documentation of the scope and outcome of the allegation.
Failure to Respond to Known Resident Elopement and Prolonged Unnoticed Absence
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from neglect by not responding to a known elopement. A cognitively intact resident, who had a BIMS score of 14 but had been deemed by the physician to lack capacity to make health care decisions, left the facility in the morning after having breakfast and receiving morning medications. The resident’s elopement risk evaluation score was 0, indicating low risk for elopement, and the MDS indicated no wander/elopement alarm was used less than daily. The resident’s care plan identified adjustment issues related to change in lifestyle and difficulty accepting placement, with interventions focused on coping and adjustment, but did not identify elopement risk prior to the incident. At approximately 9:00 AM, an activities assistant saw the resident walking outside down a public street near a store. The activities assistant contacted the social worker, who was the Manager on Duty, shortly thereafter to report the resident’s location. The activities assistant then clocked in for her shift around 9:03–9:05 AM. Despite this report, no effective action was taken by facility staff at that time to verify the resident’s whereabouts, intervene, or initiate a search. The social worker later stated she did not realize anything was going on until early afternoon, explaining that she missed the information about the resident being at the store while she was talking with other residents during the phone call. During the period from roughly 9:15 AM to 1:55 PM, there was a delay in supervision and monitoring of the resident. The LPN assigned to the resident reported administering morning medications and exchanging pleasantries with the resident earlier that morning, consistent with the facility’s elopement timeline. The CNA assigned to the resident stated that the resident was in the room during breakfast, but when she entered the room around 10:30 AM to provide a snack to the roommate, the resident was not present and she assumed he was in the bathroom. At lunchtime, when the CNA did not see the resident, she assumed he was out smoking. The facility did not recognize the resident as missing or initiate search or recovery actions until approximately 1:30 PM, when the activities assistant reported that the resident was not present for a smoke break. The State Agency determined that staff had witnessed the resident outside the facility but failed to intervene or report effectively, and that the facility remained unaware of the resident’s absence for about 4.5 hours, creating an Immediate Jeopardy situation due to the resident being unsupervised in the community for an extended period. The resident later reported that he was attempting to travel to another town to attend to personal business, hitchhiking to a nearby city and then walking further when he found the bus station closed. He described being offered a ride and food by a man who drove him to a restaurant, where he was eventually picked up by someone from the nursing home. The State Agency concluded that the facility’s failure to act on the known elopement and to promptly identify and respond to the resident’s absence constituted neglect and placed the resident at immediate risk for serious harm or death.
Failure to Use Gait Belt During Restorative Ambulation Resulting in Resident Fractures
Penalty
Summary
The facility failed to provide care and services in accordance with professional standards of practice when a resident participating in Restorative Therapy ambulation was walked without a gait belt, contrary to therapy recommendations. Record review showed the resident experienced a fall and was sent to the emergency room with pain in both legs, where diagnostic imaging revealed an anterior apex angulated distal femur diametaphyseal fracture with impaction in the left femur and an impaction and comminuted anterior apex angulated fracture of the distal fifth metaphysis in the right knee, with osteopenia noted. The resident, who is blind and requires specific instruction when ambulating, had been transferred from therapy to Restorative with recommendations documented on an Excel spreadsheet to ambulate with a walker, gait belt, and wheelchair behind the resident, up to 70 feet, along with ROM and strengthening exercises. A physician’s order for a Restorative Nursing Program for ambulating and ROM was in place, with the expectation that Restorative staff would refer back to therapy’s recommendations for safety measures. Interviews confirmed that on the day of the fall, staff ambulated the resident without a gait belt. The PTA identified the location of the fall and stated that a gait belt had not been used while walking the resident. The DOR reported that therapy staff had always used a gait belt with this resident and that the recommendation to use a gait belt was communicated via the Excel spreadsheet used by Restorative Therapy to receive therapy orders and recommendations. The resident, who had a BIMS score of 15 and thus had capacity, stated that she became tired while walking with Restorative staff, that a wheelchair was behind her but not close enough, and that she fell hard; she reported that staff did not have a gait belt on her and believed that if a gait belt had been used, she would not have fallen so hard. The DON stated she was not aware of the Excel spreadsheet and confirmed that therapy recommendations were not carried over for Restorative Therapy to follow.
Failure to Revise Activity Care Plan After Significant Change in Condition
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident received ongoing opportunities to participate in meaningful activities consistent with her interests and preferences following a significant change in condition. The resident experienced a fall on 02/18/26, was sent to a local emergency room for pain in both legs, and diagnostic radiology revealed an anterior apex angulated fracture of the distal left femur with impaction and an impaction and comminuted anterior apex angulated fracture of the distal right femur metaphysis, with osteopenia noted. She was hospitalized for these fractures and returned to the facility on 02/24/26. A subsequent MDS with an ARD of 02/27/26 documented a significant change in status and indicated that it was important for the resident to do things with groups of people, participate in her favorite activities, and attend church services. Record review showed that the resident’s activity care plan, originally initiated in 2020 and revised multiple times through 03/03/2025, contained numerous interventions reflecting her preferences, including in-room visits, participation in food committee and resident council, church and religious services, group singing and cooking, gardening, pet visits, listening to religious/bluegrass/country music, watching TV and keeping up with the news, and engaging in favorite activities such as church, sewing, cooking, reading, and gardening. The care plan also noted her use of a wheelchair and need for accommodations for visual impairments. However, there were no new or revised activity interventions added to address her new non–weight-bearing status and functional limitations after the fractures, and no changes to the activity care plan were documented following the significant change in condition. During interview, the resident, who had decision-making capacity and a BIMS score of 15, reported that prior to the fall she had been able to stand, pivot, and walk with therapy, and that she had been active in resident council, church, and social activities. She stated that since her return from the hospital she could not get into her wheelchair, could not attend resident council meetings or church, and could not participate in the group activities she enjoyed. She reported that activity staff did not visit her very often and became tearful while describing her situation. The Director of Recreation confirmed that the resident had not attended group activities since returning from the hospital, was non–weight-bearing for 10 weeks, and that anything done with her was now in-room. The Director of Recreation also stated that the resident did not receive one-to-one visits “per se” and that social visits were not documented. Surveyors identified that only two one-to-one visits had been documented since the resident’s return from the hospital and that there was a significant decline in her activity participation without corresponding revisions to her care plan, which led to the finding of failure to provide consistent, individualized activity interventions and ongoing opportunities for meaningful activities.
Failure to Provide Required 30‑Day Written Discharge Notice
Penalty
Summary
The facility failed to provide a required 30‑day written discharge notice to a resident prior to discharge. A complaint was received by the State Agency stating that the resident was being discharged to a hotel and that the facility would pay for the first 28 days, after which the resident would be responsible for their own expenses. The complainant reported the resident had no income and uncertainty existed about how the resident would obtain food and medications. Record review showed that on one date, Social Services documented discharge planning discussions and a referral to the Take Me Home program at the resident’s request, and an assessment note indicated discharge planning documentation was completed. Further record review revealed that on the day of discharge, Social Services documented that the resident was discharged to a motel with home health services arranged, a wheelchair provided, medications supplied, and a follow‑up appointment scheduled. Nursing documentation from the same day showed the resident received education on medications, blood glucose monitoring, emergency response, and home health services prior to discharge. However, there was no evidence in the medical record that the resident was provided a written 30‑day discharge notice before leaving the facility. In an interview, the Social Worker, in the presence of the Administrator, confirmed that the resident had chosen discharge to a motel and that the facility paid for 28 days at the hotel and provided 14 days of medications, and also confirmed that a 30‑day discharge notice was not issued. The deficient practice had the potential to affect the resident by limiting the ability to adequately prepare for discharge and exercise rights regarding the discharge process.
Failure to Update Activity Care Plan After Significant Change in Condition
Penalty
Summary
The deficiency involves the facility’s failure to update an activity care plan following a resident’s significant change in condition and participation. The resident experienced a fall on 02/18/26, resulting in fractures to the left distal femur and right distal femur/knee, with osteopenia noted on diagnostic imaging. She was hospitalized and returned to the facility on 02/24/26. A subsequent MDS with an ARD of 02/27/26 identified a significant change in status. Despite this, the resident’s activity care plan, originally initiated in 2020 and revised multiple times through 03/03/2025, was not revised after the fall and significant change to reflect her new limitations and altered participation in activities. Prior to the fall, the resident had been able to stand, pivot, and transfer to her wheelchair, and was walking up to 100 feet with therapy. She was active in out-of-room activities, including Resident Council, food committee, parties, socials, church, and other group activities. After the fall, she reported that she now had a rod in her left leg, a brace on her right leg, and was non-weight bearing for 10 weeks, which prevented her from getting into her wheelchair and attending the activities she previously enjoyed. She expressed distress about no longer being able to attend Resident Council meetings, church, and family gatherings, and stated that activity staff did not visit very often and that she could not go out to the groups she liked. During the interview, she was observed to be tearful. Record review of activity participation from 01/01/2026 to the present showed that the resident had participated in out-of-room activities before the fall but had no out-of-room participation after her return from the hospital. The records also showed that since the significant change, she had only two documented one-to-one visits, both on 03/04/26. The Director of Recreation confirmed that the resident had not attended group activities since returning from the hospital and was non-weight bearing, and stated that anything done with her was now in-room. The Director also stated that social visits were not documented as one-to-one visits. Surveyors noted that there were no new or revised interventions on the activity care plan since 01/2025 despite the significant change in the resident’s condition and participation, and the Administrator and Director of Recreation confirmed that the documentation reflected this lack of update.
Failure to Adjust Activities Program After Resident’s Significant Change in Condition
Penalty
Summary
The deficiency involves the facility’s failure to provide an activities program that met the interests and needs of a resident who experienced a significant change in condition and activity participation. The resident, who was cognitively intact with a BIMS score of 15 and served as president of the Resident Council, sustained fractures to the left distal femur and right distal femur/knee area after a fall and was hospitalized. Diagnostic imaging showed an anterior apex angulated, impacted distal femur diametaphyseal fracture on the left and an impacted, comminuted anterior apex angulated fracture of the distal fifth metaphysis of the right knee, with osteopenia noted. After hospitalization, the resident returned to the facility and had an MDS with a significant change assessment, with Section F indicating that it was important for her to do things with groups of people, participate in favorite activities, and attend church services. Record review showed that prior to the fall and fractures, the resident participated in out-of-room activities, including Resident Council, food committee, parties, and socials. The activity care plan, originally created in 2020 and revised multiple times through early 2025, documented numerous preferences and important activities for the resident, such as in-room visits, participation in food committee, church, singing, cooking, gardening, going outside in good weather, pet visits, listening to religious and other music, watching TV, reading, and engaging in religious services and voting. The care plan also noted that it was important for her to engage in her favorite activities and to have opportunities to make choices related to meaningful activities. However, there were no new interventions added or changes made to the activity care plan after her significant change in condition and return from the hospital. Activity participation records from the beginning of the year through the time of survey showed that since her readmission from the hospital, the resident had no out-of-room activity participation and only two documented one-to-one visits, both on the same day. During interview, the resident reported that she could no longer stand, pivot, or get into her wheelchair, and that she was now unable to attend Resident Council meetings, church, or be around people as she had before. She expressed distress about missing family gatherings she had been working toward attending and stated that activity staff did not visit very often and that she could not go out to the groups she liked. The Director of Recreation confirmed that the resident had not attended group activities since returning from the hospital due to being non–weight bearing, that anything done with her was now in-room, and that social visits were not consistently documented. The Administrator and Director of Recreation acknowledged that documentation showed only two one-to-one visits and no updated interventions on the care plan since before the significant change, leading to the finding that the facility failed to provide a program of activities to meet this resident’s needs and interests after her change in condition.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
