Tygart Center At Fairmont Campus
Inspection history, citations, penalties and survey trends for this long-term care facility in Fairmont, West Virginia.
- Location
- 1539 Country Club Road, Fairmont, West Virginia 26554
- CMS Provider Number
- 515053
- Inspections on file
- 22
- Latest survey
- February 12, 2026
- Citations (last 12 mo.)
- 18
Citation history
Health deficiencies cited at Tygart Center At Fairmont Campus during CMS and state inspections, most recent first.
The facility did not maintain a clean, comfortable, homelike environment for several residents. In one room, the PTAC unit’s filters were observed to be fully covered with about two inches of dust and debris; a housekeeper confirmed they were dirty, and the maintenance director acknowledged there was no written policy or schedule for cleaning these units. In another room, the wall behind the bed and beside the headboard had multiple scratches with missing paint, which an LPN confirmed. These environmental issues were identified during the survey and had the potential to affect more than a limited number of residents.
Surveyors identified multiple failures in infection prevention and control, including an activities assistant entering a COVID-positive resident’s room without PPE despite droplet precaution signage, staff not offering hand hygiene to several residents during meal tray delivery and setup, and an employee carrying a resident’s plate with a thumb inside the food barrier. The laundry room exhaust system did not maintain proper airflow from clean to soiled areas as required by facility policy. Additionally, doors to COVID-positive rooms were left open contrary to the facility’s Special Contact and Droplet Precautions policy, and an OT was observed providing care to a COVID-positive resident without required eye protection.
The facility did not ensure that all staff received required education on the risks and benefits of the COVID-19 vaccine or that this education was documented. Review of the HealthStream education system for several CNAs showed no records of COVID-19 vaccine education. The Infection Preventionist RN reported that she only provided COVID-19 vaccine information when staff requested it and confirmed there was no related education module in the HealthStream system. This deficiency had the potential to affect more than a limited number of the 106 residents.
The facility did not accurately post daily nurse staffing information, with discrepancies found between posted hours and actual hours worked for RNs, LPNs, and Certified Nurse Aides on most days reviewed. The DON was unable to explain the differences when questioned.
Surveyors observed mature gnats swarming around the kitchen drain area, and the district manager confirmed that although an exterminator had been contacted for advice, the facility had not yet been treated for the pest issue.
Surveyors found that several residents' rooms had dirty, stained privacy curtains and bathrooms in disrepair, including exposed screws and unfinished drywall. Staff and the DON acknowledged these issues during interviews.
Surveyors found that the facility did not consistently provide complete transfer and bed hold notices or notify the Ombudsman as required when residents were transferred or discharged. In several cases, forms were incomplete or missing, and notifications to residents, their representatives, and the Ombudsman were not documented, as confirmed by facility leadership.
Two residents experienced inadequate pain management due to delays in medication administration, improper documentation, and lack of follow-up on pain relief effectiveness. Nursing staff failed to document pain medication administration on the MAR and did not assess or record the effectiveness of PRN pain medications as required, resulting in unmet pain needs.
Several residents reported that meals were unpalatable, lacked seasoning, were sometimes served cold, and did not include fresh produce. Surveyors confirmed these concerns by tasting a meal and finding items overcooked, unseasoned, and one item below the required serving temperature.
Staff failed to reheat food to the required temperature before serving, did not follow proper hand hygiene when serving drinks, and neglected to wear appropriate hair and beard coverings in the kitchen. Additionally, staff personal items were found stored in a nourishment room alongside resident food items, contrary to posted policies.
Surveyors found that two residents had unopened nutritional supplements at the nurses' station, even though the MAR indicated they had consumed them, and a nurse admitted the records should have shown the supplements were refused. Another resident's records showed conflicting information between a physician's order for G-tube feeding and a nursing evaluation stating the resident was eating orally, though staff confirmed all nutrition was via G-tube.
A registered nurse compromised infection control during wound care by touching her glasses and allowing a nurse aide to place a bath basin on the sterile field. A nebulizer and mask were found stored on the floor next to a resident's bed, and another resident's wheelchair had a torn back rest exposing inner padding. Staff acknowledged these breaches upon observation and interview.
Two residents did not receive care in accordance with physician orders and facility policy: one resident continued to receive wound care after the wound had healed, and another did not have required neuro checks documented after a fall. The DON and RN confirmed these lapses in care.
A resident was not asked about their food preferences upon admission, did not receive information about available menu options, and had no food preferences documented in their care plan. Staff interviews confirmed that required procedures for gathering and honoring food choices were not followed, resulting in the resident receiving meals without consideration of their preferences.
A nurse told a resident she could not receive her PRN Tylenol for pain until she ate half her meal, despite no such order, and only administered the medication after staff intervention. The incident, which constituted an allegation of mental/emotional abuse, was not reported to state agencies within the required time frames, in violation of the facility's abuse prohibition policy.
A nurse told a resident she could not receive her as-needed Tylenol for arm pain until she ate at least half of her food, despite no such order in the medical record. The medication was only given after staff intervention following a surveyor's report. Facility leadership confirmed the incident was not reported to state agencies as required.
Surveyors found that the facility did not develop or update care plans for three residents, including a dialysis patient with a new AVF, a resident with bilateral knee contractures, and another whose care plan was incomplete and missing details on required assistance for daily activities. The DON confirmed these omissions during interviews.
A resident's care plan was not revised to reflect a change in code status, as the POST form indicated DNR and comfort measures only, but the care plan still listed the resident as full code. The DON confirmed the care plan had not been updated.
A resident requiring hemodialysis did not receive complete and documented dialysis care, as several Hemodialysis communication sheets were missing or incomplete, and there was no care plan or physician order to monitor a newly placed AVF as requested by the hospital. Additionally, the resident was served meals containing restricted items such as tomatoes and oranges, despite a documented diet order and her stated preferences.
A resident receiving Mirtazapine for depression did not have a timely physician response to a pharmacist's recommendation for gradual dose reduction, as required by facility policy. The pharmacist also did not identify the need for a further GDR after the last review, and the DON confirmed that no additional reviews were completed as scheduled.
A nurse aide did not complete the required 12 hours of annual education, having only 9 hours and 34 minutes documented, including limited dementia care training. No additional education records were provided when requested by the DON.
Two residents who were dependent on staff for ADL care did not receive regular showers or bed baths as required, with one resident going seven days without bathing and another not receiving a shower for 18 days, despite documented preferences and care plans indicating the need for assistance. The DON confirmed the lack of bathing during these periods.
A resident who required a sit-to-stand lift was transferred using a gait belt by a NA, contrary to the care plan, resulting in a laceration that required emergency treatment and stitches. Investigation confirmed the improper transfer method and substantiated neglect, with the issue found to be isolated to this resident.
A resident with limited mobility and incontinence reported that some staff were rough during incontinence care, specifically pulling on her leg too hard. Although the facility indicated staff education would be provided following the abuse allegation, there was no evidence of follow-up education, as confirmed by the DON.
A resident was discharged after unauthorized narcotics were found in her room, but the facility failed to ensure a safe and orderly transition. The resident was referred to a homeless shelter that could not accommodate her physical limitations, resulting in her remaining in a transport vehicle while staff searched for alternatives. Ultimately, the resident chose to be dropped off at a public location, and APS was notified. Facility leadership confirmed the discharge was not handled safely or appropriately.
A resident with a central venous access device did not have a comprehensive, person-centered care plan addressing the care of the device. Although the facility had protocols for catheter care and infection prevention, these were not incorporated into the resident's individualized care plan, as confirmed by the DON and Administrator.
A resident with a central venous access device did not have the required transparent dressing changes performed or documented, as mandated by facility policy and standard practice. Although the central line was not used for medication administration, it remained in place without evidence of dressing changes throughout the resident's stay, as confirmed by record review and staff interviews.
Failure to Maintain Clean PTAC Filters and Proper Wall Conditions in Resident Rooms
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for multiple residents, as evidenced by environmental deficiencies identified during the survey. In one resident’s room, observation of the Packaged Terminal Air Conditioner (PTAC) unit showed both filters were fully covered with approximately two inches of dust and debris. A housekeeper filling in from another building confirmed the PTAC filters were dirty and needed cleaning, and the Director of Maintenance stated there was no written policy or schedule for cleaning the PTAC units, although he reported they were cleaned monthly. In another resident’s room, the wall behind the bed and on the right side of the headboard had multiple scratches with missing paint, and an LPN confirmed the walls were in this condition. These conditions were identified as part of the Long-Term Care Survey Process and had the potential to affect more than a limited number of residents. No additional medical history or clinical conditions of the residents involved were provided in the report.
Failure to Maintain Effective Infection Prevention and Control Practices
Penalty
Summary
The deficiency involves the facility’s failure to maintain an effective infection prevention and control program, including improper use of PPE, inadequate hand hygiene practices, and noncompliance with transmission-based precautions. Surveyors observed an activities assistant entering the room of a resident on droplet precautions, with COVID-19 signage and a red stop sign on the door, without wearing any PPE, while other staff in the room were properly donned. The assistant initially stated the resident did not “have anything” and had been going to the dining room without a mask, and only acknowledged the need for PPE after being informed the resident had COVID-19. During meal tray delivery and setup on one hall, the admissions coordinator and another employee did not offer or provide hand sanitizer or other hand hygiene to multiple residents before meals and later acknowledged they had failed to do so. In the dining room, another employee was observed carrying a resident’s plate with his thumb resting inside the plate’s food barrier and admitted his thumb was too far into the plate. Additional deficiencies were identified related to environmental controls and adherence to the facility’s own infection control policies. The facility’s exhaust system policy required monthly inspection of laundry room exhaust fans and verification that airflow was sufficient to hold a piece of paper to the vent; however, during a tissue test in the laundry area, air was not pulling from the clean side to the soiled side as required. The facility’s Special Contact and Droplet Precautions policy required doors of affected residents to remain closed, yet multiple doors to COVID-positive resident rooms were observed open on two halls during the survey, and two COVID-positive room doors were later observed open again, with one nurse reporting that the resident leaves the room wearing a mask. The same policy required staff to wear appropriate PPE, including N95 respirator, gown, gloves, and recommended eye protection for encounters with positive patients, but an occupational therapist was observed inside a COVID-positive resident’s room without any eye protection and stated they did not have a face shield or glasses.
Failure to Provide and Document COVID-19 Vaccine Education for All Staff
Penalty
Summary
The facility failed to ensure that COVID-19 vaccine education was provided to all staff as required by federal guidelines, which mandate that staff receive education on the risks and benefits of the vaccine and that the vaccine be offered by the facility or that information be provided on how to obtain it. Surveyors reviewed the HealthStream education records for five nursing assistants and found no documentation of COVID-19 vaccine education. During an interview, the Infection Preventionist RN stated that she only provided COVID-19 vaccine information to staff if they requested it and confirmed that there was no COVID-19 vaccine education content in the HealthStream system. This failure had the potential to affect more than a limited number of the facility’s 106 residents. No specific residents, their medical histories, or conditions at the time of the deficiency were described in the report.
Inaccurate Daily Nurse Staffing Postings
Penalty
Summary
The facility failed to provide accurate daily postings of nurse staffing information, as required. During the annual survey, a review of nursing staffing data and time and attendance reports for 15 selected days revealed discrepancies on 14 days, where the posted nurse staffing hours for RNs, LPNs, and Certified Nurse Aides did not match the actual hours worked according to time and attendance records. For example, on several dates, the posted hours were significantly higher than the hours documented in the attendance system. When these inconsistencies were presented to the Director of Nursing, no explanation was provided for the differences.
Failure to Maintain Effective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in the presence of mature gnats swarming around the drain area under the dishwasher table in the dish room side of the kitchen. This observation was made during a walk-through, and the issue was acknowledged by the district manager, who stated that although the exterminator had been contacted for advice a week prior, the facility had not yet been treated for the gnats. The deficiency was identified as a random opportunity for discovery and had the potential to affect multiple residents, with a facility census of 106. No specific residents or their medical conditions were mentioned in relation to this deficiency.
Failure to Maintain Clean and Homelike Resident Rooms
Penalty
Summary
Surveyors observed that the facility failed to maintain a clean and homelike environment in several resident rooms. Specifically, privacy curtains in multiple rooms were found to be dirty and stained, with one resident identifying a stain as vomit. Staff interviews confirmed awareness of the issue, with an LPN acknowledging that the curtain required cleaning and describing the usual process for notifying housekeeping when such issues are noticed. Additional observations revealed that several resident bathrooms were not in good repair. Issues included screws protruding from drywall, unfinished drywall patches, and general disrepair in the bathroom areas of multiple rooms. During a walkthrough, the DON acknowledged these maintenance issues in the identified rooms.
Failure to Provide Required Transfer, Bed Hold, and Ombudsman Notifications
Penalty
Summary
Surveyors identified that the facility failed to provide required documentation and notifications related to resident transfers, discharges, and bed-hold policies for multiple residents. Specifically, for several residents who were transferred to hospitals or went on therapeutic leave, the facility did not complete or provide adequate Notice of Transfer, Bed Hold Notices, or notifications to the Office of the State Long-Term Care Ombudsman. In several instances, the forms were incomplete, missing critical information such as the number of bed-hold days remaining, the reason for transfer, or the names of individuals notified. Some forms were only partially filled out, with staff signing in multiple required signature spaces or failing to document verbal notifications appropriately. In addition, there was no evidence that the required notifications were sent to the Ombudsman, as confirmed by facility leadership during interviews. The deficiency was found across multiple resident records reviewed during the annual survey, with five out of six records lacking proper documentation and notification. The facility's Person In Charge and DON confirmed the absence of required notifications and attributed some missing documentation to lost records during an office move. The failures included not notifying residents and their representatives in writing and in a manner they could understand, as well as not sending copies of transfer or discharge notices to the Ombudsman, as required by regulation.
Failure to Provide Safe and Appropriate Pain Management
Penalty
Summary
The facility failed to provide safe and appropriate pain management for two residents, resulting in deficiencies related to the administration and documentation of pain medication. One resident reported experiencing significant pain, rating it as an eight out of ten, and stated she had been requesting pain medication without receiving it. The nurse on duty initially withheld the medication due to a misunderstanding of the dosing interval, only contacting the physician to adjust the order after the resident's continued complaints. Documentation review revealed discrepancies between the controlled substance log and the Medication Administration Record (MAR), with several instances where pain medication was signed out but not documented as administered on the MAR, and no evaluation of the medication's effectiveness was recorded as required by facility policy. Another resident, admitted for therapy following an unrepaired hip fracture, also reported ongoing pain and concern about participating in therapy due to inadequate pain control. Review of her medical records showed multiple changes in pain medication orders, but again, there were instances where pain medication was signed out on the controlled substance log without corresponding documentation on the MAR or evaluation of effectiveness. The DON was unable to provide documentation for a reported refusal of alternative pain medication and made comments regarding the resident's pain tolerance without supporting evidence. Both cases demonstrate failures to follow professional standards of practice, the comprehensive care plan, and the residents' choices regarding pain management. The lack of proper documentation and timely administration of pain medication, as well as failure to assess and record the effectiveness of pain interventions, contributed to the deficiency identified during the survey.
Failure to Provide Palatable and Properly Tempered Meals
Penalty
Summary
The facility failed to ensure that resident meals were palatable, attractive, and served at a safe and appetizing temperature. Multiple residents reported that the food was unappealing, lacked taste, was sometimes served cold, and did not include fresh fruits or vegetables. One resident stated she was supposed to receive yogurt with every meal but often did not. Residents also indicated they were not informed about an always available menu. During a meal observation, surveyors found that the macaroni and cheese and broccoli were overcooked and unseasoned, and the temperature of the fried potatoes was below the required standard at 113 degrees Fahrenheit. These findings were based on direct resident interviews and surveyor meal tasting, indicating a pattern of inadequate food quality and service.
Multiple Food Safety and Sanitation Deficiencies Identified
Penalty
Summary
The facility failed to adhere to professional standards for food safety and sanitation in multiple instances. During a noon meal service, a staff member reheated broccoli that had previously fallen below the safe holding temperature, but only reheated it to 160°F before serving, despite the requirement to reheat to 165°F. The Dietary Account Manager incorrectly advised that 160°F was acceptable, and the corporate account manager later confirmed the error. Additionally, during a dining room observation, an employee served drinks to residents without performing proper hand hygiene after touching residents and objects, which was acknowledged as improper by the person in charge. Further deficiencies were observed in the kitchen, where staff, including the Dietary Account Manager and a cook, failed to wear appropriate hairnets and beard nets, leaving hair exposed while working with food. Staff interviews revealed a lack of awareness regarding the requirements for hair and beard coverings. In the 400 Hall Nourishment Room, staff personal belongings, including drink cups, an open can, a purse, and clothing, were found stored alongside resident nourishment items, despite posted signage prohibiting staff items in these areas. The DON acknowledged that staff personal items should not have been present in the nourishment room.
Inaccurate Documentation of Supplement Intake and Nutrition Status
Penalty
Summary
The facility failed to ensure accurate and complete documentation in the medical records of several residents. For two residents, unopened nutritional supplements (mighty shakes) were observed at the nurses' station in the afternoon, despite the Medication Administration Record (MAR) indicating that both had consumed 100% of their supplements at 10:00 AM. Upon interview, the registered nurse responsible acknowledged that she should have documented the supplements as refused rather than consumed. Additionally, a review of another resident's records revealed inconsistencies between the physician's order and the skilled nursing evaluation. The physician's order specified enteral feeding via G-tube, with the resident marked as NPO (nothing by mouth), yet the skilled nursing evaluation documented that the resident was taking nutrition and hydration orally and showed no signs of swallowing disorder. Corporate nursing staff later confirmed that the resident was receiving all nutrition through the G-tube and not orally.
Infection Control Breaches During Wound Care, Equipment Storage, and Wheelchair Maintenance
Penalty
Summary
During wound care for a resident, a registered nurse repeatedly touched her glasses while performing the procedure and did not realize this action, which compromised infection control standards. Additionally, a nurse aide placed a bath basin of water and wash cloths on the over-the-bed table that was being used as a sterile field for the wound care, further breaching sterile technique. Both staff members acknowledged these actions when interviewed, and the corporate registered nurse confirmed these events as breaches of infection control. In another instance, a nebulizer machine and mask belonging to a resident were observed sitting on the floor next to the resident's bed. The registered nurse supervisor was notified and immediately removed the items from the floor. Additionally, a resident's wheelchair was found to have a tear in the covering of the back rest, exposing the inner padding. Both a nurse aide and the infection control manager acknowledged the condition of the wheelchair, with the infection control manager stating she was previously unaware of its state.
Failure to Discontinue Wound Care and Complete Neurological Assessments
Penalty
Summary
The facility failed to provide appropriate treatment and care according to physician orders and resident needs for two residents. For one resident, after sustaining a fall, the medical record and incident report indicated that neurological assessments were to be completed per policy; however, the facility was unable to provide documentation of these neurological checks when requested, and the DON confirmed the assessments could not be located. For another resident, wound care orders for an abrasion to the left gluteus remained active and were carried out ten additional times after the wound had resolved, as the order was not discontinued when the wound healed. This was confirmed by both the RN responsible and the DON, who acknowledged the treatment should have ended when the wound was resolved.
Failure to Obtain and Honor Resident Food Preferences
Penalty
Summary
A deficiency occurred when the facility failed to obtain and honor a resident's food choices, as required by regulations supporting resident self-determination. The resident reported not being asked about their food preferences and stated that meals were provided without consideration of their likes or dislikes. The resident was also unaware of the Always Available menu and had not been informed about it. Interviews with staff revealed that the designated staff member responsible for collecting food preferences within 24 hours of admission had not completed this task, citing workload issues. The staff member also could not explain how the resident would know to request the daily menu or alternative options. A review of the resident's care plan showed that no food preferences were documented, and the facility's policy required dietary staff to visit new residents within 48 hours to introduce meal options and gather preferences. This process was not followed for the resident in question, and the resident was not provided with a Personal Choice Menu. The findings indicate that the facility did not follow its own procedures or regulatory requirements to ensure resident food choices were obtained and honored.
Failure to Report Allegation of Mental/Emotional Abuse as Required
Penalty
Summary
A nurse was observed telling a resident that she could not have her pain medication, Tylenol, until she ate at least half of her food, despite there being no such requirement in the resident's medical orders. The resident expressed that she did not feel like eating because her arm was hurting and confirmed that she had been told she needed to eat to receive her medication. The nurse left the dining room without administering the medication, and the situation was only rectified after intervention by facility staff following the surveyor's report of the incident. A review of the facility's abuse prohibition policy revealed that allegations of mental or emotional abuse are required to be reported to state agencies within specific time frames. However, interviews with the Director of Nursing, Person in Charge, and Corporate RN confirmed that this allegation was not reported as required. The failure to report the incident constituted noncompliance with the facility's own abuse prohibition policy.
Failure to Timely Report Allegation of Mental Abuse
Penalty
Summary
A nurse was observed telling a resident that she could not have her pain medication, Tylenol, until she ate at least half of her food, despite the resident expressing that she did not feel like eating due to arm pain. The resident's medical record indicated no requirement to eat prior to receiving the as-needed Tylenol. The nurse left the dining room without administering the medication, and the resident confirmed she had been told she needed to eat to receive her medicine. Facility staff only intervened and ensured the resident received her medication after the incident was reported by the surveyor. Upon review, facility leadership acknowledged that this allegation of mental abuse was not reported to the required state agencies within the mandated time frames.
Failure to Develop and Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for three residents, as identified through record reviews, resident interviews, and staff interviews. One resident, who was a hemodialysis patient, had recently returned from the hospital after the placement of an arteriovenous fistula (AVF) in her left upper arm. Despite this significant change in her medical status, her care plan did not include any mention of the AVF, and the DON confirmed that no care plan had been developed for this new condition. Additionally, the resident reported discomfort with her current dialysis port and described her awareness of the AVF, but staff interviews indicated that no specific interventions or monitoring were being performed for the AVF since it was not yet in use. Another resident with bilateral knee contractures did not have these contractures documented in their care plan, a fact confirmed by the DON. A third resident's care plan was found to be incomplete, lacking personalized details regarding the assistance needed for activities such as toileting, transfers, and bathing, with several blanks left unfilled. These findings demonstrate that the facility did not ensure care plans were updated or completed to reflect residents' current needs and conditions.
Failure to Update Care Plan After Change in Code Status
Penalty
Summary
The facility failed to update the care plan for a resident following a change in code status. Record review showed that the resident had a Virginia Physician's Order for Scope of Treatment (POST) form indicating Do Not Resuscitate (DNR), comfort measures only, and no artificial means of nutrition, dated 03/03/25. Despite this, the resident's care plan continued to list the resident as a full code. The Director of Nursing (DON) confirmed during interview that the care plan had not been revised to reflect the updated code status.
Failure to Provide Safe Dialysis Care and Adhere to Dietary Restrictions
Penalty
Summary
The facility failed to provide safe and appropriate dialysis care and services for a resident requiring hemodialysis. Review of the resident's medical record revealed missing and incomplete Hemodialysis communication sheets on several dates, with the post-dialysis section left blank and not completed by nursing staff upon the resident's return from dialysis. This was confirmed by the Director of Nursing. Additionally, after the resident returned from the hospital following the placement of an arteriovenous fistula (AVF), there was no physician order or care plan in place to monitor the AVF for bruit and thrill as requested by the hospital, despite the resident expressing anxiety and requesting monitoring. The facility also failed to ensure the resident's dietary restrictions were followed. The resident had a diet order restricting tomatoes and oranges, yet the menu options provided included tomato products and oranges. During observation, the resident was served a meal containing both restricted items, and she expressed that she did not request those foods. The nurse aide confirmed the contents of the tray and offered to get the resident pudding, which was her preference. The previous Nursing Home Administrator later presented a meal selection sheet indicating the resident had chosen an option that still included restricted items, and did not address the issue when it was pointed out.
Failure to Ensure Timely Physician Response and Pharmacist Review for Gradual Dose Reduction
Penalty
Summary
The facility failed to ensure compliance with its policy regarding timely physician response to pharmacist recommendations for gradual dose reduction (GDR) of an antidepressant medication. Specifically, a resident with a physician's order for Mirtazapine for depression was identified as needing a GDR review by the pharmacist on 12/28/24. However, the attending physician did not provide a response to this recommendation within the facility's required 30-day timeframe. The pharmacist followed up with the physician on 02/27/25, and a response was finally received on 03/05/25, well beyond the policy's deadline. Additionally, the facility did not ensure that the pharmacist identified the need for a possible GDR for the resident after the last documented GDR in May 2024. When asked by the surveyor, the DON confirmed that there were no further GDR reviews after 12/28/24, despite the next review being due in February 2025. No explanation for this lapse was provided before the survey exit.
Failure to Ensure Nurse Aides Complete Required Annual Education
Penalty
Summary
The facility failed to ensure that nurse aides completed the required 12 hours of annual education, as evidenced by a review of personnel files during the annual survey. Specifically, one nurse aide was found to have completed only 9 hours and 34 minutes of education in the calendar year 2024, including just 24 minutes of dementia care education. When the Director of Nursing was asked to provide documentation of any additional education for this nurse aide, no further evidence was supplied prior to the survey exit. This deficiency was identified through record review and staff interview, and it was confirmed that the required annual training hours for nurse aides were not met for at least one staff member out of the five files reviewed.
Failure to Provide Assistance with Bathing for Dependent Residents
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADLs), specifically bathing, for two dependent residents. For one resident, records showed that no showers or bed baths were provided for a consecutive seven-day period, despite documentation on the Minimum Data Set (MDS) indicating the resident was dependent for these tasks. The Director of Nursing (DON) confirmed the absence of documentation for bathing during this timeframe. Another resident, who expressed a preference for at least one shower per week and indicated that the choice of bathing method was very important to her, did not receive a shower for an 18-day period. The care plan documented that the resident required substantial assistance for personal hygiene due to limited mobility. The DON acknowledged that the resident did not receive showers as frequently as preferred, with only one shower documented during the period in question.
Improper Transfer Procedure Results in Resident Injury
Penalty
Summary
A deficiency occurred when a nurse aide (NA) failed to use the appropriate transfer procedure for a resident who required a sit-to-stand lift, as specified in the resident's care plan. Instead, the NA used a gait belt to transfer the resident from a wheelchair to the bed, resulting in the resident sustaining a laceration to the right lower extremity that required emergency room treatment and 16 stitches. The incident was confirmed through the NA's written statement and the facility's investigation, which substantiated neglect. Further review revealed that other NAs may also have been transferring the same resident incorrectly, though a facility-wide audit found the issue to be isolated to this resident. The resident involved was observed to be alert and oriented, using a wheelchair, and did not recall the incident or report any recent falls. The deficiency was identified through record review, interviews, and direct observation.
Failure to Provide Required Staff Education Following Abuse Allegation
Penalty
Summary
The facility failed to provide the required training and education for staff on issues impacting resident care following an allegation of abuse. A resident with limited mobility, pain in her left leg, and incontinence reported that some staff were rough when providing incontinence care, specifically pulling on her leg too hard during diaper changes and linen removal. The resident's care plan indicated she required extensive assistance for personal hygiene and preferred her husband to move her legs during care, but staff interviews revealed her husband was not always present when care was needed. An internal investigation included interviews with other residents, who did not report staff being rough or impatient. Despite the facility's indication in the Facility Reported Incident (FRI) that staff education would be provided on issues impacting resident care, a review of records showed no evidence of follow-up education for staff. The Director of Nursing confirmed the absence of staff education records related to this incident.
Failure to Ensure Safe and Orderly Discharge for Resident with Physical Limitations
Penalty
Summary
The facility failed to provide sufficient preparation and orientation to ensure a safe and orderly discharge for a resident with physical limitations. The resident was notified of a pending discharge due to the discovery of an unauthorized narcotic in her room. The discharge process was initiated quickly, with the resident being informed and paperwork reviewed within a short timeframe. The facility made a referral to a local homeless shelter without confirming that the shelter could accommodate the resident’s physical needs. Upon arrival at the homeless shelter, it was determined that the resident could not be accommodated due to her inability to climb stairs, which was necessary for access to sleeping and dining areas. The facility staff kept the resident in the transport vehicle while attempting to locate another shelter that could accept her. Multiple additional shelters were contacted, but no immediate accommodations were available in the area. Ultimately, the resident requested to be taken to a public location instead of being transported to a shelter further away that had agreed to accept her. The facility complied with her request and made a referral to Adult Protective Services. The facility’s actions did not ensure that the resident’s discharge was safe and orderly, as required, and this was confirmed by facility leadership during interviews.
Failure to Develop Care Plan for Central Line
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident who had a central venous access device. Record review showed that the resident was admitted with a central intravenous line in the right chest and remained in the facility with the device for several months. Despite the presence of the central line, there was no care plan in place addressing its care. Staff interviews and documentation confirmed that the facility followed pharmacy and internal policies for venous access device care, which included protocols for dressing changes and infection prevention. However, these protocols were not reflected in the resident's individualized care plan, as confirmed by both the Director of Nursing and the Administrator.
Failure to Provide Required Central Line Dressing Changes
Penalty
Summary
A deficiency was identified when a resident with a central venous access device did not receive proper care in accordance with the facility's Infection Prevention Measures Policy and standard practice. The resident was admitted with a central intravenous line in the right chest, and facility policy, as well as pharmacy recommendations, required that the transparent dressing on the device be changed at least every seven days and as needed if the dressing became compromised. However, a review of the Medication Administration Record, Treatment Administration Record, and progress notes from the resident's admission through discharge showed no evidence that the central line dressing was ever changed during the resident's stay. Interviews with the DON and review of documentation confirmed that the central line was never used for medication administration, as the resident received IV antibiotics through a peripheral IV and later a midline IV. Despite this, the central line remained in place, and there was no documentation or evidence of dressing changes as required by policy. The deficiency was confirmed by both the DON and the Administrator, and no additional documentation was provided to show compliance with the required care protocols.
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.
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