Wayne Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Wayne, West Virginia.
- Location
- 6999 Route 152, Wayne, West Virginia 25570
- CMS Provider Number
- 515168
- Inspections on file
- 14
- Latest survey
- March 27, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Wayne Healthcare Center during CMS and state inspections, most recent first.
The facility failed to store and serve food in accordance with professional standards by keeping chocolate milk beyond its expiration date and by not ensuring all staff were wearing hairnets. A gallon of chocolate milk with an expiration date of 04/26/24 was found in the refrigerator, and an employee was observed washing dishes without a hairnet. These deficiencies were confirmed by the Dietary Corporate Manager and had the potential to affect all 60 residents.
The facility failed to maintain a clean environment by leaving an uncovered bedpan on the bathroom floor in room A13, observed on three separate occasions. Additionally, the facility did not follow its policy to test for Legionellosis annually, with the last test recorded on 09/14/22.
The facility failed to ensure the Daily Staffing Posting information was accurate and current, with discrepancies in direct care hours and incorrect inclusion of administrative staff hours as direct care. The Administrator acknowledged these inaccuracies during the survey process.
The facility failed to provide chairs in residents' rooms, leading to a resident's brother sitting on a PTAC unit due to the absence of seating. The Administrator acknowledged the issue and stated that many rooms lacked chairs, which would be replaced to ensure a functional and comfortable environment.
The facility failed to ensure a resident was treated with dignity and respect, as the resident was observed with long chin hairs that she wanted removed. The DON acknowledged the issue and stated it would be addressed immediately.
The facility failed to inform a resident or their representative about the risks and benefits of an antipsychotic medication before its administration. The Director of Nursing confirmed that the necessary education was not provided prior to starting the medication.
The facility failed to issue a beneficiary notification within the appropriate time frames for a resident. The last covered day of Medicare services was 12/14/23, but the Notice of Medicare Non-Coverage (NOMNC) was issued on the same day, making the appeal process inaccessible. This deficiency was confirmed during an interview with the Nursing Home Administrator.
The facility failed to maintain a sanitary and homelike environment, with issues including a soiled turn and positioning device, holes in the wall, and a dirty bathroom. Staff were unaware of cleaning requirements, and the Administrator confirmed the deficiencies.
The facility failed to protect a resident from abuse when another resident hit her in the eye, and another resident from inappropriate language used by a CNA. Both incidents resulted in actual harm to the residents involved.
The facility failed to accurately encode the MDS for a resident upon discharge, marking it as unplanned despite evidence of a planned discharge. This error was confirmed through staff interviews and a review of the resident's medical records.
The facility failed to update PASARR forms to reflect new mental health diagnoses for three residents. One resident had multiple new diagnoses, including Schizoaffective disorder and Major Depressive Disorder, none of which were updated in the PASARR. Another resident was diagnosed with Bipolar Disorder, but the PASARR was not updated. A third resident's PASARR did not reflect a new diagnosis of Major Depressive Disorder. The DON confirmed these oversights during interviews.
The facility failed to ensure that the PASARR reflected the admitting diagnoses for two residents. One resident's PASARR did not include Schizoaffective disorder, and another's did not include Bipolar Disorder and Mild Cognitive Impairment. These discrepancies were confirmed by the DON.
The facility failed to develop and implement an individualized comprehensive care plan for a resident diagnosed with urinary incontinence. Despite an assessment indicating the need for a toileting program, the resident's care plan did not address this diagnosis. The DON acknowledged this oversight.
A resident with a BIMS score of 8 reported a foot injury caused by a fallen walker. Despite informing a nurse, no further action was taken. Observation revealed significant bruising, and staff interviews confirmed the lack of medical treatment or documentation. The ADON acknowledged the need for an x-ray after observing the injury.
Expired Chocolate Milk and Lack of Hairnets in Kitchen
Penalty
Summary
The facility failed to store and serve food in accordance with professional standards by keeping chocolate milk beyond its expiration date and by not ensuring all staff were wearing hairnets. During an initial tour of the kitchen, a gallon of chocolate milk with an expiration date of 04/26/24 was found in the reach-in refrigerator on 04/29/24. Additionally, an employee was observed washing and putting up dishes without wearing a hairnet. These deficiencies were confirmed by the Dietary Corporate Manager and had the potential to affect all residents currently residing in the facility, which had a census of 60 residents.
Infection Control and Water Management Deficiencies
Penalty
Summary
The facility failed to ensure a clean, sanitary environment by leaving an uncovered bedpan on the bathroom floor in room A13. This was observed on three separate occasions: at 11:28 AM and 1:17 PM on 04/29/24, and again at 9:00 AM on 04/30/24, with the facility Administrator confirming the bedpan's presence. Additionally, the facility did not follow its policy to test for Legionellosis annually. The last recorded test was on 09/14/22, as confirmed by a review of the facility's Water Management/Legionella Plan and an interview with the Administrator on 05/01/24.
Inaccurate Daily Staffing Posting Information
Penalty
Summary
The facility failed to ensure the Daily Staffing Posting information was accurate and current with the actual direct care hours and the identified direct care staff. This deficiency was observed in four out of five Daily Staffing Posting forms reviewed during the long-term care survey process. Specifically, the posted direct care hours on 04/04/24, 04/05/24, 04/12/24, and 04/18/24 were found to be inaccurate when compared to the Actual Hours for Direct Care Staff Report. The discrepancies ranged from 2.75 to 28.5 hours. The Administrator acknowledged these inaccuracies during an interview on 05/01/24, agreeing that the posted hours were more than the actual reported hours worked. Additionally, the facility inaccurately included the hours of the Registered Nurse Director of Nursing (RN DON) and Registered Nurses (RNs) with administrative duties as direct care hours on the Daily Staffing Posting forms for the same dates. The Administrator explained that these hours were included because the RN DON and RNs with administrative duties sometimes assist with daily care. However, according to the Centers for Medicare & Medicaid Services (CMS) guidelines, the hours should be reported based on the employee's primary role. The Administrator acknowledged that the RN DON hours and the RNs with administrative duties hours should not have been included as direct care hours on the Daily Staffing Posting forms.
Lack of Chairs in Resident Rooms
Penalty
Summary
The facility failed to ensure a safe, functional, sanitary, and comfortable environment for residents, staff, and the public. Specifically, the facility did not provide chairs in residents' rooms for use by residents and visitors. During an interview with a resident, it was observed that the resident's brother was sitting halfway on the room's packaged terminal air conditioner (PTAC) unit due to the absence of a chair. The resident's brother mentioned that the room never had a chair, and he sometimes had to find a fold-up chair if available. The Administrator acknowledged that many rooms lacked chairs and stated that he would replace them, recognizing the need for a functional and comfortable homelike environment.
Failure to Maintain Resident Dignity
Penalty
Summary
The facility failed to ensure a resident was treated with dignity and respect. During an observation, the resident was noted to have long chin hairs that needed removal. In an interview, the resident confirmed she did not like having chin hair and wanted it removed. The Director of Nursing, present during the interview, agreed that the chin hair needed to be removed and stated she would address it immediately.
Failure to Inform Resident of Antipsychotic Medication Risks and Benefits
Penalty
Summary
The facility failed to inform the resident or the resident's representative about the risks and benefits of an antipsychotic medication before its administration. This deficiency was identified during a review of the medical record for Resident #36, who was receiving Risperidone, an antipsychotic medication ordered on 03/07/24. The review revealed no documentation indicating that education regarding the risks and benefits of the medication was provided to the resident's healthcare decision maker prior to starting the medication. The Director of Nursing confirmed that this educational step was not completed before the medication was administered.
Failure to Issue Timely Beneficiary Notification
Penalty
Summary
The facility failed to issue a beneficiary notification within the appropriate time frames for one of three residents reviewed during the long-term care survey process. Specifically, for Resident #111, the last covered day of Medicare services was 12/14/23, but the Notice of Medicare Non-Coverage (NOMNC) was issued to the responsible party on the same day, 12/14/23. The form indicated that the appeal needed to be filed by 12/13/23, which was one day before the responsible party was notified, making the appeal process inaccessible. This deficiency was confirmed during an interview with the Nursing Home Administrator on 05/01/24.
Facility Fails to Maintain Sanitary and Homelike Environment
Penalty
Summary
The facility failed to ensure a safe, functional, sanitary, and comfortable homelike environment for its residents. During a tour of the facility, room [ROOM NUMBER]A was found to have a soiled turn and positioning device in the bathroom. Licensed Practical Nurses (LPNs) #45 and #65 were unaware of the cleaning requirements for this equipment. The Administrator confirmed that the equipment was not properly cleaned and sanitary for resident use, as per the facility's infection control policies and standard procedures for maintenance and repair of equipment used for resident care. In room A14-B, two holes were observed in the wall behind the B bed, which were left from a previously replaced overhead light. The Administrator confirmed the issue and stated that the holes would be fixed as soon as possible. Additionally, the bathroom in room B14 was observed to have a brown substance smeared on the floor by the toilet on two separate occasions. The Director of Plant Maintenance confirmed that the floor needed cleaning and indicated that the room should be cleaned daily.
Failure to Protect Residents from Abuse and Inappropriate Language
Penalty
Summary
The facility failed to ensure Resident #30 was free from abuse, resulting in an incident where Resident #57 hit Resident #30 in the left eye. This incident was witnessed by the Activities Director and two guests. Resident #30, who has multiple diagnoses including Alzheimer's disease, dementia, and chronic kidney disease, was unable to indicate how the incident affected her due to her cognitive impairment. The facility's records show that the incident was reported to the physician and appropriate state agencies, and an investigation was initiated immediately. Resident #57, who has a history of epilepsy, anoxic brain damage, and other medical conditions, was placed on one-on-one supervision and later discharged from the facility. The facility conducted head-to-toe assessments and pain assessments for Resident #30, which documented no physical injuries or signs of pain following the incident. However, the reasonable person standard was applied, indicating that a reasonable person would suffer psychosocial harm from being hit by another resident, thus constituting actual harm for Resident #30. The facility also failed to ensure Resident #16 was free from inappropriate language from a staff member. Resident #16 reported hearing a CNA use profanity and express reluctance to care for her. The incident was reported to the facility's administration, and an investigation was conducted. Multiple staff members corroborated Resident #16's account, confirming that the CNA did use profanity in front of the resident. The CNA was placed on unpaid suspension and later resigned during the investigation. Resident #16, who has a history of being upset by the CNA's behavior, expressed that she no longer wanted the CNA to care for her. The facility's records show that the CNA had completed training on elder abuse and preventing, recognizing, and reporting abuse prior to the incident. Both incidents highlight the facility's failure to protect residents from abuse and inappropriate behavior, resulting in actual harm to the residents involved. The facility's immediate actions to address the incidents and prevent recurrence were noted, but the deficiencies were cited as past non-compliance due to the harm caused to the residents.
Failure to Accurately Encode MDS Upon Discharge
Penalty
Summary
The facility failed to accurately encode the Minimum Data Set (MDS) for a resident upon discharge. During a medical record review, it was found that there were no notes for the anticipated discharge of a resident prior to the discharge date. The discharge summary was completed by all required departments and included necessary follow-up information. However, the MDS was incorrectly marked as an unplanned discharge, despite evidence indicating that the discharge was planned. This discrepancy was confirmed through staff interviews, including the Unit Manager LPN and the Regional Director of Finance, who clarified that there were no financial reasons for the early discharge and that the resident had won an appeal regarding their Medicare coverage. The Administrator acknowledged that the discharge was planned and that the MDS was not encoded correctly. The error was attributed to the resident's son coming to get the resident one day before the originally planned discharge date, which led to the incorrect marking of the discharge as unplanned. This failure to accurately encode the MDS upon discharge was identified during the long-term care survey process and affected one of the two resident discharges reviewed.
Failure to Update PASARR Forms for New Mental Health Diagnoses
Penalty
Summary
The facility failed to ensure that the Preadmission Screening and Resident Review (PASARR) forms were updated to reflect new diagnoses for residents with newly diagnosed mental illnesses. This deficiency was identified for three out of four residents reviewed for the PASARR care area. Resident #26 had multiple new diagnoses, including Schizoaffective disorder, Major Depressive Disorder, Mild cognitive impairment, Delusional Disorder, Paranoid Personality Disorder, and a history of Bipolar Disorder, none of which were updated in the PASARR submitted on 03/01/23. The Director of Nursing confirmed that these new diagnoses were not submitted on a PASARR during an interview on 04/30/24. Similarly, Resident #41 was diagnosed with Bipolar Disorder on 09/15/20, but the PASARR was last completed on 08/28/20, and no new PASARR was submitted to reflect this change. The Director of Nursing acknowledged this oversight during an interview on 04/30/24. Additionally, Resident #52 was diagnosed with Major Depressive Disorder on 06/06/23, but the last PASARR completed on 01/20/23 did not include this diagnosis. The Director of Nursing confirmed that a new PASARR had not been completed for Resident #52 during an interview on 05/01/24. These failures indicate a systemic issue in updating PASARR forms to reflect new mental health diagnoses promptly.
PASARR Screening Deficiency for Mental Disorders or Intellectual Disabilities
Penalty
Summary
The facility failed to ensure that the Preadmission Screening and Resident Review (PASARR) reflected the admitting diagnoses for two residents. For Resident #26, the medical record revealed an admitting diagnosis of Schizoaffective disorder on 09/08/22, but the PASARR submitted on 03/01/23 did not reflect this diagnosis. This discrepancy was confirmed by the Director of Nursing during an interview on 04/30/24. Similarly, for Resident #14, the medical record showed admitting diagnoses of Bipolar Disorder and Mild Cognitive Impairment of Uncertain or Unknown Etiology on 05/25/23, but the PASARR submitted on 05/23/23 by a local hospital did not include these diagnoses. This was also verified by the Director of Nursing during the same interview.
Failure to Develop and Implement Individualized Care Plan for Urinary Incontinence
Penalty
Summary
The facility failed to develop and implement an individualized comprehensive care plan for a resident diagnosed with urinary incontinence. A record review revealed that the resident had a urinary incontinence assessment completed, indicating the need for a toileting program titled Check and Change. However, the resident's current care plan did not include any individualized comprehensive care plan for this diagnosis. During an interview, the Director of Nursing acknowledged that the resident had not been care planned for her urinary incontinence diagnosis as required.
Failure to Provide Timely Medical Treatment for Foot Injury
Penalty
Summary
The facility failed to provide timely medical treatment for a foot injury for one of the residents. Resident #52, who has a Brief Interview for Mental Status (BIMS) score of 8, reported that her walker fell on her foot, causing pain and bruising. Despite informing a nurse immediately after the incident, no further action was taken to address the injury. An observation revealed dark purple and red bruising on her right big toe and the adjacent toe, extending down the side and top of her foot. Interviews with staff confirmed that no medical treatment or documentation had been provided for the injury, and the Assistant Director of Nursing acknowledged the need for an x-ray after observing the resident's foot.
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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