White Sulphur Springs Center
Inspection history, citations, penalties and survey trends for this long-term care facility in White Sulphur Spring, West Virginia.
- Location
- 345 Pocahontas Trail, White Sulphur Spring, West Virginia 24986
- CMS Provider Number
- 515100
- Inspections on file
- 19
- Latest survey
- November 19, 2025
- Citations (last 12 mo.)
- 20 (1 serious)
Citation history
Health deficiencies cited at White Sulphur Springs Center during CMS and state inspections, most recent first.
A resident's missing clothing was reported by a family member, but staff failed to document the grievance, investigate the loss, or follow up with the resident's representative as required by facility policy. Interviews revealed that staff did not consistently communicate or escalate the concern, and the grievance was not logged or resolved according to established procedures.
A resident experienced fear and distress due to another resident's aggressive behavior, which included entering their room at night. The aggressive resident had a history of verbal and physical aggression, yet their care plan lacked documentation addressing these behaviors. The facility failed to follow its policies on behavior management and abuse prohibition, as no evaluations or interventions were implemented, and the incidents were not reported or discussed in team meetings.
A facility failed to follow a physician's recommendation for a biopsy of thyroid nodules for a resident upon readmission. The resident's healthcare surrogate was not informed, and there were inconsistencies in the documentation of the resident's capacity and treatment preferences. This led to a situation of immediate jeopardy.
A resident, not identified as an elopement risk, exited a facility undetected and was later found deceased outside. Despite being checked by a nurse shortly before the incident, no alarms were heard, and the facility's initial investigation could not determine how the resident left. Video footage was inconclusive, and staff interviews revealed no alarms were disabled. The incident highlighted a failure in monitoring and securing facility exits.
The facility allowed dietary staff to work without obtaining necessary food handler permits, as revealed during a record review and staff interview. Several employees had been working without permits for extended periods, which was acknowledged by the DSAM.
A survey identified deficiencies in food storage and preparation, including undated and exposed items in refrigerators and freezers, unsanitary kitchen equipment, and rusted microwaves used for resident meals. Additionally, inaccurate temperature logs for personal refrigerators in resident rooms were found, with discrepancies between recorded and actual temperatures.
The facility failed to properly dispose of refuse, potentially attracting vermin and affecting all residents. Observations revealed litter around dumpsters, open lids, and a leaking dumpster. The Dining Services District Manager acknowledged these issues.
The facility failed to update care plans for a resident's psychotropic medication and behaviors, another resident's surrogate change, and a third resident's weight monitoring orders. The care plans did not reflect current medical orders or surrogate decisions, leading to deficiencies in care.
A resident with a history of wandering and aggressive behavior was not properly managed, leading to safety concerns for other residents. Despite documented incidents, the facility did not follow its policies on behavior management and abuse prohibition. The DON acknowledged awareness of the behaviors but failed to take necessary actions, such as placing the resident under observation or discussing the issues in team meetings.
A resident receiving palliative care for COPD and Liver Cell Carcinoma experienced discrepancies in medication administration documentation. An RN failed to accurately log Morphine Sulphate doses on the MAR, despite signing them out on the narcotic count sheet. The RN struggled with military time and the facility's computer system, leading to multiple documentation errors. The DON and Unit Managers were informed, and the RN was suspended pending investigation.
A deficiency in infection control was observed when an NA placed a used meal tray back onto a cart with clean trays after discovering a resident was not present. This action, acknowledged as incorrect by the NA, could potentially affect all 64 residents in the facility.
A survey identified several deficiencies in a LTC facility, including cloudy window panes obstructing views, a cracked bedside table posing a hazard, dead flowers with unpleasant odors, and improper storage on a light fixture. Additionally, the facility lacked documentation of required fire drills for specific shifts. These issues were confirmed by the Administrator and staff during the survey.
A facility failed to involve a resident's appointed surrogate in medical decisions despite the resident's incapacity. The NP completed an invalid POST form and did not contact the surrogate regarding a biopsy recommendation or nutritional support suggested by the dietitian. The NP assumed the resident's preferences based on past discussions, leading to a deficiency in the resident's rights.
The facility failed to inform a resident of his right to participate in hospice care, despite his cognitive ability to make informed decisions. Additionally, another resident was administered Zyprexa without prior consent from their representative, violating the facility's policy on informed consent for psychotropic medications.
The facility failed to implement care plans for two residents, resulting in deficiencies in nutritional assistance. A resident was not monitored or assisted with her meal for over an hour, and another resident experienced weight loss without a developed nutritional care plan. Staff acknowledged these oversights during the survey.
The facility failed to address the nutritional needs of two residents. A resident's dietician-recommended nutritional support was declined by the NP without notifying the surrogate, despite the resident being incapacitated. Another resident's physician-ordered weekly weights were not conducted, as acknowledged by the DON. These actions led to inadequate nutritional support and monitoring.
A facility failed to follow a physician's order for a resident's tube feeding volume. An LPN administered 414 ml of Jevity 1.5 CAL instead of the prescribed 320 ml due to using non-graduated cups for measurement. The LPN acknowledged the lack of proper measuring tools and did not use a graduated syringe to verify the correct amount, resulting in the resident receiving more nutrition than ordered.
The facility failed to accurately report nurse staffing information, with discrepancies found in nine out of ten forms reviewed. Reported direct care staffing hours and HPPD calculations were incorrect, and data entries were incomplete. Additionally, RN staff with administrative roles were misclassified as direct care staff, contributing to the inaccuracies.
A resident with dementia, anxiety, and depression exhibited wandering, aggression, and refusal of care, yet the facility failed to update the care plan or schedule a psychological appointment. The DON admitted the resident's behaviors were not reviewed by the IDT, and no new interventions were developed.
A resident with dementia, anxiety, and depression exhibited aggressive and wandering behaviors, but the facility failed to update the care plan or involve the IDT to address these issues. Despite documented behaviors, no psychological evaluation was conducted, and the care plan lacked interventions for the resident's mental health needs.
A resident with dementia exhibited behaviors such as wandering and aggression, but the facility failed to involve the Interdisciplinary Team (IDT) to address these issues. The care plan was not updated with new interventions, and a psychological appointment was not arranged. The Director of Nursing acknowledged these oversights, which led to a deficiency in care.
A resident was administered Zyprexa 10mg IM for agitation without proper monitoring for side effects and without obtaining the necessary consent. The facility's Director of Nursing acknowledged the lack of consent and the improper handling of medication administration documentation.
A facility failed to properly administer a PRN psychotropic medication to a resident, as Zyprexa was given without a specific diagnosed condition documented. The administration lacked a specific consent form, and no monitoring occurred post-administration. The DON acknowledged the absence of consent and the need for a new disclosure form, highlighting inconsistencies in documentation and adherence to facility policies.
The facility's QAPI program failed to correctly implement procedures for managing Virginia Portable Order for Scope of Treatment (POST) forms, as identified during a survey. The facility attempted to modify POST forms, contrary to the requirement to void and replace them if changes are needed. The Administrator and Quality Assurance Committee were unaware of this requirement, and the necessary data to evaluate the QAPI program's effectiveness was unavailable due to technical issues.
The facility's QAPI committee failed to address deficiencies in POST form procedures, leading to inaccuracies in documentation. The administrator and committee were unaware of the correct process for voiding and completing new POST forms, and the Nurse Practitioner completed forms without the attending physician's capacity determination. This affected all residents, as POST forms were not accurately completed or modified.
Failure to Follow Grievance Policy for Missing Resident Clothing
Penalty
Summary
The facility failed to implement its grievance policy and procedure regarding a report of missing clothing for a resident. According to the electronic medical record, a resident's sister reported that she had brought in twelve pairs of socks, which were later found to be missing from the resident's room. Nursing staff checked with laundry, but the socks were not located, and the incident was documented. However, there was no further documentation in the medical record regarding follow-up or resolution of the missing items. Additionally, a review of the facility's grievance log revealed that no written grievance was completed for this incident. Interviews with staff indicated inconsistent understanding and execution of the grievance process. The resident's representative reported not being contacted after initially reporting the missing socks. The social worker stated she was not informed of the missing items, and the administrator acknowledged that there was no evidence of an investigation or follow-up as required by the facility's grievance policy. The policy specifies that concerns should be documented, logged, and followed up with timely communication to the person filing the grievance, none of which occurred in this case.
Failure to Protect Residents from Abuse and Ensure Safety
Penalty
Summary
The facility failed to protect its residents from abuse, specifically failing to prevent mental or emotional harm. This deficiency was identified during a survey process where it was found that a resident, identified as Resident #42, was experiencing fear and distress due to another resident, identified as Resident #61, entering their room at night. Resident #42 reported being scared and unable to sleep because Resident #61 would come into their room, prompting the staff to place a stop sign on the door, which was ineffective as Resident #61 continued to enter the room. Resident #61's medical records revealed a history of physical and verbal aggression towards staff and other residents, including an incident where Resident #61 wandered into another resident's room, refused to leave, and attempted to hit staff and residents. Despite these behaviors, there was no documentation in Resident #61's care plan addressing their aggression, and no assessments or follow-ups were conducted for the residents affected by these behaviors. The facility's policies on behavior management and abuse prohibition were not followed, as the necessary evaluations and interventions were not implemented. The Director of Nursing (DON) was aware of Resident #61's behaviors but had not taken appropriate actions to address the situation. There was no psychological evaluation arranged for Resident #61, and the incidents were not reported or discussed in interdisciplinary team meetings or Quality Assurance and Performance Improvement (QAPI) committee meetings. The facility failed to ensure a safe environment for its residents, as no measures were taken to prevent further incidents or to address the emotional distress experienced by Resident #42.
Failure to Follow Physician's Recommendation for Biopsy
Penalty
Summary
The facility failed to follow up on a physician's recommendation for a biopsy of thyroid nodules for a resident upon readmission. The resident, who had previously expressed a preference against certain treatments, was not consulted about the referral to an ENT specialist. The healthcare surrogate, who was the resident's grandson, was not informed of the hospital's recommendation for a biopsy. This oversight was confirmed during an interview with the Director of Nursing (DON) and the Nurse Practitioner (NP), who assumed the resident would not want the procedure based on past medical decisions. The resident's capacity to make medical decisions was inconsistently documented. Three capacity forms were completed by the attending physician, with varying conclusions about the resident's capacity. One form indicated the resident had capacity, while two others stated the resident was incapacitated. These forms were not consistently dated, and there were discrepancies between the forms and the physician's notes, which further complicated the situation. Additionally, there were inconsistencies in the Physician Orders for Scope of Treatment (POST) forms. The forms showed conflicting information about the resident's preferences for treatments and emergency contacts. The resident's grandson was initially listed as the emergency contact, but later forms indicated the resident's sister as the surrogate. These inconsistencies in documentation and communication contributed to the facility's failure to follow up on the physician's recommendation, creating a situation of immediate jeopardy.
Resident Elopement and Death Due to Facility Oversight
Penalty
Summary
The facility failed to ensure a safe environment for its residents, resulting in the elopement and subsequent death of a resident. The incident involved a resident who was not identified as an elopement risk, as per an assessment conducted prior to the event. On the day of the incident, the resident was found outside the facility, unresponsive, and later pronounced deceased. The resident had been checked by a nurse approximately 35 minutes before being discovered outside, and it was determined that she had exited the facility through a door near her room. Interviews with family and staff revealed that the resident was not known to wander and typically did not leave her room without assistance. On the day of the incident, the resident exhibited unusual behavior by getting up early and expressing feelings of nausea and fatigue. Despite these signs, staff did not perceive any immediate risk, and no alarms were heard during the time the resident exited the facility. The facility's initial investigation could not determine how the resident managed to leave the building undetected, as all door alarms were reportedly functional upon inspection. Video footage from a nearby building captured a figure matching the resident's description exiting the facility, but the footage was unclear and did not provide conclusive evidence of how the resident managed to leave. Staff interviews indicated that no alarms were heard, and the facility's alarm system was checked and found to be operational. The incident highlighted a significant oversight in monitoring and securing the facility's exits, which ultimately led to the resident's elopement and death.
Failure to Ensure Dietary Staff Have Required Food Handler Permits
Penalty
Summary
The facility failed to employ qualified dietary staff by allowing employees to work in the dietary department without obtaining the necessary food handler permits. This deficiency was identified during a record review and staff interview, revealing that several employees had been working without the required permits. Specifically, one employee had been working since October 2023 without a permit, while two others had been working since April and May 2024, respectively, without permits. The Dining Services Account Manager (DSAM) acknowledged these instances and was unable to provide the permits when initially requested, indicating a lapse in compliance with regulatory requirements for food safety and staff qualifications.
Deficiencies in Food Storage, Preparation, and Temperature Monitoring
Penalty
Summary
The facility was found to have several deficiencies related to food storage and preparation during a survey. In the kitchen's walk-in refrigerator, there were multiple items such as trays of cake, a container of beef base, and strawberries that were either undated or exposed to the elements. Additionally, a box of squash was past its discard date. Similar issues were found in the walk-in freezer, where chicken breasts were undated, and bags of frozen corn and biscuits were left open. The reach-in refrigerator contained items like barbeque sauce and hard-cooked eggs that were past their discard dates. A dietary aide confirmed these issues, attributing them to staff from other centers who did not adhere to proper dating protocols. The kitchen's oven was also found to be unsanitary, with burnt food and debris present inside. A staff member acknowledged that the oven should have been cleaned but cited a lack of available staff to perform the task. Furthermore, the nourishment rooms for different units had microwaves with rust and missing parts, which were still being used to prepare food for residents. The Dining Services Account Manager confirmed the condition of the microwaves and the ongoing attempts to replace them. The facility also failed to maintain accurate temperature logs for personal refrigerators in resident rooms. The logs showed a pattern of identical temperatures and times, suggesting inaccuracies. During a review, it was discovered that some refrigerators lacked thermometers, and the recorded temperatures did not match the actual temperatures observed. The administrator acknowledged these discrepancies, indicating a failure to properly monitor and document refrigerator temperatures as per the facility's policy.
Improper Disposal of Refuse
Penalty
Summary
The facility failed to properly dispose of refuse, which could potentially attract vermin and affect all residents. During a tour of the rear of the facility, it was observed that the area around the dumpsters was littered with an empty potato chip bag, multiple clear gloves, pieces of food, and clear plastic garbage bags. Additionally, three out of four dumpsters had their lids open, with one missing a lid entirely. One of the dumpsters was leaking a white substance onto the pavement. The Dining Services District Manager acknowledged the trash on the ground and the condition of the dumpsters.
Failure to Update Care Plans for Medications and Surrogates
Penalty
Summary
The facility failed to review and revise the care plan for a resident's psychotropic medication, dementia, and behaviors. The resident was prescribed medications such as Ativan and Lexapro for anxiety and depression, but the care plan did not reflect the use of Lexapro or the one-time administration of Zyprexa. Additionally, the resident's behaviors, including wandering and aggression, were not adequately addressed in the care plan, and there was no evidence of monitoring for adverse reactions following the administration of Zyprexa. The facility also failed to update the care plan for another resident to reflect the change in the health care surrogate. The resident's care plan initially listed the sister as the surrogate, but a checklist indicated that the sister was no longer reachable, and the grandson was appointed as the new surrogate. Despite this change, the care plan was not revised to reflect the new surrogate. Furthermore, the care plan for a third resident was not updated to reflect the physician's order and the surrogate's request for no weights to be obtained. The resident's care plan included monitoring for changes in nutritional status but did not address the specific order for no weights. This oversight indicates a failure to align the care plan with the resident's current medical orders and surrogate's wishes.
Failure to Address Aggressive Resident Behavior
Penalty
Summary
The facility failed to provide medically related social services for a resident who exhibited aggressive behaviors and for other residents affected by these behaviors. Resident #61 was noted to have a history of wandering into other residents' rooms and displaying physical and verbal aggression. Despite these behaviors being documented in the medical record, there was no corresponding care plan addressing these issues. The facility's policies on behavior management and abuse prohibition were not followed, as the interdisciplinary team did not assess the underlying causes of Resident #61's behaviors, nor was there any follow-up or intervention to address the aggressive incidents. Resident #42 reported feeling scared due to Resident #61 entering their room at night, which affected their sleep. Despite this, there was no evidence of any assessment or follow-up by social services to address the impact of these incidents on Resident #42 or other residents. The Director of Nursing (DON) acknowledged awareness of Resident #61's behaviors but admitted that no actions were taken to ensure the safety and well-being of other residents. The facility also failed to report the incident from 07/06/24, as required by their policies. Interviews with the DON, social worker, and assistant director of nursing revealed a lack of communication and coordination in addressing Resident #61's behaviors. The facility did not place Resident #61 under one-on-one observation following the incident, nor did they discuss the behaviors in interdisciplinary team meetings or quality assurance and performance improvement committee meetings. This lack of action and oversight contributed to the deficiency in providing necessary social services and ensuring a safe environment for all residents.
Medication Administration Documentation Errors
Penalty
Summary
The facility failed to accurately document medication administration times on the Medication Administration Record (MAR) and the narcotic count sheet for a resident receiving Morphine Sulphate. The resident, who was admitted with Chronic Obstructive Pulmonary Disease (COPD) and Liver Cell Carcinoma, was under palliative care. During a review, discrepancies were found between the narcotic count sheet and the MAR, indicating that several doses of Morphine Sulphate were signed out by a registered nurse (RN) but not documented as administered on the MAR. The discrepancies included multiple instances where the RN signed out doses of Morphine Sulphate but failed to document the administration on the MAR. The RN admitted to struggling with military time and the facility's computer system, which contributed to the documentation errors. Despite previous training and ongoing assistance from the facility, the RN continued to have issues with accurately logging medication administration times. The facility's Director of Nursing (DON) and Unit Managers were made aware of the discrepancies, and it was confirmed that the RN had forgotten to log several doses in the MAR. The RN was subsequently suspended pending further investigation. The report highlights the failure to maintain accurate medication records, which is a critical aspect of resident care and safety.
Infection Control Breach During Lunch Service
Penalty
Summary
During a lunch service observation in the 400 hallway of the facility, a deficiency in infection control practices was identified. Nurse Aide (NA) #10 removed a meal tray from the delivery cart and took it to a resident's room, only to find that the resident was not present. NA #10 then returned the tray to the cart with the clean, undelivered trays, which is a breach of proper infection control protocols. NA #10 acknowledged the mistake and expressed uncertainty about why the tray was placed back on the cart. This incident has the potential to affect all residents in the facility, which has a census of 64.
Environmental and Safety Deficiencies Identified in LTC Facility
Penalty
Summary
The facility failed to maintain a safe, comfortable, and homelike environment for residents, staff, and the public, as observed during a long-term care survey. Several issues were identified, including cloudy and moisture-trapped window panes in various locations, such as the exit doors to the courtyard and the front entry door, which obstructed visibility. Additionally, a bedside table in room 305 A was found with large cracks and exposed sharp edges, posing a skin tear hazard. Dead flowers with cloudy water and an unpleasant odor were found in rooms 304 and 307, and items were improperly stored on top of an over-the-bed light fixture in room 305 B, creating a potential hazard. Furthermore, the facility lacked documentation of required fire drills, specifically for the 3rd shift of the 2nd quarter of 2024 and the 2nd shift of the 3rd quarter of 2023. These deficiencies were confirmed through interviews with the facility's Administrator and other staff members, who acknowledged the issues during the survey process. The absence of fire drill records and the environmental concerns identified during the survey have the potential to affect all residents within the facility.
Failure to Involve Resident Representative in Medical Decisions
Penalty
Summary
The facility failed to involve the appointed resident representative in medical decision-making for a resident who lacked capacity. The resident, identified as having a Brief Interview for Mental Status (BIMS) score of 06, was deemed incapacitated by the attending physician. Despite this, the Nurse Practitioner (NP) completed a Physician Orders for Scope of Treatment (POST) form with the resident, which was later acknowledged as invalid due to the resident's incapacity. The NP did not contact the resident's appointed surrogate, the grandson, regarding a physician's recommendation for a biopsy of thyroid nodules, believing the resident would refuse the procedure based on previous discussions. Additionally, the facility did not consult the surrogate regarding nutritional support recommendations made by the Registered Dietitian. The resident, who had a significant weight loss and various medical conditions, was recommended to receive house shakes twice daily for nutritional support. The NP declined this recommendation, citing the resident's comfort care status and previous refusals of treatment. The NP did not consider alternative nutritional supplements and did not inform the surrogate of the dietitian's recommendations. Interviews with the NP and Director of Nursing (DON) confirmed that the surrogate was not contacted for either the biopsy referral or the nutritional support recommendation. The NP admitted to not being aware of the physician's note regarding the resident's incapacity and acknowledged that the POST form completed was invalid. The failure to involve the surrogate in these decisions resulted in a deficiency in the resident's right to have their representative exercise their rights.
Failure to Inform Residents of Care Decisions
Penalty
Summary
The facility failed to inform Resident #28 of his right to participate in hospice care, which is a significant aspect of end-of-life decision-making. Resident #28, who was diagnosed with Chronic Obstructive Pulmonary Disease and Liver Cell Carcinoma, was cognitively intact with a BIMS score of 14, indicating he had the capacity to make informed decisions. Despite being marked for end-of-life care, the Nurse Practitioner (NP) did not discuss hospice options with him, stating a personal belief that hospice services were unnecessary. This omission occurred even though the NP acknowledged that residents have the right to participate in their care decisions. Additionally, the facility failed to notify the responsible party for Resident #61 about the potential side effects of a psychotropic medication before its administration. Resident #61 was administered Zyprexa intramuscularly for agitation and restlessness without obtaining prior consent from the resident's representative. The facility's policy required that consent be obtained and documented before administering such medications. However, the Director of Nursing (DON) confirmed that no consent was obtained for Zyprexa, and the necessary documentation was not completed. These deficiencies highlight the facility's failure to ensure residents are fully informed and able to participate in their care decisions. Both residents were affected by the facility's lack of adherence to policies regarding informed consent and participation in care planning, which are critical components of resident rights in long-term care settings.
Failure to Implement Nutritional Care Plans for Residents
Penalty
Summary
The facility failed to implement care plans for two residents, leading to deficiencies in nutritional assistance. Resident #7's care plan was not followed, as she was not monitored or assisted with her meal for over an hour after it was delivered. The surveyor observed that Resident #7's lunch tray, delivered at 12:00 PM, remained uneaten by 1:05 PM. The resident's hands appeared constricted, and she was unable to feed herself. A Registered Nurse acknowledged that staff should have checked on her, and a Certified Nurse Aide later assisted her with a new meal tray. Resident #61 did not have a nutritional care plan developed despite experiencing weight loss. A review of Resident #61's medical record showed a physician's order for weekly weights and a diet order, but no dietary care plan was present. The Director of Nursing confirmed the absence of a dietary care plan for Resident #61, acknowledging the oversight.
Failure to Address Nutritional Needs and Follow Physician Orders
Penalty
Summary
The facility failed to adequately address the nutritional and hydration needs of residents, specifically for two residents identified during the survey. For Resident #29, the facility did not follow the Registered Dietician's recommendation for nutritional support through house shakes twice daily. The Nurse Practitioner (NP) declined this recommendation, citing the resident's comfort care status and previous refusal to address gallbladder issues. The NP did not notify the surrogate decision-maker about the dietician's recommendation, despite the resident being deemed incapacitated by the attending physician. The NP acknowledged that the POST form completed was invalid due to the resident's incapacity and agreed that the surrogate should have been contacted. For Resident #61, the facility failed to adhere to a physician's order for weekly weights, which was part of the resident's care plan. The medical record review showed missing weights, and the Director of Nursing (DON) acknowledged that the order had not been followed. This oversight indicates a lapse in monitoring the resident's nutritional status, which is critical for maintaining their health. These deficiencies highlight the facility's failure to implement and communicate necessary dietary interventions and to follow physician orders for monitoring residents' health. The lack of communication with surrogates and failure to adhere to care plans contributed to the inadequate nutritional support for the residents involved.
Failure to Follow Physician's Order for Tube Feeding Volume
Penalty
Summary
The facility failed to adhere to the physician's order regarding the volume of feeding to be administered to a resident with a feeding tube. The physician's order specified that the resident should receive 320 ml of Jevity 1.5 CAL five times per day, with specific instructions for flushing the tube with water before and after each feeding. However, during an observation, an LPN was seen preparing the feeding using two 7-ounce non-graduated plastic cups, which were not accurate for measuring the prescribed amount. The LPN admitted to using these cups based on a previous measurement with a manager, which was not precise, leading to the administration of 414 ml instead of the ordered 320 ml. The LPN acknowledged the discrepancy and the lack of proper measuring tools, such as graduated cups or cylinders, which contributed to the error. Despite recognizing the issue, the LPN proceeded to administer the feeding without using a graduated syringe to ensure the correct volume was given. This resulted in the resident receiving more nutrition than prescribed, highlighting a failure in following the physician's order and ensuring accurate measurement of feeding volumes.
Inaccurate Nurse Staffing Information
Penalty
Summary
The facility failed to accurately complete the Nurse staffing information, resulting in discrepancies between reported and actual direct care staffing hours. This issue was identified during a long-term care survey process, where nine out of ten Nurse Staffing forms reviewed contained inaccuracies. The discrepancies involved incorrect total direct care staffing hours and hours per patient day (HPPD) calculations, as well as incomplete data entries for certain shifts. On several occasions, the facility's Daily Staffing forms reported incorrect total direct care staffing hours compared to the actual hours recorded in the Genstar daily staffing sheet and time detail. For instance, on one date, the reported total direct care staffing hours were 148, while the actual hours were 164.65, leading to an incorrect HPPD calculation. Similar discrepancies were found on other dates, with reported hours either overestimated or underestimated compared to the actual hours worked by the staff. Additionally, the facility failed to accurately categorize staff roles according to the Centers for Medicare & Medicaid Services (CMS) guidelines. The Daily Staffing forms incorrectly included RN staff with administrative roles as direct care staff, without distinguishing between their administrative and direct care duties. This misclassification contributed to the inaccuracies in the reported staffing hours, as the facility could not identify how these RN staff members allocated their time between administrative and direct care tasks.
Failure to Provide Behavioral Health Care and Services
Penalty
Summary
The facility failed to provide necessary behavioral health care and psychiatric services to a resident, identified as Resident #61, who exhibited behaviors such as wandering, refusal of care, and physical and verbal aggression. The resident's medical record indicated multiple instances of these behaviors, including an incident where the resident wandered into other residents' rooms and refused to leave, showing aggression towards staff and other residents. Despite these documented behaviors, the facility did not have an updated care plan addressing the resident's anxiety, depression, or specific behaviors. The care plan had not been revised since its creation, and there was no evidence of a psychological appointment being scheduled for the resident. Interviews with the Director of Nursing (DON) revealed that the resident's behaviors had not been reviewed by the Interdisciplinary Team (IDT) committee for root cause analysis or for the development of new behavioral interventions. The DON acknowledged the lack of review and care plan revisions. Additionally, when questioned about scheduling a psychological appointment for the resident, the DON admitted that no such appointment had been made and expressed uncertainty about the reason for this oversight. The facility's inaction in addressing the resident's behavioral health needs and failure to update the care plan contributed to the deficiency.
Failure to Provide Individualized Care for Resident with Mental Disorders
Penalty
Summary
The facility failed to provide necessary person-centered care and individualized treatment for a resident diagnosed with mental disorders and psychosocial adjustment difficulties. The resident exhibited behaviors such as physical and verbal aggression, wandering into other residents' rooms, tearfulness, and refusal of care. Despite these behaviors being documented in the resident's medical record, there was no corresponding care plan addressing these issues, nor were there any revisions made to the existing care plan to accommodate the resident's changing needs. The resident's medical history included diagnoses of unspecified dementia with behavioral disturbances, generalized anxiety disorder, and major depressive disorder. The resident's care plan only addressed the risk of delirium related to dementia, with no interventions for anxiety, depression, or the specific behaviors observed. The facility's policy required that residents exhibiting behavioral symptoms be evaluated by the Interdisciplinary Team (IDT) to identify underlying causes and develop appropriate interventions, but this process was not followed for the resident in question. Interviews with the Director of Nursing (DON) revealed that the resident's behaviors had not been reviewed by the IDT, and no psychological appointment had been made for the resident. The DON acknowledged the lack of care plan revisions and the absence of a psychological evaluation, indicating a failure to provide the necessary treatment and services to meet the resident's mental and psychosocial needs.
Failure to Provide Interdisciplinary Care for Dementia
Penalty
Summary
The facility failed to provide an interdisciplinary approach to address the needs of a resident diagnosed with dementia, leading to a deficiency in care. The resident exhibited behaviors such as wandering into other residents' rooms, refusal of care, and physical and verbal aggression. Despite these behaviors being documented, the facility did not involve the Interdisciplinary Team (IDT) to identify the underlying causes or update the care plan with new behavioral interventions. The Director of Nursing (DON) acknowledged that the resident's behaviors had not been reviewed by the IDT committee, and the care plan had not been revised accordingly. Additionally, the facility did not arrange a psychological appointment for the resident, which could have been beneficial in managing the resident's condition. The resident's care plan included goals and interventions for managing mood symptoms related to dementia and Parkinson's, but the facility did not implement individualized, person-centered, non-pharmacological interventions as the initial strategy for behavior mitigation, as stated in their policy. The lack of a comprehensive approach and failure to update the care plan contributed to the deficiency in providing necessary services for the resident's dementia diagnosis.
Failure to Monitor and Obtain Consent for Psychotropic Medication
Penalty
Summary
The facility failed to monitor a resident for side effects after administering a psychotropic medication, Zyprexa 10mg IM, for agitation. The resident, identified as having restlessness and poor safety awareness, was given the medication following a change in condition evaluation. However, the facility did not document any monitoring of the resident's condition post-administration, which is a critical step in ensuring the resident's safety and well-being. Additionally, the facility did not obtain the necessary consent for the administration of Zyprexa. The Director of Nursing acknowledged that no consent was obtained prior to administering the medication, and a new form for Psychotropic Medication Administration Disclosure should have been completed. The existing forms only documented consent for other medications, and the addition of Lexapro to an existing form was improperly handled. This oversight in obtaining and documenting consent represents a significant deficiency in the facility's medication management process.
Failure to Administer PRN Psychotropic Medication Properly
Penalty
Summary
The facility failed to properly administer a PRN psychotropic medication for a resident diagnosed with a specific condition. On a particular date, the resident exhibited signs of agitation and restlessness, prompting the administration of Zyprexa 10 mg IM without a specific diagnosed condition documented in the clinical record. The medical record review revealed that the administration of the medication was not accompanied by a documented consent form specific to Zyprexa, as required by the facility's policy. The Director of Nursing acknowledged that no consent was obtained prior to the administration and that a new Psychotropic Medication Administration Disclosure form should have been completed. Additionally, the facility did not conduct any monitoring of the resident after the administration of Zyprexa IM. The review of the resident's medical record showed inconsistencies in the documentation of verbal consent for psychotropic medications, with different medications listed on two separate forms. The Director of Nursing admitted that a new form should have been completed instead of adding medications to an existing form. The lack of proper documentation and monitoring highlights the facility's failure to adhere to its own policies regarding the administration of psychotropic medications.
Deficiency in POST Form Management
Penalty
Summary
The facility failed to properly implement its Quality Assurance and Performance Improvement (QAPI) program concerning the completion of Virginia Portable Order for Scope of Treatment (POST) forms. During a survey, it was identified that the facility was attempting to modify POST forms, which is not permissible according to the form's instructions. The correct procedure requires voiding the existing form and completing a new one if changes are necessary. The facility's QAPI program, which was intended to address issues with POST form completions, did not account for this requirement, leading to a deficiency in the process. The Administrator acknowledged that the Quality Assurance Committee (QAC) was unaware of the correct procedure for handling POST forms, including the necessity to void and replace forms rather than modify them. The deficiency was further compounded by the lack of data available to demonstrate the effectiveness of the QAPI program, as the Administrator's computer, which contained the relevant data, was not operable. This oversight has the potential to affect all residents who require POST forms, as the facility's current practices do not align with the established guidelines for managing these documents.
Deficiency in POST Form Procedures and QAPI Oversight
Penalty
Summary
The facility's Quality Assurance and Performance Improvement (QAPI) committee failed to develop effective corrective actions to address deficiencies in the completion and modification of POST forms. During a survey, it was discovered that POST forms were being modified instead of voided and replaced as required. The facility's administrator and QAPI committee were unaware of the proper procedures for voiding and completing new POST forms, which led to inaccuracies in the documentation. Additionally, the Nurse Practitioner was completing POST forms without the attending physician's determination of capacity, which was not known to the administrator or the QAPI committee. The deficiency affected all residents, as the POST forms were not accurately completed or modified based on the physician's determination of capacity. The administrator acknowledged missing pertinent details in the QAPI process and audits related to POST form completions and corrections. The facility's failure to adhere to the correct procedures for POST forms and the lack of awareness among the staff and QAPI committee contributed to the deficiency identified during the survey.
Latest citations in West Virginia
A deficiency occurred when a lunch tray on A Hall was found to be served below required hot-holding temperature standards. During a survey, a random tray containing mashed potatoes and gravy with steak was tested by the Traveling Dietary Manager in the presence of the Administrator, and both food items measured 110°F, which did not meet required serving temperatures. The Traveling Dietary Manager and the Administrator each confirmed that the food temperature was not at the required level, and the administrative team later acknowledged this deficiency.
Surveyors found that the facility failed to provide residents with consistent and accurate readily available menus reflecting their food preferences. The Traveling Dietary Manager reported that residents could choose from multiple egg preparations, but these options were not listed on the posted menu available to residents. Additionally, the “always available” menu used in the kitchen did not match the menu provided to residents, and this discrepancy was confirmed by the Traveling Dietary Manager. The issue was identified on all menus reviewed and had the potential to affect many residents in the facility.
The facility failed to follow its abuse reporting policy when a cognitively intact resident reported that two nurses were frequently sleeping on duty and later provided an audio recording of a nurse calling the resident a "jerk." The allegation was reported by the resident to an LPN and then to an RN Infection Preventionist, but the Administrator remained unaware until the survey, and the incident was not reported to authorities within the required 2-hour timeframe. In a separate case, another resident had a verbal abuse incident reported to the state, but the facility did not complete or submit the required 5-day follow-up report, and the Administrator confirmed there was no record of that follow-up.
A resident reported unknown charges on her debit card and alleged that a former roommate had used the card without permission, estimating losses of several hundred dollars. The facility documented initial steps such as notifying external agencies, involving law enforcement, cancelling the card, separating the roommates, and assisting the resident in obtaining bank statements. However, the facility did not maintain or retain key documentation, including copies of bank statements, the total amount of funds involved, or clear follow‑up on the status and outcome of the allegation. The resident reported not receiving updates, and the BOM acknowledged that the facility lacked the resident’s financial records because they had been turned over to law enforcement and were not requested or reviewed by facility staff until shortly before the survey, resulting in an incomplete internal investigation record of the alleged misappropriation.
A resident who was cognitively intact but lacked capacity for health care decisions left the facility after breakfast and morning meds. An activities assistant saw the resident walking outside and reported this to the Manager on Duty, but no effective action was taken to verify the resident’s whereabouts or initiate a search. Nursing staff later assumed the resident was in the bathroom or out smoking when he was not in his room at mid-morning and lunchtime. The facility did not recognize the resident as missing or begin search efforts until hours later, during which time the resident hitchhiked and accepted a ride from a stranger in the community. Surveyors determined that staff had witnessed the resident outside but failed to intervene or report effectively, and that the facility remained unaware of the resident’s absence for several hours, resulting in an Immediate Jeopardy finding for neglect.
A resident who is blind and requires specific instruction during ambulation was transferred from therapy to Restorative with documented recommendations to ambulate using a walker, gait belt, and a wheelchair behind her, along with ROM and strengthening exercises. Despite a physician’s order for a Restorative Nursing Program for ambulation and ROM and the therapy recommendations communicated via an Excel spreadsheet, Restorative staff ambulated the resident without a gait belt. The resident reported becoming tired while walking, with a wheelchair behind her but not close enough, and then falling hard. She and a PTA both stated that no gait belt was used. The fall resulted in fractures to the resident’s left distal femur and right distal femur/knee area, with osteopenia noted, and the DON acknowledged that therapy recommendations had not been carried over for Restorative staff to follow.
A resident experienced multiple leg fractures after a fall, resulting in a significant change in condition and non–weight-bearing status. Although the MDS reflected that it was important for the resident to participate in group activities, favorite pastimes, and church services, the activity care plan was not revised after the injury to address her new limitations. The existing plan listed numerous preferred activities such as resident council, food committee, religious services, music, gardening, and in-room pursuits, but no new individualized interventions were added, and documentation showed only two 1:1 visits after her return from the hospital. The resident reported she could no longer get into her wheelchair, attend council or church, or join groups she enjoyed, and stated that activity staff did not visit often, while the Director of Recreation confirmed she had not attended groups since the injury and that in-room social visits were not consistently documented, resulting in a decline in activity participation and social isolation.
A resident was discharged to a motel with home health services, a wheelchair, medications, and a follow‑up medical appointment arranged, and received education on medications, blood glucose monitoring, emergency response, and home health services. Discharge planning discussions and a referral to the Take Me Home program were documented, and the facility agreed to pay for an initial period of the motel stay. However, record review and staff interviews confirmed that the resident was not given the required 30‑day written discharge notice prior to leaving, limiting the resident’s ability to prepare for discharge and exercise discharge‑related rights.
A resident sustained multiple lower extremity fractures after a fall, resulting in hospitalization, non-weight-bearing status, and loss of prior functional abilities such as standing, pivoting, and walking with therapy. Before the fall, the resident actively participated in out-of-room activities including Resident Council, food committee, church, and socials, but after returning from the hospital she no longer attended group activities and had only two documented 1:1 visits. Despite an MDS indicating a significant change in status and clear changes in activity participation, the activity care plan—last revised months earlier—was not updated with new interventions to address her altered condition and in-room activity needs, as confirmed by record review and staff interviews.
A resident with intact cognition and a history of active participation in group activities, Resident Council, and church sustained bilateral lower-extremity fractures and returned from the hospital non–weight bearing. The MDS significant change assessment and the activity care plan documented that group involvement, church services, and various preferred activities were important to the resident, yet no new interventions were added to the care plan after the change in condition. Activity participation records showed that the resident had no out-of-room activities and only two documented 1:1 visits, while the Director of Recreation acknowledged that group attendance had stopped and that in-room social visits were not consistently documented. The resident reported feeling unable to attend her usual groups, Resident Council, or church and stated that activity staff did not visit often, leading surveyors to find that the facility failed to provide an activities program that met her needs and interests following her significant change.
Improper Hot Food Serving Temperatures During Lunch Service
Penalty
Summary
The facility failed to provide resident meals at proper serving temperature during a lunch meal service on A Hall. On 03/24/26 at approximately 12:10 PM, a surveyor had a random lunch tray on A Hall temperature-tested by the Traveling Dietary Manager, with the facility Administrator present. The tested items—mashed potatoes and gravy with steak—were both measured at 110°F. During an interview at approximately 12:15 PM, the Traveling Dietary Manager confirmed that the food did not meet the required serving temperature, and at approximately 12:16 PM, the Administrator also confirmed that the food did not meet the required serving temperature. This deficiency was acknowledged by the facility’s administrative team upon survey exit on 03/25/26 at approximately 4:00 PM. No additional resident-specific clinical information or conditions were provided in the report.
Inconsistent Readily Available Menus for Resident Food Preferences
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to provide residents with consistent and accurate information about readily available menu items that accommodate resident preferences. During document review and staff interviews, the Traveling Dietary Manager stated that residents could choose from several egg preparations (omelet, scrambled eggs, hard-boiled egg, or hard-fried egg) as part of the facility’s readily available items. However, the posted readily available menu accessible to residents did not list these egg options. Additionally, the “always available” menu used in the kitchen did not match the menu provided to residents, and the Traveling Dietary Manager confirmed that the readily available menus did not correlate. This inconsistency was found on 2 of 2 menus reviewed and had the potential to affect more than a limited number of residents in a facility with a census of 90. On a subsequent interview, the facility Administrator acknowledged the deficiency during the exit interview.
Failure to Timely Report Verbal Abuse Allegation and Submit Required 5-Day Follow-Up
Penalty
Summary
The facility failed to follow its abuse prohibition policy requiring that allegations of abuse be reported to the proper authorities within two hours of identification and that required follow-up reports be completed. The policy defined verbal abuse as the willful use of disparaging or derogatory language toward residents or within their hearing. A cognitively intact resident with a BIMS score of 15 reported that two nurses who worked Monday through Thursday were "always sleeping" and that, after he reported this to administration, one of the nurses called him a "jerk." The resident had an audio recording dated 03/11/26 capturing a staff member calling him a "jerk" and confirming this characterization when questioned by the resident. The resident stated he informed an LPN, who then reported it to the RN Infection Preventionist. The RN Infection Preventionist acknowledged awareness of a phone conversation in which someone called the resident a jerk but stated she did not know the full details and thought it might have been discussed in a care plan meeting. The Administrator reported being unaware of the situation until interviewed by the surveyor, at which time the incident had not been reported within the required two-hour timeframe. The facility also failed to complete and submit a required five-day follow-up report for a separate allegation of verbal abuse involving another resident. Record review showed that this resident had been admitted and later discharged to the hospital, and that a verbal abuse incident involving this resident had been reported to the state agency on 04/15/25. However, review of the facility’s list of reportable incidents for one year revealed no evidence that the corresponding five-day follow-up report was ever sent. The Administrator confirmed there was no record of that reportable incident or of a five-day follow-up. These failures were identified for two of two residents reviewed for abuse, with a facility census of 67.
Failure to Thoroughly Investigate and Document Alleged Financial Exploitation
Penalty
Summary
The deficiency involves the facility’s failure to ensure a thorough investigation and ongoing documentation of an allegation of misappropriation of resident property for one resident. Record review showed that the resident reported unknown charges on her debit card, and the facility initiated an investigation and notified OHFLAC, APS, the Ombudsman, and local law enforcement. Progress notes documented that law enforcement interviewed the resident, the resident cancelled her debit card, and she planned to obtain information from her bank. Notes also showed that the resident obtained bank statements, attempts were made to contact the investigating officer, and law enforcement later returned to obtain the resident’s banking information and ask additional questions. The facility’s 5‑day investigation report documented that the Administrator and DON reported the allegation, assisted the resident in obtaining bank statements, reviewed charges with her, identified the alleged perpetrator as the former roommate, separated the residents, and deactivated the debit card. The investigation was labeled inconclusive with law enforcement continuing the investigation, and a later Grand Jury subpoena was issued for the resident related to alleged fraudulent use of her debit card. Despite these initial steps, at the time of survey the facility was unable to provide additional documentation or evidence of follow‑up regarding the alleged misappropriation, including the total amount of funds involved, the outcome of the investigation, or any ongoing tracking of the allegation until requested by the State Agency. In interviews, the resident stated that her former roommate used her debit card without permission, estimated that approximately $800–$900 had been spent, and reported she had not received any updates about the situation. The BOM stated the facility did not have copies of the resident’s bank statements because they had been turned over to law enforcement and that law enforcement would not release information due to an ongoing investigation. In a follow‑up interview, the resident reported that no one from the facility had requested or attempted to review her bank statements, aside from law enforcement, until shortly before the interview when the BOM inquired, demonstrating that the facility did not maintain documentation necessary to determine the extent of the alleged misappropriation. A staff member later provided a written statement that they accompanied the resident to a Grand Jury proceeding related to fraudulent use of the debit card, but the facility still lacked internal documentation of the scope and outcome of the allegation.
Failure to Respond to Known Resident Elopement and Prolonged Unnoticed Absence
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from neglect by not responding to a known elopement. A cognitively intact resident, who had a BIMS score of 14 but had been deemed by the physician to lack capacity to make health care decisions, left the facility in the morning after having breakfast and receiving morning medications. The resident’s elopement risk evaluation score was 0, indicating low risk for elopement, and the MDS indicated no wander/elopement alarm was used less than daily. The resident’s care plan identified adjustment issues related to change in lifestyle and difficulty accepting placement, with interventions focused on coping and adjustment, but did not identify elopement risk prior to the incident. At approximately 9:00 AM, an activities assistant saw the resident walking outside down a public street near a store. The activities assistant contacted the social worker, who was the Manager on Duty, shortly thereafter to report the resident’s location. The activities assistant then clocked in for her shift around 9:03–9:05 AM. Despite this report, no effective action was taken by facility staff at that time to verify the resident’s whereabouts, intervene, or initiate a search. The social worker later stated she did not realize anything was going on until early afternoon, explaining that she missed the information about the resident being at the store while she was talking with other residents during the phone call. During the period from roughly 9:15 AM to 1:55 PM, there was a delay in supervision and monitoring of the resident. The LPN assigned to the resident reported administering morning medications and exchanging pleasantries with the resident earlier that morning, consistent with the facility’s elopement timeline. The CNA assigned to the resident stated that the resident was in the room during breakfast, but when she entered the room around 10:30 AM to provide a snack to the roommate, the resident was not present and she assumed he was in the bathroom. At lunchtime, when the CNA did not see the resident, she assumed he was out smoking. The facility did not recognize the resident as missing or initiate search or recovery actions until approximately 1:30 PM, when the activities assistant reported that the resident was not present for a smoke break. The State Agency determined that staff had witnessed the resident outside the facility but failed to intervene or report effectively, and that the facility remained unaware of the resident’s absence for about 4.5 hours, creating an Immediate Jeopardy situation due to the resident being unsupervised in the community for an extended period. The resident later reported that he was attempting to travel to another town to attend to personal business, hitchhiking to a nearby city and then walking further when he found the bus station closed. He described being offered a ride and food by a man who drove him to a restaurant, where he was eventually picked up by someone from the nursing home. The State Agency concluded that the facility’s failure to act on the known elopement and to promptly identify and respond to the resident’s absence constituted neglect and placed the resident at immediate risk for serious harm or death.
Failure to Use Gait Belt During Restorative Ambulation Resulting in Resident Fractures
Penalty
Summary
The facility failed to provide care and services in accordance with professional standards of practice when a resident participating in Restorative Therapy ambulation was walked without a gait belt, contrary to therapy recommendations. Record review showed the resident experienced a fall and was sent to the emergency room with pain in both legs, where diagnostic imaging revealed an anterior apex angulated distal femur diametaphyseal fracture with impaction in the left femur and an impaction and comminuted anterior apex angulated fracture of the distal fifth metaphysis in the right knee, with osteopenia noted. The resident, who is blind and requires specific instruction when ambulating, had been transferred from therapy to Restorative with recommendations documented on an Excel spreadsheet to ambulate with a walker, gait belt, and wheelchair behind the resident, up to 70 feet, along with ROM and strengthening exercises. A physician’s order for a Restorative Nursing Program for ambulating and ROM was in place, with the expectation that Restorative staff would refer back to therapy’s recommendations for safety measures. Interviews confirmed that on the day of the fall, staff ambulated the resident without a gait belt. The PTA identified the location of the fall and stated that a gait belt had not been used while walking the resident. The DOR reported that therapy staff had always used a gait belt with this resident and that the recommendation to use a gait belt was communicated via the Excel spreadsheet used by Restorative Therapy to receive therapy orders and recommendations. The resident, who had a BIMS score of 15 and thus had capacity, stated that she became tired while walking with Restorative staff, that a wheelchair was behind her but not close enough, and that she fell hard; she reported that staff did not have a gait belt on her and believed that if a gait belt had been used, she would not have fallen so hard. The DON stated she was not aware of the Excel spreadsheet and confirmed that therapy recommendations were not carried over for Restorative Therapy to follow.
Failure to Revise Activity Care Plan After Significant Change in Condition
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident received ongoing opportunities to participate in meaningful activities consistent with her interests and preferences following a significant change in condition. The resident experienced a fall on 02/18/26, was sent to a local emergency room for pain in both legs, and diagnostic radiology revealed an anterior apex angulated fracture of the distal left femur with impaction and an impaction and comminuted anterior apex angulated fracture of the distal right femur metaphysis, with osteopenia noted. She was hospitalized for these fractures and returned to the facility on 02/24/26. A subsequent MDS with an ARD of 02/27/26 documented a significant change in status and indicated that it was important for the resident to do things with groups of people, participate in her favorite activities, and attend church services. Record review showed that the resident’s activity care plan, originally initiated in 2020 and revised multiple times through 03/03/2025, contained numerous interventions reflecting her preferences, including in-room visits, participation in food committee and resident council, church and religious services, group singing and cooking, gardening, pet visits, listening to religious/bluegrass/country music, watching TV and keeping up with the news, and engaging in favorite activities such as church, sewing, cooking, reading, and gardening. The care plan also noted her use of a wheelchair and need for accommodations for visual impairments. However, there were no new or revised activity interventions added to address her new non–weight-bearing status and functional limitations after the fractures, and no changes to the activity care plan were documented following the significant change in condition. During interview, the resident, who had decision-making capacity and a BIMS score of 15, reported that prior to the fall she had been able to stand, pivot, and walk with therapy, and that she had been active in resident council, church, and social activities. She stated that since her return from the hospital she could not get into her wheelchair, could not attend resident council meetings or church, and could not participate in the group activities she enjoyed. She reported that activity staff did not visit her very often and became tearful while describing her situation. The Director of Recreation confirmed that the resident had not attended group activities since returning from the hospital, was non–weight-bearing for 10 weeks, and that anything done with her was now in-room. The Director of Recreation also stated that the resident did not receive one-to-one visits “per se” and that social visits were not documented. Surveyors identified that only two one-to-one visits had been documented since the resident’s return from the hospital and that there was a significant decline in her activity participation without corresponding revisions to her care plan, which led to the finding of failure to provide consistent, individualized activity interventions and ongoing opportunities for meaningful activities.
Failure to Provide Required 30‑Day Written Discharge Notice
Penalty
Summary
The facility failed to provide a required 30‑day written discharge notice to a resident prior to discharge. A complaint was received by the State Agency stating that the resident was being discharged to a hotel and that the facility would pay for the first 28 days, after which the resident would be responsible for their own expenses. The complainant reported the resident had no income and uncertainty existed about how the resident would obtain food and medications. Record review showed that on one date, Social Services documented discharge planning discussions and a referral to the Take Me Home program at the resident’s request, and an assessment note indicated discharge planning documentation was completed. Further record review revealed that on the day of discharge, Social Services documented that the resident was discharged to a motel with home health services arranged, a wheelchair provided, medications supplied, and a follow‑up appointment scheduled. Nursing documentation from the same day showed the resident received education on medications, blood glucose monitoring, emergency response, and home health services prior to discharge. However, there was no evidence in the medical record that the resident was provided a written 30‑day discharge notice before leaving the facility. In an interview, the Social Worker, in the presence of the Administrator, confirmed that the resident had chosen discharge to a motel and that the facility paid for 28 days at the hotel and provided 14 days of medications, and also confirmed that a 30‑day discharge notice was not issued. The deficient practice had the potential to affect the resident by limiting the ability to adequately prepare for discharge and exercise rights regarding the discharge process.
Failure to Update Activity Care Plan After Significant Change in Condition
Penalty
Summary
The deficiency involves the facility’s failure to update an activity care plan following a resident’s significant change in condition and participation. The resident experienced a fall on 02/18/26, resulting in fractures to the left distal femur and right distal femur/knee, with osteopenia noted on diagnostic imaging. She was hospitalized and returned to the facility on 02/24/26. A subsequent MDS with an ARD of 02/27/26 identified a significant change in status. Despite this, the resident’s activity care plan, originally initiated in 2020 and revised multiple times through 03/03/2025, was not revised after the fall and significant change to reflect her new limitations and altered participation in activities. Prior to the fall, the resident had been able to stand, pivot, and transfer to her wheelchair, and was walking up to 100 feet with therapy. She was active in out-of-room activities, including Resident Council, food committee, parties, socials, church, and other group activities. After the fall, she reported that she now had a rod in her left leg, a brace on her right leg, and was non-weight bearing for 10 weeks, which prevented her from getting into her wheelchair and attending the activities she previously enjoyed. She expressed distress about no longer being able to attend Resident Council meetings, church, and family gatherings, and stated that activity staff did not visit very often and that she could not go out to the groups she liked. During the interview, she was observed to be tearful. Record review of activity participation from 01/01/2026 to the present showed that the resident had participated in out-of-room activities before the fall but had no out-of-room participation after her return from the hospital. The records also showed that since the significant change, she had only two documented one-to-one visits, both on 03/04/26. The Director of Recreation confirmed that the resident had not attended group activities since returning from the hospital and was non-weight bearing, and stated that anything done with her was now in-room. The Director also stated that social visits were not documented as one-to-one visits. Surveyors noted that there were no new or revised interventions on the activity care plan since 01/2025 despite the significant change in the resident’s condition and participation, and the Administrator and Director of Recreation confirmed that the documentation reflected this lack of update.
Failure to Adjust Activities Program After Resident’s Significant Change in Condition
Penalty
Summary
The deficiency involves the facility’s failure to provide an activities program that met the interests and needs of a resident who experienced a significant change in condition and activity participation. The resident, who was cognitively intact with a BIMS score of 15 and served as president of the Resident Council, sustained fractures to the left distal femur and right distal femur/knee area after a fall and was hospitalized. Diagnostic imaging showed an anterior apex angulated, impacted distal femur diametaphyseal fracture on the left and an impacted, comminuted anterior apex angulated fracture of the distal fifth metaphysis of the right knee, with osteopenia noted. After hospitalization, the resident returned to the facility and had an MDS with a significant change assessment, with Section F indicating that it was important for her to do things with groups of people, participate in favorite activities, and attend church services. Record review showed that prior to the fall and fractures, the resident participated in out-of-room activities, including Resident Council, food committee, parties, and socials. The activity care plan, originally created in 2020 and revised multiple times through early 2025, documented numerous preferences and important activities for the resident, such as in-room visits, participation in food committee, church, singing, cooking, gardening, going outside in good weather, pet visits, listening to religious and other music, watching TV, reading, and engaging in religious services and voting. The care plan also noted that it was important for her to engage in her favorite activities and to have opportunities to make choices related to meaningful activities. However, there were no new interventions added or changes made to the activity care plan after her significant change in condition and return from the hospital. Activity participation records from the beginning of the year through the time of survey showed that since her readmission from the hospital, the resident had no out-of-room activity participation and only two documented one-to-one visits, both on the same day. During interview, the resident reported that she could no longer stand, pivot, or get into her wheelchair, and that she was now unable to attend Resident Council meetings, church, or be around people as she had before. She expressed distress about missing family gatherings she had been working toward attending and stated that activity staff did not visit very often and that she could not go out to the groups she liked. The Director of Recreation confirmed that the resident had not attended group activities since returning from the hospital due to being non–weight bearing, that anything done with her was now in-room, and that social visits were not consistently documented. The Administrator and Director of Recreation acknowledged that documentation showed only two one-to-one visits and no updated interventions on the care plan since before the significant change, leading to the finding that the facility failed to provide a program of activities to meet this resident’s needs and interests after her change in condition.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
