Willows Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Parkersburg, West Virginia.
- Location
- 723 Summers Street, Parkersburg, West Virginia 26101
- CMS Provider Number
- 515085
- Inspections on file
- 23
- Latest survey
- March 10, 2026
- Citations (last 12 mo.)
- 31
Citation history
Health deficiencies cited at Willows Center during CMS and state inspections, most recent first.
Surveyors found that PTAC units in three resident rooms were not maintained in a clean and safe condition, with debris and a black-like substance observed in the upper vents of multiple units during a complaint survey. The facility Administrator confirmed these environmental issues, which affected the residents’ right to a safe, clean, comfortable, and homelike environment.
The facility did not submit required five-day follow-up documentation for investigations into suspected abuse and failed to report results to all necessary state agencies. For two residents, investigation files lacked timely follow-up, witness statements, and evidence of proper notification, as confirmed by the administrator.
Multiple allegations of abuse, neglect, and mistreatment were not thoroughly investigated, with missing or incomplete documentation, lack of timely reporting to authorities, and insufficient interviews of staff and residents. Investigations were often inconclusive due to conflicting statements, and required follow-up actions and reports were not consistently completed or documented.
Three residents did not receive scheduled showers or adequate assistance with ADLs as documented in their care plans, with staff and resident interviews confirming missed care and lack of refusals. The DON verified that documentation did not support that showers were provided as scheduled.
Surveyors found that the facility did not serve food and beverages at safe and appetizing temperatures, with milk on a beverage cart measured above FDA guidelines and food tray temperatures not documented. A resident reported that meal preferences were not updated, food was often cold, and meal presentation was poor, with items mixed together on the plate. The Food Service Director confirmed these issues during the survey.
Surveyors identified multiple failures in food storage, preparation, and sanitation, including soiled food delivery carts, missing temperature logs, improperly stored and undated food items, dirty kitchen equipment, and incomplete documentation of sanitizer levels. Additional issues included outdated food, improper trash can use, and food containers placed directly on the floor. Staff confirmed these deficiencies and acknowledged lapses in following proper food safety and sanitation procedures.
A resident receiving hospice care developed multiple pressure ulcers, but the facility did not document timely assessments or ensure that wound care orders were included in the TAR or MAR. The DON confirmed that full assessments and evidence of treatment were lacking for the pressure ulcers and related interventions.
A resident's MPOA was not informed of multiple medical appointments, resulting in the resident being transported and left at appointments without the MPOA's knowledge or presence. The facility acknowledged the communication lapse and confirmed that on one occasion, the resident was left at an appointment without staff present after the van driver became ill.
A resident's MPOA reported grievances about the facility transporting the resident to medical appointments without prior notification and leaving the resident at appointments without ensuring the MPOA was present. The complaints were not logged or investigated according to facility policy, and staff interviews confirmed the lack of documentation and follow-up.
A resident who required supervision during meals, as documented in their care plan and meal ticket, was served a meal without staff supervision. Staff failed to notice or follow the supervision order, and facility policy required that such residents be supervised or not served until assistance was available.
Failure to Maintain Clean and Safe PTAC Units in Resident Rooms
Penalty
Summary
The facility failed to honor residents' right to a safe, clean, comfortable, and homelike environment by not maintaining Packaged Terminal Air Conditioners (PTACs) in good condition in three of five resident rooms reviewed. During a complaint survey with a facility census of 92, the State Agency (SA) observed debris in the upper vent of the PTAC unit in one resident room at approximately 9:15 a.m., debris and a black-like substance in the upper vent of the PTAC unit in a second resident room at approximately 9:18 a.m., and debris in the upper vent of the PTAC unit in a third resident room at approximately 12:30 p.m. The facility Administrator verified these findings during an interview at approximately 1:15 p.m., and the observations were acknowledged by the administrative staff upon exit later that afternoon. No additional clinical information, medical history, or specific conditions of the residents occupying these rooms were provided in the report.
Failure to Timely Report and Document Investigation Results of Suspected Abuse
Penalty
Summary
The facility failed to report the results of investigations into suspected abuse, neglect, or theft within the required time frames to the state survey agency. For one resident, the file for a facility-reported incident was missing the required five-day follow-up documentation, despite the initial report being submitted on time. The file lacked evidence of any attempt to transmit the follow-up to the appropriate authorities, and the only documentation present included undated and unsigned statements, as well as non-disciplinary performance improvement plans with no noted corrections or follow-up actions. For another resident, an allegation of physical abuse was reported, but the investigation file did not contain documentation that the incident was reported to all required state agencies. There were no witness statements from staff or other residents, and no documented five-day follow-up was found. The administrator confirmed during interviews that there was no additional documentation or statements available regarding the incident.
Failure to Thoroughly Investigate and Document Alleged Abuse, Neglect, and Mistreatment
Penalty
Summary
The facility failed to appropriately respond to and thoroughly investigate multiple alleged violations related to abuse, neglect, exploitation, mistreatment, and injuries of unknown source. In several cases, allegations made by residents with intact cognitive status were not promptly or fully investigated, and required documentation such as witness statements, staff interviews, and resident interviews were missing or incomplete. For example, one resident reported being left soiled for four hours and not being assisted with meals, but the investigation lacked statements from staff or other residents who may have had knowledge of the incident. In another case, a resident alleged physical abuse and not receiving a meal tray, but there was no documentation that the incident was reported to all required state agencies, and no witness statements or follow-up documentation were present. Other incidents involved allegations of sexual abuse, neglect related to pressure ulcer development, and being left soiled for extended periods. In these cases, investigations were either delayed, lacked comprehensive interviews, or failed to document actions taken to determine the facts. For instance, a nursing assistant reported concerns about a resident developing a pressure sore, but the investigation concluded with an unsigned note attributing the issue to a communication and technology error, without addressing the specific failures in communication or documentation. In several cases, statements collected were undated, unsigned, or lacked sufficient detail, and follow-up actions such as call light audits were either not performed as described or not documented. Throughout the reviewed incidents, there were repeated failures to collect and document all relevant information, including statements from all staff and residents who may have had knowledge of the events, and to report allegations to the appropriate authorities in a timely manner. Investigations were often deemed inconclusive due to conflicting statements, but no secondary interviews or clarifications were attempted. In some cases, corrective actions or plans to prevent recurrence were not documented, and required follow-up reports were missing from the files. These deficiencies were confirmed by the administrator and DON during interviews, who acknowledged missing documentation and incomplete investigations.
Failure to Provide Scheduled Showers and ADL Assistance
Penalty
Summary
Surveyors identified that the facility failed to provide assistance with activities of daily living (ADLs), specifically showers and personal hygiene, to dependent residents as per their assessed needs and care plans. Three residents were found to have received fewer showers than scheduled, with documentation showing only one or two showers in a 30-day period, despite no refusals being recorded. Residents and their representatives reported that showers were not provided as ordered or preferred, and staff cited insufficient staffing as a reason for not providing showers. Observations confirmed poor personal hygiene, such as oily and uncombed hair, and interviews with the Director of Nursing verified the lack of documentation for scheduled showers. The deficiency was substantiated through resident and MPOA interviews, direct observation of residents' hygiene, and review of ADL documentation. In each case, the residents did not receive the number of showers outlined in their care plans, and there was no evidence that they refused care. The Director of Nursing confirmed the absence of documentation supporting that showers were provided as scheduled for the affected residents.
Failure to Serve Palatable and Properly Tempered Food and Beverages
Penalty
Summary
The facility failed to ensure that food and beverages were served at safe and appetizing temperatures, as well as in a palatable and attractive manner. During the survey, milk on a beverage cart was found to be at 54°F, which is above the FDA food code requirement of 41°F. The Director of Dining acknowledged this temperature violation. Additionally, when asked for food temperatures from the lunch menu, an employee stated that the cook was responsible for recording them on the production sheet, but the cook had not documented any temperatures. This deficiency was observed across four of five hallways tested for milk temperatures and in the food tray temperature for one meal tray tested. A resident reported dissatisfaction with the food, stating that meal preferences had not been updated despite requests made three months prior, and that food was often cold and not served as requested. The resident also noted that meals were sometimes served last, resulting in food running out, and that food items were mixed together on the plate. Observation of the resident's meal confirmed that baked beans were running onto the hamburger bun, and the Food Service Director agreed that the meal presentation was not appropriate. The Food Service Director also confirmed that the resident's meal preferences had not been updated.
Widespread Food Safety and Sanitation Deficiencies in Kitchen and Food Service Areas
Penalty
Summary
Surveyors observed multiple failures in food storage, preparation, distribution, and sanitation practices within the facility's kitchen and food service areas. Food delivery carts were found with food debris and dried substances on their shelves and exteriors. The kitchen walkthrough revealed missing dish machine temperature logs, soiled equipment such as the toaster, knife rack, can opener, and coffee maker, as well as improperly stored and undated food items including margarine, hamburger buns, cake mix, drink mixes, salad, ham, and sugar. Several food containers and packages were left open to air or lacked proper labeling and dating. Trash cans were found without lids, and some lacked liners. Food storage containers and sheet pans were placed directly on the floor, and the meat slicer and mixer bowl were left uncovered when not in use. Wet nesting of food storage container lids was also noted. Outdated food items were present in the walk-in cooler and nourishment room refrigerators, and the fan cover in the walk-in cooler, as well as ceiling vents in the kitchen, were dirty and rusty. Milk on a beverage cart was measured at a temperature above the FDA food code requirement. Further observations included improperly closed dumpster lids, a soiled fan in the dish room, and clean trays placed on the hand-washing sink. Employees were found to be documenting incorrect sanitizer PPM values on the dish machine log, and the three-compartment sink log was incomplete for certain meals. Trash cans in the dish room and near the steam table were missing lids when not in use. Staff interviews confirmed these deficiencies, and staff acknowledged that proper procedures were not followed regarding food safety, sanitation, and documentation.
Failure to Assess and Document Pressure Ulcer Care
Penalty
Summary
The facility failed to assess and treat pressure ulcers according to accepted standards of care for a resident who was admitted and receiving hospice services. Although a nurse practitioner identified a stage II pressure ulcer on the sacrum and provided specific wound care orders, these orders were not included in the resident's Treatment Administration Records (TARs) or Medication Administration Records (MARs) for the relevant months. The first full assessment of the coccyx pressure ulcer was not documented until two days after its identification, and there was no evidence that the prescribed wound care was administered as ordered. Additionally, a subsequent skin check identified a new deep tissue injury to the right heel and a blister to the left scapula, with new treatment orders written for these conditions. However, these orders were also not reflected in the resident's TAR or MAR, and there was no documentation that the treatments, including the application of heel boots, were carried out. The Director of Nursing confirmed the lack of timely assessment and documentation, as well as the absence of evidence that physician orders were followed.
Failure to Notify MPOA of Resident Medical Appointments
Penalty
Summary
The facility failed to inform the Medical Power of Attorney (MPOA) for a resident about scheduled medical appointments. According to interviews and record reviews, the MPOA was not notified of multiple neurology appointments, resulting in the resident being transported to these appointments without the MPOA's knowledge or presence. The MPOA only became aware of the appointments after being contacted by the doctor's office, which expected the MPOA to accompany the resident. This lack of communication occurred on at least three separate occasions. Additionally, documentation confirmed that the resident was transported to appointments with staff present, but on one occasion, the van driver became ill and left the resident at the appointment after notifying the facility. The facility's Corporate Coordinator acknowledged that the MPOA should have been notified and that the resident was left at the appointment without staff present. No information or statements were available regarding staff presence for one of the incidents.
Failure to Process and Investigate Resident Grievance Regarding Transportation
Penalty
Summary
The facility failed to process and investigate a grievance reported by a resident's MPOA regarding transportation to medical appointments. The MPOA stated that the resident was transported to appointments on multiple occasions without prior notification, and on two specific dates, the van driver dropped the resident off without ensuring the MPOA was present. The MPOA reported these concerns directly to the facility's Director of Nursing. However, a review of the facility's grievance log and records revealed that no grievances or complaints from the MPOA were logged for the relevant dates, and there was no completed grievance form or investigation documented. Further review of progress notes and appointment logs confirmed that the resident was transported to appointments on the dates in question, with staff present according to the notes. During staff interviews, the Corporate Coordinator acknowledged that the grievances were not logged and that the facility could not provide documentation of a completed investigation. Additionally, the van driver reported becoming ill and leaving the resident at an appointment on one occasion, but no information was available for the other incident. The facility's actions did not align with its grievance policy, which requires oversight, investigation, and written decisions for reported grievances.
Failure to Provide Required Mealtime Supervision
Penalty
Summary
A deficiency occurred when a resident who required supervision during mealtimes, as indicated in both the care plan and meal ticket, was served a meal without the necessary staff supervision. During a meal observation, an employee set up the resident's tray and drink but left the room, failing to remain and supervise the resident as required. Review of facility policy confirmed that staff are to sit with or supervise residents needing assistance during meals, or not deliver the tray until assistance is available. Staff interviews revealed that the employee who delivered the meal did not notice the supervision requirement on the meal ticket, and another staff member acknowledged that the resident should have been supervised during the meal.
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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