Worthington Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Parkersburg, West Virginia.
- Location
- 2675 36th Street, Parkersburg, West Virginia 26104
- CMS Provider Number
- 515047
- Inspections on file
- 20
- Latest survey
- April 2, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Worthington Healthcare Center during CMS and state inspections, most recent first.
A resident with a history of depression and schizophrenia, who was on 1:1 observation due to suicidal ideations, was found alone in their room. The assigned Nurse Aide left the resident unsupervised to get ice, contrary to the facility's policy requiring constant observation. This lapse occurred despite the resident's recent suicide attempt and severe cognitive impairment, highlighting a failure to adhere to safety protocols.
The facility failed to develop and implement comprehensive care plans for four residents, missing critical interventions for wound care and repositioning as per physician orders. The Corporate RN confirmed these omissions, highlighting a systemic issue in care plan management.
The facility failed to adhere to physician's orders for four residents, resulting in incomplete documentation of treatments and care. A resident's TAR was missing entries for wound care, preventative treatments, and repositioning schedules. Another resident's TAR lacked documentation for wound assessments and PICC line care. Similar deficiencies were noted for two other residents, with missing entries for catheter care and repositioning. The Corporate RN confirmed the TAR should have been completed as ordered.
The facility failed to implement its policies to prevent abuse, neglect, and misappropriation of resident property by not ensuring the completion of background checks before allowing staff to work. Several staff members, including CNAs and receptionists, were hired and began working without the necessary background checks, and some worked beyond the 60-day provisional period. The Administrator acknowledged these issues, which were identified during a survey.
The facility failed to comply with state and local laws regarding employment screening and background checks, allowing staff to work without completed checks. This affected all residents, as several staff members, including CNAs and a Maintenance Technician, were hired without necessary background checks and fitness determinations, violating the facility's policy.
The facility failed to effectively manage resources, leading to unaddressed allegations of abuse and involuntary seclusion. In one case, a resident's head was held during a COVID test despite distress, and in another, a resident was allegedly secluded by locking their wheelchair. Both incidents were unsubstantiated by the facility despite multiple confirmations, leaving residents at risk.
Two residents were subjected to physical restraint by staff members, leading to allegations of abuse. In one case, a resident's head was held during a COVID test, causing distress. In another, a resident's wheelchair was locked to prevent movement. Despite multiple witness accounts, the facility's investigations deemed the allegations unsubstantiated, and the involved staff remained employed.
Two residents were physically restrained by staff members in separate incidents, leading to a deficiency in ensuring resident safety. In one case, a nurse aide held a resident's head during a COVID test, while in another, a nurse locked a resident's wheelchair to prevent movement. Despite multiple witness accounts, the facility's investigations deemed the incidents unsubstantiated, leaving the involved staff employed without immediate corrective action.
The facility failed to adhere to infection control standards, with a housekeeper incorrectly stating the cleanser dwell time as five minutes instead of the required ten minutes. Additionally, a linen cart was found uncovered, contrary to protocol, as confirmed by staff and the DON.
Two residents were physically restrained by staff, violating the facility's abuse prevention policy. One resident was restrained during a COVID test, while another was involuntarily secluded in her room. Despite multiple witness statements, the facility deemed the incidents unsubstantiated, leaving residents at risk.
The facility failed to implement fall interventions for two residents. One resident, at risk for falls, did not have a fall mat beside the bed as required by the care plan. Another resident, also at risk, used a regular coffee cup instead of a recessed cup with a lid, contrary to the care plan. These deficiencies were confirmed by staff observations and interviews.
A facility failed to maintain an accurate medical record for a resident. A discharge summary incorrectly stated that the resident was unable to participate in therapy due to a fracture. However, therapy notes indicated the resident actively participated in sessions and could propel a wheelchair with standby assistance. This discrepancy was confirmed by a Clinical Manager.
Failure to Maintain 1:1 Supervision for Resident with Suicidal Ideations
Penalty
Summary
The facility failed to maintain a safe and accident-free environment for a resident who was on 1:1 observation due to suicidal ideations and a recent suicide attempt. On the day of the observation, the resident was found alone in his room, despite being on 1:1 supervision. When questioned, the resident was unaware of the staff member's whereabouts, and a Licensed Practical Nurse confirmed that the resident was supposed to be under constant observation. The staff member assigned to the resident, a Nurse Aide, was observed away from the resident's room and later stated that they had left to get the resident some ice. This absence left the resident unsupervised, which was against the facility's policy that required continuous observation for residents on 1:1 intervention. The facility's policy clearly stated that staff should be in observation of the resident at all times until the intervention is no longer required. The resident had a documented history of depression and schizophrenia, with severe cognitive impairment, and had previously attempted suicide by using a grabber to pull a pillow over his face. The resident had been sent to an acute care facility following the suicide attempt and returned to the facility with orders to remain on 1:1 supervision for safety reasons. Despite these precautions, the lapse in supervision was observed, indicating a failure to adhere to the established safety protocols.
Failure to Develop and Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for four residents, as identified during a record review and staff interview. Resident #92's care plan did not include necessary interventions for an unstageable wound on the right heel, as per the physician's orders and the Treatment Administration Record (TAR) for March 2024. Similarly, Resident #84's care plan lacked interventions for multiple wounds, including an unstageable wound on the sacrum, and did not incorporate physician-ordered wound care and repositioning strategies. Resident #39's care plan was not implemented according to the TAR, missing essential interventions such as preventative treatments and daily wound assessments. Additionally, Resident #95's care plan failed to include daily wound assessments for a surgical wound and a turning schedule, as ordered by the physician. In each case, the Corporate Registered Nurse confirmed the absence of these interventions, indicating a systemic issue in care plan development and implementation for these residents.
Failure to Follow Physician's Orders for Resident Care
Penalty
Summary
The facility failed to follow physician's orders for four residents, leading to deficiencies in care. For Resident #92, the Treatment Administration Record (TAR) was incomplete for several treatments, including daily wound treatment and assessment for a stage III sacral wound, preventative treatments, and repositioning schedules. These omissions occurred on multiple dates throughout March 2024, as confirmed by the Corporate Registered Nurse (RN) #147. Resident #84 also experienced lapses in care, with the TAR missing documentation for daily treatments and assessments of various wounds, including a bullae on the right thumb and an unstageable wound on the sacrum. Additionally, the dressing change for a PICC line and monitoring for infection were not documented as ordered. These gaps in care were noted on several dates in March 2024, and RN #147 acknowledged the incomplete records. For Resident #39, the TAR lacked documentation for daily wound care and preventative measures, such as turning and repositioning, on specific dates in March 2024. Similarly, Resident #95's TAR was incomplete for February 2024, missing entries for catheter care, wound assessments, and repositioning. The Corporate RN #147 was informed of these deficiencies and confirmed the TAR should have been completed as per the physician's orders.
Failure to Implement Background Check Policies
Penalty
Summary
The facility failed to implement its policies and procedures to prevent abuse, neglect, and misappropriation of resident property by not ensuring the completion of background checks before allowing staff to work and have direct access to residents. This deficiency was identified through a review of records, legislative rules, and staff interviews. The facility did not conduct pre-hire criminal background checks for several staff members, including CNAs, a maintenance technician, and receptionists, as required by the facility's policy and the legislative rule S 69-10-1. These staff members were allowed to work without the necessary background checks, which could potentially affect all residents. The facility also failed to adhere to the provisional employment guidelines, allowing staff to work beyond the 60-day provisional period without completing the required fingerprint-based background checks. Specific instances included CNAs and other staff members who were hired and began working before their WV Cares Self-Disclosure Application and Consent Forms were completed and signed. Additionally, some staff members received their Notification of Eligible Fitness Determination well after their hire dates, indicating a lapse in the facility's compliance with the screening process. The facility's oversight in conducting timely background checks and adhering to provisional employment guidelines was acknowledged by the Administrator during an interview. The Administrator admitted that there were issues within the IDT team regarding the completion of WV Cares background checks and that staff were permitted to work more than the provisional 60 days without the necessary checks. This failure to comply with established procedures and legislative requirements led to the deficiency identified during the survey.
Failure in Employment Screening and Background Checks
Penalty
Summary
The facility failed to comply with state and local laws regarding employment screening and background checks for staff members. Specifically, the facility did not ensure that provisional employment screening was completed, nor did it complete background checks before allowing staff to work and have direct access to residents. This deficiency affected all residents, as the facility did not adhere to the required procedures for screening potential employees, including Certified Nursing Assistants, a Maintenance Technician, and Receptionists. The report highlights several instances where staff members were hired without the necessary background checks and fitness determinations. For example, a Certified Nursing Assistant was hired in August 2022, but the self-disclosure application and consent form were not completed until January 2024, with the fitness determination received in March 2024. Similar delays were noted for other staff members, including a Maintenance Technician and a Receptionist, who were allowed to work without the required background checks and fitness determinations. The facility's policy required pre-hire criminal background checks, including checks against the Health and Human Services Office of Inspector General's List of Excluded Individuals/Entities, criminal state and federal checks, and sex offender and elder abuse screenings. However, these procedures were not followed, leading to the employment of staff without proper clearance. The facility's failure to adhere to these policies resulted in staff working beyond the provisional 60-day period without completed background checks, as acknowledged by the facility's Administrator.
Deficiency in Addressing Abuse and Seclusion Allegations
Penalty
Summary
The facility failed to administer its resources effectively and efficiently, leading to a deficiency in ensuring the safety and well-being of its residents. The administration did not adequately address and substantiate allegations of physical abuse and involuntary seclusion involving two residents. In one incident, a resident's head was held by a nurse aide while a registered nurse performed a nasal swab for COVID testing, despite the resident's apparent distress and resistance. Multiple staff and resident statements confirmed the occurrence of this incident, yet the facility's investigation deemed it unsubstantiated. In another incident, a resident was allegedly subjected to involuntary seclusion when a registered nurse locked the resident's wheelchair and held it to prevent the resident from leaving the room. This action was reported as possible involuntary seclusion, but the facility's investigation also found this allegation unsubstantiated. Despite multiple witness statements and the resident's own account, the facility administration did not take appropriate actions to ensure the safety of the residents involved or prevent future occurrences. The failure to address these incidents placed all residents at risk for serious harm, as the alleged perpetrators remained employed at the facility. The administration's inaction and failure to substantiate the allegations despite clear evidence from multiple sources highlight a significant deficiency in the facility's management and oversight of resident care and safety.
Removal Plan
- Employee(RN) #40 will have extensive abuse and neglect training by the Regional Team Member.
- Employee (NA) #55 will have extensive abuse and neglect training by the Regional Team Member.
- Residents with BIMS scores of 12 and above were interviewed for potential physical abuse.
- Residents with BIMS scores of 11 or below had a skin assessment completed for potential physical abuse.
- Staff will be reeducated on the Abuse, Neglect, and Misappropriation Policy through in person, text blast will be physically educated with signatures. The training will be conducted by the Regional Team Member.
- There will be training for all staff on Resident Rights including the right to be free from any physical restraints imposed for purposes of discipline or convenience and not required to treat the resident medical symptoms.
- The training will be conducted by the Regional Team Member.
- Staff will be reeducated on restraint alternatives.
- There will be a team review of all reportable events to determine if physical abuse occurred, per state definitions. The team will include Social Services, Director of Nursing or Designee, and Executive Director.
- Audits will be conducted by the regional Director of Clinical Operations with correction upon discovery.
- Audit results will be reviewed by the QAPI Committee.
Failure to Protect Residents from Physical Abuse
Penalty
Summary
The facility failed to protect residents from physical abuse, as evidenced by two separate incidents involving physical restraint. In the first incident, a nurse aide physically restrained a resident by holding her head while a nurse swabbed her nose for a COVID test. This action was witnessed by multiple staff members and residents, who reported that the resident was screaming and appeared distressed. Despite these accounts, the facility's investigation concluded that the incident was unsubstantiated, and the involved staff members remained employed. In the second incident, a resident became agitated, and a nurse locked the resident's wheelchair and physically held it to prevent the resident from leaving the room. This action was reported as possible involuntary seclusion. The facility's investigation also deemed this allegation unsubstantiated, despite statements from staff members who witnessed the event. The facility's response included an in-service training on abuse and neglect, but the involved nurse continued to work at the facility. Both incidents placed all residents at risk for serious harm, as the alleged perpetrators were still employed, and no immediate actions were taken to prevent further abuse. The facility was notified of the immediate jeopardy situation, and a plan of correction was submitted and accepted by the state agency. However, the initial failure to address the incidents and protect the residents from abuse highlights significant deficiencies in the facility's handling of such situations.
Removal Plan
- Employee(RN) #40 will have extensive abuse and neglect training by the Regional Team Member.
- Employee (NA) #55 will have extensive abuse and neglect training by the Regional Team Member.
- Residents with BIMS scores of 12 and above were interviewed for potential physical abuse.
- Residents with BIMS scores of 11 or below had a skin assessment completed for potential physical abuse.
- Staff will be reeducated on the Abuse, Neglect, and Misappropriation Policy through in person, text blast will be physically educated with signatures. The training will be conducted by the Regional Team Member.
- There will be training for all staff on Resident Rights including the right to be free from any physical restraints imposed for purposes of discipline or convenience and not required to treat the resident medical symptoms. The training will be conducted by the Regional Team Member.
- Staff will be reeducated on restraint alternatives.
- There will be a team review of all reportable events to determine if physical abuse occurred, per state definitions. The team will include Social Services, Director of Nursing or Designee, and Executive Director.
- Audits will be conducted by the regional Director of Clinical Operations with correction upon discovery.
- Audit results will be reviewed by the QAPI Committee.
Failure to Prevent Physical Restraint and Abuse
Penalty
Summary
The facility failed to ensure that residents were free from physical abuse, as evidenced by two incidents involving physical restraint. In the first incident, a nurse aide held the head of a resident while a registered nurse performed a nasal swab for COVID testing. Multiple staff members and a resident witnessed the event, confirming that the resident was restrained against her will. Despite these accounts, the facility's investigation deemed the incident unsubstantiated, and the involved staff members remained employed without immediate corrective action. In the second incident, a resident became agitated, and a nurse locked the resident's wheelchair and physically held it to prevent the resident from leaving the room. This action was reported as possible involuntary seclusion. The facility's investigation again found the allegation unsubstantiated, despite statements from staff members who witnessed the event. The facility conducted an in-service training on abuse and neglect but did not take further immediate action against the involved staff. Both incidents placed the residents and others at risk for serious harm, as the facility did not take adequate measures to prevent future occurrences. The facility's failure to substantiate the allegations and take appropriate action contributed to an immediate jeopardy situation for all residents, highlighting a significant deficiency in ensuring resident safety and compliance with regulations regarding physical restraints.
Removal Plan
- Employee(RN) #40 will have extensive abuse and neglect training by the Regional Team Member.
- Employee (NA) #55 will have extensive abuse and neglect training by the Regional Team Member.
- Residents with BIMS scores of 12 and above were interviewed for potential physical abuse.
- Residents with BIMS scores of 11 or below had a skin assessment completed for potential physical abuse.
- Staff will be reeducated on the Abuse, Neglect, and Misappropriation Policy through in person, text blast will be physically educated with signatures. The training will be conducted by the Regional Team Member.
- There will be training for all staff on Resident Rights including the right to be free from any physical restraints imposed for purposes of discipline or convenience and not required to treat the resident medical symptoms. The training will be conducted by the Regional Team Member.
- Staff will be reeducated on restraint alternatives.
- There will be a team review of all reportable events to determine if physical abuse occurred, per state definitions. The team will include Social Services, Director of Nursing or Designee, and Executive Director.
- Audits will be conducted by the regional Director of Clinical Operations with correction upon discovery.
- Audit results will be reviewed by the QAPI Committee.
Infection Control Deficiencies in Cleansing and Linen Storage
Penalty
Summary
The facility failed to maintain appropriate infection control standards in two areas: cleansing dwell time and linen storage. During an observation, a housekeeper on the [NAME] wing incorrectly stated that the dwell time for the cleanser used on surfaces and floors was about five minutes, whereas the Housekeeping Director confirmed that the correct dwell time, as per the cleanser's label, was ten minutes. This discrepancy indicates a lack of proper training or communication regarding the correct procedures for infection control. Additionally, a linen cart on the East wing was observed to be uncovered, with a flap across the top. This was confirmed by two nurse aides and later acknowledged by the Director of Nursing, who confirmed that the linen cart should have been covered. These findings highlight lapses in maintaining infection control protocols within the facility.
Failure to Implement Abuse Prevention Policy
Penalty
Summary
The facility failed to implement its abuse prevention policy, resulting in two residents being physically restrained. Resident #43 was restrained by a nurse aide who held her head while a nurse performed a nasal swab for COVID testing. Multiple staff members, including a registered nurse and a nurse aide, were involved in the incident, and several witness statements confirmed the occurrence. Despite this, the facility's investigation concluded the incident as unsubstantiated, even though the resident was non-verbal and unable to express how the restraint made her feel. In another incident, Resident #11 was taken to her room by a nurse who locked the resident's wheelchair and physically held it, preventing her from leaving. This was reported as possible involuntary seclusion. The facility's investigation gathered statements from staff, including a nurse who claimed the action was therapeutic and for a limited period. However, the facility also deemed this incident unsubstantiated, despite the resident's agitation and the physical restraint used. The state agency determined that these failures caused physical and mental suffering to the residents involved and placed all 95 residents at risk of serious harm. The facility did not take immediate action to remove the alleged perpetrators from resident care areas, which contributed to the immediate jeopardy situation. The facility's abuse policy required immediate removal of employees involved in abuse allegations, but this was not followed, leaving the residents vulnerable to further harm.
Failure to Implement Fall Interventions for Residents
Penalty
Summary
The facility failed to implement care plans related to fall interventions for two residents. Resident #44 was identified as being at risk for falls and had a fall from bed. The care plan included an intervention to place a fall mat beside the bed, initiated on 02/13/24. However, observations on 02/19/24 and 02/21/24 revealed that the fall mat was not present beside the bed, which was confirmed by Clinical Manager #109. Resident #1, also at risk for falls, experienced multiple falls in different locations, including the dining room and lobby. The care plan specified the use of a recessed cup with a lid to prevent spillage of hot liquids, but an observation on 02/21/24 found the resident using a regular coffee cup instead. This was confirmed by Occupational Therapy Assistant #139, who described the recessed cup and confirmed the regular cup was not compliant with the care plan.
Inaccurate Medical Record for Resident
Penalty
Summary
The facility failed to maintain a complete and accurate medical record for a resident, identified as Resident #97, during the survey process. A record review conducted on February 20, 2024, revealed a discrepancy in the discharge summary dated October 23, 2023. The discharge summary inaccurately stated that the resident was unable to participate in therapy due to a fracture. However, upon reviewing the physical therapy notes, it was found that the resident had actively participated in therapy sessions while seated in a wheelchair and was able to propel the wheelchair with standby assistance for 75 feet. This inconsistency was confirmed by Clinical Manager #109, who acknowledged the incorrect statement in the discharge summary based on the therapy notes.
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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