Wyoming Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in New Richmond, West Virginia.
- Location
- 236 Warrior Way, New Richmond, West Virginia 24867
- CMS Provider Number
- 515164
- Inspections on file
- 15
- Latest survey
- November 19, 2025
- Citations (last 12 mo.)
- 6
Citation history
Health deficiencies cited at Wyoming Healthcare Center during CMS and state inspections, most recent first.
A resident in a LTC facility engaged in multiple incidents of inappropriate touching, verbal threats, and physical aggression towards other residents. The facility failed to document, investigate, or report these incidents, preventing victim identification and necessary interventions. Staff interviews revealed a lack of awareness and action, with the resident's behavior escalating after returning from a behavioral health hospital.
The facility did not ensure that all dietary staff had food handlers cards, as required by Virginia code S16-2-16. A Culinary Aide had been working since January without the necessary certification, which the Culinary Director attributed to the aide's weekend-only schedule. This oversight could potentially impact more than a limited number of residents, with a facility census of 55.
The facility failed to maintain food safety and sanitation standards, as observed during a kitchen tour. Incomplete temperature logs, expired pinto beans, a dirty microwave, and a dented can of corn were found. The Culinary Director acknowledged these issues, which could potentially affect more than a limited number of residents.
The facility did not have the required members present at a quarterly Quality Assessment and Assurance meeting, as the Medical Director was absent. This was confirmed by the DON and had the potential to affect all 55 residents.
The facility failed to maintain a clean environment in the dining room, as the ceiling around the vent was observed to be dirty during lunch meals. Despite confirmation from the Director of Plant Maintenance that cleaning was needed, the area remained unclean in subsequent observations, potentially affecting many residents.
A resident engaged in multiple incidents of abuse and aggression towards other residents, including inappropriate touching and verbal threats. Despite documentation in progress notes, the facility failed to investigate or report these incidents to state agencies. The Administrator and Unit Manager were unaware of the victims' identities and confirmed no investigations were conducted.
The facility failed to implement comprehensive care plans for residents, including daily 1:1 visits, accurate diagnosis documentation, and proper interventions for trauma and dementia. Additionally, fall prevention and tube feeding protocols were not followed, leading to incomplete care. These deficiencies were confirmed through staff interviews and observations.
The facility failed to treat residents with dignity, as one resident was left in a soiled shirt during activities, and another experienced a delay in receiving appropriate pain medication. An LPN administered Tylenol instead of the scheduled oxycodone due to a delay in accessing the medication.
A facility failed to document a resident's schizoaffective disorder on their quarterly MDS. Although the FNP recommended adding the diagnosis alongside bipolar disorder, only the latter was recorded. This omission was confirmed by the Corporate Nurse, Regional Director, and Administrator during an interview.
A facility failed to update the PASRR for a resident diagnosed with major depressive disorder after admission. Initially assessed in 2010 with no mental illness, the resident's 2017 diagnosis was not reflected in the PASRR. The DON acknowledged the outdated PASRR during an interview.
A facility failed to include a diagnosis of schizoaffective disorder in the PASARR for a resident, despite the diagnosis being made prior to admission. This omission was confirmed by the Regional Director and Corporate Nurse during an interview.
A facility failed to update a resident's care plan after discontinuing the use of a vest for positioning. The care plan still listed the vest, but observations showed the resident without it. A nurse aide confirmed the vest had not been used for some time, and the DON acknowledged the change to a seat belt, agreeing the care plan needed revision.
The facility failed to complete neurological assessments for two residents after falls, did not notify a physician of a resident's hyperglycemia, and missed doses of a diabetes medication for another resident due to availability issues. These deficiencies were confirmed by the DON.
A resident's toenail care was neglected due to a failure in the facility's process for obtaining external services. The resident's husband reported the issue, and staff interviews revealed that the resident was deemed ineligible for contracted services, with no follow-up action taken. The DON confirmed the staff's discomfort in addressing the toenail condition.
The facility failed to implement safety interventions for two residents, leading to potential accident hazards. A resident's bed bolsters were not in place as per their care plan, and another resident with a history of wandering did not have a wanderguard device ordered until after surveyor intervention, despite previous elopement incidents.
A resident receiving enteral feeding did not receive appropriate care, as an LPN failed to administer medications correctly, omitted required water flushes, and did not check gastric residual volume. The LPN also administered feeding late and did not complete medication doses, leading to a deficiency in care.
A facility failed to assess a resident for bed rail safety, as observed during a survey. Bed rails were installed without a proper safety evaluation, and the resident's care plan did not include bed rails. A Corporate RN confirmed the lack of a safety evaluation and was unfamiliar with the process.
An LPN at a facility failed to properly administer medications and enteral feeding to a resident with a feeding tube. The LPN did not administer the entire medication mixture, failed to flush the feeding tube, and did not check the gastric volume residual before administration. The facility could not provide evidence of the LPN's competencies in feeding tube care upon hire.
A resident with dementia exhibited worsening behaviors after returning from a behavioral health facility, including aggression and elopement attempts. Despite these changes, the facility failed to notify the physician until surveyor intervention, resulting in an Immediate Jeopardy situation.
A resident experienced multiple medication administration errors by an LPN, resulting in a medication error rate of 16.67%. The LPN failed to administer full doses of medications, omitted required water flushes, and did not check gastric residual volume. Additionally, medications were not administered on schedule, contributing to the high error rate. The DON was notified of these errors.
The facility failed to maintain accurate and complete medical records for two residents. One resident's transfer form had an incorrect date, while another resident's POST form was missing the date for signatures. These discrepancies were confirmed by the Administrator and the Corporate RN.
Failure to Protect Residents from Abuse
Penalty
Summary
The facility failed to protect residents from abuse, as evidenced by multiple incidents involving a resident who inappropriately touched, verbally, and physically assaulted other residents. The facility did not properly document, investigate, or report these incidents, which prevented the identification of victims and the provision of necessary services to them. This lack of action resulted in physical and psychosocial harm to the victims and placed all residents at risk of serious harm or death. Resident #213 was involved in numerous incidents of inappropriate behavior, including touching female residents inappropriately, making threatening statements, and engaging in physical altercations with other residents. Despite these behaviors being documented in progress notes, the facility failed to cross-reference these notes with incident logs, leading to a lack of investigation and reporting. The resident's behavior was known to escalate, particularly after returning from a behavioral health hospital, yet the facility did not implement effective interventions to manage these behaviors. Interviews with facility staff revealed a lack of awareness and action regarding the resident's abusive behavior. The Administrator and Unit Manager were unable to identify the victims or confirm any interventions in place during evenings and weekends. The Social Services Designee noted that the resident had a history of similar behaviors and expressed a desire to be removed from the facility. Despite these known issues, the facility did not maintain direct supervision of the resident, further contributing to the risk of harm to other residents.
Removal Plan
- Resident #213 was placed on 1:1 direct observation with a facility staff member until physician interventions are successful in managing behaviors.
- An immediate fax reporting of allegation was completed and sent to OHFLAC.
- The physician was notified with new orders as follows; increased Trazadone to 150mg at bedtime, changed his Paxil to bedtime, and 1 on 1 with staff member.
- The resident's care plan was updated with new orders and 1:1 observation intervention.
- All alert residents were interviewed by the Unit Managers to identify other concerns and no other issues were identified.
- All staff members were immediately re-educated on reporting allegations of abuse immediately to OHFLAC, APS, Ombudsman or other licensing board as warranted by the Unit Manager.
- All staff were educated on notifying a supervisor of any allegation immediately to assist with interventions necessary for immediate protection of residents.
- All staff not available will be re-educated on reporting allegations of abuse and notifying a supervisor immediately prior to the start of their next scheduled shift.
- The Unit Managers will monitor progress notes daily to identify potential concerns of abuse.
- The Administrator and Director of Nursing will review incident and accident reports to identify potential concerns.
- Any allegations will be reported to OHFLAC, Ombudsman, APS and other licensing boards as warranted.
- All allegations of abuse and neglect will be reviewed at the facilities Quality Assurance and Performance Improvement meeting each month.
Failure to Ensure Dietary Staff Certification
Penalty
Summary
The facility failed to employ qualified dietary staff by not ensuring that each member of the dietary staff obtained food handlers cards before working in the dietary department. This deficiency was identified during a record review and staff interview, which revealed that a Culinary Aide (CA) had been working in the dietary department since January 2, 2024, without a food handlers card. The Culinary Director (CD) acknowledged the oversight, explaining that the CA only worked weekends, making it difficult to ensure they obtained the necessary certification. This failure to comply with the Virginia code S16-2-16, which mandates food safety certificates for food employees, has the potential to affect more than a limited number of residents, with the facility census being 55.
Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility failed to store food in a safe and sanitary manner and maintain sanitary equipment, which could potentially affect more than a limited number of residents. During a kitchen tour, it was observed that the breakfast temperature logs were incomplete due to new employee training. The Culinary Director (CD) confirmed the logs were not filled out, suggesting they might have been misplaced during the training process. Additionally, a container of pinto beans with an expired date was found in the reach-in refrigerator, which the CD acknowledged and disposed of immediately. Further observations revealed unsanitary conditions in the nourishment room, where a microwave used for preparing resident meals had grime inside and a paper towel with yellow stains stuck to the plate. The CD confirmed the microwave's use for resident food preparation and attempted to clean it. Moreover, a dented can of corn was found on the kitchen storage rack, which the CD also acknowledged and discarded. These findings indicate lapses in maintaining food safety and equipment sanitation standards.
Medical Director Absence at QA Meeting
Penalty
Summary
The facility failed to ensure that the Quality Assessment and Assurance committee had the required members present at their quarterly meetings. Specifically, the Medical Director did not attend the second quarter meeting in 2023. This was confirmed through a review of the Quality Assurance and Performance Sign-in Sheet and verified by the Director of Nursing (DON). This oversight had the potential to affect all residents residing at the facility, which had a census of 55 at the time of the report.
Unclean Dining Room Environment
Penalty
Summary
The facility failed to maintain a clean and homelike environment in the dining room, as observed during a lunch meal. On March 25, 2024, it was noted that the ceiling around the vent in the dining room was dirty. This observation was confirmed by the Director of Plant Maintenance on March 26, 2024, who acknowledged that the area needed cleaning. However, during a subsequent observation on March 27, 2024, the ceiling around the vent remained dirty, indicating that no cleaning had been performed. This deficiency has the potential to affect more than an isolated number of residents, given the facility's census of 55 residents.
Failure to Investigate Allegations of Abuse by a Resident
Penalty
Summary
The facility failed to investigate multiple allegations of abuse by a resident, identified as Resident #213, towards other residents. The incidents, documented in progress notes, included inappropriate touching, verbal abuse, physical aggression, and disruptive behavior. Despite these documented incidents, there were no corresponding entries in the facility's incident and reportables logs, indicating a lack of investigation or reporting to the required state agencies. The incidents spanned from mid-February to late March, involving various forms of abuse and aggression towards other residents, including inappropriate touching, verbal threats, and physical altercations. During an interview with the Administrator and Unit Manager, it was revealed that they were unaware of the identities of the victims and confirmed that no investigations had been conducted. The Administrator acknowledged the absence of incident reports and the failure to report these incidents to the necessary state agencies. This lack of action and oversight has the potential to affect more than a limited number of residents, given the nature and frequency of the incidents involving Resident #213.
Care Plan Deficiencies in LTC Facility
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for several residents, leading to deficiencies in their care. For multiple residents, including those with specific needs for daily 1:1 visits, the care plans did not reflect these requirements despite being listed by the Activity Director. This oversight was confirmed through staff interviews, indicating a lack of proper documentation and implementation of necessary activities for these residents. Additionally, the care plan for a resident with a diagnosis of Schizoaffective Disorder was incomplete, as it did not include this diagnosis despite recommendations from the pharmacy and notes from the Family Nurse Practitioner. Another resident's care plan failed to address the presence of bed rails, which were observed during an investigation of accident hazards. Furthermore, the care plan for a resident with a history of trauma included interventions that could not be implemented due to staffing limitations, and the cause of the trauma was not clearly documented. The facility also failed to adhere to care plan interventions related to fall prevention and tube feeding. For a resident requiring bed bolsters as a fall intervention, these were not in place as directed. Another resident's tube feeding care plan was not followed correctly, as observed during medication administration. The LPN did not secure the feeding tube, omitted required flushes, and failed to check gastric residual volume, leading to incomplete medication administration. These deficiencies highlight significant lapses in care plan implementation and adherence.
Failure to Maintain Resident Dignity and Timely Pain Management
Penalty
Summary
The facility failed to ensure residents were treated in a dignified manner, as evidenced by two separate incidents involving Resident #36 and Resident #162. Resident #36's shirt became soiled with tube feeding during a medication administration observation, and the shirt was not changed before the resident was taken to the dining room to play Bingo. The following day, the resident was observed in the lounge area still wearing the soiled shirt. A Registered Nurse confirmed the need for a change of clothing, indicating a lapse in maintaining the resident's dignity and hygiene. In another incident, Resident #162 expressed pain and requested a pain pill. The surveyor informed the facility staff, and an LPN administered Tylenol to the resident in the dining room, stating that the resident's assigned nurse had requested it. The LPN later returned to administer the resident's scheduled oxycodone, indicating a delay in providing the appropriate pain management. These incidents highlight the facility's failure to uphold the residents' rights to a dignified existence and proper communication regarding their care needs.
Failure to Document Schizoaffective Disorder on MDS
Penalty
Summary
The facility failed to accurately document a diagnosis of schizoaffective disorder for a resident on their quarterly Minimum Data Set (MDS). During a record review, it was found that the Family Nurse Practitioner had recommended adding the diagnosis of schizoaffective disorder and bipolar disorder to the resident's medical record on January 5, 2024. However, while the bipolar disorder was documented, the schizoaffective disorder was not included in the resident's medical diagnosis. This discrepancy was confirmed during an interview with the Corporate Nurse, Regional Director, and Administrator, who acknowledged that the diagnosis was missing from the MDS despite being present in the quarterly assessment with an Assessment Reference Date of March 8, 2024.
Failure to Update PASRR for Resident with New Mental Disorder Diagnosis
Penalty
Summary
The facility failed to update the Preadmission Screening and Resident Review (PASRR) for a resident after they were diagnosed with a major mental disorder post-admission. The resident, identified as Resident #6, was initially assessed with no mental illness or mental retardation diagnosis in 2010. However, in 2017, the resident was diagnosed with major depressive disorder, and the PASRR was not updated to reflect this new diagnosis. During an interview, the Director of Nursing acknowledged the oversight, confirming that the PASRR on file was outdated and did not include the major depressive disorder diagnosis.
Omission of Schizoaffective Disorder in PASARR
Penalty
Summary
The facility failed to include a diagnosis of schizoaffective disorder in the pre-admission screening and resident review (PASARR) for one of the residents. This oversight was identified during a review of the resident's medical records, which showed that the resident had been diagnosed with schizoaffective disorder prior to admission. However, this diagnosis was not reflected in the PASARR documentation. The issue was confirmed during an interview with the Regional Director and Corporate Nurse, who acknowledged the omission in the PASARR for the resident.
Failure to Update Care Plan for Discontinued Positioning Vest
Penalty
Summary
The facility failed to revise the care plan for Resident #36 when the use of a vest for positioning was discontinued. The resident's care plan, reviewed on March 26, 2024, indicated the use of a vest for positioning while in a high back tilt wheelchair with a pommel cushion. However, observations on March 25 and March 27, 2024, revealed that the resident was in the wheelchair without the vest. Nurse Aide #64 confirmed that the vest had not been used for some time. The Director of Nursing acknowledged that the vest was replaced with a seat belt due to issues with the vest and agreed that the care plan needed updating.
Deficiencies in Neurological Assessments, Physician Notification, and Medication Administration
Penalty
Summary
The facility failed to complete neurological assessments after falls for two residents, Resident #213 and Resident #31. For Resident #213, multiple instances of incomplete neurochecks were identified following several falls. Specific checks were either not completed or were documented at incorrect times, spanning from October 2023 to March 2024. Similarly, Resident #31's neurological assessments were missing several required checks across different dates, indicating a pattern of incomplete assessments. The facility also failed to notify the physician of hyperglycemia results for Resident #8. The resident's medical record indicated a physician order to notify if blood sugar levels exceeded 350 mg/dl. However, there were numerous instances from August 2023 to March 2024 where the resident's blood sugar levels were above this threshold, yet there was no documentation to show that the physician was notified. Additionally, the facility did not administer medication per physician's order for Resident #49. The resident had an order for Trulicity, a diabetes medication, to be administered weekly. However, four out of ten doses were missed due to the medication not being available, as noted in the Electronic Medication Administration Record. The Director of Nursing confirmed the missed doses and acknowledged the difficulty in obtaining the medication.
Failure to Provide Toenail Care for Resident
Penalty
Summary
The facility failed to provide appropriate toenail care for a resident, identified as Resident #29, which was discovered through observation, family interview, staff interview, and record review. The resident's husband expressed concern about the lack of toenail care, stating that the facility staff informed him that she was not eligible for the service, and no further action was taken. Upon observation, the resident's toenails were found to be thick, yellow, and curled over the toes. There was no record of grievances or concerns regarding toenail care in the resident's records. The Licensed Practical Nurse (LPN) and Licensed Social Worker (LSW) interviews revealed that the facility had a process involving a contracted services company for toenail care, but the resident was deemed ineligible due to resource limitations. The LSW admitted to not following up after the initial referral was denied. The Director of Nursing (DON) acknowledged the condition of the resident's toenails and expressed that the staff was uncomfortable providing care due to the toenails' condition. The deficiency was identified before any corrective actions were taken.
Failure to Implement Safety Interventions for Residents
Penalty
Summary
The facility failed to ensure the resident environment was free from accident hazards, as evidenced by the lack of fall interventions for two residents. Resident #31's care plan included the use of bed bolsters as a fall intervention, but an observation confirmed that these bolsters were not in place. This oversight indicates a failure to adhere to the prescribed safety measures outlined in the resident's care plan. Additionally, Resident #213, who had a history of wandering and elopement, was care planned to have a wanderguard device on their leg and wheelchair. However, it was discovered that the orders for this device were not entered until after surveyor intervention, despite a previous incident where the resident had removed the device and exited the facility. The Director of Nursing confirmed the lapse in implementing the necessary safety intervention, highlighting a significant oversight in managing the resident's risk for elopement.
Deficiency in Enteral Feeding and Medication Administration
Penalty
Summary
The facility failed to ensure that a resident who is fed by enteral means received the appropriate treatment and services to prevent complications. During an observation of medication administration for Resident #36, it was noted that the Licensed Practical Nurse (LPN) #35 was preparing and administering medications via the resident's feeding tube. The LPN crushed several medications together and mixed them with water before administering them through the feeding tube. However, the syringe became disconnected, causing some of the medication and water to spill onto the resident's shirt. Additionally, the LPN did not administer the full amount of medication, as evidenced by particles remaining in the cup. The LPN also failed to follow the prescribed protocol for enteral feeding and medication administration. The resident's orders required flushing the feeding tube with 30 milliliters of water before and after medication administration, which was not completed. Furthermore, the LPN did not check the gastric residual volume (GRV) before administering the medications and enteral feeding, as required by the resident's care plan. The failure to check GRV could potentially lead to complications if the residual volume was too high. Moreover, the LPN administered the Isosource 1.5 feeding an hour and a half late and did not administer the Baclofen, Haloperidol, and Norco medications in their entirety. The resident's care plan also included a 120 ml water flush for hydration, which was omitted by the LPN. These actions and inactions by the LPN resulted in a deficiency in the care provided to Resident #36, as the facility did not ensure the resident received the appropriate treatment and services to prevent complications from the enteral feeding tube.
Failure to Assess Bed Rail Safety
Penalty
Summary
The facility failed to properly assess a resident for the use of bed rails, which was identified during a long-term care survey. The deficiency involved a resident who had bed rails installed on their bed without a proper safety evaluation. An observation was made of the bed rails during an investigation of accident hazards. Upon reviewing the care plan, it was found that the resident was not care planned to have bed rails. Additionally, a bed evaluation indicated the resident's interest in bed rails, but no safety evaluation was completed. Corporate RN #85 confirmed the absence of a bed rail safety evaluation and expressed unfamiliarity with what such an evaluation entails.
LPN Lacks Competency in Enteral Feeding Tube Care
Penalty
Summary
The facility failed to ensure that an LPN had the appropriate competencies to care for a resident with an enteral feeding tube. During an observation of medication administration, the LPN was seen preparing and administering medications incorrectly for a resident who was fed by enteral means. The LPN crushed several medications together and mixed them with water, but failed to administer the entire mixture, leaving medication residue in the cup. Additionally, the LPN did not flush the feeding tube with water after administering the enteral feeding and did not check the gastric volume residual (GVR) before starting the medication administration and feeding process. The facility was unable to provide evidence that the LPN's competencies regarding feeding tube care were reviewed upon her hire. The Director of Nursing was informed of the LPN's failure to flush the tube and check the GVR, but no further information was provided. The facility provided several competencies completed with the LPN, but none were related to the care and services required for residents with an enteral feeding tube.
Failure to Notify Physician of Behavioral Changes in Dementia Resident
Penalty
Summary
The facility failed to notify the physician of a change in baseline behaviors immediately for a resident diagnosed with dementia. This deficiency was identified during a long-term care survey process, where it was found that the resident had returned from a local behavioral health facility with worsening behaviors. Despite the escalation in behaviors, the physician was not informed until surveyor intervention occurred, which led to an Immediate Jeopardy situation. The resident exhibited a range of aggressive and disruptive behaviors over several days, including physical aggression, verbal threats, and attempts to elope. These behaviors were documented on behavioral monitoring task sheets, but the facility did not take the necessary step of notifying the physician promptly. The Director of Nursing confirmed during an interview that the physician was only notified after the surveyor's intervention, highlighting a lapse in the facility's protocol for managing changes in resident behavior.
Medication Administration Errors Lead to High Error Rate
Penalty
Summary
The facility failed to maintain a medication error rate of 5% or less, with an observed rate of 16.67%. This deficiency was identified during a medication administration observation for a resident. The Licensed Practical Nurse (LPN) involved in the administration made several errors, including failing to administer medications in their entirety and omitting required water flushes before and after medication administration. Specifically, the LPN did not administer the full doses of Baclofen, Haloperidol, and Norco, and omitted a 30 ml water flush and a 120 ml hydration flush. Additionally, the LPN administered Isosource 1.5 late and failed to check the gastric residual volume (GRV) as required. The errors were compounded by the LPN's failure to ensure that all medication was delivered through the resident's feeding tube, as evidenced by medication remaining in the cup after administration. The LPN also did not adhere to the prescribed schedule for medication administration, resulting in late administration of Isosource 1.5. These actions led to a total of seven medication errors out of 45 opportunities, contributing to the high medication error rate. The Director of Nursing was informed of these errors, but no further information was provided in the report.
Incomplete and Inaccurate Medical Records
Penalty
Summary
The facility failed to maintain accurate and complete medical records for two residents during the survey process. For one resident, the transfer form was found to be incomplete, with the transfer date incorrectly listed as a date prior to the actual transfer to an acute care facility. This discrepancy was confirmed by the Administrator and the Corporate RN. For another resident, the Physician's Scope of Orders for Treatment (POST) form was incomplete, as the signatures of the resident and the resident representative were present but lacked a date. This issue was also confirmed by the Administrator.
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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