The error affected how staff addressed the resident's comfort needs and pain management. Resident 118's care plan focused on "alterations in comfort related to chronic pain, neuropathy, left knee pain, bilateral calf pain, bladder spasms, Parkinsons disease, fibromyalgia, ganglion right wrist, spondylosis, osteroarthritis."
But the resident didn't have Parkinson's disease.
Inspectors discovered the mistake during a records review on October 21. The care plan had never been corrected to reflect the resident's actual diagnosis of restless leg syndrome, a neurological disorder that causes uncomfortable sensations in the legs and an irresistible urge to move them.
The distinction matters for treatment. Parkinson's disease is a progressive disorder affecting movement, balance, and coordination. Restless leg syndrome primarily involves leg discomfort that worsens at rest and improves with movement. The medications, therapies, and care approaches differ significantly between the two conditions.
Administrator 22 confirmed the error when confronted by inspectors at 11:45 AM that same day. The administrator acknowledged that the Parkinson's disease diagnosis was incorrect and should have been restless leg syndrome.
Federal regulations require nursing homes to develop complete care plans within seven days of comprehensive assessments. These plans must be prepared, reviewed, and revised by teams of health professionals. When medical conditions change or diagnoses are corrected, facilities must update care plans accordingly.
The inspection occurred in response to a complaint, though the nature of that complaint wasn't detailed in the federal report. Inspectors reviewed 20 residents' records during the survey process and found the diagnostic error affected one person at the 116-bed facility.
Care plans guide daily treatment decisions. They determine which medications residents receive, what therapies they participate in, and how staff address their symptoms. An incorrect diagnosis can lead to inappropriate treatments or missed opportunities for symptom relief.
For someone with restless leg syndrome, effective management might include specific positioning techniques, timing of activities, or medications that target the neurological pathways involved in the condition. Parkinson's care typically focuses on different movement strategies and medication regimens.
The error persisted despite federal requirements that care plans be regularly reviewed and updated. Nursing homes must reassess residents at least quarterly and whenever significant changes occur in their condition.
Hilltop Center operates on Saddleshop Road in this small West Virginia community. The facility houses 116 residents, according to the October inspection report.
Federal inspectors classified this as a minimal harm violation affecting few residents. However, diagnostic accuracy forms the foundation of all nursing home care decisions.
The administrator's immediate acknowledgment of the error suggests staff recognized the problem once it was identified. But the inspection report doesn't indicate how long the incorrect diagnosis remained in place or what steps the facility took to prevent similar mistakes.
Medical record accuracy has become a growing concern in long-term care facilities as electronic systems make it easier to copy and paste information without verification. Diagnoses can persist in care plans long after they've been ruled out or corrected by physicians.
This case highlights the importance of regular care plan reviews and the need for nursing home staff to verify that documented conditions match residents' actual medical status. Even seemingly minor documentation errors can affect the quality and appropriateness of daily care decisions.
The inspection was completed October 23, 2025.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Hilltop Center from 2025-10-23 including all violations, facility responses, and corrective action plans.