Valley View Care and Rehabilitation
For profit - Limited Liability company
76 Beds
CONSULATE HEALTH CARE/INDEPENDENCE LIVING CENTERS/NSPIRE HEALTHCARE/RAYDIANT HEALTH CARE
Data: November 2025
Trust Grade
48/100
#209 of 417 in NC
Photo by Clc Adisdir2
Photo by Jacqueline Hanna
Photo by Jacqueline Hanna
1 / 5 photos
Last Inspection: March 2025
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
Valley View Care and Rehabilitation has a Trust Grade of D, which means it is below average with some significant concerns. It ranks #209 out of 417 nursing homes in North Carolina, placing it in the bottom half, and is #2 out of 2 in Cherokee County, indicating that there is only one local option that is better. The facility is improving, with issues decreasing from 14 in 2023 to 6 in 2025. Staffing is a notable strength here, with a perfect 5/5 star rating and a turnover rate of 39%, which is lower than the state average of 49%, suggesting staff stability and familiarity with residents. However, there are serious concerns, including incidents where a resident was not assisted with a hygiene issue, leading to feelings of neglect, and failures to provide adequate staffing for essential care tasks for multiple residents. Additionally, the kitchen cleanliness was found lacking, with expired food items and a dirty floor, which raises health concerns. Overall, while there are strengths, potential residents and their families should weigh these alongside the identified weaknesses.
- Trust Score
- D
- In North Carolina
- #209/417
- Safety Record
- Moderate
- Inspections
- Getting Better
- Staff Stability ○ Average
- 39% turnover. Near North Carolina's 48% average. Typical for the industry.
- Penalties ○ Average
- $9,770 in fines. Higher than 70% of North Carolina facilities. Some compliance issues.
- Skilled Nurses ✓ Good
- Each resident gets 61 minutes of Registered Nurse (RN) attention daily — more than 97% of North Carolina nursing homes. RNs are the most trained staff who catch health problems before they become serious.
- Violations ⚠ Watch
- 21 deficiencies on record. Higher than average. Multiple issues found across inspections.
48/100
Top 50%
Needs review
14 → 6 violations
★★★☆☆
3.0
Overall Rating
★★★★★
5.0
Staff Levels
★★☆☆☆
2.0
Care Quality
★★☆☆☆
2.0
Inspection Score
↔
Stable
2023: 14 issues
2025: 6 issues
The Good
-
5-Star Staffing Rating · Excellent nurse staffing levels
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
-
Staff turnover below average (39%)
9 points below North Carolina average of 48%
Facility shows strength in staffing levels, fire safety.
The Bad
3-Star Overall Rating
Near North Carolina average (2.8)
Meets federal standards, typical of most facilities
Staff Turnover: 39%
Near North Carolina avg (46%)
Typical for the industry
Federal Fines: $9,770
Below median ($33,413)
Minor penalties assessed
Chain: CONSULATE HEALTH CARE/INDEPENDENCE
Part of a multi-facility chain
Ask about local staffing decisions and management
The Ugly 21 deficiencies on record
2 actual harm
Mar 2025
6 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interviews with residents and staff, the facility failed to maintain repair or replace damaged bed pow...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interviews with residents and staff, the facility failed to maintain repair or replace damaged bed power cord for 2 of 12 ( Room#101 and Room#103) resident rooms on 1 of 4 resident halls reviewed for maintaining a safe, clean, and homelike environment.
The findings included:
a.On 3/11/25 at 11:16 AM an observation of room [ROOM NUMBER] b bed revealed the bed remote and power cord lying on top of the bed. Electrical tape was wrapped around multiple areas of the bed's power cord. Further observation revealed the outer protective wire coating was broken, torn, or missing exposing 3 inner color-coded wires spanning the length of the visible portion of the power cord as it attached under the bed.
The resident in room [ROOM NUMBER] was interviewed on 3/11/25 at 3:30 PM. She stated the bed power cord wire had been damaged and wrapped with electrical tape for as long as she had been in the room.
A follow-up observation of room [ROOM NUMBER] b bed on 3/14/25 at 11:30 AM found the bed cord unchanged.
b.On 3/11/25 at 3:42 PM an observation of room [ROOM NUMBER] b bed revealed the bed remote and the power cord laying on top of the bed. Black electrical tape was wrapped around the cord in 5 locations. Upon closer observation, the power cord's outer wire covering was missing sections of the protective covering. The inner color-coded wires were exposed and visible without electrical tape covering the inner wires. The resident stated during the observation that the bed remote power cord had been damaged for 2 years without repair.
On 3/14/25 at 11:30 AM an observation of room [ROOM NUMBER] b bed and 103 b bed with the Maintenance Director revealed the bed cords to be unchanged. The Maintenance Director stated the bed power cords were damaged and replacement power cords had been ordered 2-3 weeks prior.
A follow-up interview with the Maintenance Director was conducted on 3/14/25 at 11:51 AM. He stated a replacement cord for a bed was ordered 2-3 weeks prior when he was made aware of the damaged cord by an administrative staff who was conducting a round in room [ROOM NUMBER] room. The Maintenance Director presented an invoice dated 2/17/25 for one replacement bed power cord. The ordered cord was delivered to the facility earlier in the week and the replacement cord did not fit the bed in room [ROOM NUMBER] and another power cord needed to be ordered. He stated the cord had not been reordered, and he would place an order on the current day (3/14/25). The Maintenance Director said he would replace room [ROOM NUMBER] b bed with a manually operated bed until the correct cord had arrived. The Maintenance Director went on to state he was unaware how many of the bed power cords needed to be replaced in the facility, and he would conduct an audit, he was not aware of room [ROOM NUMBER] b bed's damaged bed cord. The Maintenance Director stated room [ROOM NUMBER] b bed and 103 b bed's damaged power cords did not have frayed or exposed inner wires, the outside coating of the power cords was cracked and missing in some places and he felt the damaged cords did not pose an electric shock hazard. He reported he had placed electrical tape around the damaged cords at some point and could not recall how long it had been. Additionally, the Maintenance Director reported he did not have a specific routine audit of the bed cords but did monthly checks of the mattresses that would include looking at the bed power cords.
The Administrator was interviewed on 3/14/25 at 12:17 PM and stated the damaged bed cords should have been repaired or replaced when they were identified.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
Based on observations, record review, and staff and Medical Director interviews, the facility failed to follow their infection control policies and procedures for Enhanced Barrier Precautions (EBP) fo...
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Based on observations, record review, and staff and Medical Director interviews, the facility failed to follow their infection control policies and procedures for Enhanced Barrier Precautions (EBP) for a resident (Resident #23) with a feeding tube and a resident with a wound (Resident #32) when Nurse #1 failed to wear a gown while administering a tube feeding for Resident #23 and the Wound Care Nurse failed to wear a gown while performing wound care for Resident #32. This deficiency occurred for 2 of 2 staff members reviewed for infection control practices (Nurse #1 and the Wound Care Nurse).
The findings included:
Review of the facility's policy and procedure dated August 2022 entitled Enhanced Barrier Precautions read in part:
Enhanced Barrier Precautions (EBP) are used as an infection control intervention to reduce the spread of multidrug-resistant organisms (MDROs) to residents. EBP's employ targeted gown, and glove use during high-contact resident care activities when contact precautions do not otherwise apply.
Examples of high-contact care activities requiring the use of gown and glove for EBP include: Device care or use: central line, urinary catheter, feeding tube, tracheostomy/ ventilator; wound care (any skin opening requiring a dressing).
EBPs are indicated for residents with wounds and/or indwelling medical devices, regardless of MDRO colonization.
1. An observation was completed on 3/12/25 at 2:20 PM of Nurse #1 accessing Resident #23's gastrostomy feeding tube and administering his tube feeding. The nurse performed hand hygiene using hand sanitizer and donned clean gloves. She did not don a gown. Nurse #1 checked placement of the feeding tube, flushed the tube with water, administered a bolus tube feeding through the tube, flushed the tube with water, and replaced the stopper at the end of the tube. She disposed of the trash, removed her gloves, and performed hand hygiene using hand sanitizer.
An interview was conducted with Nurse #1 on 3/12/25 at 2:30 PM. Nurse #1 said the EBP sign on the outside of Resident #23's room door was for Resident #23's roommate. She explained the EBP sign was hung above or below the name on the door to identify who in the room the EBP were for. She reported she had received education on EBP and that residents with indwelling devices and wounds should have EBP. She said she should have known Resident #23 needed EBP since he had a feeding tube, but said she did not think about it. Nurse #1 reported she should have worn a gown and gloves when she did Resident #23's tube feeding.
An interview was conducted with the Infection Preventionist (IP) on 3/14/25 at 9:39 AM. She explained residents with indwelling devices and chronic wounds should have EBP in place. She said Nurse #1 should have worn a gown and gloves when administering Resident #23's tube feeding. The IP said she thought Nurse #1 may have been nervous and just forgot. She said Nurse #1 had received education on EBP and should have known Resident #23 needed EBP since he had a feeding tube.
An interview was conducted with the Medical Director on 3/14/25 at 1:37 PM. The Medical Director reported she was familiar with EBP. She stated the facility should use and follow EBP for residents with feeding tubes.
An interview was conducted with the Director of Nursing (DON) and Administrator on 3/14/25 at 4:44 PM. The DON said residents with wounds and indwelling devices should have EBP in place. She explained nurses should follow EBP and should wear a gown and gloves for residents who require EBP. The DON reported Nurse #1 should have worn a gown when administering Resident #23's tube feeding. The Administrator added the facility has plenty of personal protective equipment (PPE) and that it was just human error.
2. An observation and interview was completed on 3/13/25 at 12:37 PM with the Wound Care Nurse. The Wound Care Nurse was observed performing wound care to Resident #32's right foot wound. The Wound Care Nurse said the wound was classified as a vascular wound and betadine was being applied to the wound because of maceration around the wound. She performed hand hygiene using hand sanitizer, donned gloves, and removed the dressing from the bottom of Resident #32's right foot and placed the dressing in the trash. She removed her gloves, performed hand hygiene using hand sanitizer, and donned new gloves. She cleaned the wound with normal saline, she removed her gloves and performed hand hygiene using hand sanitizer. She donned new gloves, applied betadine to the wound, and covered the wound with a foam dressing. She removed her gloves and performed hand hygiene using hand sanitizer.
An additional interview was conducted with the Wound Care Nurse on 3/14/25 at 8:52 AM. She reported she had not worn a gown when performing Resident #32's wound care because she was not on EBP. The Wound Care Nurse reported EBP were used if a resident grew out an organism on a wound culture, but that EBP was not used for other wounds. The Wound Care Nurse stated she was not sure if residents with wounds should have EBP. She said she thought chronic wounds may need EBP but that she would check and let the surveyor know. The Wound Care Nurse returned after a few minutes and said she checked with the Infection Preventionist (IP) and was told anyone with chronic wounds needed EBP. She reported she was not aware Resident #32 needed EBP and that was why she did not use EBP and wear a gown when she did her wound care. The Wound Care Nurse said she had received education on EBP.
An interview was conducted with the IP on 3/14/25 at 9:39 AM. She explained residents with indwelling devices and chronic wounds should have EBP in place. The IP reported gown and gloves should be worn when performing wound care. The IP said Resident #32 had not had EBP in place because the IP was not aware of her wound. She reported there should be better communication between herself and the Wound Care Nurse about wounds. The IP said the Wound Care Nurse had received education on EBP, she said she was not sure why the Wound Care Nurse did not remember Residents with wounds needed EBP.
An interview was conducted with the Medical Director on 3/14/25 at 1:37 PM. The Medical Director reported she was familiar with EBP. She stated the facility should use and follow EBP for residents with wounds.
An interview was conducted with the Director of Nursing (DON) and Administrator on 3/14/25 at 4:44 PM. The DON said residents with wounds and indwelling devices should have EBP in place. She said there was miscommunication between the IP and Wound Care Nurse and that was why Resident #32 did not have EBP in place. She explained nurses should follow EBP and wear gown and gloves for resident who required EBP. The Administrator added the facility has plenty of personal protective equipment (PPE) and that it was just human error.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident #17 was admitted on [DATE] with diagnoses that included type 2 diabetes mellitus.
Resident #17 had a care plan date...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident #17 was admitted on [DATE] with diagnoses that included type 2 diabetes mellitus.
Resident #17 had a care plan dated 6/25/24 for type 2 diabetes dated 6/25/24 with interventions that included to monitor blood glucose checks as ordered.
Resident #17 had a physician's order dated 12/14/24 for dulaglutide pen-injector 1.5 milligrams to inject 3 milligrams subcutaneously weekly every Saturday. (Dulaglutide is a once-a-week injection drug prescribed to treat type 2 diabetes mellitus.)
Resident #17 had a physician order dated with a start date 1/10/25 and end date 1/20/25 for fingerstick glucose (blood sugar check) two times daily (BID) before meals.
A review of Resident #17's Medication Administration Record (MAR) for January 2025 found blood glucose checks were not initialed as completed on 1/10/25 through 1/18/25 at 6:00 AM and 4:30PM. On 1/19/25 Nurse #2 had initialed blood glucose check was completed at 4:30 PM and the blood sugar level was not documented on the MAR.
Nurse #2 was interviewed on 4/14/25 at 12:53 PM. She stated she was assigned to Resident #17 on some of the days the blood glucose checks were not completed. Nurse #2 said she was not aware Resident #17 had an order blood glucose checks two times daily before meals from 1/10/25 through 1/18/25. Nurse #2 confirmed that Resident #17 did have an order for blood glucose checks beginning on 1/10/25 and was not able to explain why the blood sugar checks were not completed, and confirmed Resident #17 had a current order to check blood sugars. Nurse #2 stated she always followed physician orders and completed all blood sugar checks.
The Medical Director was interviewed on 3/14/25 at 1:38 PM. She stated the order for Resident #17 to receive blood sugar checks was written on 1/10/25 by the Nurse Practitioner. The Medical Director stated the Nurse Practitioner did not correctly enter the order into the electronic chart and it was not visible for the nurses to see. The Medical Director stated the NP and herself had not received much training for entering orders in the electronic medical chart and did not enter the orders correctly.
An interview was conducted with the Director of Nursing (DON) 3/14/25 at 4:44 PM. The DON explained the order for Resident #17's blood glucose checks had been entered by the Nurse Practitioner incorrectly and did not pull to the MAR to for the nurses to see. The DON stated the nurses did not know to check his blood glucose because it was not on the MAR. The DON explained orders were reviewed during the morning clinical meeting. She reported an orders report from the prior day was pulled and the orders were reviewed from the printed report. The DON stated order entries were not reviewed to ensure they had been made visible for nurses to see on the MAR. The DON said there was not a current process for a second check of orders entered by providers to ensure they had been entered correctly.
An interview was conducted with the Administrator on 3/14/25 at 4:53 PM. The Administrator said staff had not known to check Resident #17's blood glucose because the order had been entered incorrectly by the Nurse Practitioner. The Administrator said there should be a process for checking orders entered by providers to ensure they were entered correctly.
Based on record review, staff, resident and Medical Director interviews, the facility failed to follow physician orders for checking a diabetic resident's blood glucose levels twice daily for 2 of 2 residents with physician orders for blood sugar monitoring (Resident #23 and Resident #17).
The findings included:
1. Resident #23 was admitted to the facility on [DATE]. His medical diagnoses included: Diabetes Mellitus Type-2.
The admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #23 was cognitively intact.
Resident #23 had a care plan for Diabetes Mellitus type-2 dated 2/28/25. The care plan interventions read, fasting serum blood sugar as ordered by doctor.
Review of Resident #23's active physician orders for March 2025 revealed the following orders:
- An order dated 2/17/25 that read, Lantus (long-acting insulin)100 unit/ milliliter (ml), inject 20 units subcutaneously at bedtime.
- An order dated 2/21/25 entered by the Medical Director that read, blood glucose (BG) twice daily.
Review of the electronic medical record revealed the following blood glucose results:
- A result of 125 obtained on 2/20/25
- A result of 193 obtained on 2/25/25
There were no other blood glucose results documented in the electronic medical record
An interview was conducted with Resident #23 on 3/12/25 at 2:04 PM. He said it had been a while since his blood glucose had been checked at the facility. Resident #23 said he felt like he had not experienced any symptoms of high or low blood sugar.
An interview was conducted with Nurse #1 on 3/12/25 at 2:20 PM. Nurse #1 stated Resident #23 did not get blood glucose checks and he did not have an order to check them. After she reviewed his active physician order, Nurse #1 verbalized Resident #23 did have an active order for blood glucose checks twice a day. She opened the blood glucose order entry details and reviewed the order. After reviewing the order entry details, Nurse #1 explained the order had been entered in by the Medical Director. She further explained the order did not show up on Resident #23's Medication Administration Record (MAR) because the order had been entered incorrectly. Nurse #1 stated she did not know to check Resident #23's blood glucose because the order did not pull to the MAR to let her know to check it. Nurse #1 reported there was not a process she was aware of for checking orders entered by providers to ensure they were entered correctly.
An interview was conducted with the Medical Director on 3/13/25 at 1:37 PM. The Medical Director reported she had been notified about Resident #23's blood glucose order being entered She said the staff did not know to check Resident #23's blood glucose because she had not entered the order correctly to pull to the MAR.
An interview was conducted with the Director of Nursing (DON) 3/14/25 at 4:44 PM. The DON explained the order for Resident #23's blood glucose checks had been entered by the Medical Director incorrectly and did not pull to the MAR to for the nurses to see. The DON stated the nurses did not know to check his blood glucose because it was not on the MAR. The DON explained orders were reviewed during the morning clinical meeting. She reported an orders report from the prior day was pulled and the orders were reviewed from the printed report. The DON stated order entry was not checked for the orders when they were reviewed during the morning meeting. The DON said there was not a current process for a second check of orders entered by providers to ensure they had been entered correctly.
An interview was conducted with the Administrator on 3/14/25 at 4:50 PM. The Administrator said staff had not known to check Resident #23's blood glucose because the order had been entered incorrectly by the Medical Director. The Administrator said there should be a process for checking orders entered by providers to ensure they were entered correctly.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Drug Regimen Review
(Tag F0756)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident #17 was admitted on [DATE] with diagnoses that included type 2 diabetes mellitus, depression, and anxiety.
Resident ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident #17 was admitted on [DATE] with diagnoses that included type 2 diabetes mellitus, depression, and anxiety.
Resident #17's quarterly Minimum Data Set (MDS) dated [DATE] coded her as severely cognitively impaired. She was coded for taking an antidepressant.
Resident #17 had a physician's order dated 7/23/24 for trazadone Hcl oral tablet 50 milligrams give one tablet by mouth as needed (PRN) for insomnia at bedtime. The physician's order was discontinued on 11/25/24.
Pharmacy recommendations from July 2024 through February 2025 for Resident #17 were reviewed:
A recommendation dated 7/26/24 read in part Resident #17 had a PRN antidepressant trazadone without a stop date. The physician's response was to add a 14-day stop date and was signed dated 8/14/24. The pharmacy recommendation dated 9/9/24 repeated the recommendation, with the same physician response.
A pharmacy recommendation dated 11/13/24 read in part Resident #17's prescriber accepted a pharmacy recommendation to add a stop date to PRN trazadone on 8/15/24, but the order has not been processed. The pharmacy recommendation was signed by the Director of Nursing on 11/25/24 and noted the order for trazadone PRN was discontinued 11/25/24.
The DON stated on 3/14/25 at 10:25 AM the pharmacy recommendation to place a stop date on the PRN trazadone was overlooked by her in the August 2024 pharmacy review and she did not discontinue the medication until 11/24/24 pharmacy recommendation found it. The DON stated until recently, she was not retaining or scanning the pharmacy recommendations into the electronic charting when she received them from the consulting pharmacist. The DON said she was faxing the physician responses to the pharmacy recommendations to the pharmacy, and she thought the pharmacy was changing the orders.
The Consultant Pharmacist was interviewed on 3/14/25 at 11:15 AM and stated PRN psychoactive medications should have a 14-day stop date. He said he had made recommendations for a 14-day stop date for any PRN psychoactive medications a resident received that did not include a stop date and they were sent to the DON monthly.
The Medical Director was interviewed on 3/14/25 at 1:37 PM. She stated her orders should be followed to add a 14-day stop date to the antipsychotic medication.
The Administrator stated on 3/14/25 at 4:53 PM the DON was faxing signed physician pharmacy recommendations to the pharmacy. The DON did not know she needed to make the changes in Resident #17's orders.
Based on record review, and staff, Medical Director, and Consultant Pharmacist interviews, the facility failed to follow the pharmacy recommendations to complete an Abnormal Involuntary Movement Scale (AIMS) assessment for a resident (Resident #46) who received an antipsychotic medication. In addition, the facility failed to follow pharmacy recommendations that had been signed by the physician to add a 14-day stop date for a prn (as needed) psychotropic medication for a Resident #17. This deficient practice occurred for 2 of 5 residents reviewed for pharmacy recommendations (Resident #46 and Resident #17).
The findings included:
1. Resident #46 was admitted to the facility on [DATE] with diagnoses that included paranoid schizophrenia, anxiety disorder, and major depressive disorder.
A review of Resident #46's active physician's orders revealed the following orders:
-An order dated 7/10/24 that read, olanzapine (antipsychotic medication) 2.5 milligrams (mg) give one tablet by mouth one time a day every Tuesday, Thursday, and Saturday for schizophrenia.
-An order dated 12/24/24 that read, olanzapine 5 mg by mouth daily for schizophrenia.
A quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #46 was cognitively intact. He was not documented for behaviors or rejection of care. The MDS documented that he received antipsychotic medication.
Review of the Consultant Pharmacist's pharmacy consultation reports revealed an AIMS assessment was recommended on 10/12/24, 12/7/24, and on 2/9/25. (Abnormal Involuntary Movement Scale is a scale to measure abnormal involuntary movements in patients taking antipsychotic medications).
The pharmacy recommendations dated 10/12/24, 12/7/24, and 2/9/25 read, please monitor for involuntary movements now and at least every 6 months or per facility protocol. It is recommended that monitoring frequency increase following does adjustments. The comments read, [Resident #46] receives olanzapine which may cause involuntary movements, including tardive dyskinesia (abnormal involuntary movements caused by medications), but an abnormal involuntary movement scale (AIMS), or other appropriate assessment was not documented in the medical record within the previous 6 months.
-The pharmacy recommendation dated 10/12/24 was signed by the Director of Nursing (DON) on 10/24/24. Under DON comments it read, recommendations added to orders.
-The pharmacy recommendation dated 12/7/24 was signed by the Director of Nursing on 12/23/24. Under DON comments it read, order updated with recommendation.
-The pharmacy recommendation dated 2/9/25 was signed by the Director of Nursing on 2/19/25. Under DON comments it read, followed recommendation.
An interview was conducted on 3/14/25 at 11:15 AM with the Consultant Pharmacist. The consultation report recommendations for Resident #46 from 10/24/24, 12/23/24, and 2/19/24 were for an AIMS assessment to be completed due to Resident #46 receiving an antipsychotic medication. The Consultant Pharmacist stated he kept sending the recommendation because he did not see an AIMS assessment that had been done.
An interview was conducted with the Director of Nursing on 3/14/25 at 10:14 AM. She reported she was responsible for reviewing and ensuring pharmacy recommendations were completed. The DON explained she had misunderstood what the pharmacy recommendations for Resident #46 were asking for. The DON explained she had added to monitor for involuntary movements now and at least every 6 months as an order and added it to the olanzapine medication order for Resident #46. The DON reported she had not realized the pharmacy recommendations indicated an AIMS assessment needed to be completed for Resident #46.
An interview was conducted with the Medical Director on 3/14/25 at 1:37 PM. The Medical Director stated the facility should follow pharmacy recommendations.
An interview was conducted with the Administrator on 3/14/25 at 4:44 PM. The Administrator said Resident #46 should have had an AIMS completed and the pharmacy recommendations should have been followed. The Administrator stated she was not sure why the DON missed the recommendation to do an AIMS.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Medication Errors
(Tag F0758)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2.Resident #17 was admitted on [DATE] with diagnoses that included type 2 diabetes mellitus, depression, and anxiety.
Resident #...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2.Resident #17 was admitted on [DATE] with diagnoses that included type 2 diabetes mellitus, depression, and anxiety.
Resident #17's quarterly Minimum Data Set (MDS) dated [DATE] coded her as severely cognitively impaired. She was coded for taking an antidepressant
Resident #17 had a physician's order dated 7/23/24 for trazadone Hcl oral tablet 50 milligrams give one tablet by mouth as needed (PRN) for insomnia at bedtime. The physician's order was discontinued on 11/25/24.
Pharmacy recommendations from July 2024 - February 2025 for Resident #17 were reviewed. A recommendation dated 7/26/24 read in part Resident #17 had a PRN antidepressant trazadone without a stop date. The physician's response was to add a 14-day stop date and was signed dated 8/14/24.
A recommendation dated 11/13/24 read in part Resident #17's prescriber accepted a pharmacy recommendation to add a stop date to PRN trazadone on 8/15/24, but the order has not been processed. The pharmacy recommendation was signed by the Director of Nursing on 11/25/24 and noted the order for trazadone PRN was discontinued 11/25/24.
The DON stated on 3/14/25 at 10:25 AM the pharmacy recommendation to place a stop date on the PRN trazadone was overlooked by her in the August 2024 pharmacy review and she did not discontinue the medication until 11/24/24 pharmacy recommendation found it. The DON stated until recently, she was not retaining or scanning the pharmacy recommendations into the electronic charting when she received them from the consulting pharmacist. The DON said she was faxing the physician responses to the pharmacy recommendations to the pharmacy, and she thought the pharmacy was changing the orders.
The consultant pharmacist was interviewed on 3/14/25 at 11:15 AM and stated PRN psychoactive medications should have a 14-day stop date. He said he had made recommendations for a 14-day stop date for any PRN psychoactive medications a resident received that did not include a stop date and they were sent to the DON monthly.
The Medical Director was interviewed on 3/14/25 at 1:37 PM. She stated her orders should be followed to add a 14-day stop date to the antipsychotic medication.
The Administrator stated on 3/14/25 at 4:53 PM the DON was faxing signed physician pharmacy recommendations to the pharmacy. The DON did not know she needed to make the changes in Resident #17's orders.
Based on record review, staff, Medical Director, and Consultant Pharmacist interviews, the facility failed to complete an AIMS (Abnormal Involuntary Movement Scale) assessment for a resident who received an antipsychotic medication (Resident #46). In addition, the facility failed to ensure a physician order for an as needed (prn) psychotropic medication was limited to 14 days (Resident #17). This deficient practice occurred for 2 of 5 residents reviewed for unnecessary psychotropic medications (Resident #46 and Resident #17).
The findings included:
1. Resident #46 was admitted to the facility on [DATE] with diagnoses that included paranoid schizophrenia, anxiety disorder, and major depressive disorder.
A review of the electronic medical record revealed Resident #46's last AIMs was completed on 10/5/23. (Abnormal Involuntary Movement Scale is a scale to measure abnormal involuntary movements in patients taking antipsychotic medications).
A review of Resident #46's active physician's orders revealed the following orders:
-An order dated 7/10/24 that read, olanzapine (antipsychotic medication) 2.5 milligrams (mg) give one tablet by mouth one time a day every Tuesday, Thursday, and Saturday for schizophrenia.
-An order dated 12/24/24 that read, olanzapine 5 mg by mouth daily for schizophrenia.
A quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #46 was cognitively intact. He was not documented for behaviors or rejection of care. The MDS documented that he received antipsychotic medication.
An interview was conducted on 3/14/25 at 11:15 AM with the Consultant Pharmacist. He explained what he was looking for when he did the pharmacy medical record review for Resident #46 was a documented AIMS assessment with a date on it and he had not seen that completed.
An interview was conducted with the Director of Nursing on 3/14/25 at 10:14 AM. She explained the MDS nurse was historically responsible for completing the AIMS assessments. The DON reported the facility had changed MDS nurses several times in the last couple of years. She stated the current MDS nurse was new in the position and was not aware it was something she needed to do. The DON said she was not entirely sure on how often AIMS assessments needed to be completed until she looked up the policy today (3/14/25), she reported she kind of new but was not entirely sure. The DON stated after checking the policy, AIMS assessments should be completed on admission, when there were changes in the antipsychotic medication, and quarterly.
An interview was conducted with the MDS Nurse on 3/14/25 at 4:11 PM. The MDS Nurse reported she had worked at the facility since August 2024. She explained she had not been told she was supposed to do the AIMS assessments or was supposed to look and make sure they were done. She further explained she had not been told AIMS were part of her role, she said if it was, she was unaware. The MDS Nurse stated she did not know who was supposed to do the AIMS assessments or was responsible for them.
An interview was conducted with the Medical Director on 3/14/25 at 1:37 PM. The Medical Director stated the facility should complete AIMS assessments to monitor residents for side effects of antipsychotic medications.
An interview was conducted with the Administrator on 3/14/25 at 4:44 PM. The Administrator said AIMS assessments should be completed for residents who received antipsychotic medication. The Administrator said AIMS assessments should be done every three months, when a new medication was added, or if requested by pharmacy or a provider.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Dental Services
(Tag F0791)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and staff interviews the facility failed to provide dental services for 1 of 1 (Resident #17) residents ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and staff interviews the facility failed to provide dental services for 1 of 1 (Resident #17) residents reviewed for providing emergency dental services.
The findings included:
Resident #17 was admitted on [DATE] with diagnoses that included type 2 diabetes mellitus and heart failure.
Resident #17 was care planned for oral and dental health problems on 06/25/24 with interventions that included monitor document and report any signs or symptoms of oral problems needing attention and provide mouth care.
Resident #17 had a physician order dated 7/23/24 for dental consultation as needed.
A provider progress note dated 11/25/24 read in part the resident had a lesion in the left lower buccal (cheek) fold along the edge of the left lower denture. The resident is agreeable to an alteration to the lower denture area. The provider wrote that a dental consult would be beneficial to make some alterations along the lower edge of the left lower denture.
Resident #17 had a physician order dated 11/25/24 that read; dental referral to evaluate lower full denture which is causing recurrent buccal trauma.
Resident #17's quarterly Minimum Data Set (MDS) assessment dated [DATE] coded her as severely cognitively impaired. She was coded for loose or broken dentures and yes for difficulty, pain with swallowing chewing. She required a therapeutic and mechanically altered diet and needed set-up assistance with eating.
A Provider Progress Note dated 2/3/25 read in part, Resident #17 was seen for sore area on the left side of her mouth and jaw. The resident had issues with her denture causing recurrent trauma to her inner left mouth area in the last few months. The denture needed to be modified, and the dental consultation was not completed. Resident #17 had an approximately .5 to 1 centimeter laceration and the left lower buccal fold that was adjacent to the sharp edge of her lower denture. The provider note wrote Resident #17 had an appointment in-house for a dental consultation on 2/5/25.
A nursing progress note dated 2/8/25 written by Nurse #1 read Resident #17 had a sore area on her left inner cheek. The resident stated it was very sore, and magic mouthwash did not help much. The resident's bottom denture was very loose, and the resident's family was concerned. A note was left for the Physician to evaluate and advise.
Attempts to interview Nurse #1 were unsuccessful.
A progress note written by a provider dated 2/11/25 read in part the resident was seen at the request of Resident #17's family for a follow-up concern regarding a mouth lesion. The resident had been seen for this concern numerous times starting in the fall of 2024 when a dental consult was placed. The progress note wrote, it was determined the lesion was caused by the lower denture defect and required an alteration. The family did not want to take the resident out for dental care and the request was put in for residency care by the traveling dentist. She was scheduled to see the dentist at this location and was postponed until later in the week of 2/10/25 -2/14/25. The provider wrote the resident did not wear her bottom dentures that caused difficulty when eating. The progress note went on to say the provider had confirmed the dentist was coming to the facility later in the week of 2/10/25-2/14/25. The provider requested special attention that the resident was seen and if for some reason the resident was not seen by the dentist, the resident needed to be seen as soon as possible.
A note written on 3/6/25 by the Transportation Driver read Resident #17 will be seen by the dentist on 5/29/25 at 11:00 AM.
Resident #17 had a physician order dated 03/09/25 that read; lidocaine viscous (used to numb red, swollen, and painful sores in mouth) mouth and throat solution 2% with direction to place and dissolve 15 milliliters buccally before meals for left lower buccal lesion for 14 days and discontinue if lesion is healed.
A review of Resident #17's March 2025 Medication Administration Record (MAR) found the resident received the lidocaine viscous as ordered.
A review of the in-house dentist and dental hygienist visits and notes dated 10/30/24 through 3/10/25 was completed. Resident #17 was not seen by the hygienist or the dentist.
The business office manager (BOM) was interviewed on 3/13/25 at 3:28 PM. The BOM stated Resident #17's family initially did not want to enroll the resident into the dental program because they thought the resident was going to be a short-term resident. The family later decided the Resident #17 was going to be a long-term resident, and she was enrolled in the dental program on 1/27/25 by the resident's family. The residents' information along with physician order was sent to the in-house dental provider on 2/10/25. The BOM said the facility was unaware the resident was not seen on 3/10/25 and would be seen on the next visit to the facility on 4/16/25 and was unsure if the dental provider did emergent visits.
A follow-up interview with the BOM on 3/13/25 at 3:56 PM was conducted. The BOM stated the dental provider was called and asked if Resident #17 could be seen emergently. The dental provider told the BOM a triage form could be filled out and sent to the dental provider and a regional dentist would review and develop a plan of care for the resident. The BOM stated the facility was unaware of the triage form and the form would be completed on 3/13/25 and sent to the dental provider for Resident #17. Furthermore, the BOM said the dental provider told her the dentist needed to see Resident #17 for an evaluation prior to the dental hygienist providing any oral care. On 3/10/25 the dental hygienist was at the facility and Resident #17 had not been evaluated by a dentist and was not included on the list to be seen.
The Administrator was interviewed on 3/14/25 at 4:53 PM. She stated the facility did attempt to schedule Resident #17 a dentist appointment when the referral was written but was unable to find a dentist to accept the residents insurance. The Administrator said if the facility was aware of the triage option for the resident, it should have been completed and submitted soon after the resident was signed up with the in-house dentist. The resident was not included on the dental provider list to be seen on 3/10/25 because the dentist had not evaluated Resident #17. The Administrator said Resident #17 should have been seen on 3/10/25.
Nov 2023
14 deficiencies
2 Harm
SERIOUS
(G)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Actual Harm - a resident was hurt due to facility failures
Resident Rights
(Tag F0550)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and resident and staff interviews, the facility failed to maintain a resident's dignity by not providing ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and resident and staff interviews, the facility failed to maintain a resident's dignity by not providing assistance when requested by a resident (Resident #259) with a wet brief for 1 of 2 residents reviewed for dignity. Resident #259 stated this made her feel not too good, aggravated and worried that staff had forgotten her.
The findings included:
Resident #259 was admitted to the facility on [DATE] for Repair of Displaced Spiral Fracture of Right Tibia (a broken lower leg bone in a twisted motion) and Spondylosis (breakdown and separation of the lower spinal vertebra and disks).
The 5-Day admission Minimum Data Set Assessment on 10/25/23 indicated Resident #259 was cognitively intact. She was frequently continent of bladder and continent of bowel function. She had an impairment on her right lower extremity. She required partial/moderate assistance with toileting. Her vision was impaired and used glasses for reading small prints.
During an interview on 10/30/23 at 2:52 PM, Resident # 259 said she had periods of urinary incontinence since half of her perineal area was numb. She said she pressed her call light button because she had wet herself on 10/25/23 at 6:20 PM. Resident # 259 said there was a staff member who came after a while to check and ask what she needed and left. She said Nurse #4 came in next after an hour and gave her medications. She said the nurse told her she would leave her call light on and would ask staff to attend to her. She said nobody came to assist her until 9:50 PM. She said she laid in bed wet the whole time. She told the Social Worker and another nurse about the incident 3 to 4 days ago. Resident # 259 said she thought it was the Director of Nursing (DON) and Assistant Director of Nursing (ADON) who went to talk to her that next day, and they had a staff meeting.
During a follow-up interview on 11/1/23 at 10:45 AM, Resident # 259 clarified how she kept track of the time she had to wait for staff to assist her in changing her brief. She pointed to the clock in her room above the bathroom door and said that was how she knew how long she waited to be changed on 10/25/23. She said she used to be a nurse and worked in health care and knew she may have to wait a little bit. She stated it was a lady with long black hair that finally helped her at 9:50 PM. She stated she did not feel good about it mentally but physically, the urine started to burn on her back side. Resident # 259 stated what aggravated her the most was that they left her call light on, and she could not press it again when she got worried that the staff had forgotten her. Resident # 259 said she called her family member on her cell phone that night on 10/25/23 and her family member got mad and offered to go to the facility, but she told him not to. She said she had her call light on for twenty minutes the morning of 11/1/23. She said the medication nurse came in to give her medications around 9:00 AM. The nurse told her the staff were passing out ice in the other hallway and left her call light on. Resident # 259 said she got worried and thought here we go again. She said Nurse Aide (NA) #7 finally came after about 20 minutes and assisted her with changing her brief. She stated residents' needs should take precedence over passing out ice.
During another follow-up interview on 11/2/23 at 8:55 AM, Resident # 259 said it was Receptionist #1 who came to check on her first the night of 10/25/23. She said she told Receptionist #1 she needed to be dried. Resident # 259 said she could not remember the exact time and said it was between 7:00 to 8:00 PM. She said she was not changed after dinner that night because staff said they could not change anybody until trays were out. She said the staff usually served dinner at 5:30 PM. Resident # 259 said nobody ever turned her call light off when she turned it on, not even the nurse who gave her medication.
During an interview on 11/1/23 at 4:05 PM, NA #11 said she worked from 4:00 PM to 7:00 PM on 10/25/23 on D Hall where Resident #259 resided. She said NA #10 took over D Hall at 7:00 PM. She said she did remember Resident # 259's call light was on at dinner time. NA #11 said she went in and asked what the resident needed. She said Resident #259 needed her brief changed. NA #11 said she told Resident # 259 that they were passing out dinner trays and were not allowed to change residents until all trays were passed out. She said she left the call light on and went to help pass out trays. NA #11 said she got re-assigned to work on the A, E and F halls and started doing her rounds. NA #11 stated she did not provide incontinence care to Resident #259 after dinner. Nobody made her aware that Resident # 259's call light was still on after she did her rounds. NA #11 stated she was told by nurses that the resident was pretty much continent but did not want to go to the bathroom. NA #11 said Resident # 259 could go to the bathroom by herself but said she had always changed Resident # 259's briefs when she was assigned to D hall and that the resident never asked for a bed pan.
During an interview on 10/31/23 6:05 PM, NA #10 said she worked from 7:00 PM to 7:00 AM on 10/25/23 on B, C and D hall where Resident #259 resided. NA #10 said she did not remember Resident #259's call light being on for a long time. She said that she might have been with another resident in another hall and was doing her rounds with another nurse aide. She said no one told her about Resident #259 needing to be changed and did not notice her call light being on for a long time. NA #10 said there were 2 nurses and 2 nurse aides working on the night of 10/25/23 and that was the normal staffing numbers. She said Resident #259's call light was on when she responded to her, and that the resident did not complain about her call light being on for a long time. NA #10 said the resident needed her brief changed. She said she could not remember exactly what time she responded to the resident's call light but said that was after her rounds at around 9:30 PM.
During a follow up telephone interview on 11/1/23 3:20 PM, NA #10 said Resident #259's brief was not fully soaked when she went to change her on 10/25/23. She said the resident's brief was a little wet but not soaking wet. NA #10 reported Resident #259 was able use the bedside commode some. NA #10 said when she went to answer the resident's call light, she just asked to be changed. She said Resident #259 did not say anything about being upset or having to wait for a long time.
During a telephone interview on 11/2/23 at 11:55 AM, Receptionist #1 said she answered Resident # 259's call light at around 7:45 pm on 10/25/23. She asked the resident what she needed, and Resident # 259 stated she needed her brief changed. Receptionist #1 said she told Resident # 259 that she would let the staff know. Receptionist #1 stated she saw NA #11 in another hall passing out ice/snack and told her at around 7:50 PM that Resident #259 needed to be changed. Receptionist #1 also found NA #10 near the nurse's station at around 8:03 PM and told her about Resident # 259's brief needing to be changed. Receptionist #1 said she did not see NA #11 go in Resident #259's room and did not see NA #10 go in the resident's room since she clocked out and left after telling NA #10. Receptionist #1 said Resident # 259's call light had been on since after dinner at around 5:30 PM and nobody cut it off, so she went to see what she needed.
During a telephone interview on 11/1/23 at 6:50 PM, Nurse #4 said she remembered answering Resident #259's call light last week at around 8:20 PM and asked what the resident needed. She said she could not remember the exact days but Resident #259 told her she needed changed. Nurse #4 said she told Resident #259 that she would tell NA #10 and told the resident she would leave her light on. Nurse #4 said NA #10 was passing out ice and snacks at that time. Nurse #4 said she told NA #10 that Resident #259 would like to be changed if she could. Nurse #4 said NA #10 went to Resident #259's room within 5 minutes. Nurse #4 said she went to pass out medications on the other hall and did not know if Resident #259's brief was changed at that time. Nurse #4 said the nurse aides do what they could. There were not enough of them at night. Nurse #4 said Resident #259's turned her call light on again the next night, and she might have had to wait longer that next night because NA #10 was checking other residents' vital signs and was changing other residents' briefs also. Resident #259 had to wait longer for maybe an hour. Nurse #4 said Resident #259 was concerned her call light was not working that night, but Nurse #4 said it was working because she turned it off while in resident's room and turned it back on when she left Resident #259's room.
During a telephone interview on 11/1/23 8:30 AM, the Assistant Director of Nursing (ADON) said the Staff Development Manager told her about Resident #259's complaint on 10/26/23. She said Resident #259 was upset about having to wait for a long time the night before to be changed. The ADON said she and the Social Worker (SW) went in to talk to Resident #259 on 10/26/23. ADON said Resident #259 reported that she turned her light on at around shift change and the nurse came in to give her medication. She said Resident #259's medication nurse told the resident that she would get somebody to help her and that she would leave her call light on so she would not be forgotten. The ADON said Resident #259 told her from 8:00 PM to 8:30 PM, the receptionist went to check on Resident #259 and told resident she would go find someone. The ADON said Resident #259 told her that it was close to 10:00 PM when staff came in to change her. The ADON said Resident #259 did have a clock in her room and had her personal cell phone. The ADON stated it was her expectation for anybody nearby to answer call lights immediately and for the nurses to supervise their nurse aides. She said she was not done with her investigation because NA #10 was not back to work until the evening of 11/1/23.
During a telephone interview on 11/2/23 at 3:10 PM, the Director of Nursing (DON) said they have had a staffing problem since she took the DON job 3 months ago. She also stated there was an existing culture problem with regards to not answering call lights immediately in the building. She said it was the Administrator's and her goal to continue improving the building to ensure residents were taken care of. The DON said the nurses were also expected to help check on the call lights and not just the nurse aides. She said she was not aware of a written protocol for nurse aides not to assist in changing resident's briefs if the nurse aides were passing out ice, snacks, or meal trays. She said she recently asked the nurse aides to do their rounds 30 minutes before meals to ensure the residents were dry. She said she asked them to do hourly rounding and was still trying to educate them. The DON said if the rounding was performed correctly, it would help everything including maintaining residents' dignity.
SERIOUS
(G)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Actual Harm - a resident was hurt due to facility failures
Deficiency F0725
(Tag F0725)
A resident was harmed · This affected 1 resident
Based on record review, observations, and staff interviews, the facility failed to provide sufficient nursing staff to assist residents with incontinence care, showers, bed baths and hair care, wound ...
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Based on record review, observations, and staff interviews, the facility failed to provide sufficient nursing staff to assist residents with incontinence care, showers, bed baths and hair care, wound care, and to provide pneumococcal vaccines to eligible residents for 5 of 12 residents (Residents #259, #51, #13, #25, and #7) reviewed for sufficient staffing.
The findings included:
This tag was cross-referenced to:
F550 - Based on record review and resident and staff interviews, the facility failed to maintain a resident's dignity by not providing assistance when requested by a resident (Resident #259) with a wet brief for 1 of 2 residents reviewed for dignity. Resident #259 stated this made her feel not too good, aggravated and worried that staff had forgotten her.
F561 - Based on record review, observation, and resident and staff interviews, the facility failed to honor a resident request to have two showers per week for 1 of 1 resident (Resident #51) reviewed for choices.
F677 - Based on record review, observations, resident and staff interviews, the facility failed to provide a complete bed bath and hair care to a dependent resident for 1 of 3 residents (Resident #13) reviewed for activities of daily living.
F684 - Based on observations, record review, resident, staff and Medical Director interviews, the facility failed to assess, obtain a physician's order and perform dressing changes for a weeping area on a resident's lower extremity for 1 of 1 resident reviewed for skin condition (Resident #25).
F883 - Based on record review, and staff interviews, the facility failed to administer the pneumococcal vaccine to eligible residents for 2 of 5 residents (Resident #259 and Resident #7) reviewed for immunizations.
An interview with Nurse Aide (NA) #7 on 10/31/23 at 5:13 PM revealed they used to have two shower aides at the facility but a few months ago, one of the shower aides got injured so she had to go back to working on a hall. The shower aide 2 list got assigned to the hall nurse aides which was too much for them because there were usually only two to three nurse aides to care for at least 50 residents on both the day and evening shifts. NA #7 stated that they didn't have enough time to get everything done.
An interview with Nurse #1 on 10/31/23 at 3:41 PM revealed she was supposed to be the wound care nurse, but she did not get to do this full-time because she got pulled to work on the hall most of the days she was scheduled to work.
An interview with the Scheduler on 11/2/23 at 8:47 AM revealed the staffing goal was to have at least 6-8 nurse aides, 2 hall nurses and a wound nurse for day shift but they had been down to 5-6 nurse aides depending on what day of the week it was. The Scheduler stated she still had been working around vacation requests since August. They normally had 2-3 hall nurse aides and 1-2 shower aides for day shift. For the evening shift from 7:00 PM to 7:00 AM, they had 2 nurses and 2 nurse aides but sometimes a nurse aide came in at 4:00 PM and helped until 11:00 PM. The Scheduler stated they needed at least 3 nurse aides for the evening shift. She shared that the current open positions at the facility were for 2 day shift nurses, 1 night shift nurse and 2 night shift nurse aides. The Scheduler stated they had been trying to recruit staff online and had patient care aides who were getting ready to take their certification test. She also revealed that the facility did not currently use agency staff and it had been over a year since they had last used them due to a corporate decision.
A phone interview with the Director of Nursing (DON) on 11/2/23 at 2:02 PM revealed the facility had a staffing problem and she herself had been pulled to work on a hall at least 4-5 times since August. She shared that in the past two weeks, they had hired more nurses and nurse aides to cover some of the current open positions the facility had.
An interview with the Administrator on 11/2/23 at 2:55 PM revealed they did have some openings but the staffing number each day had been going up as far as how many people were employed by the facility. The Administrator stated some of the staffing challenges the facility faced was due to some staff being out due to health issues and a few of the nurse aides were terminated even before the Administrator started working at the facility. She shared that they had increased their wages, offered sign-on bonuses and referral bonuses, advertised on all the social media platforms, and ordered some signs to post around town that they were hiring. The Administrator acknowledged that staffing had been worse this week than it had been in a while.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0558
(Tag F0558)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interviews with resident and staff, the facility failed to ensure a dependent resident ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interviews with resident and staff, the facility failed to ensure a dependent resident could access a light switch located behind her bed for 1 of 1 resident reviewed for accommodation of needs (Resident #1).
Resident #1 was admitted to the facility on [DATE].
Review of Resident #1's medical records revealed she had moved to her current room on 04/17/23.
The significant change in status Minimum Data Set (MDS) dated [DATE] assessed Resident #1 with moderate impairment in cognition. The MDS indicated walking between locations inside the room did not occur for Resident #1 during the assessment period.
During an observation conducted on 10/30/23 at 10:15 AM, the switch for the light fixture behind Resident #1's bed on the wall approximately 5 feet from the floor and 5 feet from Resident #1's bed with a cord approximately 4 inches attached. Resident #1 was unable to reach the switch cord from the bed if needed.
An interview was conducted with Resident #1 on 10/30/23 at 10:17 AM. She stated that she was bed bound and non-ambulatory. She did not have any control of the light fixture behind her bed as she could not reach the broken switch cord on the wall from her bed. She had to rely on nursing staff to control the light fixture for her each time and it was very inconvenient to her. Resident #1 added the switch cord was broken since she moved into this room about 6 months ago. She had never brought up her concern to any staff so far. However, she wanted the maintenance staff to fix it as soon as possible.
Subsequent observations conducted on 10/31/23 at 9:42 AM and 11/01/23 at 10:11 AM revealed that the switch cord for the light fixture behind Resident #1's bed remained in disrepair.
During a joint observation conducted with Nurse Aide (NA) #1 and Nurse #2 on 11/01/23 at 1:11 PM, the switch cord for the light fixture behind Resident #1's bed remained inaccessible from her bed. Both nursing staff acknowledged that the switch cord needed to be fixed immediately.
An interview was conducted with NA #1 on 11/01/23 at 1:15 PM. She stated that she worked in A hall frequently and had provided care for Resident #1 on a regular basis. She did not notice that the switch cord for the light fixture behind Resident #1's bed was broken and inaccessible from her bed. NA #1 explained Resident #1 never voiced accessibility concerns for the light fixture behind her bed when receiving care so far. She added the light fixture behind Resident #1's bed should always be accessible.
During an interview conducted with Nurse #2 on 11/01/23 at 1:18 PM, she confirmed she had provided care for Resident #1 frequently, but she did not notice that the switch cord for the light fixture behind Resident #1's bed was broken and inaccessible from her bed. She added Resident #1 was bed bound and it was important for her to have accessibility to the light fixture behind the bed all the time.
An interview was conducted with the Maintenance Director on 11/01/23 at 1:22 PM. He stated that he did not notice the switch cord for Resident #1's light fixture behind her bed was broken and acknowledged that it needed to be fixed as soon as possible. He performed daily walk throughs for the facility to identify repair needs. Once a week, he would conduct a more detailed walk through that included the interior of residents' rooms and bathrooms. In most cases, he depended on the staff to report repair needs via work orders or verbal notifications. He checked the work orders at least twice daily to ensure all repair needs being addressed in a timely manner.
During a phone interview conducted on 11/02/23 at 2:10 PM, the Director of Nursing (DON) expected the staff to be more attentive to residents' living environment and report repair needs in a timely manner.
An interview was conducted on 11/02/23 at 2:57 PM with the Administrator. She expected nursing staff to be more attentive to residents' homes and reported repair needs to the Maintenance Manager in a timely manner. It was her expectation for all the dependent residents to have accessibility and full control of the light fixture behind their bed all the time.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0561
(Tag F0561)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and resident and staff interviews, the facility failed to honor a resident request to have ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and resident and staff interviews, the facility failed to honor a resident request to have two showers per week for 1 of 1 resident (Resident #51) reviewed for choices.
The findings included:
Resident #51 was admitted to the facility on [DATE] with diagnoses that included cerebrovascular disease and muscle weakness.
The admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #15 was cognitively intact, had no rejection of care behaviors, and it was very important for her to choose between a tub bath, shower, bed bath, or sponge bath. The MDS further indicated that Resident #15 required extensive physical assistance with bathing and had impairment to one side of her upper extremities.
Resident #51's care plan revised on 9/19/23 indicated Resident #51 has an activities of daily living self-care performance deficit related to history of cerebrovascular accident, decreased range of motion, unsteady gait, and general weakness. Interventions included Resident #51 required partial assistance by one staff with bathing/showering at a minimum of twice weekly and as necessary.
A review of the undated facility shower schedule indicated Resident #51 was scheduled to receive bathing and personal hygiene twice weekly on Tuesdays and Fridays during day shift (7:00 AM to 7:00 PM) under shower aide 2.
A review of the Documentation Survey Report for October 2023 indicated Resident #51 was recorded as having received a shower on 10/3/23, 10/6/23, 10/10/23, 10/13/23, 10/20/23 and 10/24/23, and a partial bed bath on 10/31/23. There was no documentation for 10/17/23 and 10/27/23 as indicated by blank spots on the report.
An observation and interview with Resident #51 on 10/30/23 at 9:50 AM revealed she was supposed to receive two showers per week, but she only received one shower because the facility did not have enough staff. Resident #51 stated she last received a shower on 10/24/23. No body odors were observed during the interview.
An interview with NA #7 on 10/31/23 at 5:13 PM revealed she worked an extra shift on 10/17/23 and came in at 9:00 AM to work until 5:00 PM. NA #7 was assigned to do the shower aide 2 list which included Resident #51. However, she was not able to give Resident #51 a shower that day because she didn't have enough time to do it. NA #7 stated whoever was assigned to do showers the next day should have given Resident #51 a make-up shower.
An interview with NA #8 on 11/1/23 at 2:48 PM revealed she was assigned to care for Resident #51 on 10/17/23 from 7:00 AM to 7:00 PM but she did not have enough time to give her shower on that day. NA #8 stated it was hard to do the scheduled showers when they had to watch the floor, assist residents during meals and provide incontinence care at least every two hours.
An interview with NA #1 on 10/31/23 at 3:55 PM revealed she started working as a shower aide on 10/30/23 but had been working as a nurse aide on the halls prior to that. NA #1 stated she was assigned to Resident #51 on 10/27/23 but she did not have enough time to give her scheduled shower.
An interview with NA#2 on 11/1/23 at 3:08 PM revealed she had been assigned to do showers from Mondays to Fridays from 8:00 AM to 4:00 PM but she sometimes got pulled to work as a nurse aide on a hall when they didn't have enough nurse aides working. NA #2 stated she had never given Resident #51 a shower because she was not on her list of residents to do. NA #2 stated she had shower aide 1 list and shower aide 2 list was assigned to NA #1.
A follow-up interview with NA #1 on 11/2/23 at 11:17 AM revealed she was assigned to give Resident #51 a shower on 10/31/23 but she did not have enough time to give her one because she had a lot of other residents to give showers to, so they moved her shower to 11/1/23.
A phone interview with the Director of Nursing (DON) on 11/2/23 at 2:02 PM revealed she was not aware that Resident #51 had not been receiving her two scheduled showers per week. The DON stated that the facility had a staffing problem, and she hoped that every staff member was doing all they could do to provide care to the residents. The DON stated that she wished the residents could get bathed more than twice a week and it was heartbreaking to find out that Resident #51 was only receiving one shower a week.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interviews with resident and staff, the facility failed to maintain a wheelchair in good...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interviews with resident and staff, the facility failed to maintain a wheelchair in good repair for 1 of 2 residents reviewed for a safe comfortable, homelike environment (Resident #37).
The findings included:
Resident #37 was admitted to the facility on [DATE].
Review of the quarterly Minimum Data Set on 7/29/23 revealed Resident #37 had moderate cognitive impairment. She was independent with transfer and was able to walk in her room. Resident #37 used wheelchair primarily for mobility.
During an observation and interview on 10/30/23 at 10:35 AM, Resident #37 was seen sitting on her wheelchair. She was wearing a short-sleeved blouse and both arms were propped on the arm rests of her wheelchair. She was holding a folded washcloth on her right hand. Both armrests on her wheelchair had lines of exposed yellow sponge with cracked, peeling black vinyl tears at the side. Resident #37 stated they were scratchy, so she used the washcloth to cover her arm to keep from getting scratched. She stated she had the wheelchair since she got to the facility, and she needed a new one. She could not remember how long the wheelchair had been torn and said her family member was supposed to get her a new one.
During a follow up observation of resident on 10/30/23 at 1:15 PM, Resident # 37 was inside her bedroom, sitting on her wheelchair and was eating her lunch. Both elbows were propped on her arm rests while she fed herself. She had the same short-sleeved blouse she was wearing earlier that day, and the washcloth was on her lap.
During a follow up observation on 10/31/23 at 10:13 AM, Resident #37 was lying in bed with eyes closed. She was wearing a long sleeve blouse. The same wheelchair with torn vinyl covering on both arm rests was parked beside her bed.
During a follow up observation on 11/1/23 8:47 AM, Resident #37 was lying in bed with eyes closed. She was wearing a long sleeve tunic. The same wheelchair with torn vinyl covering on both arm rests was parked beside her bed.
During an interview on 11/2/23 at 9:48 AM, Nurse Aide (NA) #7 stated she started working in January and had not noticed the resident's wheelchair being torn. She stated she mostly got in Resident #37's room to check on the resident herself and did not observe her wheelchair.
During an interview on 11/2/23 at 9:52 AM, Nurse #5 stated she regularly worked D Hall where Resident #37 resided. She stated she did not notice Resident #37's wheelchair being torn. She stated the night shift staff did the cleaning of the wheelchair but was not aware of the cleaning schedule.
During an interview on 11/2/23 at 10:30 AM, the Maintenance Director stated the nursing staff on third shift were responsible for cleaning the residents' wheelchairs every day. He stated his maintenance staff were responsible for repairs and maintenance of equipment. The Maintenance Director stated his staff repaired broken wheelchairs if the nursing staff would let them know. He stated nobody notified him of Resident #37's wheelchair being in disrepair.
During a telephone interview on 11/2/23 at 2:25 PM, the Director of Nursing (DON) stated the third shift nursing aides were responsible for cleaning the wheelchairs daily and as needed. If there were cracked wheels, peeling or if they needed replacement, the staff needed to replace those wheelchairs. She stated the staff had access to the Therapist's storage room at night if they needed replacement wheelchairs. The DON stated if there were repairs needed, the nurse aides knew to fill out maintenance request forms. She stated they were taught how to do that and should have submitted repair requests.
During an interview on 11/2/23 at 10:30 AM, the Administrator stated the nursing staff on third shift were responsible for cleaning the residents' wheelchairs every day. The Administrator stated the maintenance department was responsible for repairs and maintenance of equipment. The Administrator stated she was not sure if the night shift staff knew to submit repair requests when they find issues with the wheelchairs but would check on it.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations, resident and staff interviews, the facility failed to provide a complete bed bath and hair...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations, resident and staff interviews, the facility failed to provide a complete bed bath and hair care to a dependent resident for 1 of 3 residents (Resident #13) reviewed for activities of daily living.
The findings included:
Resident #13 was admitted to the facility on [DATE] with diagnoses that included congestive heart failure and muscle weakness.
Resident #13's care plan dated 10/3/23 indicated that she had an activities of daily living self-care performance deficit related to poor activity tolerance, generalized weakness and deconditioning. She was totally dependent on staff to provide bath on scheduled bath day and as necessary, and required maximum assistance by one to two staff with personal hygiene.
The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #13 was cognitively intact, had no rejection of care behaviors, and had impairment to both sides of the lower extremities. The MDS further indicated that Resident #13 required substantial or maximal assistance with bathing and personal hygiene.
A review of the undated facility shower schedule indicated Resident #13 was scheduled to receive bathing and personal hygiene twice weekly on Tuesdays and Fridays during day shift (7:00 AM to 7:00 PM) under shower aide 2.
A review of the Documentation Survey Report for October 2023 indicated Resident #13 was recorded as having received a partial bed bath on 10/3/23 and 10/31/23, and a bed bath on 10/10/23 and 10/17/23. Not applicable was documented for Resident #13's baths on 10/6/23, 10/13/23, 10/24/23, and 10/27/23. There was no documentation for 10/20/23 as indicated by a blank spot on the report.
A review of the nurses' progress notes from 10/1/23 through 10/31/23 in Resident #13's medical record indicated no notes regarding Resident #13 refusing baths or hair care.
An observation and interview with Resident #13 on 10/30/23 at 10:40 AM revealed her hair was tousled, oily and greasy with a large amount of white flakes observed on the top of her head. Resident #13 stated that she received one bed bath per week, but it had been awhile since her hair had been washed.
A follow-up observation of Resident #13 on 10/31/23 at 4:52 PM revealed Resident #13 sleeping on her bed with her head turned towards the left side. Her hair remained oily, and knots and tangles were observed at the back of her head.
A phone interview with Nurse Aide (NA) #3 on 10/31/23 at 3:49 PM revealed she was assigned to take care of Resident #13 on 10/6/23, 10/13/23 and 10/27/23 from 7:00 AM to 7:00 PM. NA #3 stated she documented not applicable for Resident #13's baths because they did not occur. NA #3 stated she didn't know she was supposed to give Resident #13 a complete bed bath on the days that she was assigned to her. NA #3 further stated that when she was assigned to Resident #13's care, she usually wiped her off which meant washing her face, hands, underarms and providing perineal care as needed. NA #3 shared that there was usually a nurse aide assigned to do just the showers or complete bed baths. She added that she had never washed Resident #13's hair.
A phone interview with NA #4 on 11/1/23 at 1:13 PM revealed she was assigned to care for Resident #13 on 10/3/23 and 10/24/23 from 7:00 AM to 7:00 PM. On 10/3/23, NA #4 documented that she gave Resident #13 a partial bed bath because she washed her underarms, back, leg and perineal area but she didn't wash her hair. NA #4 stated she must have been assigned to Resident #13's hall on those days which was why she only provided her a partial bed bath on 10/3/23. On 10/24/23, NA #4 documented not applicable on Resident #13's bath record because the shower aide for that day must have already left when she did her charting, and she didn't know whether she gave Resident #13 a bed bath or not. NA #4 shared that she didn't notice anything different with Resident #13's hair and could not describe what it looked like to her.
An interview with NA #1 on 10/31/23 at 3:55 PM revealed she started working as a shower aide on 10/30/23 but had been working as a nurse aide on the halls prior to that. NA #1 stated that Resident #13 was supposed to receive a complete bed bath instead of a shower, but she was not sure whether it was because Resident #13 didn't want to get up out of the bed or because of her needing at least two staff due to her size. NA #1 stated that she had washed Resident #13's hair once which was about two to three months ago while she was helping the nurse aide assigned to Resident #13. NA #1 further stated that Resident #13 receiving a complete bed bath and her hair washed depended on the staffing level because she required two staff members to give her a complete bed bath. NA #1 remembered seeing Resident #13 on 10/30/23 and noticed that her hair looked greasy and unkempt. She also stated that she remembered when she washed Resident #13's hair a few months ago, she had a mat at the back of her bed. NA #1 shared that Resident #13 did not refuse care or be given a bed bath and hair care.
An interview with NA#2 on 11/1/23 at 3:08 PM revealed she had been assigned to do showers from Mondays to Fridays from 8:00 AM to 4:00 PM but she sometimes got pulled to work as a nurse aide on a hall when they didn't have enough nurse aides working. NA #2 stated she had never given Resident #13 a bed bath or hair care because she was not on her list of residents to do. NA #2 stated she had shower aide 1 list and shower aide 2 list was assigned to NA #1.
A follow-up interview with NA #1 on 11/2/23 at 11:17 AM revealed she did not have enough time to give Resident #13 a complete bed bath and wash her hair on 10/31/23 because she had a lot of residents she needed to give a shower to.
An interview with NA #5 on 10/31/23 at 4:41 PM revealed she was assigned to take care of Resident #13 on 10/31/23 from 7:00 AM to 7:00 PM but she didn't give her a bed bath or washed her hair. NA #5 stated she changed Resident #13 twice on her shift, changed her gown twice and repositioned her three times. NA #5 further stated that Resident #13 asked her to shave her hair, but she didn't look at the back of Resident #13's hair if she had any mats.
A follow-up interview with Resident #13 on 10/31/23 at 6:38 PM revealed she did not receive a bed bath on 10/31/23 and they didn't usually wash her hair. Resident #13 stated that she had never refused to get her hair washed or combed and had never refused a bed bath. Resident #13 further stated that she had requested a nurse aide to shave her hair in the back because it would feel more comfortable for her. Resident #13 stated that her hair was matted at the back of her head, and she could feel it. Resident #13 shared that it had been a long time since they had washed her hair.
An interview with NA #6 on 11/1/23 at 3:23 PM revealed she had given Resident #13 a bed bath and washed her hair on 10/17/23. NA #6 stated she used a shower cap and let her hair soak as she did her bed bath. NA #6 stated she remembered Resident #13's hair was hard to manage, and she had to brush it twice to get the tangles out of her hair. NA #6 further stated that Resident #13's hair could get tangled easily because she laid on her bed all the time and she had noticed her hair being oily, greasy and flaky because she had dry skin.
An interview with Nurse #1 on 10/31/23 at 6:59 PM revealed she had noticed Resident #13's hair being oily and tangled but this was because she stayed in bed all the time and she liked to lie as flat as she could in her bed. Nurse #1 stated that the nurse aides were supposed to use a shower cap to wash Resident #13's hair whenever they gave her a bed bath, but she wasn't there all the time to make sure that they were doing what they were supposed to do.
A phone interview with the Director of Nursing (DON) on 11/2/23 at 2:02 PM revealed she did not notice any changes with Resident #13's hair but they had a bath schedule that the nurse aides should be following. The DON stated that she was not aware that Resident #13 had not been receiving a complete bed bath as scheduled or her hair not being washed. The DON further stated that Resident #13 should receive bed baths no less than twice a week as scheduled.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, resident, staff and Medical Director interviews, the facility failed to assess, obtain a p...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, resident, staff and Medical Director interviews, the facility failed to assess, obtain a physician's order and perform dressing changes for a weeping area on a resident's lower extremity for 1 of 1 resident reviewed for skin condition (Resident #25).
The findings included:
Resident #25 was admitted to the facility on [DATE] with diagnoses including hypertension, congestive heart failure, and basal cell carcinoma of the left lower limb and hip.
Review of discontinued physician orders included an order written on 7/10/23 for Muciprocin External Ointment 2%. Apply to left lower extremity topically every 24 hours as needed for chronic recurrent skin condition. Cleanse with normal saline, pat dry, apply Muciprocin Ointment, cover with Xeroform and apply dry dressing as needed (PRN). This order ended on 10/13/23.
Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #25 had moderate cognitive impairment. He did not have an open lesion at the time of assessment.
Review of the Physician Orders dated 10/13/23 included consult wound care PRN, weekly skin sweeps, and monitor left lower extremity (LLE) for open blister or drainage every shift.
An observation of Resident #25 on 10/30/23 at 3:30 PM revealed he had a yellow gauze dressing with petrolatum taped on his lower leg above his ankle that was dated 10/25/23. A moderate amount of brownish stain was showing through the tape. Resident #25 said a nurse put the dressing on but was not sure why.
An observation of Resident #25 on 10/31/23 at 10:10 AM revealed the same dressing dated 10/25/23 was still on his left lower leg. The same brownish stain was observed through the tape.
An observation of Resident #25 on 11/1/23 at 9:13 AM revealed the same dressing dated 10/25/23 was still on resident's left lower leg.
During an initial interview on 11/1/23 at 9:08 AM, Nurse #5 said she did not know Resident #25 had a dressing on that leg. She said the resident's leg swelled up from sitting too long and started draining. That dressing was to catch the drainage. Nurse #5 said the Wound Care Nurse (WCN) changed dressings Mondays to Wednesday and the nurses on the hall changed dressings on Thursdays and Fridays. She said there was a nurse coming in at 11:00 AM that day of the interview to take over the WCN's assigned hall so the WCN could change dressings.
During a follow up interview on 11/1/23 at 9:39 AM, Nurse #5 said she usually worked D hall where Resident #25 resided. She said Resident # 25 came to her on 10/25/23 showing his left lower leg that was draining light yellow substance. Nurse #5 said she was busy and thought Resident #25 had an existing PRN dressing order. She said she just put a gauze dressing with petrolatum and covered it with a dry dressing on his left lower leg. She said the WCN could enter the order if it was for simple dressings like that. Nurse #5 said she did not look at the Treatment Administration Record (TAR) and just assumed Resident #25 still had his PRN dressing order. She said she would have entered the order herself if she looked at the TAR and found there was no order. Nurse #5 said Resident #25's lower legs were edematous on 10/25/23. She said there was an old dressing on Resident #25's left lower leg that was intact and did not look saturated. Nurse #5 said she did not know who put it on and when it was applied. She said she took off the old dressing and said the skin on the resident's left lower leg was pink and had a white macerated area. She added that the skin under the macerated area was draining a lot of light yellowish drainage. Nurse #5 said the staff usually discouraged Resident #25 from staying in his wheelchair, but he did not remember instructions. Nurse #5 said she had not observed the resident out of his wheelchair very often and was always sitting on it during the day.
During an interview on 11/1/23 at 9:14 AM, the Wound Care Nurse (WCN) revealed Resident #25 had edema on his left lower leg that drained from time to time, and he had a PRN order for that dressing. The WCN checked the resident's electronic record during the interview and stated she could not find it. She said Resident #25 used to have a PRN order and for nurses to change the dressing three times a week.
On 11/1/23 at 9:30 AM, during an observation of wound care to Resident #25, the WCN peeled the resident's dressing off his left lower leg. The outer dressing had a moderate amount of yellowish-brownish liquid on it. The WCN took out two gauze pads directly over the skin and wiped the area with normal saline. The skin area had some whitish superficial skin layer that easily came off when wiped with normal saline. The whole area under the dressing, with a size approximately four inches in length and four inches in width, was reddish in color. The WCN patted the cleaned area with dry gauze and left it to air dry.
During a follow up interview on 11/1/23 at 9:35 AM, the WCN revealed that the nurse who applied the initial dressing should have entered the order so other nurses would know when to change the dressing when they looked at the Treatment Administration Record. The WCN stated Resident #25's dressing used to be changed three times a week. She stated she changed dressings for 16 hours a week only. Most of the time she was filling up holes in the schedule and worked in the hallway. She stated that they were short of nurses and so she had to help a lot of times. She stated that she did rounds with the wound care provider every Mondays and that took up majority of her time during the day.
Review of nursing progress note written on 11/1/23 at 10:10 AM revealed a late entry by Nurse #5 for 10/25/23 stating Resident #25 had a reddened open area to left lower extremity with light yellow drainage. The area was cleaned, dried and dressing applied. Order was written for wound care.
Review of the physician order written on 11/1/23 at 10:00 AM stated to apply dry dressing on Resident#25's left lower extremity as needed (PRN) and to change the dressing three times a week.
During an interview on 11/2/23 at 1:25 PM, the Medical Director (MD) revealed Resident #25 had a chronic wound on his left lower extremity. The MD said it was an old site where the wound specialist took out a basal cell carcinoma (skin cancer) and that kept draining occasionally. The MD said the nurses should enter orders for dressing changes if it did not involve any antibiotics. He said the nurses also informed him and the wound care specialist when he came in if there was a new wound care needed.
During an interview on 11/2/23 at 2:15 PM, the Director of Nursing said if there were changes in resident's condition such as break in skin integrity, she said she expected the nurses to notify the doctor and obtain orders for treatment and complete their documentation
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0883
(Tag F0883)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, and staff interviews, the facility failed to administer the pneumococcal vaccine to eligible residents f...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, and staff interviews, the facility failed to administer the pneumococcal vaccine to eligible residents for 2 of 5 residents (Resident #259 and Resident #7) reviewed for immunizations.
The findings included:
A review of the facility's policy entitled Policies and Procedures with a revision date of 9/18/17 indicated under Subject: Pneumonia Vaccines: Residents admitted to the facility will be given the opportunity to receive the pneumococcal vaccine (PPSV23) and/or the Prevnar 13 (PCV13) vaccine per physician's order.
1. Resident #259 was admitted to the facility on [DATE] with diagnoses that included right lower leg fracture and chronic obstructive pulmonary disease.
A review of a physician's order dated 10/20/23 indicated to administer pneumovax if needed.
The Informed Consent for Pneumococcal Vaccine dated 10/20/23 indicated Resident #259 had received information about the PCV-20 vaccine and understood the risk and benefits of receiving this vaccine. Resident #259 indicated consent to receiving the vaccine by signing the consent form on 10/20/23.
An interview with the Staff Development Manager (SDM) on 11/2/23 at 2:27 PM revealed she hadn't gotten around to giving Resident #259's pneumococcal vaccine because she had been busy working on the floor as a hall nurse. The SDM stated she had just compiled the consent forms and ordered the pneumococcal vaccines from the pharmacy on 10/31/23. She had planned on setting up a clinic with the Assistant Director of Nursing who would help her administer the pneumococcal vaccines to eligible residents, but it was hard to schedule this because they both had been busy working on the halls.
A phone interview with the Director of Nursing (DON) on 11/2/23 at 2:22 PM revealed she knew that the SDM had ordered the pneumococcal vaccines, but she was not aware of the process of offering these to eligible residents.
2.Resident #7 was admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease.
A review of a physician's order dated 5/7/21 indicated to administer pneumovax if needed.
The Informed Consent for Pneumococcal Vaccine dated 10/20/23 indicated Resident #7 had received information about the PCV-20 vaccine and understood the risk and benefits of receiving this vaccine. Resident #7 indicated consent to receiving the vaccine by signing the consent form on 10/26/23.
An interview with the Staff Development Manager (SDM) on 11/2/23 at 2:27 PM revealed she hadn't gotten around to giving Resident #7's pneumococcal vaccine because she had been busy working on the floor as a hall nurse. The SDM stated she had just compiled the consent forms and ordered the pneumococcal vaccines from the pharmacy on 10/31/23. She had planned on setting up a clinic with the Assistant Director of Nursing who would help her administer the pneumococcal vaccines to eligible residents, but it was hard to schedule this because they both had been busy working on the halls.
A phone interview with the Director of Nursing (DON) on 11/2/23 at 2:22 PM revealed she knew that the SDM had ordered the pneumococcal vaccines, but she was not aware of the process of offering these to eligible residents.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0582
(Tag F0582)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews, the facility failed to provide completed Skilled Nursing Facility Advanced Benefici...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews, the facility failed to provide completed Skilled Nursing Facility Advanced Beneficiary Notices (SNF-ABN) prior to discharge from Medicare Part A skilled services to 3 of 3 residents (Resident #47, Resident #23 and Resident #29) and failed to issue a Notice of Medicare Non-Coverage (NOMNC) at least two days before the end of a Medicare part A stay for 1 of 3 residents (Resident #47) reviewed for beneficiary notification.
The findings included:
1. Resident #47 was admitted to the facility on [DATE].
A review of the medical record revealed a Notice of Medicare Non-Coverage (NOMNC) was discussed with Resident #47 on 7/24/23 which indicated Resident #47's Medicare Part A coverage for skilled services would end on 7/24/23. Resident #47 remained in the facility.
A review of Resident #47's medical record revealed no evidence a SNF-ABN was also provided to Resident #47.
An interview with the Business Office Manager on 11/1/23 at 11:22 AM revealed Resident #47 had used 69 days of his Medicare Part A days and had 31 days remaining, but she didn't issue a SNF-ABN because she thought it was only used for Part B residents. She explained that she had only been issuing a NOMNC to residents who were discharged from Medicare Part A but remained at the facility because this was how she was trained by the main office. The Business Office Manager stated that she normally tried to give the notice at least three days in advance but she just found out from therapy on the same day that Resident #47 was being discharged on 7/24/23.
An interview with the Administrator on 11/2/23 at 2:55 PM revealed the residents who got discharged from Medicare Part A services but remained at the facility should be issued both notices and she just talked to the Business Office Manager about this. The Administrator also stated the notices should be issued at least 2 days in advance prior to the end of the Medicare Part A stay.
2. Resident #23 was admitted to the facility on [DATE].
A review of the medical record revealed a Notice of Medicare Non-Coverage (NOMNC) was discussed with Resident #23 on 6/5/23 which indicated Resident #23's Medicare Part A coverage for skilled services would end on 6/15/23. Resident #23 remained in the facility.
A review of Resident #23's medical record revealed no evidence a SNF-ABN was also provided to Resident #23.
An interview with the Business Office Manager on 11/1/23 at 11:30 AM revealed Resident #23 had used 78 days of his Medicare Part A days and had 22 days remaining, but she didn't issue a SNF-ABN because she thought it was only used for Part B residents. She explained that she had only been issuing a NOMNC to residents who were discharged from Medicare Part A but remained at the facility because this was how she was trained by the main office.
An interview with the Administrator on 11/2/23 at 2:55 PM revealed the residents who got discharged from Medicare Part A services but remained at the facility should be issued both notices and she just talked to the Business Office Manager about this.
3. Resident #29 was admitted to the facility on [DATE].
A review of the medical record revealed a Notice of Medicare Non-Coverage (NOMNC) was discussed with Resident #29 on 9/26/23 which indicated Resident #29's Medicare Part A coverage for skilled services would end on 10/2/23. Resident #29 remained in the facility.
A review of Resident #29's medical record revealed no evidence a SNF-ABN was also provided to Resident #29.
An interview with the Business Office Manager on 11/1/23 at 11:33 AM revealed Resident #29 had used 37 days of her Medicare Part A days and had 63 days remaining, but she didn't issue a SNF-ABN because she thought it was only used for Part B residents. She explained that she had only been issuing a NOMNC to residents who were discharged from Medicare Part A but remained at the facility because this was how she was trained by the main office.
An interview with the Administrator on 11/2/23 at 2:55 PM revealed the residents who got discharged from Medicare Part A services but remained at the facility should be issued both notices and she just talked to the Business Office Manager about this.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0658
(Tag F0658)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews with the staff, Consultant Pharmacist, and Medical Director (MD), the facility failed to t...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews with the staff, Consultant Pharmacist, and Medical Director (MD), the facility failed to transcribe a probiotic as ordered by the physician resulting in 6 months additional administration of probiotic for 1 of 5 sample residents reviewed for unnecessary medications (Residents #28).
The findings included:
Resident #28 was admitted to the facility on [DATE] with diagnoses including cystitis.
The nurse's progress notes dated 04/24/23 charted by Nurse #1 revealed Resident #28 was assessed by the physician during rounds. New orders were received to start 1 tablet of Bactrim double strength (DS) 800/160 milligrams (mg) by mouth twice daily for 5 days for cystitis and 1 capsule of probiotic by mouth once daily for 7 days for antibiotic use. Nurse #1 documented she had completed transcribing the orders in the Medication Administration Records (MARs) on the same day.
Review of physician's orders dated 04/24/23 revealed Nurse #1 had input Resident #28's orders in the MARs to receive 1 tablet of Bactrim DS 800/160 mg by mouth twice daily for 5 days for cystitis and 1 capsule of probiotic by mouth once daily for ABT use. The probiotic order did not have a stop date.
Review of the MARs for the past 6 months revealed Resident #28's Bactrim DS was started on 04/25/23 and discontinued as ordered on 05/01/23. However, the MARs indicated that she had received 1 capsule of probiotic once daily from 04/25/23 until 10/31/23.
The quarterly Minimum Data Set (MDS) dated [DATE] assessed Resident #28 with moderate impairment in cognition.
An attempt to interview Resident #28 on 11/01/23 at 1:05 PM was unsuccessful. She was terminally ill and unresponsive to the surveyor's greetings. Her sisters were accompanying her at the bedside.
During an interview conducted on 11/01/23 at 1:56 PM, Nurse #1 confirmed she was the nurse who received the phone orders from the physician on 04/24/23 to administer 1 tablet of Bactrim DS 800/160 mg twice daily for 5 days for cystitis and 1 capsule of probiotic once daily for 7 days for Resident #28. She input both orders in the MARs on the same day and acknowledged that she had forgotten to set the 7-day stop date for the probiotic order during the transcription process. She confirmed Resident #28 had received probiotic daily from 04/25/23 until 10/31/23. She stated that probiotic should be discontinued after 7 days and acknowledged that her transcription error had caused Resident #28 to receive almost 6 additional months of unnecessary probiotic.
During an interview conducted on 11/02/23 at 1:19 PM, the MD stated that the probiotic order was for antibiotic use and should be discontinued after 7 days. He denied it would cause any adverse effects to Resident #28's health for taking approximately 6 additional months of probiotic. However, he expected the nurse to transcribe the order correctly to stop the probiotic as ordered after 7 days.
A phone interview was conducted with the Director of Nursing on 11/02/23 at 2:10 PM. She stated that the probiotic should be stopped after 7 days. It was her expectation for the nurse to transcribe all the physician's orders correctly.
During an interview with the Administrator on 11/02/23 at 2:57 PM, she expected the nurse to transcribe the physician's order correctly to stop Resident #28's probiotic after 7 days.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Drug Regimen Review
(Tag F0756)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews with the staff, Consultant Pharmacist, and Medical Director (MD), the Consultant Pharmacis...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews with the staff, Consultant Pharmacist, and Medical Director (MD), the Consultant Pharmacist failed to identify drug irregularities and provide recommendations for 1 of 5 sample residents reviewed for unnecessary medications (Residents #28).
The findings included:
Resident #28 was admitted to the facility on [DATE] with diagnoses including cystitis.
The nurse's progress notes dated 04/23/23 charted by Nurse #1 revealed Resident #28 had reported burning in vaginal area. Her urinalysis results were received and placed in physician's box. On 04/24/23, Nurse #1 documented Resident #28 was assessed by the physician during rounds. New orders were received to start 1 tablet of Bactrim double strength (DS) 800/160 milligrams (mg) by mouth twice daily for 5 days for cystitis and 1 capsule of probiotic by mouth once daily for 7 days for antibiotic use. Nurse #1 documented she had completed transcribing the orders in the Medication Administration Records (MARs) on the same day.
Review of physician's orders dated 04/24/23 revealed Nurse #1 had input Resident #28's orders in the MARs to receive 1 tablet of Bactrim DS 800/160 mg by mouth twice daily for 5 days for cystitis and 1 capsule of probiotic by mouth once daily for ABT use. The probiotic order did not have a stop date.
Review of the MARs for the past 6 months revealed Resident #28's Bactrim DS was started on 04/25/23 and discontinued as ordered on 05/01/23. However, the MARs indicated that she had received 1 capsule of probiotic once daily from 04/25/23 until 10/31/23.
Review of medical record revealed the Consultant Pharmacist had conducted monthly medication regimen reviews for Resident #28 on 05/17/23, 06/20/23, 07/18/23, 08/20/23, 09/17/23, and 10/16/23. However, he did not identify any drug irregularities related to probiotic and did not make any specified recommendations to the physician or nursing staff to correct the error.
A phone interview was conducted with the Consultant Pharmacist on 11/01/23 at 2:32 PM. He confirmed he had reviewed Resident #28's medication regimens once monthly in the past 10 months. He recalled seeing the probiotic order without a stop date and thought the physician might want to use it for some other purposes. He noted the probiotic order was written for ABT use and stated that it was not a proper abbreviation for antibiotic. That was why it did not alert him to probe the order further. If the word ABT was written as antibiotic, most likely he would investigate the order and determine the needs of continuous probiotic therapy.
During an interview conducted on 11/02/23 at 1:19 PM, the MD stated that the probiotic order was for antibiotic use and should be discontinued after 7 days. He denied it would cause any adverse effects to Resident #28's health for taking approximately 6 additional months of probiotic. The MD added the Consultant Pharmacist had full access to Resident #28's medical records and had reviewed her medication regimen at least once monthly, he expected the Consultant Pharmacist to identify the drug irregularities and report it in a timely manner.
A phone interview was conducted with the Director of Nursing on 11/02/23 at 2:10 PM. She stated that the probiotic should be stopped after 7 days. It was her expectation for the Consultant Pharmacist to identify the drug irregularities and report the findings to the facility in a timely manner.
During an interview with the Administrator on 11/02/23 at 2:57 PM, she stated the Consultant Pharmacist reviewed Resident #28's medications at least once monthly. It was her expectation for the Consultant Pharmacist to identify the drug irregularities and report the incident to the facility in a timely manner.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0757
(Tag F0757)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews with the staff, Consultant Pharmacist, and Medical Director (MD), the facility failed to d...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews with the staff, Consultant Pharmacist, and Medical Director (MD), the facility failed to discontinue a probiotic as ordered by the physician resulting in 6 months additional administration of unnecessary probiotic for 1 of 5 sample residents reviewed for unnecessary medications (Residents #28).
The findings included:
Resident #28 was admitted to the facility on [DATE] with diagnoses including cystitis.
The nurse's progress notes dated 04/23/23 charted by Nurse #1 revealed Resident #28 had reported burning in vaginal area. Her urinalysis results were received and placed in physician's box. On 04/24/23, Nurse #1 documented Resident #28 was assessed by the physician during rounds. New orders were received to start 1 tablet of Bactrim double strength (DS) 800/160 milligrams (mg) by mouth twice daily for 5 days for cystitis and 1 capsule of probiotic by mouth once daily for 7 days for antibiotic use. Nurse #1 documented she had completed transcribing the orders in the Medication Administration Records (MARs) on the same day.
Review of physician's orders dated 04/24/23 revealed Nurse #1 had input Resident #28's orders in the MARs to receive 1 tablet of Bactrim DS 800/160 mg by mouth twice daily for 5 days for cystitis and 1 capsule of probiotic by mouth once daily for ABT use. The probiotic order did not have a stop date.
Review of the MARs for the past 6 months revealed Resident #28's Bactrim DS was started on 04/25/23 and discontinued as ordered on 05/01/23. However, the MARs indicated that she had received 1 capsule of probiotic once daily from 04/25/23 until 10/31/23.
The quarterly Minimum Data Set (MDS) dated [DATE] assessed Resident #28 with moderate impairment in cognition.
An attempt to interview Resident #28 on 11/01/23 at 1:05 PM was unsuccessful. She was terminally ill and unresponsive to the surveyor's greetings. Her sisters were accompanying her at the bedside.
During an interview conducted on 11/01/23 at 1:56 PM, Nurse #1 confirmed she was the nurse who received the phone orders from the physician on 04/24/23 to administer 1 tablet of Bactrim DS 800/160 mg twice daily for 5 days for cystitis and 1 capsule of probiotic once daily for 7 days for Resident #28. She input both orders in the MARs on the same day and acknowledged that she had forgotten to set the 7-day stop date for the probiotic order during the transcription process. She confirmed Resident #28 had received probiotic daily from 04/25/23 until 10/31/23. She acknowledged that her transcription error had caused Resident #28 to receive almost 6 additional months of unnecessary probiotic.
A phone interview was conducted with the Consultant Pharmacist on 11/01/23 at 2:32 PM. He confirmed he had reviewed Resident #28's medication regimens once monthly in the past 10 months. He recalled seeing the probiotic order without a stop date and thought the physician might want to use it for some other purposes. He noted the probiotic order was written for ABT use and stated that it was not a proper abbreviation for antibiotic. That was why it did not alert him to probe the order further. If the word ABT was written as antibiotic, most likely he would investigate the order and determine the needs of continuous probiotic therapy.
During an interview conducted on 11/02/23 at 1:19 PM, the MD stated that the probiotic order was for antibiotic use and should be discontinued after 7 days. He denied it would cause any adverse effects to Resident #28's health for taking approximately 6 additional months of probiotic. However, he expected the nurse to transcribe the order correctly to stop the probiotic as ordered after 7 days.
A phone interview was conducted with the Director of Nursing on 11/02/23 at 2:10 PM. She stated that the probiotic should be stopped after 7 days. It was her expectation for the nurse to transcribe all the physician's orders correctly to avoid Resident #28 from receiving 6 months of unnecessary probiotic.
During an interview with the Administrator on 11/02/23 at 2:57 PM, she expected the nurse to transcribe all the physician's order correctly to stop Resident #28's probiotic after 7 days and to avoid unnecessary probiotic for over 6 months.
CONCERN
(F)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected most or all residents
Based on observations and staff interviews, the facility failed to maintain a clean kitchen floor, discard expired food items available for resident use in 1 of 1 walk-in cooler, label and date food i...
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Based on observations and staff interviews, the facility failed to maintain a clean kitchen floor, discard expired food items available for resident use in 1 of 1 walk-in cooler, label and date food in 1 of 1 reach-in refrigerator, maintain a clean refrigerator in 1 of 1 nourishment room on E Hall and maintain air vents free from dust buildup in the kitchen. These practices had the potential to affect food and beverages served to the residents.
The findings included:
a. An initial observation of the kitchen on 10/30/23 at 9:10 AM was made with the Dietary Manager (DM). During the observation, the kitchen floor had drops of liquid spilled and when walked across, shoes stuck to the floor.
A follow up observation of the kitchen on 10/30/23 at 11:20 AM revealed a clean, dry floor but shoes still stuck to the floor when walking.
A follow up observation on 10/31/23 at 10:30 AM, revealed a sticky dry floor with several drops of liquids under the tea dispenser. The DM stated that those were spilled tea and would be mopped after serving breakfast.
b. An initial observation of the walk-in cooler on 10/30/23 at 9:12 AM revealed two brown bowls with 10/26 written on lids and a red gelatin in a small brown cup with 10/26 written on the lid. The two brown bowls contained light yellow fruit chunks. The Dietary Manager (DM) stated the two brown bowls were pineapple and should have been discarded when they were not served to the residents on 10/26/23. She stated the red gelatin should also have been discarded on 10/26/23.
c. An initial observation of the reach in cooler on 10/30/23 at 9:20 AM revealed a pack of sliced cheese inside an unlabeled plastic bag. The DM said the kitchen staff used it to make sandwiches the night before. DM took it out and stated the kitchen staff should have put a date and time on it.
d. An initial observation of the nourishment refrigerator on E hall on 10/30/23 at 9:30 AM revealed an unlabeled frozen chocolate milk shake with a straw inside the freezer compartment. The DM stated it belonged to a staff member and stated it should not have been in there. The DM took the milkshake out of the refrigerator and threw it in the trash can. There was also a plastic bag containing a disposable container which was on a glass shelf inside the refrigerator. The plastic bag was labeled with a name and was dated 10/29/23. There was a large, dried puddle of a sticky yellowish substance underneath the plastic bag. The shelves on the refrigerator door were dusty and had food crumbs on them. The DM stated the plastic bag was for a resident. The DM wet a bunch of paper towels and wiped down the refrigerator's shelves.
During an interview with the Dietary Manager (DM) on 10/30/23 at 9:35 AM, she stated the kitchen staff was supposed to clean the nourishment refrigerator every day. The DM was not aware when the refrigerator was last cleaned. The DM stated staff were not supposed to store their food in the nourishment refrigerator. She stated she checked the kitchen coolers and freezers three times a week for expired and unlabeled food items and her staff were supposed to check them every day. She stated she did not get to check this morning because a kitchen staff had to leave early, and she had to help with serving breakfast trays. DM stated there were only 2 of them serving breakfast this morning. The kitchen staff should have discarded the expired food items and should have labeled food items before storing them.
e. A follow up observation of the kitchen on 10/30/23 at 11:20 AM revealed an aluminum drying rack containing washed lids and plastic cups was parked close to the kitchen sink. Beside it was an old door with a rectangular vent above the door. The rectangular vent had grates full of thick, black, fibrous, oily looking material. Another aluminum rack containing washed plates was parked across the dishwasher. Above this rack was a square vent on the ceiling. The grates were covered with gray, dusty material.
During a follow up observation of the kitchen on 10/31/23 at 10:30 AM, there was a short aluminum drying rack containing wet blue lids beside the door with a rectangular vent full of thick, black, fibrous, oily looking materials. Another taller aluminum rack containing red cups, blue lids and white dishes was under the square ceiling vent that still had gray dust on its vents.
During another follow up kitchen observation on 11/1/23 at 10:10 AM, the short aluminum drying rack containing white dishes and cups was beside the door with the dirty rectangular vent above it. Another tall aluminum drying rack with lids and dishes was under the dusty square ceiling vent.
During an interview with the Dietary Manager (DM) and the Administrator on 11/1/23 at 10:15 AM, the DM stated the maintenance staff were responsible for cleaning the vents. She stated the maintenance staff cleaned the vents sometime in September of this year. The Administrator pointed out another clean vent over the sink and stated that vent was cleaned but not those two vents. The Administrator stated the kitchen staff were responsible for cleaning the kitchen and food storage and preparation, and maintenance was responsible for cleaning the vents and the ice machine.
During an interview on 11/1/23 at 2:45 PM, the Maintenance Director stated they cleaned the vents today. He said his staff cleaned the vents in September and was not aware where the dirt on the vents came from. The Maintenance Director said there was not a definite schedule, but they tried to clean the vents at least twice a year. He said he did not realize those vents got that dirty.
During a follow up interview on 11/2/13 at 2:58 PM, the Administrator stated the maintenance crew were responsible for cleaning those vents and cleaned them in September. She said maintenance cleaned the vents twice a year and said she would have to look at a definite cleaning schedule.
CONCERN
(F)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0882
(Tag F0882)
Could have caused harm · This affected most or all residents
Based on staff interviews, the facility failed to designate a qualified Infection Preventionist (IP), who had completed specialized training in infection prevention and control, to be responsible for ...
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Based on staff interviews, the facility failed to designate a qualified Infection Preventionist (IP), who had completed specialized training in infection prevention and control, to be responsible for the facility's Infection Prevention and Control Program. This had the potential to affect 56 of the 56 residents at the facility.
The findings included:
During the Entrance Conference with the Administrator on 10/30/23 at 9:15 AM, she revealed that the facility's designated Infection Preventionist was the Staff Development Manager. She also stated that the Assistant Director of Nursing (ADON) also helped as needed with infection control activities.
An interview with the Staff Development Manager (SDM) on 11/2/23 at 2:27 PM revealed in early September, the previous Administrator encouraged her to take the next Statewide Program for Infection Control and Epidemiology (SPICE) training and registered her for the class in November 2023. The SDM stated that she was told that most staff development coordinators were designated the IP role, but she had not gone through any type of infection control training. She shared that the current ADON helped her hold the recent influenza clinic, but the ADON had not received specialized training in infection control either.
A phone interview with Nurse #3 on 11/2/23 at 4:49 PM revealed she used to be the ADON, but she stepped down in September to be a floor nurse. She stated that she now only worked as needed but she was required to work at least one shift every two weeks. Nurse #3 stated that she had received specialized training in infection control but had not been actively doing infection control activities except showing the SDM how to do the Tuberculosis test audits.
An interview with the Administrator on 11/2/23 at 2:55 PM revealed the SDM was already designated as the IP when she started working at the facility. The Administrator stated the SDM was registered for the next SPICE training this month and she was going to register the current ADON as well for the class.
Apr 2022
1 deficiency
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews, the facility failed to develop a care plan for a resident receiving an anticoagulan...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews, the facility failed to develop a care plan for a resident receiving an anticoagulant (blood thinner) for 1 of 7 residents reviewed for unnecessary medications (Resident #46).
The findings included:
Resident #46 was admitted to the facility on [DATE].
Resident #46's diagnoses included chronic embolism (obstruction of an artery) and thrombosis (blood clot) of unspecified deep veins of lower extremity, bilateral.
Physician's orders were reviewed and revealed an order for Rivaroxaban (anticoagulant) 20 mg (milligrams) - give one tablet by mouth every day dated 9/14/2021.
An annual Minimum Data Set (MDS) assessment dated [DATE] revealed resident had received an anticoagulant 7 out of the 7 days in the look back period.
Care plan review for Resident #46 revealed there was not a care plan in place for anticoagulant medication.
An interview on 4/20/2022 at 11:17 AM with the MDS coordinator revealed there was not a care plan in place for an anticoagulant medication for Resident #46. The MDS coordinator indicated she was responsible for developing the care plans. The MDS coordinator stated she was not sure why the care plan was missed.
An interview with the Director of Nursing (DON) on 4/20/2022 at 3:14 PM revealed it was her preference to have a care plan in place for the anticoagulant. The DON indicated she was not sure exactly why the care plan was missed, but there was potential that it was because they had been busy dealing with Covid-19 and although a care plan is important, resident care came first.
Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated
K - Pattern
L - Widespread
Actual Harm
G - Isolated
H - Pattern
I - Widespread
Potential for Harm
D - Isolated
E - Pattern
F - Widespread
No Harm (Minor)
A - Isolated
B - Pattern
C - Widespread
Questions to Ask on Your Visit
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • 39% turnover. Below North Carolina's 48% average. Good staff retention means consistent care.
Concerns
- • 21 deficiencies on record, including 2 serious (caused harm) violations. Ask about corrective actions taken.
- • Grade D (48/100). Below average facility with significant concerns.
Bottom line: Trust Score of 48/100 indicates significant concerns. Thoroughly evaluate alternatives.
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About This Facility
What is Valley View Care And Rehabilitation's CMS Rating?
CMS assigns Valley View Care and Rehabilitation an overall rating of 3 out of 5 stars, which is considered average nationally. Within North Carolina, this rating places the facility higher than 99% of the state's 100 nursing homes. This mid-range rating indicates the facility meets federal standards but may have areas for improvement.
How is Valley View Care And Rehabilitation Staffed?
CMS rates Valley View Care and Rehabilitation's staffing level at 5 out of 5 stars, which is much above average compared to other nursing homes. Staff turnover is 39%, compared to the North Carolina average of 46%. This relatively stable workforce can support continuity of care.
What Have Inspectors Found at Valley View Care And Rehabilitation?
State health inspectors documented 21 deficiencies at Valley View Care and Rehabilitation during 2022 to 2025. These included: 2 that caused actual resident harm and 19 with potential for harm. Deficiencies causing actual harm indicate documented cases where residents experienced negative health consequences.
Who Owns and Operates Valley View Care And Rehabilitation?
Valley View Care and Rehabilitation is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility is operated by CONSULATE HEALTH CARE/INDEPENDENCE LIVING CENTERS/NSPIRE HEALTHCARE/RAYDIANT HEALTH CARE, a chain that manages multiple nursing homes. With 76 certified beds and approximately 60 residents (about 79% occupancy), it is a smaller facility located in Andrews, North Carolina.
How Does Valley View Care And Rehabilitation Compare to Other North Carolina Nursing Homes?
Compared to the 100 nursing homes in North Carolina, Valley View Care and Rehabilitation's overall rating (3 stars) is above the state average of 2.8, staff turnover (39%) is near the state average of 46%, and health inspection rating (2 stars) is below the national benchmark.
What Should Families Ask When Visiting Valley View Care And Rehabilitation?
Based on this facility's data, families visiting should ask: "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" "Can I speak with family members of current residents about their experience?"
Is Valley View Care And Rehabilitation Safe?
Based on CMS inspection data, Valley View Care and Rehabilitation has a clean safety record: no substantiated abuse findings (meaning no confirmed cases of resident harm), no Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death), and is not on the Special Focus Facility watch list (a federal program monitoring the lowest-performing 1% of nursing homes). The facility has a 3-star overall rating and ranks #1 of 100 nursing homes in North Carolina. While no facility is perfect, families should still ask about staff-to-resident ratios and recent inspection results during their visit.
Do Nurses at Valley View Care And Rehabilitation Stick Around?
Valley View Care and Rehabilitation has a staff turnover rate of 39%, which is about average for North Carolina nursing homes (state average: 46%). Moderate turnover is common in nursing homes, but families should still ask about staff tenure and how the facility maintains care continuity when employees leave.
Was Valley View Care And Rehabilitation Ever Fined?
Valley View Care and Rehabilitation has been fined $9,770 across 2 penalty actions. This is below the North Carolina average of $33,177. While any fine indicates a compliance issue, fines under $50,000 are relatively common and typically reflect isolated problems that were subsequently corrected. Families should ask what specific issues led to these fines and confirm they've been resolved.
Is Valley View Care And Rehabilitation on Any Federal Watch List?
Valley View Care and Rehabilitation is not on any federal watch list. The most significant is the Special Focus Facility (SFF) program, which identifies the bottom 1% of nursing homes nationally based on persistent, serious quality problems. Not being on this list means the facility has avoided the pattern of deficiencies that triggers enhanced federal oversight. This is a positive indicator, though families should still review the facility's inspection history directly.