BERKSHIRE HEALTH & REHABILITATION CENTER
For profit - Limited Liability company
180 Beds
LIFEWORKS REHAB
Data: November 2025
Trust Grade
65/100
#63 of 285 in VA
Photo by Berkshire Health & Rehabilitation Center
Photo by Willie Logan
Photo by Berkshire Health & Rehabilitation Center
1 / 5 photos
Last Inspection: June 2024
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
Berkshire Health & Rehabilitation Center has a Trust Grade of C+, which indicates that it is slightly above average but not exceptional. It ranks #63 out of 285 nursing homes in Virginia, placing it in the top half of facilities in the state, and #2 out of 3 in Roanoke County, meaning only one local option is better. Unfortunately, the facility is experiencing a worsening trend, with issues increasing from 5 in 2023 to 11 in 2024. Staffing is a concern, receiving a poor rating of 1 out of 5 stars, and while the staff turnover is average at 58%, the low RN coverage-less than that of 97% of Virginia facilities-raises alarms about the quality of care. On a positive note, there have been no fines on record, indicating compliance with regulations. However, specific incidents have been noted, such as the failure to properly store and discard outdated food items, which poses health risks, and the lack of required notifications for residents being discharged from Medicare-covered stays. Overall, while there are strengths in compliance and quality measures, families should be aware of the significant weaknesses in staffing and food safety practices.
- Trust Score
- C+
- In Virginia
- #63/285
- Safety Record
- Low Risk
- Inspections
- Getting Worse
- Staff Stability ⚠ Watch
- 58% turnover. Above average. Higher turnover means staff may not know residents' routines.
- Penalties ✓ Good
- No fines on record. Clean compliance history, better than most Virginia facilities.
- Skilled Nurses ⚠ Watch
- Each resident gets only 14 minutes of Registered Nurse (RN) attention daily — below average for Virginia. Fewer RN minutes means fewer trained eyes watching for problems.
- Violations ⚠ Watch
- 32 deficiencies on record. Higher than average. Multiple issues found across inspections.
65/100
Top 22%
No red flags
5 → 11 violations
★★★★☆
4.0
Overall Rating
★☆☆☆☆
1.0
Staff Levels
★★★★★
5.0
Care Quality
★★★★☆
4.0
Inspection Score
↔
Stable
2023: 5 issues
2024: 11 issues
The Good
-
5-Star Quality Measures · Strong clinical quality outcomes
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
Facility shows strength in quality measures, fire safety.
The Bad
Staff Turnover: 58%
12pts above Virginia avg (46%)
Frequent staff changes - ask about care continuity
Chain: LIFEWORKS REHAB
Part of a multi-facility chain
Ask about local staffing decisions and management
Staff turnover is elevated (58%)
10 points above Virginia average of 48%
The Ugly 32 deficiencies on record
Jun 2024
11 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
Transfer Requirements
(Tag F0622)
Could have caused harm · This affected 1 resident
Based on interviews and document review, the facility staff failed to ensure clinical documentation supported the need for the resident's transfer for one (1) of 40 sampled residents (Resident #219).
...
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Based on interviews and document review, the facility staff failed to ensure clinical documentation supported the need for the resident's transfer for one (1) of 40 sampled residents (Resident #219).
The findings include:
Resident #219's clinical documentation failed to include information to support the need for the resident to be transferred to a local hospital under an emergency custody order (ECO).
Resident #219's Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 7/6/23, was signed as completed on 7/13/23. Resident #219 was assessed as able to make self understood and as able to understand others. Resident #219's Brief Interview for Mental Status (BIMS) summary score was documented as a five (5) out of 15; this indicated severe cognitive impairment. Resident #219 was assessed as requiring supervision with dressing, eating, toilet use, and personal hygiene.
Review of Resident #219's clinical documentation failed to reveal documentation detailing the events on 8/10/23 which resulted in the facility staff obtaining an ECO for Resident #219. No documentation was found to indicate that a licensed nurse had assessed Resident #219 when the resident was exhibiting behaviors on 8/10/23 prior to the ECO being issued. No documentation was found to indicate what if any interventions were attempted for Resident #219, on 8/10/23, prior to obtaining the ECO.
On 6/13/24 at 9:20 a.m., the facility's current Director of Discharge Planning reported the previous Director of Discharge Planning managed Resident #219's ECO. (The previous Director of Discharge Planning was not a licensed nurse and did not have the required education/experience to independently function as the facility's social worker.)
The following information was found in a facility policy and procedure titled Behavioral Assessment/Behavior Monitor [sic] (with an effective date of 1/29/24):
- POLICY . Behaviors will be assessed and monitored. Factors influencing behaviors, as well as management interventions will be evaluated, and care planned.
- PROCEDURE . 1. Patients will be observed by nursing staff on all shifts and any unusual, increased, or change in behaviors will be reported and documented in the medical record . 5. A licensed nurse will document targeted behaviors, side effects, and interventions in the medical record.
On 6/18/24 at 1:32 p.m., the survey team met with the facility's Administrator, Director of Nursing (DON), Assistant DON, and Regional Director of Clinical Services. During this meeting, the surveyor discussed the absence of documentation supporting the need to transfer Resident #219 to a local hospital under an ECO.
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
Based on resident interview, staff interview, and clinical record review, facility staff failed to implement a person-centered care plan that addressed the resident's actual reported pain for 1 of 33 ...
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Based on resident interview, staff interview, and clinical record review, facility staff failed to implement a person-centered care plan that addressed the resident's actual reported pain for 1 of 33 current residents in the survey sample (Resident #50).
Resident #50 was admitted with diagnoses which included cerebral infarction, bilateral hemiplegia/hemiparesis, morbid obesity, type 2 diabetes mellitus, chronic osteomyelitis right thigh, epilepsy, heart failure, abscess of bursa left hip, primary osteoarthritis, hypertension, and chronic kidney disease. On the most recent Minimum Data Set (MDS) full assessment with assessment reference date 5/20/24, the resident scored 10/15 on the Brief Interview for Mental status and was assessed as without signs of delirium, psychosis, or behavior affecting care. The resident reported almost constant pain which interfered with sleep and activities of daily living. The Comprehensive Care Plan revised 5/31/24 read Focus the resident has a risk for pain related to OA, chronic wounds, impaired mobility, lumbar DDD, dry eyes with interventions entered on 4/16/24:administer medications as ordered; Notify MD as indicated; observe for physical indicators of pain. The care plan was not revised to indicate the resident was reporting actual pain almost continuously. During interviews on 6/11 and 6/12/24, the resident reported experiencing unrelieved pain which the resident had reported to nurses.
On 6/13/2/4, the MDS coordinator responsible for the resident's comprehensive care plan stated the care plan would be based on the MDS nurse interview with the resident. If the resident reported pain, the care plan would reflect that.
The Care Area Assessment for pain attached to the 5/20/24 MDS documented that the resident reported almost constant pain. Given choice between Actual or Potential pain, the assessor chose Potential. The corporate regional director for MDS stated on 6/13/24 that the assessment would care plan would only reflect actual pain if the skilled daily nursing notes documented pain.
The resident's Medication Administration Record indicated that the resident requested as needed pain medication with a reported level of 7 or 8 out of 10 almost daily. The skilled daily nursing notes document no pain most days when the resident has received PRN (as needed) pain medication since the previous day's note.
The surveyor reported the concern with the care plan not addressing actual pain experienced by the resident during a summary meeting on 6/13/2024.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0657
(Tag F0657)
Could have caused harm · This affected 1 resident
2. For Resident #121, facility staff failed to ensure the resident was provided the opportunity participate in planning care in the facility.
During initial tour on 6/11/2024, the resident told the su...
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2. For Resident #121, facility staff failed to ensure the resident was provided the opportunity participate in planning care in the facility.
During initial tour on 6/11/2024, the resident told the surveyor she had not participated in care planning or discharge planning. The resident reported expecting a meeting soon after arrival, then a care plan meeting after a couple of weeks. The resident stated she had not received a notice to schedule a care plan meeting, which she had expected. The resident stated she had also not received a copy of the care plan.
Per the unit manager, there is a jump start meeting on admission (the resident was admitted 5/3) to tell the resident what kind of services are available, then a care plan meeting at 21 days (which would be 5/24/2024). The surveyor did not find a copy of a care plan meeting in the clinical record. There was no mention of a jump start meeting in the progress notes. The surveyor was unable to locate a record of a care plan meeting at 21 days.
On 6/13/2024 at 11 AM, the surveyor and director of nursing (DON) interviewed the resident together. The resident reported that she had not been invited to a care plan meeting or received a letter of invitation, although she was expecting one. The resident reported not receiving a copy of the initial care plan or a revised care plan, although she expected one.
The surveyor was given a Care Plan Meeting created as a Late Entry on 5/24/2024 and effective date 5/21/2024 Care plan meeting held, family and rsd declined to attend, Those in attendance: [names withheld] LPN#3, activity director, Director of Rehab, Director of DC planning, CNA. Care plan reviewed and will continue POC. Face sheet, medication review list and care plan provided to resident.
The resident stated that none of those documents had been provided.
The DON was aware of the concern as of 6/13/2024.
Based on interviews and document review, the facility staff failed to review and revise care plans for two (2) of 40 sampled residents (Resident #63 and Resident #121).
The findings include:
1. The facility staff failed to review and revise Resident #63's care plan to address the removal and subsequent reimplementation of the use of a defined parameter mattress (DPM).
Resident #63's Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 5/23/24, was signed as completed on 5/27/24. Resident #63 was assessed as usually able to make self understood and as usually able to understand others. Resident #63's Brief Interview for Mental Status (BIMS) summary score was documented as a six (6) out of 15; this indicated severe cognitive impairment. Resident #63 was assessed as being depended on others for toileting hygiene, dressing, and personal hygiene.
Resident #63's fall/fall risk care plan had an intervention for a DPM dated as being created on 1/24/23. One of Resident #63's Device Assessment forms indicated the resident did not have a DPM in use on 3/9/23. Another Device Assessment form, dated 4/5/23, indicated Resident #63 had a DPM in use. Review of Resident #63's comprehensive care plan failed to show when the aforementioned DPM was removed and reimplemented. Resident #63's comprehensive care plan did not have an entry for the DPM dated 3/9/23 or 4/5/23.
The following information was found in a facility policy and procedure titled Care Planning (with an effective date of 11/1/19):
- A licensed nurse, in coordination with the interdisciplinary team, develops and implements an individualized care plan for each patient in order to provide effective, person-centered care, and the necessary health-related care and services to attain or maintain the highest practical physical, mental, and psychosocial well-being of the patient.
- Care plans will be updated on an ongoing basis as changes in the patient occur .
On 6/18/24 at 1:32 p.m., the survey team met with the facility's Administrator, Director of Nursing (DON), Assistant DON, and Regional Director of Clinical Services. During this meeting, the surveyor discussed the failure of the facility staff to review and revise Resident #63's care plan to address the removal and subsequent reimplementation of a DPM.
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 F0740
(Tag F0740)
Could have caused harm · This affected 1 resident
Based on interviews and the review of documents, the facility staff failed to provide behavior health care/interventions to address changes in condition for one (1) of 40 sampled residents (Resident #...
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Based on interviews and the review of documents, the facility staff failed to provide behavior health care/interventions to address changes in condition for one (1) of 40 sampled residents (Resident #219).
The findings include:
The facility staff failed to ensure that medical provider orders/guidance were implemented related to Resident #219's alleged behaviors on 8/2/23. The facility staff failed to ensure a licensed nurse was involved when Resident #219 was experiencing an alleged change of condition which resulted in the request for an emergency custody order (ECO) on 8/10/23.
Resident #219's Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 7/6/23, was signed as completed on 7/13/23. Resident #219 was assessed as able to make self understood and as able to understand others. Resident #219's Brief Interview for Mental Status (BIMS) summary score was documented as a five (5) out of 15; this indicated severe cognitive impairment. Resident #219 was assessed as requiring supervision with dressing, eating, toilet use, and personal hygiene.
The following information was found in Resident #219's clinical documentation in a progress note documented by a nurse practitioner on 8/2/23 at 4:59 p.m.: Staff member called on-call psych provider to alert her of this patient threatening to kill (the patient's) roommate. Staff state they were immediately separated and they are in separate rooms now. This note also indicated the nurse practitioner was informed Resident #219 was experiencing a lot of confusion and impaired reasoning. The nurse practitioner gave orders for Resident #219 to receive 30-minute checks until the resident was seen by a provider. No evidence was found to indicate that Resident #219 received the ordered 30-minute checks.
Clinical documentation indicated that Resident #219's roommate was interviewed by staff after the aforementioned event on 8/2/23, Resident #219's roommate did not wish to change rooms. Resident #219's roommate denied concerns with their safety and reported they were alright with Resident #219. Resident #219's roommate did not have a room change until the next day, on 8/3/23.
On 6/11/24 at 4:14 p.m., the survey team met with the facility's Administrator, Regional Director of Clinical Services (RDCS), Director of Nursing (DON), and the Assistant DON. The DON reported the documentation of the 30-minutes checks was not found. The RDCS reported no behaviors had been documented on Resident #219's medication administration records (MARs).
Review of Resident #219's clinical documentation failed to reveal documentation detailing the events on 8/10/23 which resulted in the facility staff obtaining an ECO for Resident #219. No documentation was found to indicate that a licensed nurse had assessed Resident #219 when the resident was exhibiting behaviors, on 8/10/23, prior to the ECO being issued. No documentation was found to indicate what if any interventions were attempted for Resident #219, on 8/10/23, prior to obtaining the ECO.
On 6/13/24 at 9:20 a.m., the facility's current Director of Discharge Planning reported the previous Director of Discharge Planning managed Resident #219's ECO. (The previous Director of Discharge Planning was not a licensed nurse and did not have the required education/experience to independently function as the facility's social worker.)
On 6/13/24 at 10:15 a.m., the Licensed Practical Nurse (LPN) #9 stated they recalled Resident #219 being discussed during the 'daily clinical meeting' on the day the resident was transferred under an ECO. LPN #9 stated it was reported the resident was exhibiting the following behaviors: (a) more difficult to redirect, (b) ambulating laps around the building, (c) would jump or lunge at others, and (d) told another resident I hope you choke and die (expletive omitted). Documentation of these behaviors was not found in Resident #219's clinical record. Documentation of the facility's response to address these behaviors was not found in Resident #219's clinical record.
On 6/12/24 at 8:33 a.m., the Director of Nursing (DON) provided the surveyor with a Criminal Incident Information Release Form from the local police department. This form indicated the local police transported Resident #219 to a local hospital due to the issue of an ECO. This document did not address the resident's behaviors and/or symptoms which resulted in the ECO being issued. The History of Present Illness - Psychiatric Illness form, dated 8/10/23, from the local hospital indicated the resident was admitted for further psychiatric care due to acting erratically at the nursing home and very agitated.
On 6/13/23 at 10:37 a.m., the facility's Medical Director reported they were aware of and in agreement with obtaining an ECO for Resident #219. The Medical Director reported that Resident #219 had become physically aggressive. The Medical Director was unable to provide details related to Resident #219 being physically aggressive; the Medical Director reported they did not document a note when contacted by the facility staff. Resident #219's clinical documentation did not include documentation to indicate the resident was physically aggressive.
The following information was found in a facility policy and procedure titled Significant Change of Condition (with an effective date of 1/29/24):
- POLICY . All staff members will communicate any information about patient status to appropriate licensed nurse immediately upon observation.
- PROCEDURE . 1. A licensed nurse will assess the patient for signs and symptoms of change of condition. 2. Notify provider and document in Progress Notes.
The following information was found in a facility policy and procedure titled Behavioral Assessment/Behavior Monitor [sic] (with an effective date of 1/29/24):
- POLICY . Behaviors will be assessed and monitored. Factors influencing behaviors, as well as management interventions will be evaluated, and care planned.
- PROCEDURE . 1. Patients will be observed by nursing staff on all shifts and any unusual, increased, or change in behaviors will be reported and documented in the medical record . 5. A licensed nurse will document targeted behaviors, side effects, and interventions in the medical record.
On 6/18/24 at 1:32 p.m., the survey team met with the facility's Administrator, Director of Nursing (DON), Assistant DON, and Regional Director of Clinical Services. During this meeting, the surveyor discussed the absence of documentation to detail the facility staff's assessment and subsequent interventions related to Resident #219's aforementioned alleged behaviors.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Pharmacy Services
(Tag F0755)
Could have caused harm · This affected 1 resident
Based on observations, interviews, and clinical record review, facility staff failed to ensure provider ordered medications were available for administration for 1 of 40 sampled residents (Resident #1...
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Based on observations, interviews, and clinical record review, facility staff failed to ensure provider ordered medications were available for administration for 1 of 40 sampled residents (Resident #116).
The findings were:
The facility staff failed to ensure Resident #116's provider ordered medication Lactulose (a laxative, ammonia reducer for liver disease) was administered to Resident #116.
Resident #116's admission record listed diagnoses to include but were not limited to alcoholic cirrhosis of liver with ascites, protein-calorie malnutrition, alcohol abuse, psychotic disorder with delusions due to known physiological condition, atrial fibrillation, schizoaffective disorder, bipolar disorder, anxiety disorder and major depressive disorder. Resident #116's quarterly minimum data set with an assessment reference date of 05/29/24 scored the brief interview for mental status a 15 out of 15.
During a medication pass and pour observation with licensed practical nurse (LPN #5) on 06/11/24 at 8:23 a.m., Resident #116's Lactulose was not available in the medication cart. LPN #5 attempted to retrieve the medication from the facility's electronic interim box (Omnicell) but was unsuccessful. LPN #5 reported the unavailable medication to the charge nurse and requested the charge nurse notify the nurse practitioner (NP). LPN #5 reported the unavailable medication to Resident #116 who was listed as the Responsible Party (RP). The resident stated he had missed Lactulose doses in the past but did not provide a date or time.
Resident #116's clinical record contained a provider order dated 05/02/24 for Lactulose Solution 10GM/15ml, give 60mls by mouth four (4) times a day for hepatic encephalopathy, cirrhosis (doses scheduled daily for 9:00 a.m., 1:00 p.m., 5:00 p.m., and 9:00 p.m.). The medication administration record (MAR) for June 2024 was reviewed with all doses documented as administered prior to the 9:00 a.m. dose on 06/11/24.
On 06/11/24 at 12:05 p.m., the regional director of clinical services (RDCS) was notified of Resident #116's missed dose of Lactulose at 9:00 a.m. on 06/11/24. The RDCS reported the administrative team was researching the concern and that the resident would receive the 1:00 p.m. dose on 06/11/24.
At the end of day meeting on 06/12/24 at 4:27 p.m., the administrator, director of nursing (DON), assistant director of nursing (ADON), and RDCS was informed of Resident #116's missed dose of Lactulose. The DON stated her expectation was the Lactulose prescription should be re-ordered and present in the medication cart. The Omnicell is the backup to dispense medications not available in the medication cart. For Resident #116's 9:00 a.m. dose on 06/11/24, the Omnicell did not recognize the specific resident to be connected to the Lactulose order which prevented the medication from being dispensed. The DON reported the issue had been corrected within the Omnicell system.
No further information was provided prior to the exit conference.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Unnecessary Medications
(Tag F0759)
Could have caused harm · This affected 1 resident
Based on observation, staff interview, clinical record review, and facility document review, the facility staff failed to ensure a medication error rate of less than 5%. There were two (2) medication ...
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Based on observation, staff interview, clinical record review, and facility document review, the facility staff failed to ensure a medication error rate of less than 5%. There were two (2) medication errors in 30 opportunities for a medication error rate of 6.67%. These medication errors affected Resident #116 and #120.
The findings were:
1. For Resident #116, the facility staff failed to ensure the provider ordered medication Lactulose (a laxative, ammonia reducer for liver disease) was administered.
Resident #116's admission record listed diagnoses to include but were not limited to alcoholic cirrhosis of liver with ascites, protein-calorie malnutrition, alcohol abuse, psychotic disorder with delusions due to known physiological condition, atrial fibrillation, schizoaffective disorder, bipolar disorder, anxiety disorder and major depressive disorder. Resident #116's quarterly minimum data set with an assessment reference date of 05/29/24 scored the brief interview for mental status a 15 out of 15.
During a medication pass and pour observation with licensed practical nurse (LPN #5) on 06/11/24 at 8:23 a.m., Resident #116's Lactulose was not available in the medication cart. LPN #5 attempted to retrieve the medication from the facility's electronic interim box (Omnicell) but was unsuccessful.
Resident #116's clinical record contained a provider order dated 05/02/24 for Lactulose Solution 10GM/15ml, give 60mls by mouth four (4) times a day for hepatic encephalopathy, cirrhosis (doses scheduled daily for 9:00 a.m., 1:00 p.m., 5:00 p.m., and 9:00 p.m.).
On 06/11/24 at 12:05 p.m., the regional director of clinical services (RDCS) was notified of Resident #116's missed dose of Lactulose at 9:00 a.m. on 06/11/24. The RDCS reported the administrative team was researching the concern and that the resident would receive the 1:00 p.m. dose on 06/11/24.
At the end of day meeting on 06/12/24 at 4:27 p.m., the administrator, director of nursing (DON), assistant director of nursing (ADON), and RDCS was informed of Resident #116's missed dose of Lactulose. The DON stated her expectation was the Lactulose prescription should be re-ordered and present in the medication cart. The Omnicell is the backup to dispense medications not available in the medication cart.
2. For Resident #120, facility staff failed to administer the correct eye drops. Pataday eye drops were provider ordered however the resident received Alaway eye drops.
Resident #120's admission record listed diagnoses to include but were not limited to non-traumatic intracranial hemorrhage, encephalopathy, acute kidney failure, gastrointestinal hemorrhage, periapical abscess without sinus, and major depressive disorder. Resident #120's annual minimum data set with an assessment reference date of 05/09/24 scored the brief interview for mental status a 15 out of 15.
On 06/11/24 at 9:00 a.m., surveyor observed a licensed practical nurse (LPN #6) prepare and administer Resident #120's medications. LPN #6 administered Alaway eye drops, one drop in each eye.
Surveyor reconciled Resident #120's administered medications with provider orders and noted a current order for Pataday Ophthalmic Solution 0.1 % (Olopatadine HCl). Instill 1 drop in both eyes one time a day for ocular pruritus.
The pharmacy provider's director of quality (a licensed pharmacist) was contacted via phone on 06/11/24 at 11:20 a.m. The pharmacist reported that although both eye drops were used to treat the same symptom, the active ingredients were different and should not be used interchangeably. The pharmacist stated she would expect a provider order to specifically name which eye drop to be administered.
On 06/11/24 at 11:40 a.m., the surveyor met with the director of nursing (DON), assistant director of nursing (ADON) and regional director of clinical services (RDCS) and discussed the concern with Resident #120's eye drop prescription versus the eye drop that was administered. On 6/11/24 at 12:05 p.m., the RDCS reported the nurse practitioner (NP) had written an order to administer Resident #120 the Alaway eye drops instead of Pataday. The RDCS provided a MEDICATION ERROR REPORT which read the eye drops administered were not the eye drops which was ordered for 06/11/24.
On 06/14/24 at 2:35 p.m., the survey team met with the DON, Administrator, RDCS, and ADON and informed them the medication error rate was 6.67% with the errors effecting Resident #116 and #120.
No further information was provided prior to the exit conference.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0776
(Tag F0776)
Could have caused harm · This affected 1 resident
Based on staff interview, clinical record review, and facility document review, the facility staff failed to provide timely radiology or other diagnostic services to meet the needs of a resident for 1...
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Based on staff interview, clinical record review, and facility document review, the facility staff failed to provide timely radiology or other diagnostic services to meet the needs of a resident for 1 of 40 sampled residents, Resident #30.
The findings include:
For Resident #30 (R30), the facility staff failed to schedule a timely CT (computed tomography) scan of the abdomen as ordered on 5/31/24 by the provider.
Resident #30's diagnosis list included diagnoses that included, but were not limited to, chronic kidney disease-stage 3 (three), essential (primary) hypertension, peripheral vascular disease, anemia in chronic kidney disease, and type 2 (two) diabetes mellitus with diabetic chronic kidney disease.
The most recent minimum data set (MDS) with an assessment reference date (ARD) of 3/23/24 assigned the resident a brief interview for mental status (BIMS) summary score of 14 out of 15 for cognitive abilities, indicating R30 was cognitively intact.
A review of R30's clinical record on 6/11/24 revealed a diagnostic order summary that read in part, .CT Abdomen without contrast per Dr. [name omitted] . with an order status displayed as, Active and an order date of, 5/31/2024. Further review of the clinical record revealed a progress note, titled, Order Note dated, 5/31/24, that read in part, .[name omitted] Nephrology called with new orders per Dr. [name omitted] for CT of abdomen without contrast . [name omitted] NP (nurse practitioner) aware . After further review of the clinical record, surveyor could not locate a radiology/diagnostic report or any indications that a CT of the abdomen was performed on R30.
On 6/18/24 at 9:10 AM, surveyor interviewed the director of nursing (DON) about the ordered CT on 5/31/24 for R30 and informed DON this surveyor could not locate any CT results in the clinical record. Surveyor requested documentation of the CT results. On 6/18/24 at 9:26 AM, Administrative/Corporate Staff #14 (ACS#14) informed surveyor they (facility) have been attempting to schedule the CT with [name omitted] (the hospital radiology department) and have not been able to get the appointment scheduled.
On 6/18/24 at approximately 9:15 AM, surveyor interviewed Other Staff#5 (OS#5) and inquired about the order for the CT of the abdomen for R30. OS#5 stated the nephrologist did not give any inclination of how soon it had to be performed and informed surveyor that certified nursing assistant#3 (CNA#3) would be the one to schedule it (the CT appointment).
Surveyor interviewed CNA#3 on 6/18/24 at approximately 9:20 AM and inquired about the scheduling for the CT of the abdomen for R30. CNA#3 stated she has been calling to get it scheduled and is waiting for radiology at [name omitted] (the hospital radiology department) to call her with the appointment. Surveyor requested documentation of attempts at scheduling the CT.
On 6/18/24 at approximately 9:40 AM, CNA#3 gave surveyor a copy of two (2) progress notes. One progress note revealed an Effective Date: 6/3/2024 with a, Created By: CNA#3 [name omitted] .Created Date: 6/18/2024 09:35:29 (9:35 AM). The note read in part, .per [name omitted] nephrology Dr. [name omitted] office to schedule patient ct scan, per [name omitted] radiology to fax order prior to scheduling, order has been faxed office to call scheduler with apt (appointment), no new apt given at this time . The second progress note revealed an Effective Date: 6/18/2024 with a, Created By: CNA#3[name omitted] .Created Date: 6/18/2024 . The note read in part, .called [name omitted] ID Clinic CT order still being processed, unable to schedule at this time, per [name omitted] Radiology office to call scheduler with apt .
On 6/18/24 at 9:45 AM, surveyor interviewed CNA#3 and inquired about the process for documenting today (6/18/24) on the communication with hospital radiology department on 6/3/24. CNA#3 stated she uses her notes and remembers. Surveyor requested a copy of the fax transmission of the order to hospital radiology department on 6/3/24. On 6/18/24 at 9:59 AM, CNA#3 informed surveyor she could not locate the fax confirmation to [name omitted] (the hospital radiology department) from 6/3/24. When asked what the next step in getting the CT scheduled would be, CNA#3 stated the next step would be to keep messaging the radiology department at [name omitted].
On 6/18/24 at 10:37 AM, surveyor interviewed the DON about her expectations for the timeliness of ordered diagnostics. The DON stated the expectation for ordered diagnostics is to get them as quickly as possible and she stated CNA#3 should have notified us (nursing/administrative staff) by email or called while we were in the building. DON brought surveyor copy of an email communication she had sent to CNA#3 dated, 6/3/24, that read in part, . [name omitted] Nephrology called with new orders per Dr. [name omitted] for CT of abdomen without contrast .NP aware .
On 6/18/24 at approximately 11:00 AM, CNA#3 brought surveyor a copy of a progress note dated 6/18/24 that read in part, .per [name omitted] clinic patient is scheduled for CT scan on July 3rd @ (at) 8am at [name omitted] .
This concern was discussed at the pre-exit meeting on 6/18/24 at 1:32 PM with the administrator, assistant director of nursing, director of nursing and the regional director of clinical services.
No further information was provided to the survey team prior to exit.
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
Medical Records
(Tag F0842)
Could have caused harm · This affected 1 resident
Based on interviews and document review, the facility staff failed to maintain complete and/or accurate clinical documentation for one (1) of 40 sampled residents (Resident #219).
The findings include...
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Based on interviews and document review, the facility staff failed to maintain complete and/or accurate clinical documentation for one (1) of 40 sampled residents (Resident #219).
The findings include:
Resident #219's clinical documentation failed to include documentation of the resident's behaviors which resulted in the facility staff requesting an emergency custody order (ECO) on 8/10/23.
Resident #219's Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 7/6/23, was signed as completed on 7/13/23. Resident #219 was assessed as able to make self understood and as able to understand others. Resident #219's Brief Interview for Mental Status (BIMS) summary score was documented as a five (5) out of 15; this indicated severe cognitive impairment. Resident #219 was assessed as requiring supervision with dressing, eating, toilet use, and personal hygiene.
Review of Resident #219's clinical documentation failed to reveal documentation detailing the events on 8/10/23 which resulted in the facility staff obtaining an ECO for Resident #219. No documentation was found to indicate that a licensed nurse had assessed Resident #219 when the resident was exhibiting behaviors on 8/10/23 prior to the ECO being requested. No documentation was found to indicate what if any interventions were attempted for Resident #219, on 8/10/23, prior to obtaining the ECO.
On 6/12/24 at 9:04 a.m., the Regional Director of Clinical Services (RDCS) stated the individual who initiated the ECO would have been responsible to document the events which resulted in the need for the ECO.
The following information was found in a facility policy and procedure titled Significant Change of Condition (with an effective date of 1/29/24):
- POLICY . All staff members will communicate any information about patient status to appropriate licensed nurse immediately upon observation.
- PROCEDURE . 1. A licensed nurse will assess the patient for signs and symptoms of change of condition. 2. Notify provider and document in Progress Notes.
The following information was found in a facility policy and procedure titled Behavioral Assessment/Behavior Monitor [sic] (with an effective date of 1/29/24):
- POLICY . Behaviors will be assessed and monitored. Factors influencing behaviors, as well as management interventions will be evaluated, and care planned.
- PROCEDURE . 1. Patients will be observed by nursing staff on all shifts and any unusual, increased, or change in behaviors will be reported and documented in the medical record . 5. A licensed nurse will document targeted behaviors, side effects, and interventions in the medical record.
On 6/18/24 at 1:32 p.m., the survey team met with the facility's Administrator, Director of Nursing (DON), Assistant DON, and Regional Director of Clinical Services. During this meeting, the surveyor discussed the absence of documentation of Resident #219's behaviors which resulted in the need for transfer under an ECO.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
2. During wound care observation of unsampled Resident #82, on 6/13/2024, the surveyor observed LPN #11 remove a wound dressing, clean the wound, and place a new dressing without performing hand hygie...
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2. During wound care observation of unsampled Resident #82, on 6/13/2024, the surveyor observed LPN #11 remove a wound dressing, clean the wound, and place a new dressing without performing hand hygiene between tasks. This resulted in placing a clean dressing with dirty gloves which had handled the soiled dressing and cleaned the wound.
The administrator and director of nursing were notified of the concern during a summary meeting on 6/14/2024.
Based on observations, staff interviews, clinical record review, and facility document review, (a) the facility staff failed to correctly perform hand hygiene during wound care for one (1) of 40 sampled residents (Resident #75), (b) the facility staff failed to follow enhanced barrier precautions during resident care for one (1) of 40 sampled residents (Resident #75), and (c) the facility staff failed to correctly perform hand hygiene and/or glove change during wound care for one (1) observation of an unsampled resident (Resident #82).
The findings include:
1. The facility staff failed to appropriately change gloves and/or appropriately perform hand hygiene while providing Resident #75's wound care. The facility staff failed to wear a gown when removing wound dressings and transferring a resident on Enhanced Barrier Precautions (EBPs) (Resident #75).
Resident #75's Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 6/8/24, was signed as completed on 6/17/24. Resident #75 was assessed as sometimes able to make self understood and as sometimes able to understand others. Resident #75 was assessed has having problems with both short-term and long-term memory. Resident #75 was assessed as being depended on others for toileting hygiene, dressing, personal hygiene, and bathing.
On 6/14/24 at 9:35 a.m., the surveyor observed three staff members performing and/or assisting with wound care for Resident #75. Resident #75 had dressing changes to three (3) wounds.
- Certified Nurse Aide (CNA) #1 was observed to reposition a trash can on the floor with their gloved hand; CNA #1 proceeded to support the positioning of Resident #75 by touching the resident without changing gloves or performing hand hygiene.
- Licensed Practical Nurse (LPN) #9, after removing Resident #75's disposable undergarment and cleaning the resident's skin surrounding the resident's wounds, was noted to change gloves without performing hand hygiene after removing the soiled gloves and before donning the clean gloves.
- LPN #11 was observed to provide wound care to Resident #75's left hip wound. LPN #11 did not perform hand hygiene when they change gloves between performing wound cleaning and applying the new dressing.
- LPN #11 was observed to provide wound care to Resident #75's sacrum. LPN #11 did not perform hand hygiene when they change gloves between performing wound cleaning and applying the new dressing.
- LPN #11 was observed to provide wound care to Resident #75's right ischium. LPN #11 did not change gloves between cleaning the wound and applying a topical medication to the cleaned wound.
On 6/14/24 at 12:27 p.m., the Administrator and the Regional Director of Clinical Services (RDCS) confirmed that hand hygiene should be performed when changing gloves.
On 6/14/24 at 12:52 p.m., the RDCS, LPN #9, and LPN #11 met with members of the survey team. The surveyor reviewed the aforementioned observations during Resident #75's wound care. LPN #11 reported they performed hand hygiene with soap and water while waiting on someone to obtain the topical medication for the right ischium wound.
On 6/17/24 at 1:18 p.m., the Infection Preventionist (IP) reported that hand hygiene should be completed whenever gloves are changed.
The following information was found in a facility policy titled Handwashing Requirements (with an effective date of 2/6/20): The following is a list of some situation that require hand hygiene: . After handling soiled equipment or utensils . After removing gloves or aprons .
On 6/13/24 at 11:03 a.m., Certified Nurse Aide (CNA) #1 and CNA #2 was observed to remove Resident #75's wound dressings without wearing a gown. CNA #1 and CNA #2 was observed to use a lift to transfer the resident to a shower bed without wearing a gown. Resident #75 was on enhanced barrier precautions. Resident #75 had a sign outside their room which indicated staff should use enhanced barrier precautions when providing care. The Enhanced Barrier Precautions sign included the following information: Wear gown and gloves when entering room to provide the following high-contact resident care activities: dressing, bathing/showering, transferring .
The following information was found in a facility document titled Enhanced Barrier Precautions (EBPs) (with an effective date of 9/26/19):
- Employees providing high-contact patient care activities will follow Enhanced Barrier Precautions (EBPs). This level of precaution is indicated during the implementation of a containment strategy to prevent the potential transfer of a novel or targeted multi-drug resistant organism (MDRO).
- EBPs require the use of gown and gloves by providers and staff during high-contact patient care activities as defined below: a. Dressing b. Bathing/showering c. Transferring .
On 6/14/24 at 12:27 p.m., the Administrator reported gowns are to be worn when care is being provided to a resident on EBPs.
On 6/18/24 at 1:32 p.m., the survey team met with the facility's Administrator, Director of Nursing (DON), Assistant DON, and Regional Director of Clinical Services. During this meeting, the surveyor discussed the aforementioned observations of staff not appropriately changing gloves and/or performing hand hygiene during wound care; the surveyor also discussed the observation of staff not wearing the appropriate PPE when providing care for a resident on EBP.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected multiple residents
Based on observation, staff interview, and facility document review, the facility staff failed to store, monitor, and discard refrigerated cold food properly and failed to maintain cleanliness of food...
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Based on observation, staff interview, and facility document review, the facility staff failed to store, monitor, and discard refrigerated cold food properly and failed to maintain cleanliness of food preparation equipment in accordance with professional standards for food safety.
The findings include:
The facility staff failed to monitor and discard out-of-date, perishable food items stored in the walk-in and reach-in facility refrigerators, failed to store food in proper containers in the reach-in refrigerator, and failed to maintain cleanliness of the convection oven to protect the equipment from grease contamination in the facility main kitchen.
On 6/10/24 at 12:42 PM, surveyor entered the facility kitchen for initial tour with Other Staff#1 (OS#1). Surveyor observed the walk-in-refrigerator at 12:47 PM and observed a large container of cottage cheese on the second (2nd) shelf with a best-used-by (BB) date of, 6/1/24. Two gallons of whole milk were also observed on the 2nd shelf with white, chunky, substances in both of them and BB dates of, 6/6/24. OS#1 removed the cottage cheese and two gallons of milk and stated she would throw them away.
Surveyor observed the reach-in, kitchen refrigerator and observed an opened package of Smithfield sliced ham wrapped in plastic wrap on the 2nd shelf and asked OS#1 to open the package. Upon examination of the original wrapper, a BB date of, 4/15/24 was observed. OS#1 agreed the date read, 4/15/24 and removed the ham. Surveyor also observed a large, opened container of dill pickle relish with a BB date of, 3/4/24 on the 2nd shelf and OS#1 agreed the BB date was, 3/4/24 and removed the dill pickle relish. Two large, opened cans of fruit cocktail were observed on the third (3rd) shelf of the refrigerator in their original cans and surveyor inquired what the process was for storing food in the original can in the refrigerator. OS#1 stated the fruit cocktail was not supposed to be stored in the original cans and she removed the fruit cocktail.
Surveyor observed the convection oven and observed the oven to have a moderate amount of grease on the top of the unit and a moderate amount of greasy, brown, sticky, substances on the inside of the glass oven doors and on the bottom inside of the unit. Surveyor asked OS#1 the process for cleaning the convection oven and she stated they (ovens) are cleaned with degreaser about once every two (2) weeks, and she agreed the oven had not been cleaned in a while. She stated the oven would be cleaned, this evening or in the morning.
On 6/11/24 at 11:45 AM, surveyor entered facility kitchen and met with OS#1 and observed the convection oven. OS#1 stated she did not clean it, but she was going to clean it. The oven was observed to have a moderate amount of grease on the top of the unit and a moderate amount of greasy, brown, sticky, substances on the inside of the glass oven doors and on the bottom inside of the unit.
These concerns were discussed on 6/11/24 at 4:14 PM, during the end of day conference and again on 6/18/24 at 1:32 PM, during the pre-exit meeting with the regional director of clinical services, administrator, director of nursing and assistant director of nursing.
Surveyor requested and received a facility document, titled, .Food Storage: Cold Policy Statement, which read in part, .It is the center policy to insure [sic] all Time/Temperature Control for Safety (TCS), .and refrigerated food items, will be appropriately stored in accordance with guidelines of the FDA (food and drug administration) Food Code .The Dining Services Director/Cook(s) insures [sic] that all food items are stored properly in covered containers, labeled and dated .
Surveyor requested, but did not receive, a facility policy for cleaning the convection oven and was informed by regional director of clinical services there was no policy for cleaning the convection oven. Surveyor requested and received a facility document titled, Monthly Cleaning Schedule, that revealed boxes with checkmarks in June for convection oven-top and convection oven-bottom. The document did not contain any specific dates or initials of when or who performed the oven cleaning. The document also revealed, the boxes for, reach-in cooler 1 and reach-in cooler 2 did not have any check marks for the month of June.
No further information regarding this concern was presented to the survey team prior to the exit conference on 6/18/24.
MINOR
(B)
Minor Issue - procedural, no safety impact
Staffing Information
(Tag F0732)
Minor procedural issue · This affected multiple residents
Based on interviews and the review of facility documents, the facility staff failed to ensure the daily staff posting contained the required information.
The findings included:
The surveyor reviewed t...
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Based on interviews and the review of facility documents, the facility staff failed to ensure the daily staff posting contained the required information.
The findings included:
The surveyor reviewed the facility's posted nurse staffing data. The facility staff used a form titled DAILY NURSE STAFFING SUMMARY to post its daily nurse staffing data. The facility staff posts one form daily for each of its three (3) units. The surveyor reviewed the most recent 30 days of the facility's DAILY NURSE STAFFING SUMMARY forms. The forms failed to contain the following required information:
- For the 6/12/24 Unit 1 posting the facility staff failed to document the hours worked by nursing staff.
- For the 6/12/24 Unit 2 posting the facility staff failed to document the hours worked by nursing staff.
- The facility staff failed to document the census for the following dates and units: 6/13/24 Unit 1; 6/12/24 Unit 1; 6/12/24 Unit 2; 6/11/24 Unit 1; 6/11/24 Unit 2; 6/10/24 Unit 2; 6/9/24 Unit 2; 6/9/24 (Unit not identified); 6/8/24 Unit 2; 6/7/24 Unit 1; 6/7/24 Unit 2; 6/6/24 Unit 1; 6/6/24 Unit 2; 6/5/24 Unit 2; 6/5/24 Unit 1; 6/3/24 Unit 1; 6/3/24 Unit 2; 6/1/24 Unit 1; 5/27/24 Unit 2; 5/27/24 Unit 1; 5/26/24 Unit 2; 5/26/24 Unit 1; 5/25/24 Unit 2; 5/25/24 Unit 1; and 5/24/24 Unit 2.
The following information was found on the facility's DAILY NURSE STAFFING SUMMARY form: Post this document in a prominent place; accessible to patients and visitors. Complete at the beginning of each shift; update any changes to information as needed.
On 6/18/24 at 1:32 p.m., the survey team met with the facility's Administrator, Director of Nursing (DON), Assistant DON, and Regional Director of Clinical Services (RDCS). The surveyor discussed the facility staff posting incomplete daily nurse staffing data.
Apr 2023
4 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
Deficiency F0552
(Tag F0552)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, family interview, and staff interviews, facility staff failed allow the resident to choose the trea...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, family interview, and staff interviews, facility staff failed allow the resident to choose the treatment options he or she prefers as evidenced by reports that a staff member informed the resident that going to the hospital emergency department would result in loss of nursing home placement for 1 of 6 residents in the survey sample (Resident #4).
Resident #4 was admitted to the facility with diagnoses that included cerebral infarction, hemiplegia/hemiparesis following cerebral infarction, diabetes mellitus, and hypertension. On the Minimum Data Set assessment with assessment reference date 11/28/22, the resident scored 13/15 on the Brief Interview for Mental Status and was assessed as without signs of delirium, psychosis, or behaviors affecting care. The assessment indicated that the resident had reported occasional pain with pain severity as high as 10/10 with 10 being the highest possible score.
During an interview on 4/4/23, the resident reported that there had been two nights, 12/6/22 and 12/7/22 when the resident was in pain and did not receive treatment that reduced the pain to an acceptable level. The resident became tearful when recounting the events of the two nights. The resident reported asking the nurse to go to the hospital emergency department to seek treatment. The resident stated the room mate witnessed the interaction and the resident's daughter was on the phone at the time. The surveyor spoke with the resident's room mate on 4/4/23 and the room mate confirmed witnessing the resident crying with pain for the 2 nights in question and that the resident had asked to be sent to the emergency department for treatment of pain. The room mate stated the nurse told the resident that pain was not an emergency and the resident would lose the nursing home bed if the resident left to go to the hospital. On 4/5/23 the surveyor interviewed the resident's daughter, who reported being on the phone with the resident through the interaction with the nurse who told the resident that the resident could not go to the hospital for treatment and return to the facility.
The surveyor interviewed the resident's nurse (LPN #5) by phone on 4/5/23. The nurse stated the resident did complain of pain the nights in question and was given something (per [NAME] Administration Record, at 4:30 AM, and 5:36 AM on 12/7/22, the second night). The nurse did not remember the resident asking to go to the hospital.
The surveyor received similar reports from two residents and 1 family member and the employee involved did not remember the reported incident. The preponderance of evidence suggests the resident was told that going to the hospital for treatment would result in loss of nursing home placement.
The administrator and director of nursing were made aware of the concern during a summary conference on 4/4 and 4/5/23.
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 F0563
(Tag F0563)
Could have caused harm · This affected 1 resident
Based on observation, staff interview, resident interview, and family interviews, facility staff failed to allow the resident to receive visitors at times of choosing as evidenced by limiting visitati...
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Based on observation, staff interview, resident interview, and family interviews, facility staff failed to allow the resident to receive visitors at times of choosing as evidenced by limiting visitation to specific hours not dependent on clinical or safety concerns for 1 of 6 residents in the survey sample (Resident #4).
Resident #4 was admitted to the facility with diagnoses that included cerebral infarction, hemiplegia/hemiparesis following cerebral infarction, diabetes mellitus, and hypertension. On the Minimum Data Set assessment with assessment reference date 11/28/22, the resident scored 13/15 on the Brief Interview for Mental Status and was assessed as without signs of delirium, psychosis, or behaviors affecting care. The assessment indicated that the resident had reported occasional pain with pain severity as high as 10/10 with 10 being the highest possible score.
The surveyor interviewed the resident's sister by phone on 4/5/23 about concerns expressed by the resident. The resident's sister stated that she had only been allowed to visit during the day. Staff informed her that she had to leave before 8 PM and could not return until after 8 AM. She and other family members had asked to go sit with the resident on some nights when the resident was having problems and had been told that it was outside visiting hours and to wait. The sister also stated that her husband had tried to drop off clean clothing for the resident on his way to work one day. He arrived at around 7:45 AM and knocked on the door. A staff member looked at him, he held up the clothes basket, and the staff member shook her head and walked away.
The surveyor reported the conversation to the administrator and director of nursing on 4/5/23. The administrator stated that facility doors are locked for safety between 8 PM and 8 AM. She stated that locked doors and unmanned front desk did not equal banning visitors.
The surveyor determined that staff statements that visitation was not allowed, and the report that staff did not open the door to accept the clean laundry indicated that visitation was disallowed.
The administrator and director of nursing were made aware of the concern during a summary conference on 4/4 and 4/5/23.
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
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, clinical record review, and facility document review, facility staff failed to ensure the resident rec...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, clinical record review, and facility document review, facility staff failed to ensure the resident received adequate supervision to prevent accidents for 1 of 5 residents in the survey sample (Resident #1). This is past noncompliance.
Resident #1 was admitted to the facility with diagnoses including Alzheimer's dementia, dementia with agitation, severe malnutrition, dysphagia, congestive heart failure, hearing loss, hypertension, and arthritis. On the Minimum data set assessment with assessment reference date 2/20/23, the resident scored 1/15 on the brief interview fro mental status (indicating significant cognitive impairment) and was assessed as exhibiting physical and verbal behaviors 1-3 of the prior 7 days, significant interference with care, putting others at risk, and disrupting the care environment. The resident was discharged to the hospital for a procedure and readmitted on [DATE].
A facility reported incident indicated the resident had an unwitnessed fall with head injury requiring hospitalization on 3/12/23.
A nursing Fall note dated 3/12/23 Patient went outside in wheelchair and fell. Patient has laceration on right side of eye/head. Contributing factors were wander guard not in place, wheelchair lock. New interventions were: wander guard, geri chair (a recliner).
Clinical record review revealed an administrative order for Left ankle Check Wander Prevention patient band every shift every to start 2/15/2023 and discontinued 3/9/2023.
The surveyor interviewed LPN#4 on 4/5/23 at 11:20 AM. LPN#2 stated that the first time the resident sought exit after returning from the hospital on 3/9/23. On 3/12/23 the resident became aggressive and would not let staff touch him. The resident was moving around the nursing unit in a wheelchair. The receptionist at the front door yelled for help from a nurse. The nursing supervisor and another nurse went outside to bring the resident back inside. The supervisor and nurse witnessed the resident stand and fall to his knees, then face down. When they brought the resident back inside, he was bleeding from his forehead and swinging at staff as they tried to clean his wounds. The resident's color changed and was still bleeding, so staff called 911 to send him to the hospital. The resident had not returned to the facility by the end of the survey on 4/5/23.
The surveyor interviewed the director of nursing (DON) on 4/5/23 at 11 AM. The DON stated the resident's wander guard was not replaced on admission because the resident was not having any of the behaviors that caused the wander guard to be placed on him. The surveyor asked for the assessment that resulted in not replacing the wander prevention device on the resident's return from the hospital on 3/9. No wander assessment had been completed on readmission.
The DON stated that the facility recognized there was an issue and initiated a QA(quality assurance) investigation and plan of correction. The plan, except for staff education, had been completed on 3/31/23. The QA team determined that a wander assessment on readmission could have resulted in replacement of the wander prevention device prevented the resident from exiting through the front door and falling outside. Nursing staff reviewed all admissions and readmissions from 3/13 through 3/31/23 and ensured each had a wander assessment within 24 hours of admission and appropriate interventions were put in place. An inservice education program addressing elopement and conducting elopement assessment on admission. All licensed nurses received training by 4/3/23. The DON and/or designee will review all admissions to ensure wander assessments are completed within 24 hours. Results will be reported to the QA committee monthly until the QA committee determines the problem no longer exists, at which time wander assessment on admission will become part of the random audit process.
Surveyors reviewed residents admitted within 30 days of the survey and all had wander assessments conducted on admission and appropriate interventions in place.
During a summary meeting on 4/5/23, the administrator and director of nursing were notified that the issue was to be considered past non-compliance with a correction plan completed.
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 F0697
(Tag F0697)
Could have caused harm · This affected 1 resident
Based on resident interview, family interview, and staff interviews, facility staff failed ensure pain management was provided to the resident for 1 of 6 residents in the survey sample (Resident #4).
...
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Based on resident interview, family interview, and staff interviews, facility staff failed ensure pain management was provided to the resident for 1 of 6 residents in the survey sample (Resident #4).
Resident #4 was admitted to the facility with diagnoses that included cerebral infarction, hemiplegia/hemiparesis following cerebral infarction, diabetes mellitus, and hypertension. On the Minimum Data Set assessment with assessment reference date 11/28/22, the resident scored 13/15 on the Brief Interview for Mental Status and was assessed as without signs of delirium, psychosis, or behaviors affecting care. The assessment indicated that the resident had reported occasional pain with pain severity as high as 10/10 with 10 being the highest possible score.
During an interview on 4/4/23, the resident reported that there had been two nights, 12/6 and 12/7/2013 when the resident was in pain and did not receive treatment that reduced the pain to an acceptable level. The resident became tearful when recounting the events of the two nights. The resident reported asking the nurse to go to the hospital emergency department to seek treatment. The resident stated the room mate witnessed the interaction and the resident's daughter was on the phone at the time. The surveyor spoke with the resident's room mate on 4/4/23 and the room mate confirmed witnessing the resident crying with pain for the 2 nights in question. The room mate confirmed that the resident had cried and been awake all night with pain. On 4/5/23 the surveyor interviewed the resident's daughter, who reported being on the phone with the resident on those 2 nights and heard the resident asking for pain management.
Clinical record review revealed two medications were available as needed for pain:
1- an order for acetaminophen 325 milligrams give 2 tablets by mouth every 6 hours as needed for pain started 11/23/22 and discontinued 12/8/22. The medication administration record (MAR) indicated the resident received the medication one time on 12/7/22 at 5:36 AM for pain at a level 8/10.
2- an order for baclofen tablet 5 milligrams give 1 tablet every 8 hours as needed for muscle pain/spasms started 11/23/22 and discontinued 12/8/22 was administered on 12/7/23 at 4:30 AM.
The surveyor interviewed the resident's nurse (LPN #5) by phone on 4/5/23. The nurse stated the resident did complain of pain the nights in question and was given something (per MAR, at 4:30 AM and 5:36 AM the second night). The nurse did not offer a reason for not administering available medications on the night of 12/6 or earlier in the night on 12/7/22.
The administrator and director of nursing were made aware of the concern with pain management during a summary conference on 4/4 and 4/5/23.
Mar 2023
1 deficiency
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
Notification of Changes
(Tag F0580)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and clinical record review,and in the course of a complaint investigation, facility staff failed to not...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and clinical record review,and in the course of a complaint investigation, facility staff failed to notify the resident's responsible party after a resident fall for 1 of 5 residents with falls in the survey sample (Resident #1).
Resident #2 was admitted to the facility with diagnoses including Parkinson's, cardiopulmonary disease, dysphagia, aphasia, hypertension, urinary tract infection, bronchitis, chronic kidney disease, unsteadiness on feet, and depression. On the minimum data set assessment with assessment reference date 12/1/2022, the resident scored 1/15 on the brief interview for mental status and was assessed as without signs of delirium, psychosis, and behaviors affecting care. The resident was assessed as needing supervision with transfers, walking in the room, and walking in the corridor and with limited assistance with toileting. The resident had no falls in the facility prior to 12/1/22.
The surveyor spoke with the complainant by phone on 3/7/23. The complainant had no further allegations, and expressed the major concern was with communication from the facility.
Clinical record review revealed the resident had falls on 2/13 and 2/14/2023. The fall note dated 2/13/23 at 13:38 in answer to 'was the provider/resident and RP (responsible party) notified at the time of the fall? ' [name] NP made aware. A Late Entry fall note dated 2/15/23 at 11:29 AM documented that a fall occurred on 2/14/23 at 1:05 PM. Under Additional Comments the nurse wrote RP [name] notified by this nurse of the fall.
The surveyor interviewed the unit manager on 3/7/23. The unit manager explained that on 2/13/23, the day shift nurse passed the information to the evening shift nurse to make the notification. This is a common practice if no injuries are immediately apparent and there are no new orders. The resident's RP was in the facility to visit the resident at 6:14 PM (from the visitor entry register) and was notified in person of the fall. For the fall on 2/14, the unit manager acknowledged that the RP was not notified of the fall that day.
During a summary meeting on 3/7/2022, the surveyor reported the findings to the administrator, assistant administrator, director of nursing, and assistant director of nursing. No additional information was offered.
Aug 2022
5 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Assessment Accuracy
(Tag F0641)
Could have caused harm · This affected 1 resident
Based on staff interview and clinical record review, the facility staff failed to ensure an accurate minimum data set (MDS) assessment for 1 of 3 discharged residents reviewed for discharge process, R...
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Based on staff interview and clinical record review, the facility staff failed to ensure an accurate minimum data set (MDS) assessment for 1 of 3 discharged residents reviewed for discharge process, Resident #163.
For Resident #163, the facility staff coded the discharge MDS assessment indicating the resident was discharged to an acute hospital when in fact the resident had been discharged to an independent living facility.
The findings included:
Resident #163's diagnosis list indicated diagnoses, which included, but not limited to Chronic Respiratory Failure, Acute on Chronic Combined Congestive Heart Failure, Atherosclerotic Heart Disease of Native Coronary Artery, Chronic Atrial Fibrillation, and Adult Failure to Thrive.
The most recent discharge MDS assessment with an assessment reference date (ARD) of 5/24/22 coded the resident as being discharged to an acute hospital.
A review of Resident #163's clinical record revealed a nursing progress note dated 5/24/22 at 6:45 pm stating in part Patient discharged this shift. Left being pushed in wheel chair by family, left with all personal belongings .
A 5/20/22 3:37 pm discharge planning progress note stated in part Patient is to return back to (Name Omitted) Independent Living Facility on 5/24/22 .Transportation has been arranged with the patient's (spouse) and (adult child) via private vehicle .
On 8/17/22 at 3:09 pm, surveyor spoke with MDS registered nurse (RN) #1 regarding the coding of Resident #163's 5/24/22 discharge MDS assessment. MDS RN #1 returned to the surveyor at 3:20 pm and stated the discharge MDS assessment had been modified and re-submitted.
On 8/18/22 at 1:17 pm during a meeting with the facility management team including the Interim Administrator, Director of Nursing (DON), Assistant DON, Regional Director of Clinical Services #1 and #2, and the [NAME] President of Professional Development, surveyor discussed the concern of Resident #163's 5/24/22 discharge MDS coding.
No further information regarding this concern was presented to the survey team prior to the exit conference on 8/18/22.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected 1 resident
2. Resident #144's face sheet listed diagnoses which included but not limited to morbid obesity, rheumatoid arthritis, type 2 diabetes mellitus, and depression.
Resident #144's admission minimum data ...
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2. Resident #144's face sheet listed diagnoses which included but not limited to morbid obesity, rheumatoid arthritis, type 2 diabetes mellitus, and depression.
Resident #144's admission minimum data set with an assessment reference date of 07/26/22 assigned the resident a brief interview for mental status score of 15 out of 15 in section C, cognitive patterns. This indicates that the resident is cognitively intact. Section G, functional status, coded the resident as needing extensive assistance of one person physical assist, in the area of personal hygiene.
Resident #144's comprehensive care plan was reviewed and contained a care plan for The resident has an ADL self-care performance deficit r/t (related to) weakness.
Surveyor spoke with Resident #144 on 08/15/22 at 8:15 pm. Surveyor observed resident's fingernails, which were extremely long. Surveyor asked Resident #144 if staff assisted them with nail care, and Resident #144 stated, Will they do that? and also stated that the length of nails bothered them. Resident #144 asked surveyor if staff would cut their toenails as well, and showed surveyor that toenails were long and thickened.
Surveyor, along with director of nursing (DON), spoke with Resident #144 again on 08/17/22 at 9:15 am. Resident #144 again stated that the length of their fingernails bothered them. DON stated to resident that they would cut the nails for resident. Resident asked DON about cutting toenails as well and DON stated they would look at them and cut them, if they could. After exiting resident's room, surveyor asked DON who is responsible for cutting residents' nails and DON stated that all staff are.
The concern of not providing nail care was discussed with the interim administrator, director of nursing, assistant director of nursing, regional director of clinical services, and vice-president of professional development on 08/17/22 at 2:55 pm.
No further information was provided prior to exit.
Based on observation, staff interview, and clinical record review, the facility staff failed to provide activities of daily living (ADL) care in regards to nail care for 2 of 34 Residents, Resident #146 and #144.
For Resident #146, fingernails were observed to long and jagged with debris present.
For Resident #144, fingernails and toenails were observed to long and jagged.
The findings included:
1. Resident #146's diagnoses included, but were not limited to, unspecified injury of head, aphasia, dysphagia, contracture right hand, seizures, and personal history of traumatic brain injury.
Section C (cognitive patterns) of Resident #146 annual minimum data set (MDS) assessment with an assessment reference date (ARD) of 08/03/22 was coded 1/1/3 to indicate the resident had problems with long and short-term memory and was severely impaired in cognitive skills for daily decision-making. Section G (functional status) was coded 4/2 for personal hygiene indicating the resident was totally dependent on one person to complete this task. Range of motion was coded to indicate the resident had impairment on both sides of the upper and lower extremities.
The residents comprehensive care plan included the focus areas-impaired communication related to aphasia, contracture of right hand, resistive to care, and refuses nail care.
08/15/22, during initial tour Resident #146's fingernails were observed to be long and jagged on their right hand.
08/16/22 12:20 p.m., checked nails with Licensed Practical Nurse (LPN) #4 and Certified Nursing Assistant (CNA) #1 nails left hand long and jagged with debris present. Nails on right hand long and jagged, contracture's bilateral hands. CNA #1 stated they would cut Resident #146's nails.
08/17/22 a.m., 7:55 a.m., checked nails with registered nurse (RN) #1 nails remain long and jagged.
08/17/22 2:00 p.m., LPN #5, stated the CNA did not cut nails yesterday, she forgot and it has been addressed.
08/17/22 8:05 a.m., the Director of Nursing (DON) made aware of issue with Resident #146's nails.
08/17/22 2:55 p.m., during an end of the day meeting with the DON, Interim Administrator, Regional Director of Clinical Services #1 and #2, and [NAME] President of Professional Development the issue regarding Resident #146's nail care was reviewed.
No further information regarding this issue was provided to the survey team prior to the exit conference.
CONCERN
(D)
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 observation, staff interview, clinical record review and during a medication pass and pour the facility staff failed to...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, clinical record review and during a medication pass and pour the facility staff failed to follow physician's orders for 1 of 34 Residents, Resident #15.
For Resident #15, the facility staff failed to follow physician's orders for the administration of the medication, venlafaxine 25 mg. Venlafaxine is a medication used to treat, depression, generalized anxiety disorder and panic disorder.
The findings included:
Resident #15's face sheet listed diagnoses which included but not limited to schizophrenia, insomnia and depression.
Resident #15's most recent annual minimum data set with an assessment reference date of 05/18/22 assigned the resident a brief interview for mental status score of 15 out of 15 in section C, cognitive patterns. This indicates that the resident is cognitively intact.
Resident #15's comprehensive care plan was reviewed and contained a care plan for The resident has potential for impaired thought processes r/t (related to) Disease Process, has dx (diagnosis) of schizophrenia. Interventions for this care plan include Give medications as ordered.
Surveyor observed licensed practical nurse (LPN) #3 during a medication pass and pour on 08/16/22 at 8:35 am. While preparing Resident #15's medications, LPN #3 stated to surveyor that they could not locate resident's 25 mg venlafaxine in the medication cart, and would need to ask the unit manager what they should do. LPN #3 did not look in the medication room to see if they could locate the medication. LPN #3 informed unit manager that they could not locate Resident #3's venlafaxine, and unit manager advised LPN #3 to contact the physician and obtain an order to hold the medication. LPN #3 contacted physician and an order was obtained to hold the medication for one day.
Surveyor reconciled Resident #15's medications on 08/16/22. The resident's physician's order summary contained and entry, which read in part Venlafaxine HCl 25 mg. Give 1 tablet by mouth two times a day related to SCHIZOPHRENIA, UNSPECIFIED (F20.9) for 2 weeks. This order had a start date of 08/15/22 at 6 pm.
Surveyor spoke with pharmacy tech on 08/17/22 at 3:20 pm. Surveyor asked pharmacy tech when Resident #15's venlafaxine was dispensed and pharmacy tech stated that the medication was dispensed on 08/15/22 at 11:18 pm.
On 08/18/22, director of nursing (DON) provided the surveyor with a copy of a pharmacy manifest that indicated the medication was out for delivery from the pharmacy on 08/15/22 at 11:18 pm and delivered to the facility on [DATE] at 2:29 am. DON stated they did not know why the medication was not placed on the medication cart or why LPN #3 did not look in the medication room for the medication.
The concern of not following the physician's orders was discussed with the interim administrator, DON, assistant director of nursing, regional director of clinical services and vice president of professional development during a meeting on 08/18/22 at 1:20 pm.
No further information was provided prior to exit.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Medical Records
(Tag F0842)
Could have caused harm · This affected 1 resident
2. Resident #163's diagnosis list indicated diagnoses, which included, but not limited to Chronic Respiratory Failure, Acute on Chronic Combined Congestive Heart Failure, Atherosclerotic Heart Disease...
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2. Resident #163's diagnosis list indicated diagnoses, which included, but not limited to Chronic Respiratory Failure, Acute on Chronic Combined Congestive Heart Failure, Atherosclerotic Heart Disease of Native Coronary Artery, Chronic Atrial Fibrillation, and Adult Failure to Thrive.
The most recent discharge MDS assessment with an assessment reference date (ARD) of 5/24/22 coded the resident as being discharged to an acute hospital, however, Resident #163 was discharged to an independent living facility.
A review of Resident #163's clinical record revealed a nursing progress note dated 5/24/22 at 6:45 pm stating in part Patient discharged this shift. Left being pushed in wheel chair by family, left with all personal belongings .
A 5/20/22 3:37 pm discharge planning progress note stated in part Patient is to return back to (Name Omitted) Independent Living Facility on 5/24/22 with a 30-day supply of medications through (Name Omitted) as (his/her) insurance has authorized a discharge date . Transportation has been arranged with the patient's (spouse) and (adult child) via private vehicle .
Surveyor reviewed Resident #163's physician's orders and was unable to locate an order for discharge from the facility. On 8/18/22 at 10:33 am, surveyor spoke with the Director of Nursing (DON) regarding a physician's order for discharge for Resident #163. Surveyor asked the DON if the resident should have an order for discharge and they stated yes. On 8/18/22 at 11:47 am, the DON returned and stated they did not have a discharge order for Resident #163.
Surveyor requested received the facility policy entitled Discharge Planning which included a Discharge Audit Worksheet which stated in part Charts are deficient until all of the following items are completed, Number five (5) on the worksheet stated Physician's Order for Discharge.
On 8/18/22 at 1:17 pm during a meeting with the facility management team including the Interim Administrator, DON, Assistant DON, Regional Director of Clinical Services #1 and #2, and the [NAME] President of Professional Development, surveyor discussed the concern of Resident #163 not having a physician's order for discharge.
No further information regarding this concern was presented to the survey team prior to the exit conference on 8/18/22.
Based on staff interview and clinical record review, the facility staff failed to maintain a complete and accurate clinical record for 2 of 8 closed record reviews, Resident #362 and Resident #163.
Resident #362's clinical record did not include a discharge summary or a discharge order.
Resident #163's clinical records did not include a physicians discharge order.
The findings included:
1. Resident #362 had been discharged from the facility in December of 2021.
Resident #362 diagnoses included, but were not limited to, chronic atrial fibrillation, asthma, moderate protein-calorie malnutrition, hypertensive heart disease, bilateral aural vertigo, and major depressive disorder.
Section C (cognitive patterns) of Resident #362 admission minimum data set (MDS) assessment with an assessment reference date (ARD) of 10/20/21 included a brief interview for mental status (BIMS) summary score of 15 out of a possible 15 points.
During the clinical record review, the surveyor was unable to find a discharge order or physicians discharge summary for this resident.
08/16/22 2:20 p.m., the Director of Nursing (DON) stated they did not have a discharge summary for this Resident.
08/16/22 4:22 p.m., during an end of the day meeting with the Interim Administrator, Regional Director of Clinical Services #1 and #2, DON, Assistant Director of Nursing (ADON), and [NAME] President of Professional Development the issue regarding the missing discharge summary was reviewed.
08/17/22 11:20 p.m., the DON stated they did not have a discharge order for this Resident.
08/17/22, the Regional Director of Clinical Services provided the survey team with a copy of their policy titled, DISCHARGE PLANNING POLICES AND PROCEDURES MANUAL updated April 20, 2022. This policy read in part, .Charts are deficient until all of the following items are completed. Charts are considered delinquent if items are not complete within 30 days from the discharge date . Number 5 on this list was Physician's Order for Discharge. Number 6 was Physician's Discharge Summary has been completed.
No further information regarding this issue was provided to the survey team prior to the exit conference.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0582
(Tag F0582)
Could have caused harm · This affected multiple residents
Based on interviews and facility document review, it was determined the facility staff failed to provide Beneficiary Protection Notifications, when discharged from a Medicare covered Part A stay with ...
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Based on interviews and facility document review, it was determined the facility staff failed to provide Beneficiary Protection Notifications, when discharged from a Medicare covered Part A stay with benefit days remaining, for three (3) of three (3) residents sampled for beneficiary notice review (Resident #17, Resident #72, and Resident #225).
The findings include:
Three (3) residents (Resident #17, Resident #72, and Resident #225) were selected for review from the Beneficiary Notice - Residents discharged Within the Last Six Months form completed by the facility staff.
On 8/17/22 at 1:00 p.m., Administrative Staff Member (ASM) #6 reported the Beneficiary Protection Notifications for the aforementioned three (3) residents were not available. ASM #6 reported the Discharge Planner who was responsible for providing the notifications, in question, no longer worked at the facility.
The following information was found as part of a facility policy titled Notice of Medicare Non-Coverage (NOMNC) (with an effective date of 4/1/22): POLICY: A generic notice of non-coverage (NOMNC) must be given to any patient with benefit days remaining who is no longer going to be receiving services covered by Medicare or a Medicare Advantage Plan. PROCEDURE: Medicare A: 1. The Discharge Planner or designee will complete and issue the Notice of Medicare Non-Coverage in advance of the Part A coverage ending date as determined by Center clinical personnel. a. The Medicare Notice of Non-Coverage must be issued no later than 2 days before the coverage will end .
On 8/18/22 at 1:17 p.m., a survey team meeting occurred with the facility's Interim Administer, Director of Nursing, [NAME] President of Professional Development, Assistant Director of Nursing, and two (2) Regional Directors of Clinical Services. The failure of the facility staff to have evidence of providing Resident #17, Resident #72, and Resident #225 with the aforementioned Beneficiary Protection Notifications was discussed, for a final time, during this meeting. No additional information related to this issue was provide prior to the conclusion of the survey.
Jan 2020
11 deficiencies
CONCERN
(D)
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, staff interview, and during the course of a complaint investigation, the facility staff failed to maintain...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and during the course of a complaint investigation, the facility staff failed to maintain a clean, comfortable, and homelike environment on 1 of 3 units (unit 2). The surveyor observed a brown substance on the shower chair in shower room [ROOM NUMBER] and one cracked shower chair in shower room [ROOM NUMBER].
The findings included:
Shower room [ROOM NUMBER] on unit 2 was observed by the surveyor to have a brown substance on a shower chair. Shower room [ROOM NUMBER] was observed to have a cracked shower chair seat.
On 01/15/2020 at 5:14 a.m., the surveyor and LPN (licensed practical nurse) #2 entered shower room [ROOM NUMBER] on unit 2. During this observation, the surveyor and LPN #2 observed a brown substance on a shower chair in this shower room. LPN #2 identified this brown substance as poo.
Upon leaving this shower room the surveyor entered shower room [ROOM NUMBER] on this same unit and observed a cracked shower chair seat.
The administrator, DON (director of nursing), ADON (assistant director of nursing), administrator in training, and nurse consultant were notified of these issues on 01/22/2020 at 3:08 p.m.
No further information regarding these issues were provided to the survey team prior to the exit conference on 01/22/220.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0655
(Tag F0655)
Could have caused harm · This affected 1 resident
Based on staff interview and clinical record review, the facility staff failed to complete a baseline care plan that included the residents isolation status for 1 of 39 Residents, Resident #159.
The ...
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Based on staff interview and clinical record review, the facility staff failed to complete a baseline care plan that included the residents isolation status for 1 of 39 Residents, Resident #159.
The findings included:
Resident #159 was on contact isolation for clostridioides (clostridium) difficle. The facility staff failed to add this to the residents baseline care plan.
Per the CDC (centers for disease control and prevention) website accessed 01/24/2020 clostridioides difficle (C. diff) is a bacterium that causes diarrhea and colitis (an inflammation of the colon).
The EHR (electronic health record) included the diagnoses, chronic obstructive pulmonary disease, cerebral infarction, encephalopathy, and essential hypertension.
Section C (cognitive patterns) of the residents admission MDS (minimum data set) assessment with an ARD (assessment reference date) of 12/26/2019 included a BIMS (brief interview for mental status) summary score of 11 out of a possible 15 points.
The residents EHR included a physician discharge summary with a date of service of 12/23/2019 indicating this resident was receiving vancomycin (antibiotic) for clostridium difficle colitis.
The EHR also included a nursing progress note dated 12/24/2019 that read in part, .Continues on contact isolation for C. Diff . A second progress note dated 12/26/2019 read, Discontinue precautions for C-diff. Received verbal order to discontinue precautions from Dr. _____. Resident aware of discontinuance of precautions.
The surveyor was unable to locate any information regarding the contact isolation in the residents care plan or in the physician orders.
MDS coordinator #1 was asked about the missing information on the care plan on 01/21/2020 at 9:44 a.m.
On 01/21/20 at 10:25 a.m., the DON (director of nursing) verbalized to the surveyor that there was no care plan for isolation and no order and she would expect an order.
The administrator, DON, ADON (assistant director of nursing), administrator in training, and nurse consultant were notified of the issue regarding Resident #159's care plan on 01/22/2020 at 3:08 p.m.
No further information regarding this issue was provided to the survey team prior to the exit conference on 01/22/2020.
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
Based on observation, family interview, staff interview, and clinical record review, the facility staff failed to implement the comprehensive care plan in regards to floor mats for 1 of 39 residents, ...
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Based on observation, family interview, staff interview, and clinical record review, the facility staff failed to implement the comprehensive care plan in regards to floor mats for 1 of 39 residents, Resident #140.
The findings included:
Resident #140 had been care planned for falls with an intervention for fall mats. The surveyor did not observe these to be in use.
The EHR (electronic health record) included the following diagnoses, Alzheimer's disease, abnormalities of gait, and muscle weakness.
Section C (cognitive patterns) of the residents admission MDS (minimum data set) assessment with an ARD (assessment reference date) of 12/20/2019 included a BIMS (brief interview for mental status) summary score of 3 out of a possible 15 points. Section G (functional status) was coded to indicate the resident required extensive assistance of one person for bed mobility and locomotion on and off the unit. Transfers were coded to indicate the resident required extensive assistance of two people to complete this task. Section J (health conditions) had been coded to indicate the resident had falls in the last month.
The residents comprehensive care plan included the focus area Actual fall with increased risk for falls r/t (related to) Gait/balance problems; safety unawareness. Interventions included, but were not limited to, .fall mats .
On 01/14/2020 at 4:10 p.m., during an interview with Resident #140's family the residents family verbalized to the surveyor that Resident #140 should have fall mats beside his bed. The surveyor did not observe any fall mats in the room.
On 01/16/2020 at 7:35 a.m., Resident #140 was observed by the surveyor resting on their bed. The surveyor did not observe any falls mats beside Resident #140's bed or in the room.
On 01/16/20 at 9:10 a.m., another observation was made of Resident #140. The resident was observed to be resting on their bed. Again, the surveyor did not observe any fall mats in the room. Upon exiting the room, the surveyor asked the unit manager to accompany them into the room. The unit manager acknowledged to the surveyor that there were not any fall mats beside the residents bed and stated it was everyone's responsibility to ensure they were in place.
On 01/16/2020 at 12:20 p.m., the facility administrator, DON (director of nursing), administrator in training, assistant director of nursing, and nurse consultant were made aware of the missing fall mats.
No further information regarding this issue was provided to the survey team prior to the exit conference.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
2. For Resident #126, the facility staff failed to follow physician's orders for the administration of the medication Gabapentin (an anticonvulsant also used to treat nerve pain).
Resident #126's dia...
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2. For Resident #126, the facility staff failed to follow physician's orders for the administration of the medication Gabapentin (an anticonvulsant also used to treat nerve pain).
Resident #126's diagnosis list indicated diagnoses, which included, but not limited to Alcohol Dependence with Withdrawal, Anxiety Disorder, Chronic Pain Syndrome, Chronic Obstructive Pulmonary Disease, Major Depressive Disorder, and Unspecified Diastolic (Congestive) Heart Failure.
The most recent quarterly MDS (minimum data set) with an ARD (assessment reference date) of 12/20/19 assigned the resident a BIMS (brief interview for mental status) score of 15 out of 15 in section C, Cognitive Patterns.
A review of Resident #126's medical record revealed the following documentation:
A progress note dated 1/11/20 10:06 states in part, new order to discontinue Lyrica 50 mg and start Gabapentin 100 mg TID (three times a day).
The January 2020 MAR (medication administration record) includes a physician's order dated 1/11/20 0959 stating Gabapentin Capsule 100 mg give 1 capsule by mouth three times a day related to other chronic pain. The first dose was scheduled on the MAR to be administered on 1/11/20 at 1400 (2:00pm).
The January 2020 MAR was not signed for the administration of Gabapentin 100 mg on 1/11/20 at 1400 (2:00pm).
On 1/22/20 at 9:31am, the DON (director of nursing) stated it looks like the Gabapentin was not given.
The surveyor requested and received the policy Medication Shortages/Unavailable Medications which stated in part:
2. If a medication shortage is discovered during normal Pharmacy hours:
2.1 Facility nurse should call Pharmacy to determine the status of the order. If the medication has not been ordered,
the licensed Facility nurse should place the order or reorder for the next scheduled delivery.
2.2 If the next available delivery causes delay or a missed dose in the resident's medication schedule, Facility nurse
should obtain the medication from the Emergency Medication Supply to administer the dose.
The surveyor requested and received a list of the contents of the facility emergency medication supply boxes. The list labeled Ekit Contents includes the medication Gabapentin Capsule 100 mg.
On 1/22/20 at 3:09pm, the administrative team consisting of the administrator, administrator in training, director of nursing, assistant director of nursing, and the corporate nurse were made aware of Resident #126 not receiving Gabapentin as ordered on 1/11/20.
No further information regarding this issue was presented to the survey team prior to the exit conference on 1/22/20.
Based on staff interview, resident interview, and clinical record review, the facility staff failed to ensure that residents receive treatment and care for 2 of 39 residents (Residents #81 and #126) by not scheduling a medical appointment until it was brought to their attention by the surveyor and failed to administer medications per the physician's orders.
The findings included:
1. For Resident #81, the facility staff failed to schedule a GI (gastroenterologist) appointment that had been ordered by the physician assistant on 01/06/2020 until it was brought to the facility attention by the surveyor on 01/15/2020.
The residents EHR (electronic health record) included the diagnoses, anxiety disorder, encounter for attention to colostomy, dementia, irritable bowel syndrome, and gastro-esophageal reflux disease.
Section C (cognitive patterns) of the Residents quarterly MDS (minimum data set) assessment with an ARD (assessment reference date) of 11/25/2019 included a BIMS (brief interview for mental status) summary score of 11 out of a possible 15 points.
The clinical record was reviewed on 01/15/2020.
The residents clinical record included a progress note dated 01/06/2020 that had been transcribed by the physician assistant. This progress note read in part, .Resident reports feeling tired today .had swollen/discolored stoma over the weekend that improved on its own .
On 01/05/2020 LPN (licensed practical nurse) #1 transcribed the following, .PA (physician assistant) gave new order to .f/u (follow up) with GI ASAP (as soon as possible) .
On 01/15/2020 at 6:22 a.m., the DON (director of nursing) was asked to provide confirmation that this appointment had been scheduled.
On 01/1520/20 at 7:02 a.m., LPN #2 reviewed the clinical record and appointment book and stated, I don't see anything. LPN #2 identified CNA (certified nursing assistant) #1 as being responsible for scheduling appointments.
On 01/15/2020 at 10:25 a.m., CNA #1 verbalized to the surveyor that this appointment had not been scheduled.
On 01/15/2020 at 10:39 a.m., during an interview with the PA, the PA verbalized to the surveyor that originally, the residents colostomy had been swollen but it resolved on its own so it is not as urgent now.
On 01/15/20 at 10:51 a.m., during an interview with Resident #81, this resident verbalized to the surveyor that this had been a longstanding issue and that sometimes their stoma looked infected and sometimes not and that sometimes it hurt and sometimes it did not.
On 01/16/2020 at 12:20 p.m., the facility administrator, DON, administrator in training, assistant director of nursing, and nurse consultant were made aware that the facility had not scheduled the residents GI appointment until it was brought to their attention by the surveyor.
Prior to the exit conference on 01/22/2020 the facility provided the surveyor with a yellow post it note with the residents name and stated the appointment had been scheduled for 01/24/2020 at 10:15 a.m.
No further information regarding this issue was provided to the survey team prior to the exit conference.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
Based on observation, family interview, staff interview, and clinical record review, the facility staff failed to ensure a hazard free environment as evidenced by not following the residents comprehen...
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Based on observation, family interview, staff interview, and clinical record review, the facility staff failed to ensure a hazard free environment as evidenced by not following the residents comprehensive care plan in regards to fall mats for 1 of 39 residents, Resident #140.
The findings included:
The facility failed to place fall mats beside the residents bed. The resident had actual falls and had been care planned to use fall mats.
The EHR (electronic health record) included the following diagnoses, Alzheimer's disease, abnormalities of gait, and muscle weakness.
Section C (cognitive patterns) of the residents admission MDS (minimum data set) assessment with an ARD (assessment reference date) of 12/20/2019 included a BIMS (brief interview for mental status) summary score of 3 out of a possible 15 points. Section G (functional status) was coded to indicate the resident required extensive assistance of one person for bed mobility and locomotion on and off the unit. Transfers were coded to indicate the resident required extensive assistance of two people to complete this task. Section J (health conditions) had been coded to indicate the resident had falls in the last month.
The residents comprehensive care plan included the focus area Actual fall with increased risk for falls r/t (related to) Gait/balance problems; safety unawareness. Interventions included, .fall mats .
On 01/14/2020 at 4:10 p.m., during an interview with Resident #140's family the residents family verbalized to the surveyor that the resident should have fall mats beside their bed. The surveyor did not observe any fall mats in the room.
On 01/16/2020 at 7:35 a.m., Resident #140 was observed by the surveyor resting on their bed. The surveyor did not observe any falls mats beside the residents bed or in the residents room.
On 01/16/20 at 9:10 a.m., during an observation of Resident #140 the surveyor did not observe any fall mats in the residents room. The resident was observed to be resting on their bed. The surveyor asked the unit manager to accompany them to the residents room. The unit manager acknowledged that there were not any falls mats beside the residents bed and stated it was everyone's responsibility to ensure they were in place.
On 01/16/2020 at 12:20 p.m., the facility administrator, DON (director of nursing), administrator in training, assistant director of nursing, and nurse consultant were made aware of the missing fall mats.
On 01/22/2020, the DON provided the surveyor with documentation to indicate this resident had an unwitnessed fall on 12/18/2019 and on 01/10/2020 with no injuries.
No further information regarding this issue was provided to the survey team prior to the exit conference.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Pharmacy Services
(Tag F0755)
Could have caused harm · This affected 1 resident
Based on staff interview, clinical record review and facility document review, the facility staff failed to provide pharmaceutical services to meet the needs of each resident as evidenced by failure t...
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Based on staff interview, clinical record review and facility document review, the facility staff failed to provide pharmaceutical services to meet the needs of each resident as evidenced by failure to administer a physician's ordered medication for 1 of 39 residents in the survey sample, Resident #126.
The findings included:
For Resident #126, the facility staff failed to ensure the medication Lyrica (an anticonvulsant also used to treat nerve pain) was available for administration.
Resident #126's diagnosis list indicated diagnoses, which included, but not limited to Alcohol Dependence with Withdrawal, Anxiety Disorder, Chronic Pain Syndrome, Chronic Obstructive Pulmonary Disease, Major Depressive Disorder, and Unspecified Diastolic (Congestive) Heart Failure.
The most recent quarterly MDS (minimum data set) with an ARD (assessment reference date) of 12/20/19 assigned the resident a BIMS (brief interview for mental status) score of 15 out of 15 in section C, Cognitive Patterns.
A review of Resident #126's medical record revealed the following documentation:
A physician's order dated 12/19/19 read in part, Lyrica 50 mg (milligrams) give 1 capsule by mouth three times a day related to other chronic pain.
The January 2020 MAR (medication administration record) is coded with an H for the administration of Lyrica on 1/04/20 2100 (9:00pm), 1/05/20 0500 (5:00am), and 1/05/20 1300 (1:00pm). The legend for Chart Codes/Follow Up Codes indicates an H is On Hold By Physician. Further review of the January 2020 MAR revealed an omission for Lyrica on 1/10/20 2100 (9:00pm) and 1/11/20 0500 (5:00am).
A progress note dated 1/04/20 18:58 states in part new order received from physician assistant to hold Lyrica until Monday 1/06/20. An order dated 1/04/20 18:56 placed the Lyrica on hold from 1/04/20 18:56 to 1/06/20 14:00 with the reason documented as per MD. An order to resume the Lyrica was obtained on 1/05/20 18:13 with the reason documented as per MD.
On 1/16/20 at 9:55am, the DON (director of nursing) stated that when the resident's nurse noticed the Lyrica was not in the cart on 1/04/20, they called the pharmacy but it was at 7:00pm on a Saturday and it was past the pharmacy cut off time for delivery. DON stated a medication error would not have been completed since the nurse obtained a hold order. DON also stated they would expect the nurses to reorder medications prior to running out.
On 1/16/20 at 10:46am, the DON provided the surveyor with a pharmacy Refill Re-Order Form dated 1/01/20 that included a refill barcode for Resident #126's Pregabalin (generic for Lyrica). The fax transmission information on the bottom of the form is dated 1/01/20 10:24pm.
The surveyor requested and received a list of the contents of the facility emergency medication supply boxes. Lyrica is not include on the lists provided.
The surveyor requested and received the policy Medication Shortages/Unavailable Medications which stated in part:
3.2 If the ordered medication is not available in the Emergency Medication Supply, the licensed facility nurse should call
Pharmacy's emergency answering service and request to speak with the registered pharmacist on duty to manage
the plan of action. Action may include:
3.2.1 Emergency delivery; or,
3.2.2 Use of an emergency (back-up) Third Party Pharmacy
4. If an emergency delivery is unavailable, Facility nurse should contact the attending physician to obtain orders or
directions.
On 1/21/20 at 2:55pm, the DON provided the surveyor with a pharmacy Non-Covered Medication Notification form dated 1/02/20. The form states in part, Resident #126's Pregabalin refill was canceled because facility instructions for Non-Covered Medications indicate facility authorization is required for this fill. Prior authorization is required for the prescribed medication. The plan requires that a nurse or the prescribing physician review and sign the prior authorization. The form also includes the following response options to complete and fax back to the pharmacy: the facility is accepting financial responsibility or the responsible party has been notified by the facility and is accepting financial responsibility. The DON provided an email dated 1/20/20 3:53pm with the form from the pharmacy stating, Here is a copy of what was sent to your building on 1/02/2020 in response to the refill request. The DON stated that she never received the form.
On 1/22/20 at approximately 9:15am, the DON stated the omissions for Lyrica on 1/10/20 and 1/11/20 were due to an insurance issue and provided the surveyor with a Medication Error Report dated 1/13/20 for Resident #126. The error report stated in part, Lyrica was not administered on 1/10/20 and 1/11/20 with the description of the error stating residents insurance would not cover medication and was requesting a prior authorization. The error report also stated the nurse practitioner was notified and the order was changed to discontinue the Lyrica and start Gabapentin 100 mg TID (three times a day).
On 1/22/20 at 3:09pm, the administrative team consisting of the administrator, administrator in training, director of nursing, assistant director of nursing, and the corporate nurse were made aware of Resident #126 not receiving Lyrica as ordered on 1/04/20, 1/05/20, 1/10/20, and 1/11/20.
No further information regarding this issue was presented to the survey team prior to the exit conference on 1/22/20.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0757
(Tag F0757)
Could have caused harm · This affected 1 resident
Based on staff interview and clinical record review, the facility staff failed to ensure 1 of 39 Residents (Resident #161) was free of an unnecessary drug. Resident #161 was administered the medicatio...
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Based on staff interview and clinical record review, the facility staff failed to ensure 1 of 39 Residents (Resident #161) was free of an unnecessary drug. Resident #161 was administered the medication Midodrine without adequate indications for use.
The findings included:
Resident #161 was administered the medication Midodrine for a BP (blood pressure) greater than 130. The physicians order read to hold for a BP greater than 130. Midodrine is used to treat symptoms of low blood pressure when standing. This condition is also known as orthostatic hypotension.
This was a closed record review.
The EHR (electronic health record) included the diagnoses atherosclerotic heart disease, orthostatic hypotension, secondary hypertension, and chronic diastolic congestive heart failure.
Section C (cognitive patterns) of the residents admission MDS (minimum data set) assessment with an ARD (assessment reference date) of 08/14/2019 included a BIMS (brief interview for mental status) summary score of 14 out of a possible 15 points.
The clinical record included an order for the medication Midodrine 5 mg give 1 tablet by mouth three times a day related to orthostatic hypotension. Hold for SBP (systolic blood pressure) greater than 130. The systolic blood pressure is the top number of a blood pressure reading.
A review of the residents eMARs (electronic medication administration records) revealed that the nursing staff had documented the following BP's.
09/06/2019 at 8:00 p.m. 173/74.
09/09/2019 at 8:00 a.m. 185/80, 2:00 p.m. 158/72, 8:00 p.m. 143/75.
09/13/2019 at 8:00 a.m. 165/80, 8:00 p.m. 145/75
There was no documentation to indicate this medication had been held.
On 01/21/2020 at 9:15 a.m., the DON (director of nursing) was made aware that the nursing staff had signed they had administered the medication Midodrine in September 2019 when the residents BP was greater than 130.
On 01/21/20 at 10:13 a.m., LPN (licensed practical nurse) #7 reviewed the clinical record with the surveyor. LPN #7 identified their initials on the eMAR for 09/13/2019 at 8:00 a.m. LPN #7 then verbalized to the surveyor that it looks like I made a mistake.
On 01/22/2020 at 3:08 p.m., the facility administrator, DON, administrator in training, assistant director of nursing, and nurse consultant were made aware of the issue regarding this residents BP medication being administered when the BP was greater than 130.
No further information regarding this issue were provided to the survey team prior to the exit conference on 01/22/2020.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Unnecessary Medications
(Tag F0759)
Could have caused harm · This affected 1 resident
Based on staff interview, clinical record review, and during a medication pass and pour observation, it was determined the facility staff failed to ensure a medication error rate of less than 5%. Ther...
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Based on staff interview, clinical record review, and during a medication pass and pour observation, it was determined the facility staff failed to ensure a medication error rate of less than 5%. There were two (2) errors in 25 opportunities for a medication error rate of 8%. These medication errors occurred during the administration of Resident #14's medications.
The findings include:
The facility staff failed to ensure a medication error rate of less than 5% during the medication pass and pour observations. Two (2) medication errors were noted out of 25 opportunities resulting in an 8% medication error rate. Both medication errors occurred during medication administration to Resident #14 on 1/15/20 at 8:10 a.m.
Resident #14's minimum data set (MDS) assessment, with an assessment reference date (ARD) of 1/18/20, had the resident's Brief Interview for Mental Status (BIMS) scored as 15 out of 15. Resident #14 was documented as experiencing shortness of breath with exertion and when lying flat. Resident #14 was assessed as requiring limited assistance with bed mobility, transfers, and toilet use. Resident #14's diagnoses included, but were limited to: heart failure, lung disease, low blood pressure, and muscle weakness.
On 1/15/20 at 8:10 a.m., Staff Member (SM) #11 was observed administering medications to Resident #14. This observation included the administration of: one (1) puff of a Dulera Aerosol inhaler and one (1) 5mg tablet of Midodrine by mouth. Review of Resident #14's provider orders revealed Resident #14 should have received two (2) puffs of the Dulera Aerosol inhaler. Resident #14's provider order for the Midodrine stated it should have been given before meals. On 1/15/20 at 10:10 a.m., the facility's Dietary Manager (DM) was interviewed about breakfast times on Resident #14's unit. The DM provided a document which indicated Resident #14's unit is provided breakfast between 7:05 a.m. and 7:40 a.m. The DM reported the 1/15/20 breakfast trays had been provided to the unit on time. SM #11 was interviewed on 1/15/20 at 10:25 a.m., SM #11 confirmed the Midodrine was administered to Resident #14 after the resident had had breakfast.
Resident #14's Care Plan included the Focus of The resident has altered respiratory status/difficulty breathing (related to) COPD with Administer medication/puffers as orders . as part of the interventions.
The aforementioned medication errors resulting in an 8% medication error rate during the medication pass and pour observation was discussed with the facility's administrative team on 1/15/20 at 1:38 p.m. and on 1/22/20 at 3:10 p.m. (The administrative team included: the administrator, the director of nursing, the assistant director of nursing, a corporate nurse, and an administrator-in-training.)
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and facility document review, the facility staff failed to dispose of expired treatment s...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and facility document review, the facility staff failed to dispose of expired treatment supplies and laboratory blood tubes that were stored on 1 of 3 units (unit 2) and failed to keep schedule II narcotics and controlled substances with the potential for abuse in a separately locked compartment that were stored on 1 of 3 units (unit 3).
The findings included:
The treatment cart on unit 2 contained treatment supplies that expired in 2018 and 2019. The medication room contained expired laboratory blood tubes that expired in 2019. The medication cart on unit 3 included schedule II narcotics and controlled substances with the potential for abuse that were not in a separately locked compartment. The nurse had failed to lock the narcotic box.
On [DATE] at 11:46 a.m., the surveyor and LPN (licensed practical nurse) #7 checked the treatment carts on unit 2. Cart #1 contained aquacel AG that expired in 02/2019 and 3 packages of kaltostat with an expiration date of 10/2018.
On [DATE] at 7:36 a.m., the surveyor and RN (registered nurse) #1 checked the medication room on unit 2. This medication room contained 6 green top blood tubes that had expired. Three of these tubes expired [DATE], two of these tubes expired [DATE], and one expired [DATE]. RN #1 verbalized to the surveyor that they would discard the expired tubes.
On [DATE] at 10:52 a.m., the surveyor and LPN #6 checked medication cart #1 on unit 3. This cart was sitting in the hallway outside the nurses station. This medication cart was observed to be locked. However, the narcotic/control box was unlocked and contained 26 cards of controlled substances and narcotics to include the medications oxycodone, gabapentin, alprazolam, hydrocodone, morphine sulfate, pregabalin, and hydromorphone. When LPN #6 was asked if the narcotic box should have been locked LPN #6 stated, Yeah.
On [DATE] at approximately 11:10 a.m., the DON (director of nursing) provided the surveyor with a copy of their policy titled 5.3 Storage and Expiration of Medications, Biologicals, Syringes and Needles. This policy read in part, .Facility should store Schedule II controlled substances and other medications deemed by Facility to be at risk for abuse or diversion in a separate compartment within the locked medication carts .
On [DATE] at 3:08 p.m., the facility administrator, DON (director of nursing), administrator in training, assistant director of nursing, and nurse consultant were made aware of the above issues.
No further information regarding these issue were provided to the survey team prior to the exit conference on [DATE].
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, staff interviews, clinical record review, and facility document review, it was determined the facility staff failed to perform point-of-care testing in a manner to prevent the r...
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Based on observations, staff interviews, clinical record review, and facility document review, it was determined the facility staff failed to perform point-of-care testing in a manner to prevent the risk of transmitting potentially infections material for two (2) of 39 residents (Residents #6 and #71).
The findings include:
During medication pass and/or pour observations on 1/15/20, two (2) facility staff members were observed to perform point-of-care (glucometer) testing in a manner that potently increased the risk of transmitting potential infections material between patients. Staff Member (SM) #14 was observed to not completely clean a glucometer after checking Resident #71's blood sugar level. SM #15 was observed to place a used lancet (with a self-retracting safety device) in own shirt pocket after obtaining Resident #6's blood sugar level.
On the morning of 1/15/20, SM #14 was observed using a glucometer to check Resident #71's blood sugar prior to administering the 11:00 a.m. sliding scale insulin dose. When SM #14 removed the glucometer from the medication cart, a small brown colored spot was noted on the right lower corner of the device. SM #14 did not clean the glucometer prior to checking Resident #71's blood sugar. SM #14 was observed to clean the glucometer after checking Resident #71's blood sugar. After SM #14 reported the cleaning of the glucometer was complete, the surveyor noted the aforementioned brown spot was still on the glucometer; closer inspection of the device revealed a second small spot (gray colored) on the right side of the glucometer. The surveyor, using the cleaning supplies provided by SM #14, was able to clean both spots off the glucometer.
Resident #71's minimum data set (MDS) assessment, with an assessment reference date (ARD) of 10/31/19, had the resident's Brief Interview for Mental Status (BIMS) scored as 13 out of 15. The resident was assessed as requiring supervision with eating and personal hygiene. Resident #71's diagnoses included, but were not limited to: high blood pressure, diabetes, kidney disease, and vision problems.
On the morning of 1/15/20, SM #15 was observed using a glucometer to check Resident #6's blood sugar prior to administering the 11:30 a.m. sliding scale insulin dose. After obtaining Resident #6's blood sugar reading, SM #15 was observed to place the used lancet into own shirt pocket. SM #15 confirmed the used lancet had been placed in the shirt pocket until it was disposed of in the biohazard box.
Resident #6's minimum data set (MDS) assessment, with an assessment reference date of 1/8/20, had the resident's Brief Interview for Mental Status (BIMS) scored as 13 out of 15. The resident was assessed as requiring extensive assistance with dressing, toilet use, and personal hygiene. Resident #71's diagnoses included, but were not limited to: high blood pressure, diabetes, anemia, and edema.
The following information was found in a facility policy/procedure titled Standards of Practice in the facility's Infection Prevention & Control Policies & Procedures Manual (with an effective date of 12/26/17): POLICY: The care and treatment of the patients by auxiliary service providers as well as the care of the provider's equipment and supplies must be practiced to prevent cross contamination and center-acquired infection. [sic] PROCEDURE: . Equipment that is contaminated or likely to be contaminated shall be cleaned, sanitized, or disinfect between patient use as appropriate.
The following information was found in the User Instruction Manual for the glucometer used in the aforementioned observations: Cleaning & Disinfecting Guidelines . We suggest cleaning and disinfecting the meter between patient use . Cleaning and disinfecting can be completed by using a commercially available EPA-registered disinfectant detergent or germicide wipe. To use a wipe, remove from container and follow product label intructions [sic] to disinfect the meter. Take extreme care not to get liquid in the test strip and key code ports of the meter. Many wipes act as both a cleaner and disinfectant, though if blood is visibly present on the meter, two wipes must be used; use one wipe to clean and a second wipe to disinfect.
The aforementioned infection control observations was discussed, for a final time, with the facility's administrative team on 1/22/20 at 3:10 p.m. (The administrative team included: the administrator, the director of nursing, the assistant director of nursing, a corporate nurse, and an administrator-in-training.)
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Smoking Policies
(Tag F0926)
Could have caused harm · This affected 1 resident
Based on resident interview, staff interview, clinical record review, and facility document review, the facility staff failed to implement their policy in regards to completing a self-smoking assessme...
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Based on resident interview, staff interview, clinical record review, and facility document review, the facility staff failed to implement their policy in regards to completing a self-smoking assessment and a patient smoking acknowledgement form for 1 of 39 residents, Resident #159.
The findings included:
For Resident #159, the facility failed to follow their policy for smoking in regards to completing a self-smoking assessment and having the resident sign a patient smoking acknowledgement form.
During the survey, the facility was asked to provide to the survey team a list of smokers at the facility. The only person listed on this document was Resident #159. Smoking times were designated as 8:00 a.m. through 8:00 p.m.
Resident #159's EHR (electronic health record) included the diagnoses, chronic obstructive pulmonary disease, cerebral infarction, encephalopathy, and essential hypertension.
Section C (cognitive patterns) of the residents admission MDS (minimum data set) assessment with an ARD (assessment reference date) of 12/26/2019 included a BIMS (brief interview for mental status) summary score of 11 out of a possible 15 points.
The residents comprehensive care plan included the focus area The resident is a smoker. Interventions included Instruct resident about the facility policy on smoking: Locations, times, safety concerns. Notify charge nurse immediately if it is suspected resident has violated facility smoking policy.
During an interview with Resident #159 on 01/16/2020 at 8:07 a.m., this resident verbalized to the surveyor that they kept their cigarettes in their coat pocket. Upon exiting the room, the surveyor notified the floor nurse that Resident #159 stated they had cigarettes in their room. At one point, the Resident asked the surveyor to take them out to smoke.
On 01/16/2020 at 8:20 a.m., the unit manager verbalized to the surveyor that she had removed a pack of cigarettes from the residents room but they refused to allow her to remove an empty pack. The unit manager also verbalized to the surveyor that no lighter was found in the residents room.
The surveyor requested from the facility their policy on smoking.
On 01/16/2020, the facility provided the surveyor with their policy titled Patient Smoking. This policy read in part, .A patient may smoke in designated smoking areas that may be established on the ground of the Center .if the patient has been assessed by the interdisciplinary team, and it has been determined through the Safe Smoking Assessment that it is safe for the patient to smoke .If a smoking area is administratively designated on the grounds of the Center, any patient who wishes to smoke will be evaluated (see Safe Smoking Assessment) by the Interdisciplinary Team upon admission to determine safety and ability to handle smoking material. This patient must also sign the ___ Patient Smoking Acknowledgement form which is to be maintained in the patients medical record .
The nurse consultant verbalized to the surveyor that no assessment was completed on this resident and that the family accompanied the resident when smoking.
On 01/16/2020 at 8:30 a.m., the DON (director of nursing) verbalized to the surveyor that the Resident would not let the facility complete an assessment and that they only wanted their family to take them out to smoke.
On 01/16/2020 at 12:20 p.m., the facility administrator, DON, administrator in training, assistant director of nursing, and nurse consultant were made aware that the facility had not followed their policy on smoking in regards to completing a self-smoking assessment and having the resident sign a patient smoking acknowledgement form.
No further information regarding this issue was provided to the survey team prior to the exit conference.
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
- "Why is there high staff turnover? How do you retain staff?"
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • No major safety red flags. No abuse findings, life-threatening violations, or SFF status.
- • No fines on record. Clean compliance history, better than most Virginia facilities.
Concerns
- • 32 deficiencies on record. Higher than average. Multiple issues found across inspections.
- • 58% turnover. Above average. Higher turnover means staff may not know residents' routines.
Bottom line: Mixed indicators with Trust Score of 65/100. Visit in person and ask pointed questions.
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About This Facility
What is Berkshire Health & Rehabilitation Center's CMS Rating?
CMS assigns BERKSHIRE HEALTH & REHABILITATION CENTER an overall rating of 4 out of 5 stars, which is considered above average nationally. Within Virginia, this rating places the facility higher than 99% of the state's 100 nursing homes. This rating reflects solid performance across the metrics CMS uses to evaluate nursing home quality.
How is Berkshire Health & Rehabilitation Center Staffed?
CMS rates BERKSHIRE HEALTH & REHABILITATION CENTER's staffing level at 1 out of 5 stars, which is much below average compared to other nursing homes. Staff turnover is 58%, which is 12 percentage points above the Virginia average of 46%. High turnover can affect care consistency as new staff learn residents' individual needs. RN turnover specifically is 58%, which is notably high. RNs provide skilled clinical oversight, so turnover in this role can affect medical care quality.
What Have Inspectors Found at Berkshire Health & Rehabilitation Center?
State health inspectors documented 32 deficiencies at BERKSHIRE HEALTH & REHABILITATION CENTER during 2020 to 2024. These included: 31 with potential for harm and 1 minor or isolated issues.
Who Owns and Operates Berkshire Health & Rehabilitation Center?
BERKSHIRE HEALTH & REHABILITATION CENTER 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 LIFEWORKS REHAB, a chain that manages multiple nursing homes. With 180 certified beds and approximately 173 residents (about 96% occupancy), it is a mid-sized facility located in VINTON, Virginia.
How Does Berkshire Health & Rehabilitation Center Compare to Other Virginia Nursing Homes?
Compared to the 100 nursing homes in Virginia, BERKSHIRE HEALTH & REHABILITATION CENTER's overall rating (4 stars) is above the state average of 3.0, staff turnover (58%) is significantly higher than the state average of 46%, and health inspection rating (4 stars) is above the national benchmark.
What Should Families Ask When Visiting Berkshire Health & Rehabilitation Center?
Based on this facility's data, families visiting should ask: "How do you ensure continuity of care given staff turnover, and what is your staff retention strategy?" "Can you walk me through typical staffing levels on day, evening, and night shifts?" "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?" These questions are particularly relevant given the facility's high staff turnover rate and the below-average staffing rating.
Is Berkshire Health & Rehabilitation Center Safe?
Based on CMS inspection data, BERKSHIRE HEALTH & REHABILITATION CENTER 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 4-star overall rating and ranks #1 of 100 nursing homes in Virginia. While no facility is perfect, families should still ask about staff-to-resident ratios and recent inspection results during their visit.
Do Nurses at Berkshire Health & Rehabilitation Center Stick Around?
Staff turnover at BERKSHIRE HEALTH & REHABILITATION CENTER is high. At 58%, the facility is 12 percentage points above the Virginia average of 46%. Registered Nurse turnover is particularly concerning at 58%. RNs handle complex medical decisions and coordinate care — frequent RN changes can directly impact care quality. High turnover means new staff may not know residents' individual needs, medications, or preferences. It can also be disorienting for residents, especially those with dementia who rely on familiar faces. Families should ask: What is causing the turnover? What retention programs are in place? How do you ensure care continuity during staff transitions?
Was Berkshire Health & Rehabilitation Center Ever Fined?
BERKSHIRE HEALTH & REHABILITATION CENTER has no federal fines on record. CMS issues fines when nursing homes fail to meet care standards or don't correct problems found during inspections. The absence of fines suggests the facility has either maintained compliance or corrected any issues before penalties were assessed. This is a positive indicator, though families should still review recent inspection reports for the full picture.
Is Berkshire Health & Rehabilitation Center on Any Federal Watch List?
BERKSHIRE HEALTH & REHABILITATION CENTER 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.