TYGART VALLEY HEALTH & REHABILITATION
For profit - Limited Liability company
60 Beds
HILL VALLEY HEALTHCARE
Data: November 2025
Trust Grade
50/100
#89 of 122 in WV
Photo by Good Samaritan Society - Barbour County
Photo by Tygart Valley Health & Rehabilitation (formerly Good Samaritan Society - Barbour County)
Photo by Tygart Valley Health & Rehabilitation (formerly Good Samaritan Society - Barbour County)
1 / 5 photos
Last Inspection: January 2024
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
Tygart Valley Health & Rehabilitation has a Trust Grade of C, which means it is average and falls in the middle of the pack compared to other facilities. It ranks #89 out of 122 nursing homes in West Virginia, placing it in the bottom half, and #2 out of 2 in Barbour County, indicating that only one local option is better. Unfortunately, the facility is worsening, with issues increasing from 20 in 2022 to 25 in 2024. Staffing is a concern, with a rating of 2 out of 5 stars and a turnover rate of 49%, which is around the state average. While there have been no fines, which is a positive sign, the facility has less RN coverage than 88% of state facilities, which may impact the quality of care. Inspectors found several serious concerns, including that residents were not informed about their rights regarding Medicare coverage, which could affect their care decisions. Additionally, the temperatures in the shower room were not within required limits, and one resident's room was reported as unclean, with sticky substances and debris found under the bed. Overall, while Tygart Valley Health & Rehabilitation has some strengths, such as no fines, it also has significant weaknesses that families should consider carefully.
- Trust Score
- C
- In West Virginia
- #89/122
- Safety Record
- Low Risk
- Inspections
- Getting Worse
- Staff Stability ⚠ Watch
- 49% turnover. Above average. Higher turnover means staff may not know residents' routines.
- Penalties ✓ Good
- No fines on record. Clean compliance history, better than most West Virginia facilities.
- Skilled Nurses ⚠ Watch
- Each resident gets only 24 minutes of Registered Nurse (RN) attention daily — below average for West Virginia. Fewer RN minutes means fewer trained eyes watching for problems.
- Violations ⚠ Watch
- 50 deficiencies on record. Higher than average. Multiple issues found across inspections.
50/100
Bottom 28%
No red flags
20 → 25 violations
★★☆☆☆
2.0
Overall Rating
★★☆☆☆
2.0
Staff Levels
★★★★☆
4.0
Care Quality
★★☆☆☆
2.0
Inspection Score
↔
Stable
2022: 20 issues
2024: 25 issues
The Good
-
4-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
2-Star Overall Rating
Below West Virginia average (2.7)
Below average - review inspection findings carefully
Staff Turnover: 49%
Near West Virginia avg (46%)
Higher turnover may affect care consistency
Chain: HILL VALLEY HEALTHCARE
Part of a multi-facility chain
Ask about local staffing decisions and management
The Ugly 50 deficiencies on record
Jan 2024
25 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Resident Rights
(Tag F0550)
Could have caused harm · This affected 1 resident
Based on observation and staff interview the facility failed to promote a dignified dining experience by not providing meals to all residents seated at the same table at the same time. This failed pra...
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Based on observation and staff interview the facility failed to promote a dignified dining experience by not providing meals to all residents seated at the same table at the same time. This failed practice was a random opportunity for discovery. Resident identifiers: #5 and #30. Facility census 47.
Findings included:
a) Resident #5
During an observation, on 01/08/24 at 1:00 PM, Resident #5 was seated at a dining room table for lunch. Two (2) other residents seated at the same table were served their lunch tray. Staff then served 2 residents seated at another table. Another resident seated by herself was served at another table. Resident #5 still did not have her tray.
During an interview, on 01/08/24 at 1:10 PM, with the Activity Director, she stated, I'm not really sure how they have them , maybe the resident is at the wrong table.
During an observation on 01/08/24 at 1:12 PM, Resident #5 received her lunch tray.
During an interview on 01/08/24 1:12 PM, Nursing Assistant (NA)# 36 stated, She must have parked herself there.
During an interview on 01/10/24 at 10:54 AM, with the Director of Nursing ( DON), she stated, I don't think that there is a specific policy on that. They typically try to go in order unless someone is disruptive or something like that.
b) Resident #30
During observation, on 01/10/24 at 1:19 PM, Resident #30 was seated at a table in the dining room. Everyone else at her table had finished eating and had left the dining room. The Resident did not have her meal.
During an interview on 01/10/24 at 1:20 PM, NA #15 stated, Resident # 30 has been here the entire time, but she is an assistant. We will get her.
Observation on 01/10/24 at 1:23 PM, found Resident #30's tray was still in the kitchen on the steam table.
During an interview on 01/10/24 at 01:25 PM, with the administrator, she stated, Well I think they are perceiving it as she is asleep so she doesn't know, but I don't guess it's right.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0578
(Tag F0578)
Could have caused harm · This affected 1 resident
Based on record review and staff interview the facility failed to ensure [NAME] Virginia Physician Orders for Scope of Treatment (POST) forms were completed correctly for two (2) of twenty-three (23) ...
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Based on record review and staff interview the facility failed to ensure [NAME] Virginia Physician Orders for Scope of Treatment (POST) forms were completed correctly for two (2) of twenty-three (23) residents in the long-term care survey sample. Resident identifiers: #18 and #15. Facility Census: 47.
Findings included:
a) Resident #18
On 01/08/24 at 2:51 PM, record review found the POST form for Resident #18, dated 03/31/23 with a verbal signature for the Medical Power of Attorney (MPOA).
On 01/09/24 at 12:15 PM an interview with Social Worker (SW) #43 confirmed the POST form was not completed correctly because the MPOA had not physically signed the POST form in a timely manner. The POST form contained only verbal consent from the MPOA. The SW also confirmed that there was no documentation of reaching out to the MPOA to have the POST signed by her.
According to the [NAME] Virginia Center for End-of-Life Care the following guidelines are to be followed.
The signature section provides a declaration on behalf of the patient (or incapacitated patient's Medical Power of Attorney (MPOA) representative or health care surrogate) related to their voluntary participation in the completion of the POST form and agreement with the orders on the form. The patient (or incapacitated patient's MPOA representative or health care surrogate) must sign and date this section for the form to be legally valid. If the incapacitated patient's MPOA representative or health care surrogate is unavailable at the time of form completion, this section can be signed by two witnesses for verbal confirmation of agreement from the patient's MPOA representative or health care surrogate. The form should be signed at the earliest available opportunity .
This was confirmed with the Director of Nursing on 01/10/24 at 2:00 PM. No additional information was obtained prior to completing the long-term survey process.
b) Resident #15
On 01/08/24 at 2:55 PM, record review found the POST form for Resident #15, dated 10/09/17 with a verbal signature for the Medical Power of Attorney (MPOA) and only one staff member witnessed the verbal consent.
On 01/09/24 at 12:15 PM an interview with Social Worker (SW) #43 confirmed the POST form was not completed correctly because the MPOA had not physically signed the POST form in a timely manner. The POST form contained only verbal consent from the MPOA. The SW also confirmed that there was no documentation of reaching out to the MPOA to have the POST signed by her. The SW also confirmed that it is required to have two (2) staff members witness verbal consent.
According to the [NAME] Virginia Center for End-of-Life Care the following guidelines are to be followed.
The signature section provides a declaration on behalf of the patient (or incapacitated patient's Medical Power of Attorney (MPOA) representative or health care surrogate) related to their voluntary participation in the completion of the POST form and agreement with the orders on the form. The patient (or incapacitated patient's MPOA representative or health care surrogate) must sign and date this section for the form to be legally valid. If the incapacitated patient's MPOA representative or health care surrogate is unavailable at the time of form completion, this section can be signed by two witnesses for verbal confirmation of agreement from the patient's MPOA representative or health care surrogate. The form should be signed at the earliest available opportunity .
This was confirmed with the Director of Nursing on 01/10/24 at 2:00 PM. No additional information was obtained prior to completing the long-term survey process.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Investigate Abuse
(Tag F0610)
Could have caused harm · This affected 1 resident
Based on record review and staff interview, the facility failed to report the results of a thorough investigation of a fall with serious bodily injury to Adult Protective Services and the State Survey...
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Based on record review and staff interview, the facility failed to report the results of a thorough investigation of a fall with serious bodily injury to Adult Protective Services and the State Survey Agency, within five (5) working days of the incident in accordance with State law. This was true for two (2) of two (2) residents reviewed under falls in the Long-Term Care Survey Process. Resident identifiers: #3 and #144. Facility census: 47.
Findings included:
a) Resident #3
A record review of the facility reportables, completed on 01/10/24 at 9:20 AM, demonstrated that Resident #3 had experienced a fall with serious bodily injury on 11/05/23 and an Immediate Fax Reporting was sent to the appropriate state agencies. There was no evidence the facility shared the Five (5) Day Follow-Up / Investigation Details with Adult Protective Services (APS).
During an interview on 01/10/24 at 9:55 AM, the Social Worker reported he could not produce any evidence results of the Five (5) Day Follow-Up was shared with APS in accordance with State Law.
b) Resident #144
A record review of the facility reportables, completed on 01/10/24 at 9:35 AM, demonstrated that Resident #144 had experienced a fall with serious bodily injury on 12/25/23 and an Immediate Fax Reporting was sent to the appropriate state agencies. There was no evidence the facility shared the Five (5) Day Follow-Up / Investigation Details with Adult Protective Services (APS).
During an interview on 01/10/24 at 9:57 AM, the Social Worker reported he could not produce any evidence results of the Five (5) Day Follow-Up was shared with APS in accordance with State Law.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Transfer Notice
(Tag F0623)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to provide evidence a copy of the notice of transfer/dis...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to provide evidence a copy of the notice of transfer/discharge was sent to the Ombudsman. This was true for one (1) of four (4) residents reviewed under the Hospitalization pathway in the Long-Term Care Survey Process. Resident identifier: #144. Facility census: 47.
Findings included:
a) Resident #144
A record review, completed on 01/09/24 at 11:40 AM, revealed Resident #144 was transferred to the hospital on [DATE]. There was no evidence in the electronic medical record that a copy of the Notice of Transfer/Discharge was sent to the long-term care Ombudsman.
During an interview on 01/09/24 at 2:21 PM, the Social Worker reported he could not produce evidence the Notice of Transfer/Discharge form had been faxed to and received by the Ombudsman.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Assessment Accuracy
(Tag F0641)
Could have caused harm · This affected 1 resident
b) Resident #21
On 01/10/24 at 1:15 PM record review found the following medical diagnoses listed for Resident #21:
Alzheimer's disease, unspecified
Unspecified dementia, unspecified severity with oth...
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b) Resident #21
On 01/10/24 at 1:15 PM record review found the following medical diagnoses listed for Resident #21:
Alzheimer's disease, unspecified
Unspecified dementia, unspecified severity with other behavioral disturbance
Adjustment disorder with mixed disturbance of emotions and conduct
Unspecified dementia, moderate, with mood disturbance
Anxiety disorder, unspecified.
Resident #21 had a order dated 05/23/23 for an anti-anxiety agent, Buspirone HCL Oral Tablet 5 milligrams (mg), give one tablet by mouth three times a day related to dementia with other behavior disturbances, anxiety disorder On 01/04/24 the medication was increased to 7.5 mg give 1 tablet by mouth three times a day related to anxiety disorder.
Review of the Minimum Data Sheet, Section N (medications) with an Assessment Reference Date (ARD) date of 12/22/23 was marked that Resident #21 did not receive any anti anxiety medication.
This was confirmed with the Director of Nursing on 01/10/24 at 2:00 PM.
Based on record review, observation, staff interview and resident interview, the facility failed to ensure two (2) of 23 residents had an accurate Minimum Data Sets (MDS) which reflected the resident's status at the time of the assessment. Resident identifiers: #12 and #21. Facility census: 47.
Findings included:
a) Resident #12
On 01/08/24 at 2:16 PM, the resident said, I need some false teeth so I can eat. My teeth hurt and I need them pulled. I was supposed to have an appointment but I don't know what's going on. I don't think I have any appointments to see a dentist.
Review of the last annual MDS with an assessment reference date (ARD) of 07/12/23 coded the resident as having no dental issues.
At 8:33 AM on 01/10/24, the Director of Nursing (DON) was asked about the Resident's dental status. The DON said, She wants dentures but she doesn't want to pay for them.
At 8:45 AM on 01/10/24, the DON and the surveyor observed the resident's dental status. The Resident said I have a toothache. The cardiologist I saw yesterday said those teeth need to come out.
Review of the Resident's current care plan found a focus, dated 07/22/23:
Resident has acute and chronic pain/discomfort related to broken teeth and muscle spasms .
Review of the oral/dental status with the MDS coordinator, Registered Nurse (RN) #42 found the oral dental status section was signed by RN #42 on 07/22/23, the same day the care plan was created.
RN #42 said, I guess I just missed checking the box for obvious cavity or broken natural teeth. She has had dental issues for a long time.
On 01/10/24 at 9:47 AM, the DON was advised RN #42 said she made a mistake in coding the Resident's oral/dental status on the annual MDS. No further information was provided.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0655
(Tag F0655)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure Resident #35 had a baseline care plan developed within...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure Resident #35 had a baseline care plan developed within 48 hours of admission which addressed a Urinary Tract Infection (UTI) treated with an antibiotic. This was true for one (1) of three (3) residents recently admitted to the facility. Resident identifier: #35. Facility census: 47.
Findings included:
a) Resident #35
Record review found the Resident was a new admission to the facility on [DATE]. The resident was admitted to the facility from the hospital with a UTI. She was being treated with the antibiotic: Doxycycline Hyclate Oral Tablet 100 MG (Doxycycline Hyclate), 1 tablet two (2) times a day. The Resident received the antibiotic at the facility through 12/22/23.
At 10:55 AM on 01/10/24, the Director of Nursing (DON) reviewed the baseline care plan triggers created on 12/14/23 with the surveyor. The DON confirmed the antibiotic usage and the UTI was never care planned for Resident #35.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0660
(Tag F0660)
Could have caused harm · This affected 1 resident
Based on record review and staff interview the facility failed to involve the resident and/or resident representative when developing a comprehensive person-centered care plan for discharge planning f...
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Based on record review and staff interview the facility failed to involve the resident and/or resident representative when developing a comprehensive person-centered care plan for discharge planning for Resident #42. This was true for one (1) of one (1) resident reviewed for discharge planning during the Long-Term Care Survey Process. Resident identifier: #42.
Facility census: 47.
Findings included:
a) Resident #42
Medical record review, on 01/09/24, revealed during an interdisciplinary team meeting on 10/27/23 there was discussion of the upcoming discharge. Resident #42 had self initiated a discharge to return home. The progress note did not indicate the resident was present during the meeting.
In an interview with, the Licensed Social Worker (LSW) on 01/09/24 at 2:10 PM, the LSW reported he was unable to provide any verification that Resident #42 had attended the discharge meeting on 10/27/23.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0661
(Tag F0661)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to complete the discharge/physician's recapitulation of residents...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to complete the discharge/physician's recapitulation of residents stay. This was true for two (2) of two (2) residents reviewed for the area of discharges during the Long-Term Care Survey Process. Resident #42 had no recapitulation for a community discharge and Resident #43 expired at the facility and also had no physician's recapitulation. Resident identifiers: #42 and #43. Facility census: 47.
Findings included:
a) Resident #42
During a medical record review on [DATE], it revealed there was no discharge summary or physician's recapitulation completed for Resident #42 when he was discharged to the community on [DATE].
In an interview with the Director of Nursing (DON) on [DATE] at 2:48 PM, verified there was no discharge summary or physician's recapitulation for Resident #42's discharge.
b) Resident #43
During a medical record review on [DATE], it revealed there was no discharge summary or physician's recapitulation completed for Resident #43 when the resident expired at the facility on
[DATE].
In an interview with the Director of Nursing (DON) on [DATE] at 2:48 PM, verified there was no discharge summary or physician's recapitulation for Resident #43's stay and when resident expired.
on record review and staff interview the facility failed to complete the discharge/physician's recap for Res #42 and #43 who was discharged to the community. 2 of 2 reviewed for discharge.
PS- DR
a) R #42 - DR
b) R #43- DR
Resident #42
Discharge
F660 Based on RR and SI the fac failed to involve the resident and/or resident representative when developing a person-centered care plan for discharge planning for R42
F661 Based on RR and SI the fac failed to complete the discharge/physician's recap for R42 who was discharged to the community.
[DATE] 08:45 AM
MDS with ARD of [DATE] D/C return not anticipated
a-home/community
Care Plan
CANCELLED: [NAME] wishes to return
home
Date Initiated: [DATE]
Revision on: [DATE]
Cancelled Date: [DATE]
CANCELLED: [NAME]'s
discharge goals are: to regain
previous function and return
home
Date Initiated: [DATE]
Revision on: [DATE]
Target Date: [DATE]
Cancelled Date: [DATE]
CANCELLED: Establish a pre-discharge plan with [NAME] and evaluate progress and
revise plan as needed.
Date Initiated: [DATE]
Revision on: [DATE]
Cancelled Date: [DATE]
Progress notes
[DATE] [NAME] was discharged to his home 884 South Main St [NAME] WV 26416. He was transported by his brother [NAME] and his wife via personal vehicle. Medications were reviewed with [NAME] and he voiced how to administer them with times. Also made sure he was aware medications were at Walgreens in [NAME] waiting to be picked up. Gave him a script for Ultram. He also took all paperwork such as: a list of when medications, when medications are to be given, discharge instructions and list of upcoming doctor appointments. Order was received to discharge to home with current meds, Continue No added salt diet, 6 Soft & Bite-Sized texture, 0 Thin consistency. Referrals made to [NAME] home health. [NAME] took all personal belongings and signed the personal inventory sheet. No voiced concerns. Dr. High notified at this time of resident was discharged to home. Medications sent back to pharmacy and Narcotics, removed, final counted, and locked for destruction per policy.
[DATE] 14:46
*Care Conference Note
Note Text: IDT team met for care plan review. Care plan was reviewed, and changes made as needed. He is planned for discharge on Friday [DATE].
[DATE] 14:46
*Care Conference Note
Note Text: IDT team met for care plan review. Care plan was reviewed, and changes made as needed. He is planned for discharge on Friday [DATE].
[DATE] 15:03
*Discharge
Note Text: Called [NAME] Home Health to let them know he is planning to go home on Friday 10/27, 2023.
PT d/cd on [DATE] R42 had met max pot.
In an interview with MDS Coord #42 and Licensed Social Worker #43 on [DATE], were unable to provide a completed discharge summary or a physician's recap for the discharge for R42 when he returned to the community.
Interview with the LSW on [DATE] at 2:00PM was unable to provided any verification R42 was included in the development of his care plan for discharge planning.
Resident #43
FTag Initiation
F661 Based on RR and SI the fac failed to complete the discharge summary and the recapitulation of R43 stay in the fac.
[DATE] 12:11 PM
R43 expired at the facility on [DATE] the physician did not complete a discharge summary/ or a recap of her stay.
In an interview with MDS Coord #42 and Licensed Social Worker #43 on [DATE], were unable to provide a discharge summary of a physician recap for death in the facility for R43.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0676
(Tag F0676)
Could have caused harm · This affected 1 resident
Based on record review, staff interview, and observation, the facility failed to provide the communication book and dry erase board used as assistive device to communicate with staff. This was true fo...
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Based on record review, staff interview, and observation, the facility failed to provide the communication book and dry erase board used as assistive device to communicate with staff. This was true for one (1) of one (1) residents reviewed for communication during the Long-Term Care Survey Process. Resident identifier: #27. Facility census: 47.
Findings included:
a) Resident #27
A medical record review on 01/09/24 for Resident #27,with a hearing deficit had a comprehensive care plan with an intervention for the resident to have a communication book to assist her in communicating with the staff.
In an interview on 01/09/24 at 1:35 PM, with the Licensed Social Worker (LSW), explained Resident
#27 used a dry erase board, when she was unable to read your lips.
During an observation on 01/09/24 at 1:40 PM, the LSW and the Minimum Data Set (MDS) Coordinator, both were unable to locate the communication book or dry erase board used as assistive devices to communicate with staff.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0679
(Tag F0679)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, and staff interview the facility failed to provide an ongoing program of activities to meet the interests ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, and staff interview the facility failed to provide an ongoing program of activities to meet the interests of and support the physical, mental, and psychosocial well-being for one (1) of three (3) residents. Resident identifier: # 32. Facility census 47.
Findings included:
a) Resident #32
During an observation on 01/08/24 at 11:30 AM, Resident #32 was sitting in the dining room by herself with no music, television or interaction from staff or other residents.
During an observation, on 01/08/24 at 2:00PM, Resident #32 was sitting at the nurses station, there was an activity going on in the facility chapel but Resident #32 was not in attendance.
During an observation, on 01/09/24 at 1:00 PM, Resident #32 was sitting at nurses station with no interaction from staff or residents.
During an observation, on 01/09/24 at 3:32 PM, Resident #32 was sitting at nurses station with no interaction from staff or residents.
During an interview, on 01/09/24 at 03:35 PM, with the facilities Activity Director, she stated, Resident #32 has had a big change around 8 months ago and her participation has not been the same since. She probably needs to be on one to one visits. I will look at that.
A record review on 01/09/24 at 4:00 PM of Resident #32 annual Activity assessment dated [DATE] revealed she had interest in doing crafts, listening to music, and attending church. It also reveals that she enjoys spending her time with others.
A record review on 01/09/24 at 4:10 PM of esident #32's activity participation for the past 3 months revealed that Resident #32 participated in an activity on 11/12/23, two (2) activities on 11/21/23, and one (1) activity on 12/23/22. This is 4 activities in the past 70 days.
A record review on 01/10/24 at 9:00 AM of Resident #32's care plan revised on 12/13/23 reads that Resident #32 was dependent on staff for meeting emotional, intellectual, physical and social needs due to cognitive deficits, and physical limitations.
During an observation on 01/10/24 at 11:42 AM, Resident #32 was sitting in the dining room by herself with no Television, music and no interaction from staff or residents.
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
c) Resident #28
A record review was completed on 01/09/24 at 10:21 AM. The record review found the following physician's order dated 07/03/22:
NovoLIN R Solution 100 UNIT/ML
(Insulin Regular Human) In...
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c) Resident #28
A record review was completed on 01/09/24 at 10:21 AM. The record review found the following physician's order dated 07/03/22:
NovoLIN R Solution 100 UNIT/ML
(Insulin Regular Human) Inject as per sliding scale:
if 201 - 250 = 2 units;
251 - 300 = 4 units;
301 - 350 = 6 units;
351 - 400 = 8 units;
401 - 600 = 10 units Greater than
600 or symptomatic = Call MD,
subcutaneously before meals and at bedtime related to Type 2 Diabetes Mellitus with Hyperglycemia
A review of the Medication Administration Records (MARS) for October 2023, November 2023, and December 2023 revealed the following dates the physician had not been notified when two (2) consecutive doses had been refused:
On 10/04/23, Resident #28 refused the NovoLIN injection at 11:00 AM and 4:00 PM.
On 10/05/23, Resident #28 refused the NovoLIN injection at 9:00 PM and on 10/06/23, Resident #28 refused the NovoLIN injection at 7:00 AM.
On 10/17/23, Resident #28 refused the NovoLIN injection at 11:00 AM and 4:00 PM.
On 10/18/23, Resident #28 refused the NovoLIN injection at 11:00 AM and 4:00 PM.
On 10/19/23, Resident #28 refused the NovoLIN injection at 11:00 AM and 4:00 PM.
On 10/22/23, Resident #28 refused the NovoLIN injection at 11:00 AM and 4:00 PM.
On 11/02/23, Resident #28 refused the NovoLIN injection at 7:00 AM and 11:00 AM.
On 11/03/23, Resident #28 refused the NovoLIN injection at 11:00 AM and 4:00 PM.
On 11/10/23, Resident #28 refused the NovoLIN injection at 11:00 AM and 4:00 PM.
On 11/15/23, Resident #28 refused the NovoLIN injection at 11:00 AM and 4:00 PM.
On 11/16/23, Resident #28 refused the NovoLIN injection at 7:00 AM, 11:00 AM, and 4:00 PM.
On 11/18/23, Resident #28 refused the NovoLIN injection at 11:00 AM and 4:00 PM.
On 11/25/23, Resident #28 refused the NovoLIN injection at 11:00 AM, 4:00 PM, and 9:00 PM. Additionally, on 11/26/23, Resident #28 refused the NovoLIN injection at 7:00 AM and 11:00 AM.
On 12/05/23, Resident #28 refused the NovoLIN injection at 7:00 AM and 11:00 AM.
On 12/06/23, Resident #28 refused the NovoLIN injection at 7:00 AM, 11:00 AM, and 4:00 PM.
On 12/12/23, Resident #28 refused the NovoLIN injection at 11:00 AM, 4:00 PM, and 9:00 PM.
On 12/13/23, Resident #28 refused the NovoLIN injection at 4:00 PM and 9:00 PM.
On 12/14/23, Resident #28 refused the NovoLIN injection at 11:00 AM and 4:00 PM.
On 12/15/23, Resident #28 refused the NovoLIN injection at 11:00 AM and 4:00 PM.
On 12/18/23, Resident #28 refused the NovoLIN injection at 7:00 AM and 11:00 AM.
On 12/21/23, Resident #28 refused the NovoLIN injection at 11:00 AM and 4:00 PM.
On 12/23/23, Resident #28 refused the NovoLIN injection at 9:00 PM and on 12/24/23, Resident #28 refused the NovoLIN injection at 7:00 AM.
On 12/25/23, Resident #28 refused the NovoLIN injection at 11:00 AM and 4:00 PM.
On 12/27/23, Resident #28 refused the NovoLIN injection at 7:00 AM, 11:00 AM and 4:00 PM.
On 12/28/23, Resident #28 refused the NovoLIN injection at 11:00 AM, 4:00 PM, and 9:00 PM. Additionally, on 12/29/23, Resident #28 refused the NovoLIN injection at 7:00 AM and 11:00 AM.
The facility's Medication Administration General Guidelines policy address resident refusal of medication by instructing, If two consecutive doses of a vital medication are refused, the physician is notified.
During an interview on 01/09/24 at 2:35 PM, the Director of Nursing (DON) reported the facility could produce no evidence the physician had been notified of the above-mentioned refusals.
Based on resident interview, observation, record review, and staff interview, the facility failed to provide care and services in accordance with professional standards of practice for three (3) of 23 residents reviewed during the long term care survey. Resident #36 did not have an Unna boot as ordered by the physician. For Resident #12 the facility did not follow the physician ordered parameters for medication administration. For Resident #28 the facility failed to notify the physician when the resident refused medication. Resident identifiers: #36, #12, and #28. Facility census: 47.
Findings included:
a) Resident #36
Observation of the Resident on 01/08/24 at 3:08 PM, found both lower legs were a variation of red and purple and both lower legs were swollen. The left lower leg was dry and scaly. When asked about the observation, the Resident said, I was supposed to have an Unna boot on my right leg but the nurse told me they don't have any. The resident said he had been several days without the boot but he could not recall exactly how long and he could not recall the name of the nurse who told him no Unna boot was available.
At 2:40 PM on 01/08/24, the Director of Nursing (DON) was asked about the Unna boot. The DON said, He probably doesn't have one on because he got a shower today. Licensed Practical Nurse (LPN) #1 observed the resident and determined he was not wearing an Unna boot. LPN #1 confirmed the resident has orders for an Unna boot to be worn daily and changed on Mondays and Thursdays.
Nurse Aide (NA) #36 was present during the observations and said the Resident had not had a shower on this day. NA #36 said it is his shower day, and the shower will be given later in the day.
Review of the physician's orders found an order for:
Unna-Flex Elastic Unna Boot External Miscellaneous (Wound Dressings) - Apply to right lower extremity topically one time a day every Monday and Thursday for vascular insufficiency/ulcerations.
b) Resident #12
Review of the Medication Administration Record (MAR) on 01/09/24 found a physician's order, with a start date of 07/07/23 for: Blood Pressure (BP) 2 times a week on Monday and Thursday prior to AM dose of Lisinopril.
Further review found the Lisinopril was scheduled to be given at 12:00 noon each day.
Review of the medical record with the Director of Nursing (DON) at 10:08 AM on 01/09/24 found the following dates in January when the blood pressure was not obtained prior to giving the noon dose:
01/04/24 (Thursday) no blood pressure was obtained on this date.
01/08/24 (Monday) documentation on the MAR noted the medication (Lisinopril) was administered at noon but the Resident's BP was not taken until 6:51 PM on 01/08/24.
Review of the December MAR with the DON found the following dates then the BP was not obtained prior to administering the medication, Lisinopril:
On 12/04/23 (Monday) no BP was obtained
On 12/18/23 (Monday) the medication was administered at 12:00 Noon but the BP was not obtained until 1:47 PM on 12/18/23.
On 12/21/23 (Thursday) no BP was obtained.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Pressure Ulcer Prevention
(Tag F0686)
Could have caused harm · This affected 1 resident
Based on observation and staff interview the facility failed to ensure pressure ulcer treatments and care were performed within professional standards of care. This was true for two (2) of two (2) wou...
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Based on observation and staff interview the facility failed to ensure pressure ulcer treatments and care were performed within professional standards of care. This was true for two (2) of two (2) wound dressings observed during the long term survey process. Resident Identifiers: #194 and #11 Facility Census: 47.
Findings Included:
a) #194
On 01/08/24 at 2:38 PM record review shows Resident #194 has a stage 2 pressure ulcer to the right buttock. There is a dressing change order as follows:
Cleanse stage 2 with soap and water. Pat dry. Cover with border dressing daily and porn if loose or soiled until clear one time a day for Stage 2 pressure Ulcer related to PRESSURE ULCER OF RIGHT BUTTOCK, STAGE 2 until clear and as needed for of loose or soiled related to PRESSURE ULCER OF RIGHT BUTTOCK, STAGE 2 until clear.
On 01/09/24 at 01:50 PM wound care was observed with Licensed Practical Nurse (LPN) #1 performing the care. The Resident was in bed on her side and had a brief on, she had had a bowel movement. The LPN placed her gloves on, removed the old dressing in place and cleaned the resident of the bowel movement. She then proceeded to place a clean dressing on the wound without changing her gloves throughout the process.
This was confirmed with LPN #1 on 01/09/24 at 1:56 PM and the Director of Nursing on 01/09/24 at 2:00 PM.
b) Resident #11
On 01/08/24 at 02:12 PM, record review shows Resident #11 has a stage II pressure ulcer to his right shoulder. There is a dressing change order as follows:
Pressure Ulcer stage two to the right shoulder rear: cleanse area with normal saline. Apply calcium alginate then cover with ABD (abdominal) pad and PORN if dressing becomes soiled, loose, or detached, one time a day related to PRESSURE ULCER OF OTHER SITE, STAGE 2 Discontinue when site is clear. AND every 24 hours as needed related to PRESSURE ULCER OF OTHER SITE, STAGE 2 Discontinue when site clear.
On 01/09/24 at 11:19 AM wound care was observed when Licensed Practical Nurse (LPN) #2 performed the dressing change.
When Resident #11 was turned to his side, it was noted that the old dressing was not in place, there was however a hand towel under his shoulder at the ulcer site. LPN #2 stated your old dressing is off. He then took the towel from under the resident's shoulder and placed it on the floor and not in a laundry bag or on a barrier. The towel contained a brown colored drainage and blood on it from the wound.
The above was confirmed with LPN #2 on 01/09/24 at 11:25 AM and then with the Director of Nursing at 11:30 AM.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Tube Feeding
(Tag F0693)
Could have caused harm · This affected 1 resident
Based on record review and staff interview the facility failed to address a resident receiving nutrition via peg tube when weight loss occurred. This failed practice was true for 1 of 2 residents revi...
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Based on record review and staff interview the facility failed to address a resident receiving nutrition via peg tube when weight loss occurred. This failed practice was true for 1 of 2 residents reviewed for tube feeding during the long term care survey process. Resident Identifier: #1. Facility census 47.
Findings included:
a) Resident #1
An record review on 01/08/24 at 2:56 PM, revealed Resident #32 who receives all nutrition via peg tube weighed 100.6 lbs on 6/02/23, 96.8 lbs on 10/31/23, 93 lbs on 12/14/23 and 89.8 lbs on 01/02/24. This calculated out to be a 10.74% weight loss in the past 6 months.
During a record review on 01/08/24 at 3:15 PM, of Resident #32's last 3 quarterly nutritional assessments it reads that resident is tolerating his tube feeding well and shows the calculation of the weight loss. It also revealed that the weight loss was not addressed in no other way but to add him to weekly weights.
During a record review on 01/08/24 at 3:30 PM, the surveyor found no notes in Resident #32's medical chart from the doctor addressing the weight loss.
During an interview on 01/09/24 at 10:00 AM, with the facilities Dietary Manager (DM), she stated, Resident #32's roommate has been in the hospital and they are really close. That could be why he is losing weight. The surveyor asked how that would affect a Resident who receives all nourishment via a tube feeding?
During an interview on 01/09/24 at 10:00 AM, with the facilities Registered Dietician (RD) she stated, We looked at Resident #32 today in weight meeting, I'm not sure what is going on but we are going to change his tube feeding and put him on daily weights.
During an interview on 01/09/24 at 1:00 PM, with Licensed Practical Nurse (LPN) #2, he stated, When I do Resident #32's feedings his bandages are wet. Maybe there is a leak, but they aren't saturated so its not a big leak if there is one.
During an interview on 01/09/24 at 1:30 PM with DM, she stated, There are no notes in resident #32's medical chart from the doctor related to weight loss.
A record review on 01/09/24 at 2:00 PM, of Resident #32's care plan reads {Resident #32 has nutritional problem or potential nutritional problem related to having a G-Tube E/B not being able to state hunger or fullness.} Under interventions it reads {Observe for weight loss or gain}. No further information is mentioned in the care plan about weight loss.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
Could have caused harm · This affected 1 resident
Based on observation, resident interview, record review, and staff interview, the facility failed to ensure the oxygen humidifier bubbler on the oxygen concentrator was working. This was true for one ...
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Based on observation, resident interview, record review, and staff interview, the facility failed to ensure the oxygen humidifier bubbler on the oxygen concentrator was working. This was true for one (1) of one (1) resident reviewed for respiratory care during the long term care survey process. Resident identifier: #12. Facility census: 47.
Findings included:
a) Resident #12
On 01/08/24 at 12:25 PM, the Resident said the water bottle on her oxygen tank was empty. She said they only fill it once a week and that is not enough, it runs dry. She said the water makes her nose not dry out so quickly. She said she is supposed to use oxygen all the time and she receives 2 liters of oxygen.
On 01/08/24 at 12:29 PM, the Resident's Licensed Practical Nurse (LPN) #1 observed the humidifier bubbler and said the water level is too low for it to work. I will take care of it right now.
Review of the Resident's physician's orders found an order for:
Oxygen at 2 liters per minute (LPM) per nasal cannula via O2 concentrator and/or tank as needed
Change Bubbler and fill to maximum fill line with distilled water, one time a day, every Friday.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Dental Services
(Tag F0791)
Could have caused harm · This affected 1 resident
Based on record review, resident interview, observation and staff interview, the facility failed to ensure follow up dental services were provided to one (1) of two (2) Resident's reviewed for the car...
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Based on record review, resident interview, observation and staff interview, the facility failed to ensure follow up dental services were provided to one (1) of two (2) Resident's reviewed for the care area of dental services during the long-term care survey. Resident identifier: #12. Facility census: 47.
Findings included:
a) Resident #12
On 01/08/24 at 2:16 PM, the Resident said, I need some false teeth so I can eat. My teeth hurt and I need them pulled. I was supposed to have an appointment, but I don't know what's going on. I don't think I have any appointments to see a dentist.
The last annual minimum data set (MDS) with an assessment reference date (ARD) of 07/12/23 coded the resident as having no dental issues.
At 8:33 AM on 01/10/24, the Director of Nursing (DON) was asked about the Resident's dental status. The DON said, She wants dentures, but she doesn't want to pay for them.
Review of the medical record found the resident's payer source was Medicaid and had been since 01/25/21.
At 8:45 AM on 01/10/24, the DON and the surveyor visited the resident in her room. The Resident said I have a toothache. The cardiologist I saw yesterday said those teeth need to come out.
Review of the Resident's current care plan found a focus, dated 07/22/23:
Resident has acute and chronic pain/discomfort related to broken teeth and muscle spasms .
Review of the oral/dental status with the MDS coordinator, Registered Nurse (RN) #42 found the oral dental status section was signed by RN #42 on 07/22/23, the same day the care plan was created.
RN #42 said, I guess I just missed checking the box for obvious cavity or broken natural teeth, she has had dental issues for a long time.
On 01/10/24 at 9:47 AM, the resident's dental visits were reviewed with the DON. On 06/22/23, the Resident had a dental consultation. The dentist concluded: broken filling #2 and needs cleaning last cleaning was in 2015. The resident did not received the services noted to be needed by the dentist on 06/22/23. The DON said she thought the resident had been out for another visit, but she was unable to find confirmation of any further visits.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0810
(Tag F0810)
Could have caused harm · This affected 1 resident
Based on observation, record review, and staff interview, the facility failed to ensure Resident #35 had physician ordered assistive devices available to improve her ability to drink. This was a rando...
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Based on observation, record review, and staff interview, the facility failed to ensure Resident #35 had physician ordered assistive devices available to improve her ability to drink. This was a random opportunity for discovery. Resident identifier: #35. Facility census: 47.
Findings included:
a) Resident #35
Record review found a physician's order for, Kennedy cups at all meals, dated 12/18/23.
Observation on 01/09/24 at 12:37 PM, with Occupational Therapist (OT) #47 found the resident had two (2) Kennedy cups on her lunch tray, one filled with water and one with punch. However, the resident also had a glass of tomato juice and a carton of milk. The Resident was observed trying to drink her tomato juice from the glass. OT #47 said the Resident needed a Kennedy cup for each of her liquids.
On 01/09/24 at 1:05 PM, the Director of Nursing was advised of the above observation with OT #47. No further information was provided.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0574
(Tag F0574)
Could have caused harm · This affected multiple residents
Based on observation and staff interview the facility failed to support the residents' rights, by not placing the name and contact information for the State Ombudsman in a location that was easily acc...
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Based on observation and staff interview the facility failed to support the residents' rights, by not placing the name and contact information for the State Ombudsman in a location that was easily accessible for all residents to read. This was a random opportunity for discovery and had the potential to affect more than a limited number of residents. Facility census: 47.
Findings included:
a) During the Resident Council meeting, on 01/09/24 at 11:00 AM, the resident council members all said they did not know where the information was located for the Ombudsman.
An observation, on 01/09/24 at 11:45 AM, of the posting for the Ombudsman information revealed the information was posted in a case mounted to the wall on 100 hall. The case was high on the wall and was not accessible for residents who were in wheelchairs.
During an interview, on 01/10/24 at 10:28 AM, with Registered Nurse (RN) Assessment Coordinator, she stated, Well I can see it, if I was in a wheelchair I couldn't see it and especially with that glare off that glass.
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 record review and staff interview, the facility failed to provide the required Skilled Nursing Facility Advanced Beneficiary Notice of Non-Coverage (SNF ABN) form to three (3) of three (3) re...
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Based on record review and staff interview, the facility failed to provide the required Skilled Nursing Facility Advanced Beneficiary Notice of Non-Coverage (SNF ABN) form to three (3) of three (3) residents reviewed for the facility's beneficiary protection notification practice. This failure placed residents at risk of not being informed of their rights prior to the end of Medicare Part A covered services. Resident identifiers: #38, #40, and #5. Facility census: 47
Findings Included:
a. Failure to Issue a Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN) Form
Form Instructions Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNF ABN) Form CMS-10055 (2018) indicates Medicare requires Skilled Nursing Facilities to issue the SNF ABN to Medicare beneficiaries prior to providing care that Medicare usually covers, but may not pay for because the care is:
- not medically reasonable and necessary; or
- considered custodial.
The SNF ABN provides information to the beneficiary so that he/she can decide whether or not to get the care that may not be paid for by Medicare and assume financial responsibility.
On 01/09/24 at 8:55 AM, a brief medical record review revealed:
-Resident #38 began Medicare Part A skilled service on 05/01/23.
The last day of offered Medicare Part A skilled services was 06/20/23. There was no evidence in the medical record that a SNF ABN had been issued.
-Resident #40 began Medicare Part A skilled service on 09/13/23.
The last day of offered Medicare Part A skilled services was 10/10/23. There was no evidence in the medical record that a SNF ABN had been issued.
-Resident #5 began Medicare Part A skilled service on 09/26/23. The last day of offered Medicare Part A skilled services was 11/07/23. There was no evidence in the medical record that a SNF ABN had been issued.
During an interview on 01/09/24 at 2:15 PM, the Social Worker reported he had not issued Residents #38, #40, and #5 a SNF ABN form. The Social Worker noted he was not familiar with the form and would need to begin to issue the required SNF ABN for residents who remained in the facility with benefit days remaining, following their last covered day of Medicare Part A skilled services.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected multiple residents
Based on observation, resident interview and staff interview the facility failed to ensure the temperatures were within the required parameters, which is 71 degrees Fahrenheit (F) to 81 Degrees F. in ...
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Based on observation, resident interview and staff interview the facility failed to ensure the temperatures were within the required parameters, which is 71 degrees Fahrenheit (F) to 81 Degrees F. in the shower room. In addition, the facility failed to ensure Resident #1's room was clean. This failed practice has the potential to affect more than a limited number of residents. Resident Identifiers #1. Facility census 47.
Findings Included:
a) Resident #1
During an observation on 01/08/24 at 12:00 PM, in Resident #1's room, under the bed there is a very sticky substance with black dirt and dust buildup on it. There were also 6 caps of what appears to be tops to the tube feeding bolus under the bed.
During an observation on 01/09/24 at 10:00 AM, of Resident #1's room under the bed there is a very sticky substance with black dirt and dust buildup on it. There were also 6 caps of what appears to be tops to tube feeding bolus under the bed.
During an interview on 01/09/24 at 1:31 PM, with the facilities Maintenance Director, he stated, They clean these rooms daily. Yes, that is dirty under his bed and that looks like the caps to the tube feeding
During a record review on 01/09/24 at 2:00 PM, of the facilities Daily Cleaning and Disinfecting Checklist dated for 01/09/24, it showed that Resident #1's room had already been cleaned for the day.
During a record review on 01/09/24 at 2:10 PM, of the listed housekeeping duties it reads {sweep and mop, making sure to get under the beds}.
b) Shower rooms
During the resident council meeting on 01/09/23 at 11:00 AM, multiple resident council members said the shower rooms are cold when they take a shower.
During an observation on 01/10/23 at 1:00 PM, the shower room on 200 hall felt cool. No thermometer was in the room. There is a baseboard heater covered in dust.
On 01/10/23 at 1:15 PM, the maintenance director checked temperatures in the bathroom. The temperatures read as follows: 64.5 degrees F. by the wall, 66 degrees F. at the shower head and 67 degrees F. by the heater that was off.
During an observation on 01/10/23 at 1:30 PM, the shower room on 300 hall felt cool. No thermometer was in the room. There was a baseboard heater that was on, but the bathtub is in front of it.
On 01/10/23 at 1:35 PM, the maintenance director checked temperatures in the shower room. The temperatures read as follows: 68.5 degrees F. by the wall, 69.5 degrees F. by the shower head and 74 degrees F. by the heater that is blocked by the bathtub
During an interview on 01/10/23 at 1:38 PM, the maintenance director stated, No I don't feel that's warm enough to take a shower in there and its not up to the correct temperature. I will check into it.
During an interview on 01/10/24 at 01:44 PM, Nurse Aide (NA) 15 stated, Sometimes they complain that it is cold, I shut the door and turn on the heat.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on record review, staff interview observation the facility failed to develop and or implement the comprehensive person-ce...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on record review, staff interview observation the facility failed to develop and or implement the comprehensive person-centered care plan as required. This was true for four (4) of twenty-three (23) care plans reviewed during the long-term care survey. Resident identifiers: #195, #21, #15, #27 Facility Census: 47.
Findings included:
a) Resident 195
On 01/08/24 at 1:11 PM observation of Resident #195 sitting at his bedside. During our conversation a round tin of Grizzly long cut tobacco product was observed on his over the bed table. The surveyor questioned if he used tobacco, and he replied, I use snuff, (pointing to the tin) been using it since I was 11.
The tobacco at bedside was confirmed with Licensed Practical Nurse #2.
The facility was a smoke free facility; however, smokeless tobacco was permitted. On 01/09/24, record review shows a Safety Resident Evaluation dated 01/02/24, completed by Registered Nurse (RN) #29. Section #4 on the evaluation is for smoking safety. Question #1 for tobacco utilization ask: Does the resident use tobacco products? RN #29 marked b) No.
On 01/09/24 at 11:00 AM, review of Resident #195's care plan shows he was not care planned for tobacco use of any kind.
This was confirmed with the Director of Nursing, who stated I didn't even know he had it.
b) Resident #21
On 01/10/24 1:15 PM record review found the following medical diagnoses listed for Resident #21:
Alzheimer's disease, unspecified
Unspecified dementia, unspecified severity with other behavioral disturbance
Adjustment disorder with mixed disturbance of emotions and conduct
Unspecified dementia, moderate, with mood disturbance
Anxiety disorder, unspecified.
Resident #21 had an order dated 05/23/23 for an anti-anxiety agent, Buspirone HCL Oral Tablet 5 milligrams (mg), give one tablet by mouth three times a day related to dementia with other behavior disturbances, anxiety disorder On 01/04/24 the medication was increased to 7.5 mg give 1 tablet by mouth three times a day related to anxiety disorder.
Review of the Minimum Data Sheet, Section N (medications) with an Assessment Reference Date (ARD) date of 12/22/23 is marked that Resident #21 does not receive any anti anxiety medication. Review of the care plan shows no focus, goal or interventions for a diagnosis of anxiety.
This was confirmed with the Director of Nursing on 01/10/24 at 2:00 PM. No additional information was obtained prior to completing the long term survey process.
c) Resident #15
On 1/08/24 02:45 PM record review shows Resident #15 had an outstanding urine culture at the laboratory. The preliminary urinalysis showed Escherichia coli (E Coli) and she was started on Augmentin 250-62.5 milligrams (mg) three times a day for seven (7) days. Once the culture report was returned to the facility on [DATE], the physician was contacted, and the antibiotic was changed to Nitrofurantoin 100 mg twice a day for 7 days for Extended-spectrum beta-lactamases (ESBL) in the urine. This was due to the bacteria being resistant to Augmentin.
Upon review of Resident #15's care plan it was found that there was no care plan for a urinary tract infection (UTI). Further review shows she had several UTI's in the past. There is a documented medical diagnosis of Urinary Tract Infection / Acute Infections dated 07/14/23.
On 01/10/24 10:35 AM during an interview with the Director of Nursing (DON) she confirmed that Resident #15 does have a history of UTI's.
d) Resident #27
A medical record review on 01/09/24 for Resident #27,with a hearing deficit had a comprehensive care plan with an intervention for the resident to have a communication book to assist her in communicating with the staff.
In an interview on 01/09/24 at 1:35 PM, with the Licensed Social Worker (LSW), the LSW explained Resident #27 used a dry erase board, when she was unable to read your lips.
During an observation on 01/09/24 at 1:40 PM, the LSW and the Minimum Data Set (MDS) Coordinator, both were unable to locate the communication book or dry erase board.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected multiple residents
b) Resident #195
On 01/08/24 at 01:11 PM, observation found Resident #195 sitting at his bedside. During our conversation I observed a round tin of Grizzly long cut tobacco product on his over the bed...
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b) Resident #195
On 01/08/24 at 01:11 PM, observation found Resident #195 sitting at his bedside. During our conversation I observed a round tin of Grizzly long cut tobacco product on his over the bed table. I questioned if he used tobacco, and he replied I use snuff, (pointing to the tin) been using it since I was 11.
The tobacco at bedside was confirmed with Licensed Practical Nurse #2.
The facility was a smoke free facility, however; smokeless tobacco was permitted. On 01/09/24, record review showed a Safety Resident Evaluation dated 01/02/24, completed by Registered Nurse (RN) #29. Section #4 on the evaluation was for smoking safety. Question #1 for tobacco utilization, asked, Does the resident use tobacco products? RN #29 marked - b as (No.)
On 01/09/24 at 11:00 AM, review of Resident #195s care plan showed he was not care planned for tobacco use of any kind.
This was confirmed with the Director of Nursing, who stated I didn't even know he had it.
Based on record review, observation, and staff interview, the facility failed to ensure it was free from accident hazards in which it had control. One (1) medication cart was left unlocked and unattended. Additionally, the facility failed to complete a safety assessment on Resident #195 related to his use of smokeless tobacco in his room. These were random opportunities for discovery and had the potential to effect more than a limited number of residents. Resident identifier: #195. Facility census: 47.
Findings included:
a) Unlocked Medication Cart on 3 [NAME] Hall
The facility's Medication Storage policy states, Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing drugs and biologicals shall be locked when not in use, and trays or carts used to transport such items shall not be left unattended if open or otherwise potentially available to others.
On 01/10/24 at 11:33 AM, Surveyor observed the medication cart on the 3 [NAME] Hall was unlocked and unattended. The Regional Director of Clinical Operations #72 confirmed the medication cart was unlocked and unattended and immediately secured the medications by locking the medication cart. Surveyor remained with the unlocked cart until RN #2 came back on the unit at 11:37 AM. RN #2 stated, I've been running around everywhere and must have forgot.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Staffing Information
(Tag F0732)
Could have caused harm · This affected multiple residents
Based on observation and staff interview, the facility failed to ensure the staff posting was accurate and correct. This had the potential to affect more than a limited number of residents residing at...
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Based on observation and staff interview, the facility failed to ensure the staff posting was accurate and correct. This had the potential to affect more than a limited number of residents residing at the facility. Facility census: 47.
Findings included:
a) Staff posting
During a random opportunity for discovery on 01/09/24, the staff posting had not been updated from 01/08/24 to 01/09/24. Also the staff posting was not in a prominent place readily accessible to residents and visitors.
In an interview with the Director of Nursing (DON) on 01/10/24 at 11:00 AM, the DON verified the staff posting had not been updated and it was not posted in a prominent place accessible to residents and visitors.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0804
(Tag F0804)
Could have caused harm · This affected multiple residents
Based on staff interview, resident interview, and record review the facility failed to ensure food was served at a safe and appetizing temperature. This failed practice had the potential to affect mor...
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Based on staff interview, resident interview, and record review the facility failed to ensure food was served at a safe and appetizing temperature. This failed practice had the potential to affect more than a limited number of residents. Facility census 47.
Findings included:
a) Dining Services
Based on anonymous resident interviews during the long term care survey process, multiple residents had complaints of the hot food being cold.
During the resident council meeting on 01/09/23 at 11:00 AM, the resident council members made complaints that the food being served at meals is cold.
Observation on 01/10/24 01:10 PM, found the temperatures of the last tray served on 300 hall were: noodles with meat sauce tempted at 122 degrees Fahrenheit and the vegetable barley soup tempted at 122 degrees Fahrenheit.
During an interview on 01/10/24 at 1:15 PM, the facilities Dietary Manager (DM) stated, The food normally temps at 165 degrees before we serve the residents. When it is served to the residents it should be between 135 degrees and 140 degrees.
Observation of the temperature log in the kitchen with the DM on 01/10/24 at 1:30 PM, found temperatures were not recorded for the lunch or breakfast meal on 01/09/24 at the time of service to the residents.
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 and staff interview the facility failed to store, prepare, and distribute food in accordance with professional standards for food service safety. It was discovered the ice machine...
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Based on observation and staff interview the facility failed to store, prepare, and distribute food in accordance with professional standards for food service safety. It was discovered the ice machine was not draining properly, there was expired food found in walk-in cooler and food stored on the floor in the storage area. This had the potential to affect all residents receiving nutrition from the kitchen. Facility census: 47.
Findings included:
a) Ice machine
During a random opportunity for discovery, on 01/09/23 at 2:10 PM, it was discovered the ice machine was not draining properly. The drain was located below the floor drain, which provided for a no stop gap of one (1) inch to prevent backflow.
In an interview with the Director of Maintenance on 01/09/24 at 2:50 PM, verified the drain line did not have a stop gap between the floor and the drain.
b) Initial tour of the kitchen
At 11:45 AM on 01/08/24, a tour of the kitchen with Dietary Manager (DM) #25 found the following items in the walk-in refrigerator that were expired:
A plastic container labeled as Lunch Meat, had two dates written on the lid, 12/31/23 and 01/02/24. The DM said she assumed the lunch meat should have been discarded on 01/02/24.
Sliced Ham, out of the original packaging, was stored in a plastic container with 2 dates written on the lid, 12/28/23 and 12/31/23. The DM said the ham should have been discarded on 12/31/23.
A plastic container of beef stew had 2 dates written on the lid, 01/05/24 and 01/07/24. The DM said the stew should have been discarded on 01/07/24.
In addition, the DM confirmed the step-on trash can by the employee hand washing sink was broken. This would not allow employees to discard hand drying paper towels after sanitizing their hands without touching the lid of the trash can to get it open.
The DM manager confirmed a 50-pound bag of sugar was sitting on the stock room floor. She said, I guess the bin was full, but it shouldn't be on the floor.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected multiple residents
Based on observation and staff interview the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help preve...
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Based on observation and staff interview the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. This had the potential to affect more than an isolated number of residents. Resident Identifiers: #194 and #11. Facility Census: 47.
Findings Included:
a) 300 [NAME] hallway
On 01/08/24 at 12:50 PM during observation of the lunch meal trays being passed on the 300 [NAME] hallway, no hand hygiene was provided to the residents prior to their meal.
When Nurse Aide (NA) #69 and #27 were asked how they provide hand hygiene, they looked at each other and laughed. NA #27 stated, 'they use to put hand wipes on the trays, but they don't anymore. They both then continued to pass the remaining meal trays without providing hand hygiene. It was confirmed with NA #69 and #27 that they did not provide hand hygiene.
This was confirmed with the Director of Nursing on 01/08/24 at 1:10 PM.
b) Resident #194
On 01/08/24 at 2:38 PM record review shows Resident #194 has a stage 2 pressure ulcer to the right buttock. There is a dressing change order as follows:
Cleanse stage 2 with soap and water. Pat dry. Cover with border dressing daily and porn if loose or soiled until clear one time a day for Stage 2 pressure Ulcer related to PRESSURE ULCER OF RIGHT BUTTOCK, STAGE 2 until clear AND as needed for of loose or soiled related to PRESSURE ULCER OF RIGHT BUTTOCK, STAGE 2 until clear.
On 01/09/24 at 01:50 PM wound care was observed with Licensed Practical Nurse (LPN) #1 performing the care. The Resident was in bed on her side and had a brief on, she had had a bowel movement. The LPN placed her gloves on, removed the old dressing in place and cleaned the resident of the bowel movement. She then proceeded to place a clean dressing on the wound without changing her gloves throughout the process.
This was confirmed with LPN #1 on 01/09/24 at 1:56 PM and the Director of Nursing on 01/09/24 at 2:00 PM.
c) Resident #11
On 01/08/24 at 02:12 PM record review revealed Resident #11 had a stage 2 pressure ulcer to his right shoulder. There was a dressing change order that stated:
Pressure Ulcer stage two to the right shoulder rear: cleanse area with normal saline. Apply calcium alginate then cover with ABD (abdominal) pad and PORN if dressing becomes soiled, loose, or detached, one time a day related to PRESSURE ULCER OF OTHER SITE, STAGE 2 Discontinue when site is clear. AND every 24 hours as needed related to PRESSURE ULCER OF OTHER SITE, STAGE 2 Discontinue when site clear.
On 01/09/24 at 11:19 AM wound care was observed when Licensed Practical Nurse (LPN) #2 performed the dressing change.
When Resident #11 was turned to his side, it was noted that the old dressing was not in place, there was however a hand towel under his shoulder at the ulcer site. LPN #2 stated your old dressing is off. He then took the towel from under the resident's shoulder and placed it on the floor and not in a laundry bag or on a barrier. The towel contained a brown colored drainage and blood on it from the wound.
The above was confirmed with LPN #2 on 01/09/24 at 11:25 AM and then with the Director of Nursing at 11:30 AM.
d) No resident hand hygiene on the 2 [NAME] Hall.
On 01/08/24 at 12:40 PM, the delivery of lunch trays began on the 2 [NAME] Hall. NA #54 and NA #31 were the staff members who passed the lunch trays on the 200 hall. No hand hygiene was provided to residents when their meals were delivered to their rooms.
During an interview, on 01/08/24 at 12:57 PM, NA #31 reported she had worked in the building for approximately six (6) years and no hand hygiene is typically done with residents when they eat in their rooms. NA #31 reported that residents who eat in the dining room are given washcloths/green rags to sanitize their hands before their meals are served. NA #31 stated staff did not offer residents who choose to eat in their rooms the opportunity to sanitize their hands before the meal was served. During an interview on 01/09/24 at 3:30 PM, the DON reported she had been made aware of the issue.
Sept 2022
20 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Resident Rights
(Tag F0550)
Could have caused harm · This affected 1 resident
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Based on observation, resident interview, staff interview and resident council meeting, the facility failed to provide care and treatment in a dignified manner for Resident #28 and Resident #43. Thi...
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Based on observation, resident interview, staff interview and resident council meeting, the facility failed to provide care and treatment in a dignified manner for Resident #28 and Resident #43. This was a random opportunity for discovery. Resident Identifiers: Resident #28 and Resident #43. Facility Census: 48.
Findings Included:
a) Resident #28
During an interview on 09/19/22 at 1:17 PM, Resident #28 stated I need help, nobody will help you here, I will not come back to this place again. When you don't feel good, and you just want to lay down. The resident then started crying and stated, The girl brought me back from the dining room and just left me and I just wanted to go to bed.
Resident #28 pulled her call light at 1:20 PM. A nurses Aide came into the room and turned off the call light at 1:22 PM. Resident stated she wanted to lay down, a Nurse aide, stated I will ask your aide and left the room. At 1:25 PM Two nurse aides came into the Residents room with a sit to stand lift to assist the resident to bed. Resident #28 stated thank you, I am not sure how long I would have waited if you were not here.
During an interview on 09/19/22 at 2:00 PM the Director of Nursing (DON) stated the nurse aides usually bring all the residents back from the dining room before they start taking them to the bathroom and laying them down.
b) Resident Council
During a Resident Council meeting held on 09/20/22 at 10:00 AM the following concerns were presented:
Confidential interviews with the Resident group found the following concerns related to call lights:
-They turn off the call light and ask what you need and never come back.
-And you have to turn the call light back on and they come back in again and turn off the call light and never return it happens all the time.
-It happens mostly on daytime shift.
-Sometimes you wait about one hour.
During an interview on 09/20/22 at 4:21 PM with DON stated I will do an education with them, I thought the call lights were improving.
c.) Resident #43
On 09/19/22 at 01:31 PM, the catheter bag for Resident #43 was observed from the door to be uncovered and in plain view when standing at the resident's doorway.
An observation, on 09/20/22 at 08:13 AM, revealed the catheter bag for Resident #43 was observed to be uncovered when entering the resident's room from the hallway.
An interview , with Registered Nurse (RN) #35, on 09/20/22 at 08:13 AM, verified the catheter bag was not covered and should have been.
An observation, on 09/20/22 at 01:23 PM , revealed the catheter bag for Resident #43 was in plain view from the hallway and was observed not to be covered.
An interview with the Director of Nursing (DON). on 09/20/22 at 01:23 PM , confirmed Resident #43's catheter bag was not covered and should have been. The DON further explained, covering the catheter bags was a facility policy.
d) Resident interview
During a confidential resident interview, on 09/19/22 at 02:20 PM, a resident complained when the call light is activated to request assistance, staff would often come to the room to determine the request but not provide assistance at that time. The resident stated further, staff would turn off the call light before leaving the room, informing the resident they would return in a minute but would not return to provide the assistance needed.
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CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0554
(Tag F0554)
Could have caused harm · This affected 1 resident
Based on observation, record review, resident and staff interview, the facility failed to ensure when a resident self administered medications, the interdisciplinary team had determined this practice ...
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Based on observation, record review, resident and staff interview, the facility failed to ensure when a resident self administered medications, the interdisciplinary team had determined this practice was clinically appropriate. This deficient practice was identified during a random opportunity for discovery when Resident #36 was observed in the dining room to have a medication cup with medications present. The licensed nurse passing the medications was not present to supervise the administration and left the medications with the resident. Resident identifier: Resident #36. Census: 48.
Findings included:
a.) Policy review
A review of the policy, Resident Self-Administration of Medication, revision date: 10/15/22, noted staff were required to complete a process to determine if the resident could safely administer medications. After a determination was made to allow self- administration, a physicians order would be obtained, and that determination of self-administration of medication would be included in the care plan process.
b) Resident #36 Observation
An observation on 09/26/22 at 12:43 PM, found Registered Nurse (RN) #34 was with a medication cart outside of the main dining room during meal time.
During a dining observation in the main dining room on 09/26/22 at 12:45 PM a medication cup of pills was observed sitting on Resident # 36 lunch tray. RN #34 was not present in the main dining room at the time of the observation. Several residents were in the main dining room for the lunch meal.
c) Resident interview
Resident #36 was observed in the dining room on 09/26/22 at 12:50 PM , eating the lunch meal. A medicine cup with medications were present on the tray. Resident #36 was interviewed at this time, which revealed the medications were left during the meal so the resident could take them throughout the time she was eating.
d) Staff Interview with DON and RN #34
On 09/26/22 at 12:46 PM, This surveyor went to interview RN #34, concerning Resident #36's medication. This surveyor asked several staff members throughout the facility where she might be, the DON and other staff members were unable to locate her for over 15 minutes.
During an interview on 09/26/22 at 12:59 PM, the DON stated, we still can not find her, as soon as we do I will send her to you.
During an interview on 09/26/22 at 1:05 PM RN #34 verified she left the dining room and did not supervise Resident #36 taking her medication. She stated, I gave (First Name of Resident # 36's name) her afternoon medication, she takes them on her own per her request. It is customary to provide the cup of meds and then return later to see if she took them. I don't give her the medication she refuses, like Potassium. I just checked on her and she took them all.
During an interview on 09/26/22 at 1:15 PM, RN #34 presented a copy of the medication administration record (MAR), with a check mark beside the medication that was administered in the medicine cup for Resident #36.
The following medications were selected on the MAR:
-Cholecalciferol tablet 50 mcg, Give three (3) tablets by mouth one time a day
-Diltiazem CD Capsule Extended Release 24 hour 120 mg, Give one (1) capsule by mouth one time a day.
-Fenofibrate Micronized Capsule 67 mg, Give one (1) capsule by mouth one time a day.
-Furosemide Tablet 40 mg, Give one (1) tablet by mouth one (1) time a day.
-Isosorbide Mononitrate Tablet, Give 120 mg by mouth one (1) time a day.
-Lisinopril Tablet 5mg, Give one (1) tablet by mouth one (1) time a day.
-Pepcid AC Tablet 10 MG, Give two (2) tablets by mouth one (1) time a day.
-Plavix Tablet 75 mg, Give one (1) tablet by mouth one(1) time a day.
-Singulair Tablet 10 mg, Give one (1) tablet by mouth one (1) time a day.
-Vitamin E Capsule, Give 400 IU by mouth one (1) time a day.
-Eliquis Tablet 5 mg, Give one (1) tablet by mouth two (2) times a day.
-MagOx 400 Tablet, Give one (1) tablet by mouth two (2) times a day.
-Metoprolol Tartrate Tablet 100 mg, Give 1.5 tablet by mouth two (2) times a day.
-Ranolazine ER Tablet Extended Release 12 hour 500 mg, Give two (2) tablet by mouth two (2) times a day.
-Spironolactone Tablet 25 mg, Give one (1) tablet by mouth two (2) times a day.
e) The DON and The MDS Nurse Interviews.
An interview with the DON and the Minimum Data Set Nurse (MDS) on 09/26/22 at 2:09 PM, confirmed, Resident # 36 does not have a self administration assessment and there is no focus on the care plan for self administration. She is not able to self administer medications and there are no physician orders. When I give her the medications it can take over 30 minutes, she will go through each pill one (1) by one (1) and ask what it is and tell you if she is going to take it or refuse it. Resident # 36 will take some pills for me and don't for others.
The DON stated the Resident is to be supervised during medication pass and confirmed the nurse administering the medications was not supervising the administration with Resident #36. The DON added I know because I was not able to find her.
During a medical record review on 09/26/22 no evidence of a physician order for self administration, no self administration of medication assessment was completed nor was a care plan completed to reflect Resident #36's ability to self administer medications.
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CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0565
(Tag F0565)
Could have caused harm · This affected 1 resident
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Based on resident council minutes, policy review, resident interview and staff interview, the facility failed to consider the voiced concerns of residents in resident council as grievances. The faci...
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Based on resident council minutes, policy review, resident interview and staff interview, the facility failed to consider the voiced concerns of residents in resident council as grievances. The facility failed to act promptly to investigate resident grievances concerning issues of Television and meal delivery. This had the potential to affect a limited number of residents living in the facility. Facility census: 48.
Findings Included:
a) Policy Review
A review of the facility policy titled Grievances, Suggestions or Concerns-Rehab/Skilled with a revision date of 09/16/21 found the following.
.4. The grievance will be documented on the Suggestion or Concern (GSS #213) and submitted to the grievance official.
5. The grievance official will route the GSS #213 to the appropriate department manager as soon as is reasonably possible.
6. An investigation must be completed for all grievances
b) Resident Council Meeting
During a Resident Council meeting held on 09/20/22 at 10:00 AM the following concerns were presented:
Confidential interviews with the Resident group found the following concerns related to call lights:
-They turn off the call light and ask what you need and never come back
-And you have to turn the call light back on and they come back in again and turn off the call light and never return it happens all the time.
-It happens mostly on daytime shift.
-Sometimes you wait about one hour.
-The TV cable is always messing up and the maintenance guy tries to fix it.
-The TV never works
-The TV is always freezing up.
-The cable is out for days at a time.
c) Previous Resident Council Meetings
During a Resident Council Meeting held on 09/15/22, the Residents voiced concerns about the following issue:
-TV Channels not working properly ( Ancillary Services Supervisor #38 (name)) is aware and a ticket has been turned in for repairs.
During a Resident Council Meeting held on 06/28/22, the Residents voiced concerns about the following issues:
-Meals being late.
-Channels on the TV not working.
During a Resident Council Meeting held on 05/31/22 , the Residents voiced concerns about the following issue:
-A resident had an issue with another resident snapping at him at lunch.
c) Staff Interviews
During an interview on 09/26/22 at 3:42 PM, the Social Worker (SW) was asked about the process to address concerns voiced during the resident council meetings. He stated I just tell the department manager, and they take care of it. I think that month the cable was fixed and then broke again. I don't do a grievance for the resident council's concerns. I did not know we had a policy for grievances.
During an interview on 09/26/22 at 4:26 PM, the Activities Supervisor was asked about the process to address the concerns voiced during the resident council meetings. The activities supervisor indicated the facility social worker has told them they will take care of the resident concerns. When I lead the resident council meeting, and the residents voice concerns I will take them to the department manager. I don't know if an investigation is completed, or if the concern was fixed. I did not know we had to do grievance forms for resident concerns, the social worker never trained us to do that.
During a review of the grievance/concerns reports there were two (2) grievances for the year, which neither were from the resident council concerns.
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CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Notification of Changes
(Tag F0580)
Could have caused harm · This affected 1 resident
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Based on medical record review, policy review and staff interview the facility failed to notify the physician or resident representative in a timely manner when the resident suffered a change in con...
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Based on medical record review, policy review and staff interview the facility failed to notify the physician or resident representative in a timely manner when the resident suffered a change in condition. Resident #4 suffered side effects from the medication Seroquel and the physcian was not notified of the side effects. The facility also failed to notify Resident #8's representative when they had an incident involving a medicated cream. This was a random opportunity for discovery. Resident Identifiers: Resident #4 and Resident #8. Facility census: 48.
Findings Included:
a) Resident #4
A review of the facility policy titled Medication Documentation-R/S, LTC with a revision date of 09/22/22 found the following.
.7. Notify physician of any side effects, adverse reaction, medication error, corrective action taken, consequences or any reading outside the parameters established by the physician.
A review of Resident #4's medical record on 09/27/22 revealed a physician order dated 04/06/22 for Quetiapine Fumarate Tablet (Seroquel) 100 MG Give 1 tablet by mouth one time a day.
A review of Resident #4's MAR for 08/2022 revealed on 08/31/22 Resident #4 experienced side effects from the medicaiton.
A review of Resident #4's Medication Administration Record (MAR) for 09/2022 revealed from 09/01/22 to 09/12/22 the resident experienced side effects of the medication daily.
Further review of the medical records revealed no evidence of documentation the physician was notified of the side effects experineced by Resident #4 on 13 consecutive days.
During an interview on 09/27/22 at 10:26 AM the Minimum Data Set Nurse (MDSN), stated the abbervation (SE) on Resident #4's MAR is a code for side effects and when a resident has a side effect they mark yes/no. When they answer yes it triggers a progress note, which the nurse must then document what side effects were exhibited. She indicated, the nurses are not documenting the side effects like they are supposed to, we need to do more education.
On 09/27/22 at 10:39 AM the MDSN acknowledged there is no documentation for the side effects. She also acknowledged there was nothing to indicate the physician had been notified of the residents side effects.
b) Resident #8
A review of the facility policy titled Notification of Change with a revision date of 04/26/22 found the following.
.POLICY
A facility must immediately inform the resident, consult with resident's physician's and notify, consistent with his or her authority, the resident representative .
A Review of Resident #8's medical record on 09/27/22 revealed an incident that occured on 09/14/22.
An incident report/note dated on 09/14/22 at 8:05 PM by Licensed Practical Nurse (LPN) #40 (typed as written) stated:
Nursing Description: CNA staff reported to this nurse that (Resident #8's name) entered another resident's room, when staff entered the room to redirect her she had a medicine cup with cream in her hand and was seen putting a small amount on her finger in her mouth. Staff intervened and retrieved the medication From ( Resident #8's Name) and ensured her mouth was clear of anything and redirected (Resident #8's name) out of the Resident room.
Immediate Action Taken:
Description: Resident redirected, VS were attempted, but resident was restless and uncooperative with staff. Poison control contacted and stated that zinc oxide cream is nontoxic, but that resident may experience stomach discomfort or diarrhea.(Name of Attending Physician) notified.
Further record review of progress notes dated 09/16/22 at 10:27 AM revealed Resident #8's representative was not notified of the incident that occurred on 09/14/22.
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CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0583
(Tag F0583)
Could have caused harm · This affected 1 resident
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Based on observation and staff interview, the facility failed to promote privacy during medical treatments for two (2) of six (6) treatments observed during the Long Term Care Survey Process (LTSP)....
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Based on observation and staff interview, the facility failed to promote privacy during medical treatments for two (2) of six (6) treatments observed during the Long Term Care Survey Process (LTSP). This deficient practice was identified for Resident #43 during two (2) separate wound treatments. Resident identifier: Resident #43. Census: 48.
Findings included:
a) Resident #43
During a treatment observation, on 9/19/22 at 04:45 PM, Registered Nurse (RN) #35 entered Resident #43's room to complete a dressing change to the residents upper legs. RN #35 did not close the door or pull the privacy curtain to provide privacy to the resident during the dressing change. RN #35 assisted the resident with removal of clothing exposing the groin and thigh area where the area was being treated. At this time, residents and staff were observed in the hallway while the treatment was being done.
An interview with RN #35, on 09/20/22 at 10:14 AM, verified the door remained open during the treatment and the curtain was not pulled to provide privacy during the treatment. RN #35 further stated, during the interview, the door should have been closed because that was the policy of the facility to do so.
During a treatment observation, on 09/26/22 at 11:27 AM , Licensed Practical Nurse (LPN) #53 entered Resident #43's room to perform a dressing change to the resident's buttock area. LPN #53 did not close the door or pull the privacy curtain prior to exposing the residents buttocks to perform the treatment.
At 11:35 AM, while LPN #53 was performing the treatment for Resident #43, this resident's roommate, whose bed is located by the window, walked by Resident #43 and entered the restroom. During the time , Resident #43's buttocks were exposed and the treatment was in progress. At 11:47 AM, Resident #43's roommate came out of the restroom, walked past the resident who was still receiving the treatment and returned to bed. At this time, Resident #43 stated the curtain should have been pulled to provide some privacy.
An interview, with LPN #53 on 09/26/22 at 11:50 AM, verified the curtain should have been pulled to provide privacy but stated she did not think the roommate was going to walk by while the treatment was being done.
An observation on 09/26/22 at 11:50 AM, revealed there was no privacy curtain present that could be pulled around the outside perimeter of the beds.
An interview with the Maintenance Director, on 09/26/22 at 11:55 AM, verified the privacy curtain that was supposed to be present was missing. The maintenance Director stated further, the only curtain was between the resident's beds but that one was only for privacy between the beds and could not be pulled around to provide full privacy.
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CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected 1 resident
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Based on record review, resident interview and staff interview, the facility failed to ensure that all alleged violations of abuse and neglect, including serious bodily injury, were reported immedia...
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Based on record review, resident interview and staff interview, the facility failed to ensure that all alleged violations of abuse and neglect, including serious bodily injury, were reported immediately, and failed to ensure the results of the investigations were reported to other officials (including to the State Survey Agency and Adult Protective Services (APS) where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures. Resident #4 sustained serious bodily injury in the facility and the injury was not reported within two (2) hours of staff's knowledge of the severity of the resident's injuries sustained from a fall. This deficient practice was identified through a random opportunity for discovery and had the potential to affect a limited number of residents. Resident identifier: Resident #4. Census: 48.
Findings included:
a) Resident #4
An interview, with Resident #4, on 09/19/22 at 12:49 PM, revealed the resident stating she had fallen in the facility and broke her face.
A review of the electronic medical record revealed a progress note, dated 07/06/22 at 05:00 AM, Resident #4 was sitting in a puddle of blood, center of forehead , right upper lip and nose bleeding. Resident #4 was transported to the hospital.
A progress note, dated 07/06/22 at 11:00 Am, the hospital had alerted facilty staff, Resident #4 was being admitted for observation due to the residents being diagnosed with multiple fractures.
An interview with the Director of Nursing (DON), on 09/20/22 at 03:23 PM , verified the the initial report was reported late because the facility was aware the fracture had occurred 7/6/22 at 11:00 AM, and the documentation of reporting was not done until 2:23 PM. The DON verified the reporting was not done in the two (2) hour time frame and was only reported to the state agency, OHFLAC, and not reported to APS as required.
A review of the investigation for the 07/06/22 incident, showed no evidence the results were reported to APS.
An interview with the Social Services Director, on 09/20/22 at 02:05 PM, confirmed the facilty had failed to notify APS of the investigation results of the incident on 07/06/22.
An interview with the DON on 09/20/22 at 3:23 PM, verified the facility had not reported the results of the investigation to APS.
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CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Transfer Notice
(Tag F0623)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on medical record review and staff interview, the facility failed to provide evidence that a copy of the Notice of Trans...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on medical record review and staff interview, the facility failed to provide evidence that a copy of the Notice of Transfer was sent to to the Office of the State Long-Term Care Ombudsman. This was true for one (1) of two (2) reviewed for the care area of hospitalization during the Long-term care process. Resident Identifiers: Resident # 249. Facility Census: 48
Findings Included:
a) Resident # 249
During an interview on 09/19/22 at 1:37 PM Resident # 249's Husband stated She has been in the hospital a few times.
A medical record review on 09/19/22 revealed Resident #249 was transferred to the hospital on [DATE]. The records did not reveal a notification of Transfer was sent to the Ombudsman.
During an interview on 09/19/22 at 11:20 AM the Social Worker stated Resident # 249's transfer to the hospital on [DATE] was not reported to the office of the State of the Long-term Care Ombudsman.
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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
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Based on record review, staff interview and resident interview the facility failed to implement the care plan for Residents #36 and #38. This was true for two (2) of 26 sampled residents. Resident i...
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Based on record review, staff interview and resident interview the facility failed to implement the care plan for Residents #36 and #38. This was true for two (2) of 26 sampled residents. Resident identifiers: #36 and #38. Facility Census: 48
Findings Included:
a) Resident #36
An interview with Resident #36 on 09/19/22 at 1:30 PM, revealed the resident stating he/she had not been receiving rehabilitation services that had been ordered to help with physical limitations identified.
A review of the comprehensive person centered care plan for Resident #36 showed the resident had a problem / focus area identified for the need for restorative intervention due to Activities of Daily Living (ADL) self-care performance deficit / limited physical mobility related to hemiplegia as evidenced by limited mobility.
The approaches for Resident #36 included the following restorative measures to assist the resident with the identified problem:
- Omnicycle level 2 up to 15 minutes to bilateral lower extremities 3-6 times weekly PRN (as needed )to help maintain strength.
- Active range of motion to right upper extremity using Omnicycle Level4 x 1 time daily, x 3-6 days per week prn to help maintain strength.
- Passive range of motion passive stretch to left lower extremity X15 mins per day, X 1 times/day, X 3-6 days/week to help main strength lower body.
-Transfers with x 1 staff assist, STS/SPT from bed to wheelchair and wheelchair back to bed x 15 minutes per day, x 3-6 days per week prn to help maintain strength.
- Walking with Hemi-walker up to 60' with x 2 staff with orthotic on, x 1 times daily x 3-6 days per week to help maintain body strength. Make sure brace is on leg
Review of the progress notes showed monthly nurse documentation for September 2022 indicating resident often refuses with no evidence of how many refusals had occurred , time of the refusals and progress or lack of progress of which approaches the resident participated in.
Review of the daily documentation to further investigate how often the resident was offered, received or refused each approach showed no data found and no notation the services were offered and /or refused by Resident #36.
An interview, with RN #69, on 09/27/22 at 10:10 AM, verified there was no evidence of providing restorative services outlined in the care plan to Resident #36.
An additional interview with RN # 69, on 09/27/22 at 10:17 AM, verified he/she could not find dates and/or reasons for any refusals and could not validate the basis for the documentation in the progress notes showing frequent refusals of the restorative services.
f) Resident #38
A review of the comprehensive person centered care plan for Resident #38 showed a problem / focus area of being at risk for falls related to orthostatic hypotension initiated on 08/26/22. The care plan approaches included documenting orthostatic blood pressures when lying, sitting and standing every day and night shift.
A review of the documented blood pressure readings for September 2022, showed the following :
- blood pressures taken for 09/01/22 through 09/19/22 did not have notation as to if the blood pressure taken was done lying, sitting or standing, as addressed in the care plan, with all readings recorded.
-blood pressure readings for 09/11/22 only included one (1) blood pressure reading per a 24 hour period when the care plan noted the blood pressure readings were to be acquired day and night shifts.
An interview with the Director of Nursing (DON), on 09/27/22 at 12:10 PM, verified staff had failed to obtain and/or document the blood pressure readings for lying, sitting and standing in accordance with directive on the care plan.
An interview with the MDS/care plan coordinator, on 08/27/22 at 12:50 PM, confirmed blood pressures for Resident #38 were missing and could find no further evidence the blood pressure readings were taken in accordance to the care plan.
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CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected 1 resident
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Based on observation, medical record review, family interview and staff interview the facility failed to provide care required to maintain proper nail care to a resident who is dependent for Activit...
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Based on observation, medical record review, family interview and staff interview the facility failed to provide care required to maintain proper nail care to a resident who is dependent for Activities Of Daily Living (ADL) care. This was true for one (1) of one (1) reviewed for ADL's during the long term care survey process. Resident Identifiers: Resident #249 Facility Census: 48
Findings Included:
a) Resident #249
During a resident representative interview on 09/19/22 at 1:37 PM Resident #249's Husband stated my only concerns are her jagged toenails and fingernails. They look awful, just look at them.
An observation on 09/19/22 at 1:39 PM Resident #249's toenails were long and jagged and fingernails were broken and jagged and fingernail polish was faded.
A medical record review on 09/20/22 revealed on 05/05/22 a physician order which stated:
Foot Assessment: Assess both feet for abnormalities and clean and trim nails Q(every) month. every day shift every 4 weeks on Tuesday for Foot Assessment.
A review of Treatment Administration Record (TAR) was void of evidence of documentation to verify foot assessment was completed on 08/02/22. Documentation on 08/30/22 indicated the foot assessment was completed.
During an in interview on 09/20/22 at 12:45 PM RN #34 acknowledged the void on 08/02/22 and she stated I performed nail care on 08/30/22. I must have just filed her toe nails. I thought I did a good enough job. Her nails grow fast. I am not sure when her fingernails were done last, I will have to check. Her husband brought in a nail kit today for us to do her nails.
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CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Pressure Ulcer Prevention
(Tag F0686)
Could have caused harm · This affected 1 resident
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Based on observation, record review and staff interview, the facility failed to provide care to residents with pressure ulcers consistent with professional standards of practice to promote healing, ...
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Based on observation, record review and staff interview, the facility failed to provide care to residents with pressure ulcers consistent with professional standards of practice to promote healing, prevent infection and prevent new pressure ulcers from developing for one (1) of six (6) residents reviewed for pressure ulcers during the LTCSP. Resident identifier: Resident # 41
Findings included:
a) Resident #41
A review of the electronic medical record for Resident #41, showed a physician's order for the resident to have bilateral heel boots while in bed because of an identified risk for pressure ulcer development and a history or pressure ulcers.
An observation, on 09/21/22 at 09:37 AM, revealed the resident lying in bed with no heel boots in place as ordered by the physician.
An interview with Registered Nurse (RN) #35, on 09/21/22 at 09:37 AM, verified Resident #41 did not have the heel boots in place during the observation made. An additional interview with RN #35 , on 09/21/22 at 09:42 AM, revealed staff had removed the heel boots and had forgotten to put them back on the resident.
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CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
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ensure the environment over which it had control was as free from accident hazards as possible. This was a random opportunity for discovery. Resident Identifiers: Resident # 8. Facility Census: 48.
...
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ensure the environment over which it had control was as free from accident hazards as possible. This was a random opportunity for discovery. Resident Identifiers: Resident # 8. Facility Census: 48.
Findings Included:
a) Resident #8
A review of facility policy titled Incident Report-Rehab/Skilled with a revision date of 04/05/22 found the following.
.Procedure
.4 The investigation will be initiated by a supervisor or a member of the investigation team as soon as possible after the incident occurred.
5. The investigation team consisting of the administrator, the director of nursing services and social services will review each incident no later than the next business day. Ensure that someone is assigned to complete the investigation and that the care plan has been update with new interventions put into place.
A Review of Resident #8's medical record on 09/27/22 revealed an incident that occurred on 09/14/22.
A incident report/note dated on 09/14/22 at 8:05 PM by Licensed Practical Nurse (LPN) #40 (typed as written) stated:
Nursing Description: CNA staff reported to this nurse that (Resident #8's name) entered another resident's room, when staff entered the room to redirect her she had a medicine cup with cream in her hand and was seen putting a small amount on her finger in her mouth.
Staff intervened and retrieved the medication from ( Resident #8's Name) and ensured her mouth was clear of anything and redirected (Resident #8's name) out of the Resident room.
Immediate Action Taken:
Description: Resident redirected, VS were attempted, but resident was restless and uncooperative with staff. Poison control contacted and stated that zinc oxide cream is nontoxic, but that resident may experience stomach discomfort or diarrhea. (Name of Attending Physician) notified.
During an interview on 09/27/22 at 2:44 PM the Minimum Date Set Nurse (MDSN) stated after an incident occurs, it is up to the Social Worker's name, to investigate the incidents. I am unable to find any documentation that the investigation was completed.
During an interview on 09/27/22 at 3:16 PM the Social Worker stated I did not investigate the incident with Resident #8's name, I can not find anything which was done. Write it up, I guess that's another deficiency. I am racking them up.
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CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Incontinence Care
(Tag F0690)
Could have caused harm · This affected 1 resident
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Based on observation and staff interview, the facility failed to ensure a resident with a urinary catheter received care and treatment to prevent infections. This was true for one (1) of two (2) res...
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Based on observation and staff interview, the facility failed to ensure a resident with a urinary catheter received care and treatment to prevent infections. This was true for one (1) of two (2) residents reviewed with urinary catheters. Resident #43 was observed to have the catheter bag laying on the floor. Resident identifier: Resident #43. Census: 48
Findings included:
a) Policy and Procedure for Catheter Care
A review of the Policy and Procedure for Catheter: Insertion and Removal, Drainage Bags, Irrigation and Specimen, dated 08/24/22, showed under the area of Catheter tubing/drainage bags : Catheter tubing should never be allowed to touch the floor. Non-obstructed downhill flow is maintained at all times.
b) Resident #43
An observation on 09/20/22 at 08:13 AM, revealed the catheter bag for Resident #43 was found to be laying on the floor.
An interview, on 09/20/22 at 08:13 AM, with Registered Nurse (RN) #35, verified the urinary catheter bag was laying on the floor and should have been hanging from the bed off the floor, in accordance with facilty policy for catheter care.
An observation on 09/26/22 at 11:27 AM revealed the catheter bag for Resident #43 was noted to be on the floor again.
An interview with Licensed Practical Nurse (LPN) #53, on 09/26/22 at 11:27 AM, revealed the catheter bag for Resident #43 was verified to be laying on the floor and confirmed the catheter should have been attached to the bed in order to prevent the catheter tubing and bag from touching the floor.
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CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
Could have caused harm · This affected 1 resident
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Based on observation, policy review and staff interview the facility failed to provide necessary respiratory care and services that were in accordance with professional standard practice. A Nebulize...
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Based on observation, policy review and staff interview the facility failed to provide necessary respiratory care and services that were in accordance with professional standard practice. A Nebulizer treatment T-piece was hanging from the residents' bed railing. This observation was a random opportunity for discovery. Resident identifier: Resident #27. Facility census: 48.
Findings Included:
a) Resident #27
A review of the facility policy titled Oxygen Administration, Safety, Mask Types- R/S, LTC, Therapy & Rehab with a revision date of 06/29/22 found the following.
.11. When not in use, store in zip lock/plastic bag .
During initial tour of the facility on 09/19/22 at 12:08 PM Resident # 27's Nebulizer treatment T-piece was hanging from the resident's bed railing.
During an interview on 09/19/22 at 12:12 PM Registered Nurse #9 acknowledged the Nebulizer treatment T-piece should have been stored in a bag and not hanging from the bed railing.
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CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Drug Regimen Review
(Tag F0756)
Could have caused harm · This affected 1 resident
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Based on medical record review and staff interview the pharmacist failed to identify and report the irregularity of Resident #4 Seroquel, as evidenced by documentation of side effects by nursing. Th...
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Based on medical record review and staff interview the pharmacist failed to identify and report the irregularity of Resident #4 Seroquel, as evidenced by documentation of side effects by nursing. This was true for one (1) of five (5) reviewed for unnecessary medications during the long term care survey process. Resident identifier: Resident #4. Facility Census: 48
Findings Included:
a) Resident # 4
A review of Resident #4's medical record on 09/27/22 of revealed a physician order dated 04/06/22 Quetiapine Fumarate Tablet (Seroquel) 100 MG Give 1 tablet by mouth one time a day.
A review of Resident #4's Medication Administration Record (MAR) for 09/2022 revealed from 09/01/22 to 09/12/22 had documented yes for side effects daily.
A review of the Resident #4's MAR for 08/2022 revealed on 08/31/22 Resident #4 had side effects from the medication.
During an interview on 09/27/22 at 10:26 AM the Minimum Data Set Nurse (MDSN) stated the (SE) on Resident #4's MAR is a code for side effects and when a resident has a side effect the nurse marks yes/no. When they answer yes it triggers a progress note, which the nurse must then document what the side effects were exhibited. The nurses are not documenting the side effects like they are supposed to, we need to do more education.
A pharmacist consultation report dated 09/18/22 revealed a recommendation for Seroquel 50 mg am and 100 mg hs for schizo-affective disorder since 04/06/22. (typed as written) Rationale for Recommendation: CMS requires that antipsychotics, used to treat an enduring condition other than dementia, be evaluated at least quarterly with documentation regarding continued clinical appropriateness. A GDR should be attempted in 2 separate quarters, with at least 1 month between attempts, within the first year in which an individual is admitted on an antipsychotics or after the facility has initiated an antipsychotics, and then annually unless clinically contraindicated.
There was no evidence of the identification of the side effects in this rationale.
During an interview on 09/27/22 at 11:04 AM the DON acknowledged the pharmacist did not identify the side effects on the pharmacist consultation report for September for the Seroquel 100 mg. And she also acknowledged there were side effects marked yes on the MAR for Seroquel 100 mg for 09/01/22 till 09/12/22, that should have been identified by the pharmacist.
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CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected 1 resident
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Based on observation, policy and procedure and staff interview the facility failed to ensure the medication room controlled substance box was double locked. This failed practice had the potential to...
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Based on observation, policy and procedure and staff interview the facility failed to ensure the medication room controlled substance box was double locked. This failed practice had the potential to affect a limited number of residents. Facility Census: 48
Findings Included:
a) On 9/20/22 at 9:10 AM while observing the medication storage room, the controlled medication double lock box in the refrigerator was not locked. This was confirmed on 9/20/22 at 9:10 AM with Registered Nurse #9.
According to their Policy for Medications: Acquisition Receiving Dispensing and Storage dated 2/08/22 If the medication requires a refrigerator, these need to be locked in a separate container which they failed to do.
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CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Menu Adequacy
(Tag F0803)
Could have caused harm · This affected 1 resident
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Based on observation, record review and staff interview the facility failed to provide nutritional adequacy by providing inconsistent portions of the food to maintain perimeters of health. This fail...
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Based on observation, record review and staff interview the facility failed to provide nutritional adequacy by providing inconsistent portions of the food to maintain perimeters of health. This failed practice had the potential to a limited number of residents currently receiving nourishment from the facility's kitchen. Facility Census: 48.
Findings Included:
a) Resident #41
During a dining observation of the main dining room on 09/26/22 at 12:09 PM, Resident # 41 received a very small amount of ground meat with gravy, a small portion of mashed potatoes.
Resident #41's meal tray ticket diet order level 2 no restrictions did not have an order for smaller portions of meat/protein.
An observation on 09/26/22 of several other residents' lunch tray no portions on the lunch trays were consistent.
During an interview on 09/26/22 at 12:20 PM the Nutrition Food and Service Supervisor was asked the question about portion sizes? She stated we use a specified scoop size, we have a spreadsheet with the menu and diets and it states what size scoop to use. Resident #41 should be getting a four (4) ounce scoop of pureed meats with gravy. That is not four (4) ounces that is the size of a fifty cent piece. An observation of several other residents' lunch tray's with this surveyor she acknowledged the portions were not consistent.
During an interview on 09/26/22 at 1:48 PM Resident #36 stated there is never enough food, I asked for more mashed potatoes and gravy because I did not get enough for lunch. I was still hungry. They told me there was none left.
During a interview on 09/27/22 at 12:50 PM [NAME] #25 stated, when I left yesterday there was plenty of mashed potatoes, no one asked for mashed potatoes. I left at 12:45 PM, the person that came in to relieve me threw them away and was probably cleaning up the steam table, that's probably why there was none. The question was asked: what scoop do you use to serve the resident's meal? She stated I use the spreadsheet, it tells me what scoop to use with what diet. We don't make a lot of extra food due to the cost of it, I don't give them the portions if I know they are not going to eat it, some residents eat better than others.
During an interview on 09/27/22 at 12:54 PM the Nutrition Food and Service Supervisor stated we try to make enough for the resident so we don't waste any food, and some foods are hard to get since COVID. I will make sure the correct scoops are being used so we have extra portions if residents want seconds.
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CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Medical Records
(Tag F0842)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on medical record review and staff interview the facility failed to ensure Resident #249, and #46 medical record was com...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on medical record review and staff interview the facility failed to ensure Resident #249, and #46 medical record was complete and accurate. The Physician Orders for Scope of Treatment (POST) forms were not completed per directions specified by the [NAME] Virginia Center for End of Life Care. This is true for three (3) of 18 reviewed for the Long-Term Care Survey Process . Resident Identifiers: Resident #249 and Resident #46. Facility Census: 48.
Findings Included:
a) Resident #249
A medical record review on 09/19/22 revealed a POST form on Resident # 249's chart signed and dated by the physician on 09/12/22 which was void of the following:
Section F entitled Signature Health Care Provider Printed Full Name: required; was void of physician's name
During an interview on 09/20/22 at 8:21 AM the Social Worker acknowledged the POST form did not contain the physician's printed name which is required.
During an interview on 09/20/22 at 8:32 AM the Unit Secretary #41, acknowledged the POST form did not contain the physician's printed name which is required.
During an interview on 09/20/22 at 8:36 AM the DON, acknowledged the POST form did not contain the physician's printed name which is required.
b) Resident #46
A medical record review on 9/19/22 revealed a POST form on Resident # 46's chart had the following issues:
Section D was signed by the physician and dated on 06/27/18.
Medical Power of Attorney signed and dated on 07/09/17.
Section E Person Preparing Form was void of any information.
During the medical record review on 09/19/22 revealed Resident #46 was admitted on [DATE] and discharged to a local assisted living facility on 07/11/17.
Record review revealed Resident #46 was readmitted on [DATE], with no evidence of a review of the POST form.
The directions for reviewing the POST form states this form should be reviewed if there is substantial change in patient/resident health status or patient/resident treatment preferences. According to state law, the form MUST be reviewed if the patient/resident is transferred from one health care setting to another
During an interview on 09/20/22 at 8:21 AM the SW stated I must have missed that one, we should have done a new one or at least reviewed it.
During an interview on 09/20/22 at 8:24 AM the Unit Secretary #41 stated I have never seen this one, I did not do her admission.
During an interview on 09/21/22 at 8:36 AM the DON acknowledged that the POST form should have been reviewed on admission.
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CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0678
(Tag F0678)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on record review, policy review and staff interview the facility failed to ensure staff maintained current Cardiopulmona...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on record review, policy review and staff interview the facility failed to ensure staff maintained current Cardiopulmonary Resuscitation (CPR) certification for healthcare providers through a CPR provider whose training includes hands-on practice and in-person skills assessment. This was true for four (4) licensed nursing staff. This was a random opportunity of discovery. Employee Identifiers: Registered Nurse (RN) #35, Licensed Practical Nurse (LPN) #12, #40, and #27. Facility Census: 48
Findings Included:
a) On [DATE] at 12:29 PM during a review of records of active CPR certified nursing employees, it was found that four (4) nursing employees were not certified in CPR.
Registered Nurse (RN) #35 was not certified through the American Red Cross or The American Heart Association. Her certification was from the national CPR foundation making it invalid.
According to the facility's Cardiopulmonary Resuscitation Certification Requirements policy dated [DATE] The only two recognized providers are the American Heart Association and the American Red Cross.
Licensed Practical Nurse (LPN) #12 was employed [DATE] and has never been CPR certified.
LPN #40 certification expired in July of 2022.
LPN #27 certification expired in June of 2022.
These findings were confirmed on [DATE] at 2:00 PM with the Director of Nursing. She was unable to provide any further information prior to the end of the survey.
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CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected multiple residents
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Based on record review and staff interview the facility failed to meet professional standards of practice in providing the medical needs of the resident. Resident #11's physician was not notified of...
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Based on record review and staff interview the facility failed to meet professional standards of practice in providing the medical needs of the resident. Resident #11's physician was not notified of a weight gain as directed by the physicians orders. For Resident #4 and Resident #41 neurological checks were not performed as required following falls. This was true for three (3) of 26 sampled residents. Resident Identifiers: # 11, #4, #41. Facility Census: 48
Findings Included:
a) Resident #11
Resident #11 has a history of Congestive Heart Failure. There is a Physicians order to weigh the resident daily and call the Physician if the weight gain is greater than three (3) pounds in 24 hours.
There were four (4) instances that the Residents' weight reflected a gain of three (3) or more pounds in 24 hours and the Physician was not notified.
The following dates indicated the weight gain and need to notify the physician.
On 3/30/22 he weighed 224.6 pounds and on 3/31/22 he weighed 227.8 pounds indicating a 3.2 pound weight gain in 24 hours. Weighed by Certified Nursing Assistant (CNA) #70.
On 4/06/22 he weighed 222.6 pounds and on 4/07/22 he weighed 226 pounds indicating a 3.4 pound weight gain in 24 hours. Weighed by Licensed Practical Nurse (LPN) #62.
On 7/01/22 he weighed 195.8 pounds and on 7/03/22 he weighed 204 pounds indicating a 8.2 pound weight gain in two (2) days. Documentation indicates the Resident had refused to be weighed on 7/02/22. Weighed by LPN #40.
On 9/05/22 he weighed 185.6 pounds and on 9/06/22 he weighed 192 pounds indicating a 6.4 pound weight gain in 24 hours. Weighed by CNA #49.
According to the Director of Nursing (DON) it is the responsibility of the staff that weighs the Resident to notify the Physician. All of the above information was confirmed with the DON on 09/20/22 at 2:08 PM.
b) Resident #4
A review of the Policy: Neurological Evaluation, dated 02/08/22, showed the policy should be used in cases following a witnessed fall when resident has hit his/her head, following an unwitnessed fall and following a resident event that results in a known or suspected head injury. The policy procedure noted a baseline neurological evaluation was to be completed, after which, the facility was to complete the neurological evaluations every 30 minutes x (times) four (4), then every eight (8) hours x three (3) days or as directed by the physician.
An interview with Resident #4, on 09/19/22 at 12:49 PM, revealed the resident had a problem with falling and had fallen a few times hitting her head as Resident #4 showed the surveyor a heater that he/she had fallen against.
A review of the electronic medical record showed two incidents where Resident #4 was assessed as a fall in which he/she had hit his/her head. One incident, dated 05/04/22, which noted resident fell hitting head on heater and a second incident, dated 07/01/22, which noted resident fell hitting head.
A review of neurological evaluations for the 05/04/22 incident where the resident was known to hit the head, showed one (1) neurological (neuro) check on 05/04/22 and one neuro check on 05/06/22.
A review of the neurological evaluations for the 07/01/22 incident where the resident was known to hit the head, showed missing neuro checks.
An interview with the Director of Nursing (DON), on 09/21/22 at 03:04 PM, verified the neuro checks had been missed for Resident #4 for both fall incidents
c) Resident #41
A review of the Policy: Neurological Evaluation, dated 02/08/22, showed the policy should be used in cases following a witnessed fall when resident has hit his/her head, following an unwitnessed fall and following a resident event that results in a known or suspected head injury. The policy procedure noted a baseline neurological evaluation was to be completed, after which, the facility was to complete the neurological evaluations every 30 minutes x (times) four (4), then every eight (8) hours x three (3) days or as directed by the physician.
A review of the electronic medical record for Resident #41, showed incidents on 05/09/22 and 08/16/22 where the resident was found on the floor and the fall was identified as being unwitnessed.
A review of the neurological evaluations for the 05/09/22 incident, which occurred at 10:00 AM, where the resident's fall was unwitnessed, showed neuro checks had not been completed every eight (8) hours after the initial 30 minute checks. There were missing neuro checks for 05/10/22 and 05/11/22, with no entries noted for 05/12/22.
A review of the neurological evaluations for the 08/16/22 incident, which occurred at 07:10 PM, where the resident's fall was unwitnessed, showed missing neuro checks. On 08/18/22, only one entry was noted for neuro check evaluations.
An interview with the DON, on 09/21/22 at 03:04 PM, confirmed neuro checks were to be completed with the initial checks every four (4) hours and proceed to every eight (8) hours checks after that for three (3) days. In a further discussion at this time, the DON verified the neuro checks for Resident had not been completed according to facility policy and were incomplete for the incident follow-up assessment period.
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CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected multiple residents
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Based on observation, policy review and staff interview the facility failed to store food in accordance with professional standards for food safety. The facility failed to label and date food items ...
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Based on observation, policy review and staff interview the facility failed to store food in accordance with professional standards for food safety. The facility failed to label and date food items that were open and failed to dispose of expired food items. The facility also failed to maintain an accurate dishwasher and resident refrigerator temperature log. The facility also stores other food in the resident's refrigerator. This failed practice had the potential to affect more than a limited number of residents currently receiving nourishment from the facility's kitchen and the Resident's refrigerator. Facility Census: 48
Findings Included:
a) Walk-in Freezer
A review of a facility policy titled date marking-food and nutrition with a revision date of 05/03/22 found the following.
Procedure:
.2 a 1) The date/time the original container is opened
2) The date or day by which the food shall be consumed on the premised, or discarded.
An initial tour of the kitchen with the Nutrition and Food Service Supervisor (NFSS) beginning on 9/19/22 at 11:25 AM the walk-in refrigerator revealed the following issues:
-An opened gallon of Ranch dressing no open date
-An opened gallon of Mustard no open date
-An opened gallon of Italian dressing no open date
-A open container of cottage cheese no open date
-A storage container of Tomato Soup dated 09/09/22 no use by date (UBD)
-A storage container of potatoes dated 09/13/22 no UBD
-A storage container of applesauce dated 09/10 no UBD
-A storage container of chicken noodle soup dated 09/16/22 a UBD 09/18/22
-A storage container of pea salad dated 09/15/22 USB 09/16/22
-A storage container of coleslaw dated 09/11/22 UBD 09/13/22
-A opened gallon of skim milk with manufacture stamped use by date 09/16/22
The Dietary Manager acknowledged the failure to label food items with a Date Opened and/or Use by Date. Also indicated the item needed to be discarded because they were out of date or not dated.
b) Walk in Freezer:
An initial tour of the kitchen with the Nutrition and Food Service Supervisor (NFSS) beginning on 9/19/22 at 11:25 AM the walk-in freezer revealed the following issues:
-A bag of opened corn with no open date
-A pan with foil with no label or date the NFSS stated I think its cake.
The Dietary Manager acknowledged the failure to label food items with a Date Opened and/or Use by Date. Also indicated the item needed to be discarded because they were out of date or not dated.
c) Dishwasher Temperature log
An initial tour of the kitchen with the Nutrition and Food Service Supervisor (NFSS) beginning on 9/19/22 at 11:25 AM the reveal the dishwasher temperature log was void temperatures on the following dates and times:
-On 09/08/22, Morning
-On 09/10/22, Morning
-On 09/12/22, Evening
-On 09/16/22, Noon and Evening
-On 09/17/22, Noon and Evening
-On 09/18/22, Noon and Evening
The NFSS acknowledged the dishwasher temperature log was void of temperatures on different shifts.
d) Resident's Refrigerator in the Activity Room
A review of a facility policy titled Safe Handling of Personal Food, Outside Food-Food and Nutrition with a revision date of 05/16/22 found the following.
.Policy . Personal food is stored separate from the location's food.
An observation on 09/19/22 at 2:00 PM found a refrigerator in the activity room with a sign stating Resident's refrigerator, please label and date food.
During an interview on 09/20/22 at 12:00 PM Activity Assistant #64 stated this is the resident's refrigerator, it stores their pop and food. The resident's items were dated and labeled correctly.
This refrigerator also contained:
-opened bottle sno cone flavoring
-two (2) opened jars of jelly
-an opened bottle of ketchup
-an opened bottle of salad dressing
-drink mixes
The resident freezer had the follow issues:
-an opened bag of flour
-an opened bag of cornmeal,
-two bags ramps
-an opened container of ice cream.
The AA # 64 stated all of those things belong to the Activity department. We store our items in the Resident's refrigerator, because we don't have one.
An interview on 06/20/22 at 12:22 pm the NFSS stated I did not know they were storing other things in with Residents'. I will discard the items and let the Activity Director know they need a separate refrigerator for activity items.
e) Resident Refrigerator temperature log
A review of a facility policy titled Safe Handling of Personal Food, Outside Food- Food and Nutrition with a revision date of 05/16/22 found the following.
.Employees monitor temperature of the refrigerated units to ensure that food is kept at 41 degrees Fahrenheit or below
An observation on 09/26/22 at 1:15 PM revealed the Resident's refrigerator temperate log was void refrigerator and freezer temperatures on the following days:
-On 09/03/22
-On 09/04/22
-On 09/26/22
During an interview on 09/26/22 at 1:21 PM Activity Director acknowledged refrigerator temperature log were void temperatures.
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May 2021
5 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Incontinence Care
(Tag F0690)
Could have caused harm · This affected 1 resident
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Based on observation and staff interview, the facility failed to ensure a resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary track infections to th...
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Based on observation and staff interview, the facility failed to ensure a resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary track infections to the extent possible. This finding was a random opportunity for discovery. Resident identifiers: #13 and #14. Facility census: 44.
Findings included:
a) Resident #13
On 05/24/21 at 11:40 AM and again at 2:00 PM, Resident #13's catheter bag and tubing was observed touching the floor, by the surveyor.
On 05/24/21 at 4:20 PM, Resident #13's catheter bag and tubing was observed touching the floor.
At 4:25 PM on 05/25/21, Registered Nurse (RN) #62, agreed the catheter bags and tubing were touching the floor.
b) Resident #14
On 05/25/21 at 4:23 PM, Resident #14's catheter bag and tubing was observed touching the floor.
At 4:25 PM on 05/25/21, RN #62, agreed the catheter bags and tubing were touching the floor.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected 1 resident
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Based on observation and staff interview, the facility failed to ensure medications were stored and labeled in accordance with currently accepted professional standards. A bottle of Potassium Suspen...
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Based on observation and staff interview, the facility failed to ensure medications were stored and labeled in accordance with currently accepted professional standards. A bottle of Potassium Suspension for Resident #32 was not dated when opened. This was a random opportunity for discovery. Resident identifier: #32. Facility census: 44
Findings included:
a) Observation
On 05/25/21 at 10:10 AM, an observation was made of an opened bottle of Potassium 20 meq (milliequivalent)/15 ml (milliter) solution stored in the 200 hall medication cart for Resident #32 that was not dated when opened. The pharmacy label indicated the bottle was sent from the pharmacy on 05/16/21 with an expiration date of 08/31/22. Licensed Practical Nurse (LPN) #27 verified the bottled was not dated when opened.
b) Interview
During an interview on 5/26/21 at 10:42 AM the Interim Director of Nursing (IDON) agreed and verified the bottle of Potassium Suspension medication for Resident #32 should have been dated when opened.
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CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected multiple residents
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Based on observation, staff interview, and record review, the facility failed to provide an environment that is free from accident hazards over which the facility had control. Laryngectomy care prod...
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Based on observation, staff interview, and record review, the facility failed to provide an environment that is free from accident hazards over which the facility had control. Laryngectomy care products were found within Resident #3's room inappropriately stored with the potential of accidental consumption or exposure to other residents. This was a random opportunity for discovery. This failed practice had the potential to affect more than a limited number of Residents residing at the facility. Resident identifiers: R #3, R #25, R #44, R #8, R #27, R #30, R #16, R #19, R #147. Facility census: 44.
Findings included:
a) Observation
During observation of Laryngectomy stoma care on 05/24/21 at 10:40 AM, an opened 32 oz. bottle of Swan (brand) Hydrogen Peroxide 3% was observed to be setting on Resident #3's dresser by the doorway of the Resident's room. Licensed Practical Nurse (LPN) # 50 was asked if she brought the bottle of Hydrogen Peroxide into the room, and the LPN stated, No that was already in here, I guess they leave it here since we use it so much. The hydrogen peroxide had a flip top lip and was full of the product. The bottle was positioned on the corner of the dresser closest to the room door, easily visible and assessable to anyone passing by the Residents room.
The Swan (brand) Hydrogen Peroxide bottle contained a warning label that stated: Warning: for external use only. Do not use in the eyes or apply over large areas of the body. Keep out of reach of children. If swallowed, get medical help or contact poison control right away. The label also indicated to keep tightly closed and at controlled room temperature. Do Not shake bottle and hold away from face when opening.
b) Staff Interview
At 10:50 AM, the Administrator observed the Hydrogen Peroxide and dressing supplies (spilt sponges, suction catheter tray, 3M medical tape) stored on Resident #3 dresser and stated, No none of this should be in stored in here, especially that (Hydrogen Peroxide), this isn't a med (medication) storage room. The Administrator then instructed the staff to dispose of all the items and get the room 'cleaned up'.
c) Record Review
In addition to Resident #3, wandering Residents with potential for accidental exposure to the Hydrogen Peroxide were provided by the Administrator as follows: R #25, R #44, R #8, R #27, R #30, R #16, R #19, R #147.
Review of the Resident #3's orders indicated the Hydrogen Peroxide was used daily and as needed for the care of the Provox Larytube (a flexible silicone tube designed to maintain the stoma after laryngectomy surgery) as a disinfecting agent.
The Safety Data Sheet (SDS) for Swan 3% Hydrogen Peroxide (revision date January 8, 2020) stated in the case of Ingestion to rinse mouth immediately and drink plenty of water. Do not induce vomiting. Call a physician immediately. The SDS also indicated to avoid all potential to eyes and if accidental exposure occurs to rinse eyes immediately with plenty of water, also under the eyelids, for at least 15 minutes and seek immediate medical attention.
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CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0692
(Tag F0692)
Could have caused harm · This affected multiple residents
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b-2) Resident #19
On 05/26/21 at 8:59 AM, an observation was made of Resident #19 with no water at the bedside within reach of the resident. The Resident's bedside table was pushed up against the ...
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b-2) Resident #19
On 05/26/21 at 8:59 AM, an observation was made of Resident #19 with no water at the bedside within reach of the resident. The Resident's bedside table was pushed up against the wall at the room door with the blue water pitcher setting on it. RN #62 verified the Resident could have helped herself and was able to consume a drink at her own will without assistance if she had the cup within reach.
A record review indicated the resident was not on fluid restrictions at that time. The Interim Director of Nursing confirmed the Resident was not ordered to be under fluid restrictions and should have water available at the bedside.
c) Resident #21
During an observation of the mediation pass on 5/25/21 at 8:42 AM, Resident #21 was heard yelling out to RN #62 for her to get him some water. Another wandering Resident (R #25) entered Residents room propelling in a wheelchair and Resident #21 also asked that Resident to hand him his water. Resident #21 was laying in bed unable to reach water that was on dresser against the wall. No form of hydration was available for the resident at his bedside. Licensed Practical Nurse (LPN) #27 entered Resident #21's room, removed the wandering Resident and handed Resident #21 his water pitcher. Resident #21 proceeded to take a drink of water.
A record review indicated the Resident was not on any fluid restrictions. The Interim Director of Nursing (IDON) confirmed the resident was not ordered to be under fluid restrictions and should have water available at the bedside.
d) Resident #10
On 05/25/21 at 8:56 AM, observation was made of Resident #10 without any water available at bedside or within reach of the resident. The Resident's blue water pitcher was setting across the room on the dresser. RN #62 verified the Resident #10 was able to consume a drink of water at will without assistance if the cup was within reach.
Record Review indicated the resident was not on any fluid restrictions. The IDON confirmed the resident had no order for fluid restrictions and should have water available at the bedside.
e) Resident #22
During the initial screening of the Long Term Survey Process on 05/24/21 at 11:57 AM, Resident #22's voice was noted to be raspy and the resident had dry lips. The resident stated he was having a problem talking due to his dry mouth. The Resident's water pitcher was empty, and no other form of hydration was available. At that time LPN #57 got ice water for the Resident. The Resident #22 then proceeded to immediately take a drink.
A record review indicated the resident was not on any fluid restrictions. The IDON confirmed the resident was not ordered to be under fluid restrictions and should have water available at the bedside.
Based on observation, staff interview and record review, the facility failed to offer a therapeutic diet when there is a nutritional problem with residents, and failed to offer sufficient fluid intake to residents. This was true for five (5) of five (5) residents reviewed for nutrition. Resident identifiers: #16, #19, #21, #10 and #22. Facility census: 44.
Findings included:
a) Resident #16
With Resident #16 having diagnoses of dementia and weight loss, the Dietician #79, made a recommendation on 05/13/21 to increase Two-cal from one (1) time a day, to two (2) times a day.
A review of the medical records on 05/26/21 found no evidence the Two-cal was increased as recommended by the Dietitian.
On 05/26/21 at 10:35 AM, the Dietary Manager explained she had no order to increase the Two-cal for Resident #16.
b-1) Resident #19
Resident #19 medical diagnoses included dementia and weight loss. On 05/10/21 the Dietician #79, made a recommendation to increase Glucerna 120 milliliters (ml) one (1) time a day, to Glucerna 120 ml two (2) times a day.
A review of the medical record on 05/25/21 found no evidence the Glucerna was increased as recommended by the Dietitian.
On 05/25/21 at 3:30 PM, the Dietician #79 confirmed the recommendation to increase the Glucerna should have been reviewed by the physician and the expectation was for the dietary supplement to be increased.
On 05/25/21 at 3:30 PM the Dietary Manager expressed an order had not been recieved to increase the Glucerna from one (1) time a day to two (2) times a day.
On 05/26/21 at 10: 45 AM the interim director of nursing (IDON) acknowledged there is a problem with how the Dietician recommendations were being sent to the physician and the Dietary Manager and the facility was in the process of correcting the problem.
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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 and staff interview, the facility failed to ensure staff followed hand hygiene practices consistent with accepted standards of practice to prevent the spread of infections. This p...
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Based on observation and staff interview, the facility failed to ensure staff followed hand hygiene practices consistent with accepted standards of practice to prevent the spread of infections. This practice was found during a random opportunity for discovery and had the potential to affect more than an isolated number of residents. Facility Census 45.
Findings included:
a) Kitchen Dish room
On 05/25/21 at 8:39 AM, while observing dish machine temperatures, Dietary Aide (DA) #12 was observed doing dishes on the dirty side of the dish machine. When asked who puts away clean dishes, DA #12 stated that she does.
When asked how do you sanitize your hands between touching the clean and dirty dishes, DA #12 stated that she washed her hands in the Clorox bucket that contained dirty utensils.
The Dietary Manager (DM) was asked to come to the dish room to observe the process of washing hands in Clorox water that contained dirty utensils. The DM stated, I was not aware that is how the staff were sanitizing hands between dirty and clean dishes. DM also stated, I will in service all staff on the proper procedure of hand washing between dirty and clean dishes while using the dish machine.
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Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated
K - Pattern
L - Widespread
Actual Harm
G - Isolated
H - Pattern
I - Widespread
Potential for Harm
D - Isolated
E - Pattern
F - Widespread
No Harm (Minor)
A - Isolated
B - Pattern
C - Widespread
Questions to Ask on Your Visit
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • No major safety red flags. No abuse findings, life-threatening violations, or SFF status.
- • No fines on record. Clean compliance history, better than most West Virginia facilities.
Concerns
- • 50 deficiencies on record. Higher than average. Multiple issues found across inspections.
- • Grade C (50/100). Below average facility with significant concerns.
Bottom line: Mixed indicators with Trust Score of 50/100. Visit in person and ask pointed questions.
✓ Report will be sent to your email
About This Facility
What is Tygart Valley Health & Rehabilitation's CMS Rating?
CMS assigns TYGART VALLEY HEALTH & REHABILITATION an overall rating of 2 out of 5 stars, which is considered below average nationally. Within West Virginia, this rating places the facility higher than 0% of the state's 100 nursing homes. A rating at this level reflects concerns identified through health inspections, staffing assessments, or quality measures that families should carefully consider.
How is Tygart Valley Health & Rehabilitation Staffed?
CMS rates TYGART VALLEY HEALTH & REHABILITATION's staffing level at 2 out of 5 stars, which is below average compared to other nursing homes. Staff turnover is 49%, compared to the West Virginia average of 46%.
What Have Inspectors Found at Tygart Valley Health & Rehabilitation?
State health inspectors documented 50 deficiencies at TYGART VALLEY HEALTH & REHABILITATION during 2021 to 2024. These included: 50 with potential for harm.
Who Owns and Operates Tygart Valley Health & Rehabilitation?
TYGART VALLEY HEALTH & REHABILITATION is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility is operated by HILL VALLEY HEALTHCARE, a chain that manages multiple nursing homes. With 60 certified beds and approximately 55 residents (about 92% occupancy), it is a smaller facility located in BELINGTON, West Virginia.
How Does Tygart Valley Health & Rehabilitation Compare to Other West Virginia Nursing Homes?
Compared to the 100 nursing homes in West Virginia, TYGART VALLEY HEALTH & REHABILITATION's overall rating (2 stars) is below the state average of 2.7, staff turnover (49%) is near the state average of 46%, and health inspection rating (2 stars) is below the national benchmark.
What Should Families Ask When Visiting Tygart Valley Health & Rehabilitation?
Based on this facility's data, families visiting should ask: "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?" "Can I speak with family members of current residents about their experience?" These questions are particularly relevant given the below-average staffing rating.
Is Tygart Valley Health & Rehabilitation Safe?
Based on CMS inspection data, TYGART VALLEY HEALTH & REHABILITATION has a clean safety record: no substantiated abuse findings (meaning no confirmed cases of resident harm), no Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death), and is not on the Special Focus Facility watch list (a federal program monitoring the lowest-performing 1% of nursing homes). The facility has a 2-star overall rating and ranks #100 of 100 nursing homes in West 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 Tygart Valley Health & Rehabilitation Stick Around?
TYGART VALLEY HEALTH & REHABILITATION has a staff turnover rate of 49%, which is about average for West Virginia nursing homes (state average: 46%). Moderate turnover is common in nursing homes, but families should still ask about staff tenure and how the facility maintains care continuity when employees leave.
Was Tygart Valley Health & Rehabilitation Ever Fined?
TYGART VALLEY HEALTH & REHABILITATION 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 Tygart Valley Health & Rehabilitation on Any Federal Watch List?
TYGART VALLEY HEALTH & REHABILITATION is not on any federal watch list. The most significant is the Special Focus Facility (SFF) program, which identifies the bottom 1% of nursing homes nationally based on persistent, serious quality problems. Not being on this list means the facility has avoided the pattern of deficiencies that triggers enhanced federal oversight. This is a positive indicator, though families should still review the facility's inspection history directly.