BERKELEY SPRINGS HEALTHCARE CENTER
For profit - Corporation
120 Beds
COMMUNICARE HEALTH
Data: November 2025
1 Immediate Jeopardy citation
Trust Grade
36/100
#63 of 122 in WV
Photo by Berkeley Springs Healthcare Center
Photo by Berkeley Springs Healthcare Center
Photo by Berkeley Springs Healthcare Center
1 / 5 photos
Last Inspection: March 2025
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
Berkeley Springs Healthcare Center has received a Trust Grade of F, indicating significant concerns about the quality of care provided. Ranking #63 out of 122 facilities in West Virginia places it in the bottom half, and it is the second of two options in Morgan County, suggesting limited choices for families. The facility's trend is improving, with a reduction in issues from 26 in 2023 to 13 in 2025, which is a positive sign. Staffing is average with a rating of 3 out of 5 stars, and while the turnover rate is at 44%, it aligns with the state average. However, the center has incurred $15,593 in fines, which raises concerns about compliance. In terms of RN coverage, the facility has more registered nurses than 83% of other West Virginia facilities, which is beneficial for resident care. Unfortunately, there have been critical incidents, such as a resident not being properly positioned during enteral feeding, which could lead to severe complications. Additionally, there were concerns about the personal hygiene of residents, as some were found with unkempt appearances and inadequate bathing. Overall, while there are strengths in staffing and improving trends, the facility has serious weaknesses that families should consider.
- Trust Score
- F
- In West Virginia
- #63/122
- Safety Record
- High Risk
- Inspections
- Getting Better
- Staff Stability ○ Average
- 44% turnover. Near West Virginia's 48% average. Typical for the industry.
- Penalties ○ Average
- $15,593 in fines. Higher than 55% of West Virginia facilities. Some compliance issues.
- Skilled Nurses ✓ Good
- Each resident gets 46 minutes of Registered Nurse (RN) attention daily — more than average for West Virginia. RNs are trained to catch health problems early.
- Violations ⚠ Watch
- 51 deficiencies on record. Higher than average. Multiple issues found across inspections.
36/100
Bottom 49%
Review needed
26 → 13 violations
★★☆☆☆
2.0
Overall Rating
★★★☆☆
3.0
Staff Levels
★★★★☆
4.0
Care Quality
★★☆☆☆
2.0
Inspection Score
↔
Stable
2023: 26 issues
2025: 13 issues
The Good
-
4-Star Quality Measures · Strong clinical quality outcomes
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
-
Staff turnover below average (44%)
4 points below West Virginia average of 48%
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: 44%
Near West Virginia avg (46%)
Typical for the industry
Federal Fines: $15,593
Below median ($33,413)
Minor penalties assessed
Chain: COMMUNICARE HEALTH
Part of a multi-facility chain
Ask about local staffing decisions and management
The Ugly 51 deficiencies on record
1 life-threatening
Mar 2025
13 deficiencies
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
Based on staff interview and documentation review the facility failed to implement the Abuse / Neglect policy of reported incidents of abuse to the appropriate agencies. Resident identifier: #31. Faci...
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Based on staff interview and documentation review the facility failed to implement the Abuse / Neglect policy of reported incidents of abuse to the appropriate agencies. Resident identifier: #31. Facility census: 99.
Findings included:
a) Resident #31
Review of an incident report for Resident #31 dated 08/22/24 revealed an incident of abuse by staff was reported to the Nurse Aide Registry and Adult Protective Services with no evidence that the incident was reported to Office of Health Facility Licensure and Certification (OHFLAC).
A review of the facility form titled Policies and Standard Procedures, Subject: [NAME] Virginia Abuse, Neglect and Misappropriation revealed the following:
Page 13, number two (2.) A Suspected Abuse (c.) The Executive Director, Director of Nursing, or designee will report immediately to the appropriate agencies, and document the time and date of that report on the investigation form.
Page 15, number VII. Reporting of Incidents and Facility Response. Number two (2.) The Executive Director/designee will report appropriate incidents to Office of Health Facility Licensure and Certification (OHFLAC), Adult Protective Services (APS), the Regional Ombudsman, and other local authorities, including but not limited to local law enforcement (if appropriate), as required by State law.
c) During an interview with the Facility Administrator on 3/26/25 at approximately 3:30 PM regarding incident reported filed on 08/22/24. He acknowledged that he did not report to OHFLAC because he had reported the incident to the Nurse Aide Registry, and he did not believe that he had to report to both.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
PASARR Coordination
(Tag F0644)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews, the facility failed to ensure that the resident's newly mental disorder was referre...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews, the facility failed to ensure that the resident's newly mental disorder was referred to the appropriate state-designated authority for review or one (1) of three (3) residents reviewed for the category of PASARR, during the long-term care survey. Resident identifier: #49. Facility census: 99.
Findings include:
a) Resident #49.
A Review of Resident #49's medical record revealed a physician's order:
--Risperidone 2 MG one time a day for schizophrenia.
On 03/25/25, a record review of the resident's electronic medical record (EMR), the resident's most recent PAS, dated 09/02/20, indicated no level II not required. Section lll #30 MI/MR Assessment indicated current diagnosis of Major Depression.
The record also revealed the resident had a diagnosis of schizophrenia on admission [DATE] but did not receive a new PAS to address whether specialized services were needed.
An interview on 03/26/25 at 12:30 PM with the Regional Director of Operations verified
Resident #49's PAS did not reveal his diagnosis of schizophrenia and confirmed a new PAS was not completed.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
Based on record review and staff interview, the facility failed to have a comprehensive and individualized care plan in discharge planning for one (1) of 28 residents reviewed in the Long-Term Care Su...
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Based on record review and staff interview, the facility failed to have a comprehensive and individualized care plan in discharge planning for one (1) of 28 residents reviewed in the Long-Term Care Survey Process. Resident identifier: 98. Facility census: 99.
Findings included:
a) Resident #98
During a record review, completed on 03/26/25 at 10:18 PM, the following details were identified:
-A Pre-admission Screening (PAS), dated 10/09/24, reflected Resident #98's expected length of stay was less than three (3) months.
-A physician encounter note, dated 10/09/24, stated, Prior to her ground-level fall the patient had been dwelling with her husband at the [Name of Facility] memory unit and she had been ambulatory with some assistance.
-An Activities Progress Note, dated 10/10/24 at 12:28 PM, stated, She is here for short term rehab and goal to return to [Name of Assisted Living Facility] where she resides on their Memory Unit.
-A social service note, dated 12/23/24 at 2:39 PM, stated that the Director of Social Work (DOSW) had spoken to staff at the assisted living facility and discussed what information the assisted living facility would need to assess if they could accommodate resident's needs in their facility. The Director of Social Work completed her section of the necessary information and then passed the form on to nursing to complete the necessary medical details.
During an interview, on 03/27/25 at 10:40 AM, the DOSW reviewed Resident #98's care plan and did not find evidence that the care plan reflected discharge goals. DOSW stated she would look at the situation closer and get back to Surveyor after attending a care plan meeting. No further information was given prior to the end of the survey.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0658
(Tag F0658)
Could have caused harm · This affected 1 resident
Based on record review and staff interviews, the facility failed to ensure Professional standards care and services were provided according to accepted standards of clinical practice in regard to medi...
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Based on record review and staff interviews, the facility failed to ensure Professional standards care and services were provided according to accepted standards of clinical practice in regard to medications left at bedside. This practice has the potential to affect a limited number of residents. Resident identifier: #79. Facility census: 99.
An observation on 03/26/25 at 8:08 AM found, Resident #79 taking medications from a medication cup, unattended.
During an interview on 03/26/25 at 8:10 AM, Licensed Practical Nurse (LPN) #59 verified, she should not have left the room before Resident 49 took her medication.
Medical record review revealed Resident #49 did not have physician's order for medication self-administration.
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
Based on record review and staff interview, the facility failed to follow a physician's order for administration of an antibiotic. This was true for one (1) of five (5) residents reviewed under the un...
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Based on record review and staff interview, the facility failed to follow a physician's order for administration of an antibiotic. This was true for one (1) of five (5) residents reviewed under the unnecessary medications pathway. Resident identifier: #32. Facility census: 99.
Findings included:
a) Resident #32
A record review, completed on 03/25/25 at 3:40 PM, found a physician order for Amoxicillin-Pot Clavulanate tablet 875-125 MG. The order directed, give one (1) tablet by mouth every 12 hours for bacterial infection - PNA [pneumonia] for seven (7) days.
A review of the February 2025 Medication Administration Record (MAR) revealed Resident #32 began taking the antibiotic on 02/08/25 and the resident only received 12 of the 14 ordered doses:
-02/08/24 at 8:00 AM
-02/08/25 at 8:00 PM
-02/09/25 at 8:00 AM
-02/09/25 at 8:00 PM
-02/10/25 at 8:00 AM
-02/10/25 at 8:00 PM
-02/11/25 at 8:00 AM
-02/11/25 at 8:00 PM
-02/12/25 at 8:00 AM
-02/12/25 at 8:00 PM
-02/13/25 at 8:00 AM
-02/13/25 at 8:00 PM
-03/09/23 at 8:00 AM
The Medication Administration Record (MAR) provided no evidence Resident #32 received the full ordered course of the antibiotic. Further record review revealed the medical record lacked evidence that the physician had been contacted about the missed doses.
During an interview on 03/26/25 at 10:05 AM, the Director of Nursing (DON) reported Resident #32 had not finished the full 14 doses of the antibiotic and that the physician's order had not been followed correctly.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Staffing Information
(Tag F0732)
Could have caused harm · This affected 1 resident
Based on observation and staff interview, the facility failed to post an updated staffing report sheet for 03/24/25. This was a random opportunity for discovery. Facility census: 99.
Findings include...
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Based on observation and staff interview, the facility failed to post an updated staffing report sheet for 03/24/25. This was a random opportunity for discovery. Facility census: 99.
Findings included:
a) Nurse Staffing Information
On 03/03/25 at 12:56 PM, upon entrance to the facility, the facility census on the posted daily staffing report sheet had not been updated that morning. The daily staffing report sheet stated the facility census was 98 which was not accurate. The correct census was 99.
b) Administrator Interview
On 03/24/25 at 12:51 PM, in an interview with the Administrator, he acknowledged that the Daily Staffing report sheet posted the census was incorrect at 98. A resident had been admitted the previous evening. The system updates everyday between 10am and 12 PM the posted report was not updated until after surveyors arrived.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0806
(Tag F0806)
Could have caused harm · This affected 1 resident
Based on resident interview, record review, and staff interview, the facility failed to accommodate resident food preferences. This was true for one (1) of 28 residents reviewed in the Long-Term Care ...
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Based on resident interview, record review, and staff interview, the facility failed to accommodate resident food preferences. This was true for one (1) of 28 residents reviewed in the Long-Term Care Survey Process. Resident identifier: 19. Facility census: 99.
Findings included:
a) Resident #19
During an interview on 03/25/25 at 11:03 AM, Resident #19 reported he disliked fish, and it was listed as a dislike in his dietary record. The resident reported he was served fried fish on 03/10/25 and 03/24/25. The resident then showed Surveyor pictures of the fried fish on his tray beside his tray tickets for 03/10/25 and 03/24/25.
During a medical record review, completed on 03/25/25 at 7:30 PM, the Diet History / Food Preferences assessment reflected resident disliked fish.
On 03/26/25 at 8:40 AM, the Culinary Director confirmed that Resident #19 was erroneously served fried fish on 03/10/25 and 03/24/25. The Culinary Director stated it had been an oversight and immediately revised resident's dislike information to prevent the error from occurring again.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Garbage Disposal
(Tag F0814)
Could have caused harm · This affected 1 resident
Based on observation and staff interview the facility failed to store garbage and kitchen refuse in a proper manner. Facility Census 99.
Findings included:
a) On 03/25/25 at 2:30 PM a tour of the outs...
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Based on observation and staff interview the facility failed to store garbage and kitchen refuse in a proper manner. Facility Census 99.
Findings included:
a) On 03/25/25 at 2:30 PM a tour of the outside of the facility revealed medical supplies and kitchen refuse in the parking lot and along grass area beside parking lot. (disposable plates, face masks, hair nets, gloves etc.).
On 03/25/25 at 2:50 PM during an interview with the Facility Administrator (FA), the FA acknowledged that there were medical supplies and kitchen trash outside of the facility in the parking lot and on the property. He reported that he would take care of it and hold an in-service with staff.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
Based on observation and staff interview, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment an...
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Based on observation and staff interview, the facility failed to establish and 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 with regards to the resident's personal products and unsanitary practices. This failed practice was a random opportunity of discovery. Resident identifier: #82.Facility census: 99.
Findings included:
a) Resident #82
During an interview with resident #82, on 03/24/25 at 3:34 PM, it was observed a geri-chair in her room had rips and holes in the plastic cover on both of the arm rests. Resident #82 stated she used that geri chair when going out to activities, dining room, and to the shower room.
In an interview with the Infection Prevention manager, on 03/25/25 at 3:50 PM, she acknowledged the geri-chair had holes and rips in the plastic arm pads and agreed the chair could not be cleaned to prevent infection. The chair was immediately removed from the room.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** f) room [ROOM NUMBER]
During a walk-through of the facility, completed on 03/24/25 at 1:00 PM, it was identified that room [ROOM...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** f) room [ROOM NUMBER]
During a walk-through of the facility, completed on 03/24/25 at 1:00 PM, it was identified that room [ROOM NUMBER] had window blinds that had slots that were broken and/or missing.
On 03/26/25 at 10:50 AM, LPN #71 verified one (1) blind slat was partially missing on the left, three (3) blinds slats were partially missing on the right side, and one (1) blind slat was missing altogether. LPN #71 agreed the blinds were not in good repair and did not afford visual privacy.
g) room [ROOM NUMBER]
During a walk-thru of the facility, completed on 03/24/25 at 1:00 PM, it was identified that room [ROOM NUMBER] had window blinds that were bent with dangling slats.
On 03/26/25 at 10:55 AM, LPN #71 was unable to lower the blinds in the room successfully. She confirmed the two (2) bottom window slats were bowing. LPN #71 agreed the blinds were not in good repair and did not afford visual privacy.
Based on observation and staff interview, the facility failed to provide a safe, clean, comfortable, and homelike environment for residents on the two (2) of four (4) hallways. Resident rooms affected were on the 100 and 300 halls. Room Numbers: #112, #114, #117, #301, #104, and #103. Resident identifier: #82. Facility census: 99.
Findings included:
a) room [ROOM NUMBER]
Upon survey entrance on 03/24/25 at 11:30AM, the following issues were observed in room [ROOM NUMBER]:
-black scuff marks on right wall inside the door
- window missing curtains,
- broken blinds
During a walk through with the Infection Prevention Manager, on 03/25/25 at 3:50 PM, she acknowledged the scuffs and black marks, missing curtains, and broken window blinds and stated she would make sure the room repair would be placed on the list with the maintenance department.
b) room [ROOM NUMBER]
Upon survey entrance, on 03/24/25 at 11:30AM, the following issues were observed in room [ROOM NUMBER]:
-rips and tears in the dry wall from the chair rail to the floor and chips in the wood of the chair rail behind head of resident's bed
- missing a Window curtain
- yellow stains on the floor behind the toilet and stains on the toilet seat.
- cracked bathroom caulking around the sink
- loose and hanging Baseboard trim on the back wall under the window
c) Resident #82
On 03/24/25 at 03:34 PM, during an interview with Resident # 82 She stated she would like to have a curtain for her window because it is hard to sleep during the day with no way to block out the sunlight. She stated she had asked for a curtain about a month ago, but hasn't gotten one yet.
During a walk through with the Infection Prevention Manager, on 03/25/25 at 3:50 PM, she acknowledged the loose baseboards missing curtains, bathroom floor stains and stained toilet seat, and cracked caulking around the bathroom sink and stated she would make sure the room repair would be placed on the list with the maintenance department.
d) room [ROOM NUMBER]
Upon survey entrance on 03/24/25 at 11:30AM, the following issues were observed in room [ROOM NUMBER]:
- broken window blinds
- missing window curtain
- loose and hanging baseboard trim on the left wall
e) room [ROOM NUMBER]
Upon survey entrance on 03/24/25 at 11:30AM, the following issues were observed in room [ROOM NUMBER]:
- black scuff marks and tears in the drywall behind resident's bed
During a walk through with the Infection Prevention Manager, on 03/25/25 at 3:50 PM, she acknowledged the scuffs and black marks as well as the tears in the drywall behind resident's bed and stated she would make sure the room repair would be placed on the list with the maintenance department.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** d) Resident #49
An observation of Resident #49 sitting in a resident sitting area 3/24/25 11:45 AM with disheveled oily hair.
A ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** d) Resident #49
An observation of Resident #49 sitting in a resident sitting area 3/24/25 11:45 AM with disheveled oily hair.
A second observation on 03/25/25 at 9:24 AM found Resident #49 with oily hair.
Medical record review revealed, Resident #49 shower schedule and preference are two (2) times weekly.
A continued review of Resident #49s ADL documentation found:
Two (2) showers given, one (1) bed bath, and no refusals documented in 30 days.
On 03/27/25 at 12:30 PM the Regional Director of Operations verified the facility could not provide any other documentation for Resident #49's showers.
Based on interviews, observation and review of documentation the facility failed to provide Activities of Daily Living (ADL) care for dependent residents in the area of bathing. This was true for four (4) of four (4) residents reviewed in this area. Resident identifiers: #66, #94, and #49. Facility census: 99.
Finding included:
a) Resident #66
On 03/24/25 at 01:33 PM an interview with Resident #66 revealed she bathed herself and would prefer to have someone bath her to wash her back and hair. Resident was observed to have unkempt hair.
On 03/26/25 at approximately 12:20 PM resident's shower log was reviewed from date of admission on [DATE] to 03/26/25 which revealed that resident had a Shower on 3/20/2025 2:15 PM. No further documentation was presented.
On 03/26/25 at 12:30 PM an interview with Director of Clinical Operations # 161 was conducted and she acknowledged that the facility had no further documentation to prove that resident had more showers than listed.
b) Resident #94
03/24/25 01:39 PM would prefer to have a shower at least one time per week. She reports that she had only been given one since her admission. Wants her head washed and said she had not been getting assistance with that and had been getting only bed baths. She had asked and been told she will be on the list but has not had one. She stated that her hair was dirty. Resident was observed to have uncombed, unkempt. oily hair.
On 03/26/25 at approximately 12:20 PM resident's shower log was reviewed from date of admission on [DATE] to 03/26/25 which revealed that resident had a Bed Bath on 3/10/2025 1:28 PM. No further documentation was presented.
On 03/26/25 at 12:30 PM an interview with Director of Clinical Operations # 161 was conducted and she acknowledged that the facility had no further documentation to prove that resident had more showers than listed.
c) Resident #86
During a brief interview of Resident #86 on 03/24/25 at approximately 3:11 PM, the resident was observed in a wheelchair. Resident #86 appeared unkempt, and her hair appeared greasy. Resident #86's Brief Interview for Mental Status (BIMS) revealed a score of 10. The resident stated that she had not been offered a shower. However, the resident was unable to state the date of her last shower.
Record review on 03/25/25 at approximately 2:45 PM revealed that the resident had not received showers or baths for the following periods:
02/11/24 to 02/23/24 - 12 days
03/11/25 to 03/23/25 - 12 days
A review of the shower log for Resident #86 on 03/25/25 at approximately 1:10 PM verified this finding:
02/03/25
13:59
Type Bath/Shower
Shower
02/06/25
12:19
Type Bath Shower
Bed Bath
02/10/25
13:21
Type Bath/Shower
Shower
02/13/25
13:14
Type Bath/Shower
Response Not Required
02/17/25
13:31
Type Bath/Shower
Response Not Required
02/20/25
13:42
Type Bath/Shower
Response Not Required
02/24/25
13:09
Type Bath/Shower
Refused
03/03/25
13:53
Type Bath Shower
Bed Bath
03/06/25
13:27
Type Bath Shower
Shower
03/10/25
13:59
Type Bath Shower
Bed Bath
03/13/25
13:59
Type Bath/Shower
Response Not Required
03/17/25
13:59
Type Bath/Shower
Response Not Required
03/20/25
13:24
Type Bath/Shower
Response Not Required
03/24/25
9:55
Type Bath Shower
Bed Bath
During an interview with the Director of Nursing (DON) on 03/25/25 at 3:52 PM, the DON stated that the documentation should state if the resident was not available or had refused a bath or shower.
DON confirmed that Response Not Required meant that no shower, or bath, had been performed.
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 resident interview and observation the facility failed to provide palatable, attractive, and appetizing food. This practice had the potential to affect more than an isolated number of residen...
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Based on resident interview and observation the facility failed to provide palatable, attractive, and appetizing food. This practice had the potential to affect more than an isolated number of residents who received their nutrition from the facility dietary department. Facility Census 99.
Findings included:
a) Resident #94
An interview was held with Resident #94 on 03/24/25 at 01:36 PM who reported the food is served cold and is not served in a timely manner.
On 03/25/25 at 12:50 PM a test tray temperature was measured after the last tray was served to residents in the facility. The serving temperatures we as follows:
Hamburger 104 degrees
Tator Tots 107 degrees
Pureed Vegetable Salad 33 degrees
Mixed fruit 30 degrees
Milk 33 degrees
Slaw 40 degrees
coffee 146 degrees
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected multiple residents
Based on observation, staff interview and policy review the facility failed store food and wear hair net in accordance with professional standards for food service. This practice had the potential to ...
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Based on observation, staff interview and policy review the facility failed store food and wear hair net in accordance with professional standards for food service. This practice had the potential to affect more than an isolated number of residents. Facility census: 99.
Finding included:
a) Upon initial tour of the kitchen on 03/24/25 at 12:00 PM, the following foods were found:
-Two (2), five (5) pound tubs of United Dairy Sour Cream dated Best By 03/05/25 in stand-up cooler.
-A box labeled crustables with random, unlabeled popsicles and no dates in walk in freezer.
-A zip lock bag containing eight (8) Sub Rolls labeled 12-11- 3-11-25 in the walk-in freezer.
-A container of prepared spaghetti for puree dated 8-6-2/6 in the walk-in freezer.
The Kitchen Account Manager (KAM) accompanied the initial tour on 03/24/25 at 12:00 PM and acknowledged these foods were not stored in accordance with professional standards. She stated that foods were usually thrown away after best by dates and that the popsicles were for staff use only for hydration.
On 03/26/25 a review of policy titled Healthcare Services Group Policy 019, Procedure number five (5.) stated All foods will be stored, wrapped or in covered containers, labeled and dated, and arranged in a manner to prevent cross contamination.
b)On 3/25/25 at 11:20 AM Culinary Aide # 95 observed with hair not properly contained in hair net. KAM acknowledged and asked staff to re-tuck her hair and replace her gloves.
On 03/26/25 a review of policy titled Healthcare Services Group Policy 024, Procedure number one (1.)
stated All staff members will have their hair off the shoulders, confined in a hair net or cap, and facial hair properly restrained.
Mar 2023
26 deficiencies
1 IJ
CRITICAL
(J)
Immediate Jeopardy (IJ) - the most serious Medicare violation
Tube Feeding
(Tag F0693)
Someone could have died · This affected 1 resident
.
Based on observation, record review, and staff interview, the facility failed to ensure a resident who received enteral feeding was provided that feeding in accordance with professional standards of...
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.
Based on observation, record review, and staff interview, the facility failed to ensure a resident who received enteral feeding was provided that feeding in accordance with professional standards of being in a semi-Fowler's position during the tube feeding administration. This deficient practice was identified in one (1) of one (1) resident reviewed who received enteral feedings. Resident identifier: Resident #41. Census: 102.
On 03/28/23 at 5:26 PM, the State Agency determined these failures placed Resident #41 and six (6) other residents receiving enteral feeding in an immediate jeopardy situation due to potential complications from improper positioning. On 03/28/23 at 5:27 PM, the State Agency notified the Nursing Home Administrator of the immediate jeopardy. The facility submitted a Plan of Correction (POC) on 03/28/23 at 6:51 PM. The State Agency requested changes and a revised POC was submitted at 8:14 PM. At 8:25 PM, the POC was accepted by the State Agency. The State Agency verified the POC was implemented by reviewing training and audit documentation and conducting staff interviews. The immediate jeopardy was abated at 10:34 AM on 03/29/23. Once the immediate jeopardy was abated, deficient practices remained and the scope and severity was decreased from a J to an D.
Findings included:
a) Resident #41
The facility's policy titled Enteral General Nutritional Guidelines with no implementation date on the policy defined bolus enteral feeding as delivered using a syringe or gravity that provides for a single dose or preparation delivered all at one time.
A review of physician's orders for Resident #41 showed an order for enteral feedings, Jevity 1.5 bolus, 247 ml, every four (4) hours, related to dysphagia following a cerebral Infarction, beginning 02/20/23. The resident had a gastrostomy tube (G-tube). The resident also had an order to flush the G-tube with at least 30 cc of water before and after feeding.
Further review of previous physician's orders revealed on 02/20/23, an order for Jevity 130 ml/hour for 12 hours a day was discontinued due to a history of aspiration pneumonia while the resident resided at the facility.
A record review noted on 11/29/22, Resident #41 was transferred to the hospital with a diagnosis of most likely aspiration pneumonia and returned 12/22/22. On 02/11/23, Resident #41 was transferred to the hospital for vomiting, crackles in the lungs, oxygen saturation of 93%, heart rate of 138, and clamminess. Resident #41 returned on 02/19/23 with a diagnosis of suspected aspiration for the second time.
Resident #41 also had an order related to the enteral feeding for the head of bed (HOB) to be elevated at least 30 degrees or higher while receiving enteral feeding. A sign was observed above the resident's bed which stated, REMINDER: Please keep resident in semi- fowler's position or higher while G-tube feeding infused and after flushes and medication administration. Semi-Fowlers 15 degrees to Fowlers 60 degrees.
On 03/28/23 at 3:45 PM, Licensed Practical Nurse (LPN) #116 was observed administering Resident #41's enteral feeding. LPN #116 checked the resident's G-tube for placement by aspiration and auscultation and flushed the tube with 30 cc of water without ensuring Resident #41 was positioned in a semi-Fowler's position. LPN #116 then began the feeding without ensuring Resident #41 was positioned in a semi-Fowler's position. The resident had slid down in bed. His head was on the lower edge of the pillow, and his torso was flat in bed. The resident's feet reached the foot board. The resident was repositioned after surveyor intervention.
Additionally, the enteral feeding was administered via an enteral feeding pump at 247 cc/hr for an hour instead of by bolus by syringe or gravity.
A staff interview with LPN #116 on 03/28/23 at 03:51 PM, revealed LPN #116 confirmed the resident did need to be repositioned prior to the feeding administration but failed to do so before surveyor intervention. LPN #116 also stated Resident #41's enteral feeding was administered by pump over an hour because the resident tended to grab at the nurse's hands when feeding was administered by bolus syringe.
On 03/28/23 at 8:14 PM, the facility submitted the following final Plan of Correction to abate the Immediate Jeopardy (typed as written):
1. The tube feeding for resident #41 was stopped and resident #41 repositioned according to physician order and the tube feeding was restarted.
a) Nurse #116 was educated on proper positioning and elevation of bed was completed on 03/28/23 6:00 p.m.
b) A Licensed Nurse has been placed at bedside during the tube feed and 1 hour after.
2. ADON and Unit Manager rounded on like patients.
a) [Resident #32]
b) [Resident #8]
c) [Resident #29]
d) [Resident #1]
e) [Resident #20]
3. Retraining and education will be provided to all Licensed Nurses and Certified Nurse Aides following proper policy and procedure for residents receiving tube feedings for proper positioning and elevation of bed.
a) Licensed Nurses and Certified Nurse Aides will be required to complete a test post education.
b) Education will be provided prior to start of next shift, 3/28/23 10:00 p.m. shift, for oncoming Licensed Nurses and Certified Nurse Aides.
c) Education will be completed by 4/4/23 with current staff any new staff will be educated during orientation afterwards.
4) Resident #41 will be observed every meal x 5 days, 2 meals per day for 5 days, then 1 meal per day for 5 days, and PRN afterwards by professional nurse for proper positioning to reduce potential aspiration risk.
a) Like residents identified will be audited daily for 1 meal x 5 days by nursing staff.
i) Duration will be reviewed after 5 days for continued auditing.
5) Education and audits will be submitted to QAPI for review weekly for the first 3 weeks and then PRN afterwards based on findings.
On 09/30/23 at 9:40 AM, the Director of Nursing (DON) stated the facility had no reference source to define semi-Fowler's positioning. The DON presented Internet research showing semi-Fowler's positioning was 30 degree elevation.
On 03/29/23, the Nurse Practitioner wrote an order to administer Resident #41's enteral feeding by pump infusion.
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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 and staff interview, the facility failed to ensure meal trays were delivered in a manner to protect and promote the rights of resident dignity by failing to serve roommates a me...
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Based on observation and staff interview, the facility failed to ensure meal trays were delivered in a manner to protect and promote the rights of resident dignity by failing to serve roommates a meal tray at the same time. This was based on a random opportunity for discovery and had the potential to affect a limited number of residents. Census: 102.
Findings included:
a) Resident #67
An observation of the tray delivery, on 03/27/23 at 12:38 PM, revealed Resident #67's roommate was served the noon meal and began eating. Resident #67 continued to wait on the meal tray for 27 minutes after the resident's roommate had been served and was eating.
On 03/27/23 at 01:04 PM, Resident #67's roommate had finished the tray when Nursing Assistant #61 served Resident #67 the meal tray.
An interview with the Director of Nursing (DON), on 03/28/23 at 01:14 PM , revealed it was facility policy to serve residents at the same time regardless of whether residents ate in the room or in the dining room and stated further it was a breach in a dignity standard that Resident #67 did not receive the meal tray when the roommate was served.
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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 record review and staff interview, the facility failed to ensure the resident's representative was notified when the resident had a change in condition. The resident representative was not ...
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Based on record review and staff interview, the facility failed to ensure the resident's representative was notified when the resident had a change in condition. The resident representative was not notified when the resident experienced weight loss for one (1) of three (3) residents reviewed for the care area of nutrition. Resident identifier: #85. Facility census: 102.
Findings included:
a) Resident #85
Review of Resident #85's medical records showed the resident weighed 175 pounds on 02/10/23. On 2/24/2023, Resident #85 weighed 144 pounds. The resident did not have capacity to make medical decisions. The medical records contained no documentation the resident's representative was notified regarding Resident #85's weight loss.
On 03/28/23 at 12:34 PM, the Director of Nursing (DON) presented a nursing note written on 3/6/2023 at 2:50 PM. The nursing note stated, Spoke with niece who was her care giver. Talked about resident having issues recently with vomiting after eating. Resident did not have a history of issues with vomiting. She said the vomiting started while in the hospital. Notified the NP [nurse practitioner] of these findings. Notified nurse to start the bowel protocol for no BM [bowel movement]. Niece notified of plan at this time. The DON stated the resident's representative had been notified regarding the resident's weight loss at this time, although the note did not explicitly state this. The DON acknowledged this nursing note was written ten (10) days after Resident #85's weight loss, and understood this would not be considered timely notification.
No further information was provided through the completion of the survey.
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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 record review and staff interviews, the facility failed to provide a notice of discharge to resident/representative a...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on record review and staff interviews, the facility failed to provide a notice of discharge to resident/representative and/or ombudsman for two (2) of two (2) residents reviewed for the category of hospitalization, during the long term care survey. Resident identifiers: #30 and #41. Facility census 102.
Findings Included:
a) Resident #30
On 03/28/2023 at 9:51 AM, discharge /transfer documentation was requested from the Administrator for resident #30 regarding recent hospitalization.
On 03/28/2023 at 12:22 PM, the administrator stated, I do not think anything was sent with the resident, in regards to discharge paperwork. He stated that they are still looking.
On 03/28/2023 at 12:50 PM, the Director of Nursing (DON) reviewed the medical record with the surveyor. The DON confirmed Resident #30 lacks capacity per capacity form dated 02/13/2023. An e-interact transfer form was located under the assessment tab, dated 03/26/2023, stating that the patient was notified of the transfer, not the Medical Power of Attorney (MPOA).
Record review also indicates that the residents most recent Brief Interview for Mental Status (BIMS) score was a five (5), indicating severe impairment.
On 03/28/2023 at 2:15 PM, the DON confirmed the incapacity determination on 02/13/2023 was the most recent capacity form completed for Resident #30. The DON confirmed she was unable to locate any new documentation about the resident's discharge/transfer notifications to the family.
b) Resident #41
Review of Resident #41's medical records showed the resident had a transfer to the hospital on [DATE], returning to the facility on [DATE]. The resident also had a transfer to the hospital on [DATE], returning to the facility on [DATE]. The resident did not have capacity to make medical decisions. The resident's representative was notified about the transfers to the hospitals. However, no discharge notices to the resident's representative for these hospitalizations could be located in the resident's medical record.
During an interview on 3/28/23 at 4:42 PM, the Director of Nursing (DON) confirmed no discharge notices were provided to Resident #41's representative for the resident's admissions to the hospital on [DATE] and 02/11/23. The DON also stated the ombudsman had not been notified about the resident's admissions to the hospital.
No further information was provided through the completion of the survey process.
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CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0625
(Tag F0625)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on record review and staff interviews, the facility failed to the resident/represenative of their bed hold policy for tw...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on record review and staff interviews, the facility failed to the resident/represenative of their bed hold policy for two (2) of two (2) residents reviewed for the category of hospitalization, during the long term care survey. Resident identifiers: #30 and #41. Census 102.
Findings Included:
a) Resident #30
On 03/28/2023 at 9:51 AM discharge /transfer documentation was requested from the Administrator for resident #30 regarding recent hospitalization.
On 03/28/2023 at 12:22 PM, the administrator stated, I do not think anything was sent with the resident. He stated that they are still looking.
Record review also indicates that the residents most recent Brief Interview for Mental Status (BIMS) score was a five (5), indicating severe impairment.
On 03/28/2023 at 2:15 PM, the Director of Nursing (DON) confirmed that the incapacity determination on 02/13/2023 was the most recent capacity form completed for resident #30. The DON stated she was unable to locate an information to indicate the Resident's responsible party was provided with a copy of the bed hold notice.
b) Resident #41
Review of Resident #41's medical records showed the resident had a transfer to the hospital on [DATE], returning to the facility on [DATE]. The resident also had a transfer to the hospital on [DATE], returning to the facility on [DATE]. The resident did not have capacity to make medical decisions. The medical records contained no documentation the resident representative was notified regarding bed hold policy, including reserve payment, for these hospitalizations.
During an interview on 3/28/23 at 4:42 PM, the Director of Nursing confirmed no bed hold notice was provided to Resident #41's representative for the resident's admissions to the hospital on [DATE] and 02/11/23.
No further information was provided through the completion of the survey process.
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CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0657
(Tag F0657)
Could have caused harm · This affected 1 resident
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Based on record review and staff interview, the facility failed to ensure the resident's comprehensive care plan was revised when the resident experienced weight loss. This deficient practice had th...
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Based on record review and staff interview, the facility failed to ensure the resident's comprehensive care plan was revised when the resident experienced weight loss. This deficient practice had the potential to affect one (1) of three (3) residents reviewed for the care area of nutrition. Resident identifier: #85. Facility census: 102.
Findings included:
a) Resident #85
The facility's Policy and Standard Procedure titled Resident Height and Weight was reviewed. No implementation date was given on the policy. The policy stated the Interdisciplinary Care Plan would be updated as needed.
Review of Resident #85's medical records showed the resident weighed 175 pounds on 02/10/23. On 2/24/2023, Resident #85 weighed 144 pounds. This was a 17% weight loss in two (2) weeks.
Resident #85's comprehensive care plan contained the following focus, initiated on 02/13/23, Resident with potential for altered nutrition status/nutrition related problems d/t: Elevated BMI [body mass index], disease dx [diagnosis] HTN [hypertension], morbid obesity. Resident #85's comprehensive care plan did not contain a focus or interventions related to the resident's weight loss.
During an interview on 03/28/23 at 11:22 AM, the Director of Nursing confirmed Resident #85's comprehensive care plan was not revised when the resident experienced weight loss.
No further information was provided through the completion of the survey.
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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 and staff interview the facility failed to provide care required to maintain proper hygiene to a female resident who was dependent for Activities Of Daily...
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Based on observation, medical record review and staff interview the facility failed to provide care required to maintain proper hygiene to a female resident who was dependent for Activities Of Daily Living (ADL) care. This is true for one (1) of four (4) residents reviewed for ADL's care area during the Long-Term Care Survey Process. Resident Identifier: Resident #27. Facility Census: 102
Findings Included:
a) Resident #27
During the initial interview on 03/27/23 at 1:17 PM, Resident #27 was unable to answer questions appropriately. Observation of Resident # 27 found she had facial hair under her chin and on her upper lip. Resident #27 was rubbing her chin and pulling her untrimmed hair during the interview.
During an interview on 03/28/23 at 10:18 AM Hospitality aide (HA) #10 stated, I shave the men and women, everyone gets checked daily and most men get shaved daily. I trim the women when I see a little bit of fuzz on them. Resident #27 refused to let me trim her, it takes two aides. She hits and bites me. I have told the aides and the nurses that Resident # 27 needs to be trimmed and they still have not done it yet.
During an interview on 03/28/23 at 10:28 AM, Registered Nurse #104 acknowledged Resident # 27 needed to be trimmed. She stated, I am not sure of the facility's policy, the residents should get shaved on their shower days. I know she has behaviors. I will try to find all the information and bring it to you.
Further review on 03/28/23 found the Resident received a shower on the following days:
-03/25/23
-03/18/23
-03/14/23
-03/11/23
-03/04/23
During an interview on 03/28/23 at 12:05 PM, RN #104 stated Resident # 27's shower days are Tuesday and Saturday. There are no nurses notes documenting behaviors of refusing personal care or refusal of removal her facial hair. But we are removing her facial hair now.
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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
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Based on record review and staff interview the facility failed to follow a physician's order to notify the physician when blood sugar is above 400. This was true for one (1) of five (5) residents re...
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Based on record review and staff interview the facility failed to follow a physician's order to notify the physician when blood sugar is above 400. This was true for one (1) of five (5) residents reviewed for the care area of unnecessary medications. Resident identifier: Resident #5. Facility census 102.
Findings included:
a) Resident #5
A review of the medical records revealed an order to notify the physician if Resident #5 had a blood sugar above 400.
A review of the Medication Administration Record (MAR) on 03/06/23, found the Resident's blood sugar was greater than 400. There was no documentation to support the physician was notified per the physician order.
On 03/28/23 at 11:23 AM, the Director of Nursing (DON) confirmed there was no nursing notes or assessment notes showing physician notification of the elevated blood sugar on 03/06/23.
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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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Based on medical record review and staff interview, the facility failed to ensure the environment is free from accident hazards over which it has control. This was a random opportunity for discovery...
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Based on medical record review and staff interview, the facility failed to ensure the environment is free from accident hazards over which it has control. This was a random opportunity for discovery. Resident Identifier: Resident # 56. Facility Census: 102
Findings Included:
a) Resident #56
During the initial interview on 03/27/23 at 10:22 AM, Resident # 56 stated they were supposed to fix my lift chair. Resident # 56 showed this surveyor the wired remote to her recliner. The wires were exposed and bare with an attempt of a repair with electrical tape peeling away. Resident # 56 stated they were supposed to order me a new cord but never did they just taped this one.
During an interview on 03/27/23 at 11:56 AM, the administrator acknowledged the recliner was an accident hazard and needed to be replaced.
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CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0692
(Tag F0692)
Could have caused harm · This affected 1 resident
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Based on record review and staff interview, the facility failed to monitor residents who experienced weight loss in accordance with accepted standards of care. This deficient practice had the potent...
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Based on record review and staff interview, the facility failed to monitor residents who experienced weight loss in accordance with accepted standards of care. This deficient practice had the potential to affect two (2) of three (3) residents reviewed for the care area of nutrition. Resident identifiers: #85 and #91. Facility census: 102.
Findings included:
a) Resident #85
The facility's Policy and Standard Procedure titled Resident Height and Weight was reviewed. No implementation date was given on the policy. The following procedures were given:
- On admission, obtain weekly weights times four (4) weeks for baseline.
- Compare weight to previous weight obtained. If a variance of five (5) pounds or more is noted, reweigh resident to verify weight.
Review of Resident #85's medical records showed the resident weighed 175 pounds during her admission weight on 02/10/23. The resident's initial physician's order was for monthly weights. On 02/17/23, the physician wrote an order for weekly weights for four (4) weeks until stable. Resident #85 was not weighed on 02/17/23 despite the physician's order and the facility's policy to do so.
On 2/24/2023, Resident #85 weighed 144 pounds. This was a weight loss of 31 pounds in two (2) weeks. The facility's policy to reweigh the resident due to weight loss of more than five (5) pounds was not followed. On 03/03/23, Resident #85 weighed 145 pounds.
During an interview on 03/28/23 at 12:34 PM, the Director of Nursing confirmed Resident #85 was not weighed according to the physician's order and the facility's policy.
No further information was provided through the completion of the survey process.
b) Resident #91
A record review for Resident #91, revealed the resident had sustained a 12 percent weight loss during 11/2022. Weights recorded in the electronic medical record showed on 11/04/22 the resident weighed 106 pounds (lbs) and on 11/24/22, the resident weighed 93 lbs.
Further record review showed a physician's order, dated 11/04/22 for weekly weights weekly for four (4) times or until stable every day shift every Friday until stable.
Review of the documented weights obtained for Resident #91 showed no evidence of the weekly weights being completed in accordance with the physician's order.
An interview with the DON, on 03/28/23 at 12:34 PM , revealed weekly weights were not completed with any consistency and Resident #91 should have had two additional weights obtained based on the physicians order, verifying the resident should have been weighed 11/11/22 and 11/18/22. After further review, the DON verified there was no evidence those weights were obtained and documented in the medical record.
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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 and staff interview, the facility failed to provide necessary respiratory care consistent with professional standard practice. Resident #93 and Resident #90's nebulizer masks we...
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Based on observation and staff interview, the facility failed to provide necessary respiratory care consistent with professional standard practice. Resident #93 and Resident #90's nebulizer masks were on their bedside tables with no protective covering. This was a random opportunity for discovery. Resident identifier: Resident #93 and Resident #90. Facility census: 102.
Findings Included:
a) Resident #93
During the initial tour on 03/27/23 at 11:36 AM, Resident # 93's nebulizer mask was on the bedside table without a protective covering.
During an interview on 03/27/23 at 11:38 AM, RN #9 acknowledged the mask was not stored appropriately.
b) Resident #90
During the initial tour on 03/27/23 at 11:36 AM, Resident # 90's nebulizer mask was on the bedside table without a protective covering.
During an interview on 03/27/23 at 11:38 AM, RN #9 acknowledged the mask was not stored appropriately.
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CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0726
(Tag F0726)
Could have caused harm · This affected 1 resident
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Based on observation, record review, and staff interview, the facility failed to ensure staff had the appropriate competencies and skill sets to care for a resident receiving enteral (tube) feeding....
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Based on observation, record review, and staff interview, the facility failed to ensure staff had the appropriate competencies and skill sets to care for a resident receiving enteral (tube) feeding. This deficient practice had the potential to affect one (1) of one (1) resident reviewed for the care area of tube feeding. Resident identifier: #41. Facility census: 102.
Findings included:
a) Resident #41
The facility's policy titled Enteral General Nutritional Guidelines with no implementation date on the policy defined bolus enteral feeding as delivered using a syringe or gravity that provides for a single dose or preparation delivered all at one time.
A review of physician's orders for Resident #41 showed an order for enteral feedings, Jevity 1.5 bolus, 247 ml, every four (4) hours, related to dysphagia following a cerebral Infarction, beginning 02/20/23. The resident had a gastrostomy tube (G-tube). The resident also had an order to flush the G-tube with at least 30 cc of water before and after feeding.
Further review of previous physician's orders revealed on 02/20/23, an order for Jevity 130 ml/hour for 12 hours a day was discontinued due to a history of aspiration pneumonia while the resident resided at the facility.
A record review noted on 11/29/22, Resident #41 was transferred to the hospital with a diagnosis of most likely aspiration pneumonia and returned 12/22/22. On 02/11/23, Resident #41 was transferred to the hospital for vomiting, crackles in the lungs, oxygen saturation of 93%, heart rate of 138, and clamminess. Resident #41 returned on 02/19/23 with a diagnosis of suspected aspiration for the second time.
Resident #41 also had an order related to the enteral feeding for the head of bed (HOB) to be elevated at least 30 degrees or higher while receiving enteral feeding. A sign was observed above the resident's bed which stated, REMINDER: Please keep resident in semi- fowler's position or higher while G-tube feeding infused and after flushes and medication administration. Semi-Fowlers 15 degrees to Fowlers 60 degrees.
On 03/28/23 at 3:45 PM, Licensed Practical Nurse (LPN) #116 was observed administering Resident #41's enteral feeding. LPN #116 checked the resident's G-tube for placement by aspiration and auscultation and flushed the tube with 30 cc of water without ensuring Resident #41 was positioned in a semi-Fowler's position. LPN #116 then began the feeding without ensuring Resident #41 was positioned in a semi-Fowler's position. The resident had slid down in bed. His head was on the lower edge of the pillow, and his torso was flat in bed. The resident's feet reached the foot board. The resident was repositioned after surveyor intervention.
Additionally, the enteral feeding was administered via an enteral feeding pump at 247 cc/hr for an hour instead of by bolus by syringe or gravity.
A staff interview with LPN #116 on 03/28/23 at 03:51 PM, revealed LPN #116 confirmed the resident did need to be repositioned prior to the feeding administration but failed to do so before surveyor intervention. LPN #116 also stated Resident #41's enteral feeding was administered by pump over an hour because the resident tended to grab at the nurse's hands when feeding was administered by bolus syringe.
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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 record review and staff interview the facility failed to ensure the attending physician provided a rationale as to why a Gradual Drug Reduction (GDR) suggested by the facility Pharmacist wa...
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Based on record review and staff interview the facility failed to ensure the attending physician provided a rationale as to why a Gradual Drug Reduction (GDR) suggested by the facility Pharmacist was not acted upon. This was true for one (1) out of five (5) residents reviewed for unnecessary medication. Facility census 102.
Findings included:
a) Resident #16
Record review found two occasions when the facility pharmacist suggested a GDR. On 04/29/22 and 09/28/22 the pharmacist recommended a reduction in the dose of Seroquel 50 mg (given for behaviors of pacing) and Sertraline 100 mg (given for depression). No rationale was provided by the attending physician for not complying with the recommendation.
At 2:46 PM on 03/29/23, the Director of Nursing (DON) confirmed there was no documentation from the physician as to why the identified irregularities were not acted upon.
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CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0583
(Tag F0583)
Could have caused harm · This affected multiple residents
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Based on observation and staff interview, the facility failed to ensure each resident had the right to personal privacy during treatments and confidentiality of personal health information for three...
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Based on observation and staff interview, the facility failed to ensure each resident had the right to personal privacy during treatments and confidentiality of personal health information for three (3) of three (3) residents whose treatments were observed. This was found true for Residents #41, #20 and #1 who was not provided privacy during a treatment and Residents #41, and #1 had personal medical care instructions displayed above the beds in the room. Resident identifiers: #41, #20 and #1. Facility census: 101.
Findings included:
a) Policy Review
A review of the policy titled: Resident's Rights, Policy #NS1021-00, not dated, showed under the Procedure, Section 1. d., residents would have their privacy respected when treatment, medication or care was being administered including, door closed or privacy curtain drawn.
b) Resident #20
An observation of a treatment for Resident #20, on 05/30/23 at 1:36 PM, revealed Licensed Practical Nurse (LPN) #73 providing the treatment without pulling the privacy curtain or closing the door.
An interview, with the Director of Nursing (DON) on 05/31/23 at 7:20 AM, confirmed it was the policy of the facility to maintain privacy during treatments and the curtain should have been pulled and door closed during the care provided to Resident #20 on 05/30/23.
c) Resident # 41
An observation of a treatment for Resident #41, on 05/30/23 at 4:10 PM, revealed Registered Nurse (RN) #78 failed to pull the privacy curtain between the roommate and failed to the close door. Staff Nurse Aide (NA) #25 and NA in training #71 was observed to pass by the room during the treatment. Resident #41 could be seen from the hall when passing by the resident's room.
Further observation in Resident #41's room, on 05/30/23 at 4:10 PM, showed signs posted above the bed noting the following instructions for medical care and treatment:
Sign #1- Please keep resident in semi-Fowler's position or higher while Gtube feeding infused. Also, during and after flushes and medication administration.
Sign #2- Put roll splint on right hand each day after breakfast. You can apply antifungal to palm and fingers before applying splint.
An interview with RN #78 on 05/30/23 at 4:50 PM, verified the signs with health care information and instruction for medical care were posted above resident's bed and should not have been posted in that manner. Additionally, RN #78 stated she failed to provide privacy during the resident's treatment and should have done so.
d) Resident #1
An observation on 05/30/23 at 4:25 PM, revealed RN #78 providing a treatment to Resident #1, in the resident's room while he was seated in a chair. RN #78, attempted to pull the curtain but did not pull the curtain enough to provide privacy from the door. The curtain was not pulled in between the resident and the roommate and the door was not closed to provide privacy during the treatment.
An additional observation, made while observing the treatment ,on 05/30/23 at 4:25 PM, noted signs above the resident's bed with instructions for medical care and treatment:
Sign #1 : Please keep resident in semi-Fowler's position or higher while Gtube feeding infused. Also, during and after flushes and medication administration.
Sign #2 - Abdominal binder on at all times except laundry and shower. Apply a soft pillow case or T-shirt under binder.
Sign #3- {Residents name} and to nursing staff, please place hand roll splint on right hand for six (6) hours each day. Please check his skin and provide readjustments to the splint as needed to ensure good fit and skin integrity. Any issues, please see a member of the therapy department.
An interview with RN #78, on 05/30/23 at 4:50 PM, verified privacy was not maintained for Resident #1 during the treatment and verified there were signs above the bed with resident information and they should not be placed on the wall for public view.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Assessment Accuracy
(Tag F0641)
Could have caused harm · This affected multiple residents
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c) Resident #93
A Review of the quarterly MDS on 03/28/23 with ARD 03/09/23 revealed the following:
Section 0, titled Special Treatment, Procedures, and Programs Section 00100, Respiratory Treatmen...
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c) Resident #93
A Review of the quarterly MDS on 03/28/23 with ARD 03/09/23 revealed the following:
Section 0, titled Special Treatment, Procedures, and Programs Section 00100, Respiratory Treatments C. Oxygen therapy 2. Received oxygen while a Resident of this facility was void
A review on 03/28/23 at 8:30 AM, of Resident #93's medical record revealed a physician order dated 12/18/22 for oxygen at 4 liters/min nasal cannula humidification: yes frequency: continuously.
During an interview on 03/28/23 at 10:44 AM, the MDS Coordinator #89 acknowledged the MDS with ARD of 03/09/23 was coded incorrectly.
During an interview on 03/28/23 at 2:50 PM, the DON acknowledged the MDS was coded incorrectly.
Based on record review and staff interview, the facility failed to ensure a complete and accurate Minimum Data Set (MDS) assessments for three (3) of 26 residents reviewed during the long-term care survey process. Resident identifiers: #49, #76, #93. Facility census: 102.
Findings included:
a) Resident #49
Review of Resident #49's medical records showed the resident experienced a fall on 1/2/2023 during which he fractured his left clavicle.
Resident #49's Minimum Data Set (MDS) assessment with Assessment Reference Date (ARD) 03/13/23 showed the resident had not experienced a fall since the last assessment.
During an interview on 03/29/23 at 10:21 AM, the Director of Nursing (DON) confirmed Resident #49's MDS assessment with ARD 03/13/23 was incorrect. The DON stated the MDS had been corrected to reflect the resident had experienced one (1) fall with major injury.
No further information was provided through the completion of the survey process.
b) Resident #76
Review of Resident #76's medical records showed the resident developed an unstageable pressure ulcer on her right lateral ankle and an unstageable pressure ulcer on her right lateral foot on 02/28/23. Weekly pressure ulcer assessments were performed. Assessments of the pressure ulcers on 03/08/23 classified the pressure ulcers as unstageable with 100% slough. Pressure ulcers covered with slough, or dead tissue, are unstageable by definition because the base of the wound cannot be visualized in order to determine the stage.
Resident #76's quarterly Minimum Data Set (MDS) assessment with Assessment Reference Date (ARD) 03/09/23 showed the resident had two (2) pressure ulcers classified as deep tissue injury. During an interview on 03/28/23, MDS Coordinator #89 confirmed Resident #76's MDS assessment was incorrect, and the pressure ulcers should have been classified as unstageable.
No further information was provided through the completion of the survey process.
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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
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b) Resident #93
A record review on 03/28/23 at 8:30 AM, revealed a physician order dated 02/28/23 - Ipratroplum-Albuterol Aerosol Solution 20-100MCG/ACT 1 inhalation inhale orally every 8 hours for ...
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b) Resident #93
A record review on 03/28/23 at 8:30 AM, revealed a physician order dated 02/28/23 - Ipratroplum-Albuterol Aerosol Solution 20-100MCG/ACT 1 inhalation inhale orally every 8 hours for cough congestion wheezing URI.
A record review on 03/28/23 at 8:32 AM, found Resident #93's comprehensive care plan did not include the Nebulizer treatment.
During an interview on 3/28/23 at 10:45 AM, the MDS Coordinator #89 acknowledged the care plan did not reflect the Nebulizer treatment.
During an interview on 03/28/23 at 2:50 PM the DON acknowledged the care plan was incomplete.
c) Resident #99
During a confidential interview on 03/27/23 at 12:12 PM, a resident reported Resident #99 sometimes enters the resident's room. The resident reported he was concerned Resident #99 might remove or destroy his personal property. At the time of the interview, Resident #99 was observed walking in the hallway.
During an interview on 03/28/23 at 10:40 AM, Registered Nurse (RN) #9 stated Resident #99 does go into other residents' rooms and the resident requires extra monitoring to prevent this. RN #9 stated stop signs are placed across the entrance to other residents' rooms to prevent Resident #99 from entering. Resident #99 was observed walking in the hallway at this time.
Review of Resident #99's Minimum Data Set (MDS) assessment with Assessment Reference Date (ARD) 03/10/23 showed the resident had exhibited the behavior of wandering one (1) to three (3) days during the look back period.
Review of Resident #99's comprehensive care plan showed the resident was not care planned for the behavior of wandering.
During an interview on 03/28/23 at 2:15 PM, MDS Coordinator #89 confirmed Resident #99 was not care planned for wandering. MDS Coordinator #89 stated she would add a focus related to wandering to Resident #99's comprehensive care plan.
No further information was provided through the completion of the survey process.
Based on record review and staff interview the facility failed to implement the care plan in the care area of notifying the physician of a blood sugar over 400, failed to develop a care plan in the care areas of wandering and storage of respiratory equipment. This failed practice had the potential to affect a limited number of residents. Resident Identifiers: #5, #99, and #93. Facility census 102.
Findings included:
a) Resident #5
A review of the medical records revealed an order to notify the physician if Resident #5 had a blood sugar above 400.
A review of the Medication Administration Record (MAR) found on 03/06/23 the Resident's blood sugar was greater than 400. There was no documentation to support the physician was notified.
The care plan for Resident #5 stated the physician would be notified of any elevated blood sugars.
On 03/28/23 at 11:23 AM, the Director of Nursing (DON) confirmed there were no nursing notes or assessment notes showing the physician was notification on 03/06/23.
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CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0727
(Tag F0727)
Could have caused harm · This affected multiple residents
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b) No Registered Nurse Coverage for 8 Hours Per Day
Record review on 03/28/2023, of the facility's Staff Postings for the last two weeks revealed three (3) days that did not have the required eight ...
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b) No Registered Nurse Coverage for 8 Hours Per Day
Record review on 03/28/2023, of the facility's Staff Postings for the last two weeks revealed three (3) days that did not have the required eight (8) hours of Registered Nurse (RN) coverage:
On 03/16/2023 there were zero (0) RN hours worked
On 03/18/2023 there were zero (0) RN hours worked
On 03/19/2023 there were a total of four (4) RN hours worked on the 6:00 AM to 2:00 PM shift, zero (0) on the other shifts
Staff Interview on 03/29/2023 at 10:55 AM, with the Nurse Scheduler #72, stated that she would have to check to see if there were eight (8) hours of RN coverage on 03/16/2023, 03/18/2023, or 03/19/2023. At 11:54 AM Nurse Scheduler #72 confirmed that there was not RN coverage for eight (8) hours on dates in question. #72 stated that two (2) RN's have been sick.
Record review on 03/29/2023 1:39 PM, of the facility's Payroll Based Journal (PBJ) confirmed that the three (3) days in question were without eight (8) hours of RN coverage.
Based on facility record review and staff interview the facility failed to ensure the Director of Nursing was not working dual roles and a Registered Nurse was in the facility at least eight (8) hours every day. This failed practice had the potential to affect more than a limited number of residents. Facility census 102.
Findings included:
a) Role of DON
During an interview on 03/29/23 at 12:45 PM, the Administrator said the Director of Nursing (DON) was also the Infection Preventionist (IP) from 01/01/22 to 06/01/22. The Administrator confirmed the facility census was above 60 residents during the entire time frame.
The above information was discovered while reviewing the sign-in sheets for the Quality Assessment and Assurance committee.
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CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected multiple residents
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Based on observation and staff interview, the facility failed to ensure medications, used in the facility, were stored, in accordance with current accepted professional practices. This was true for ...
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Based on observation and staff interview, the facility failed to ensure medications, used in the facility, were stored, in accordance with current accepted professional practices. This was true for medications stored in two (2) of two (2) medication storage rooms. The facility failed to ensure the temperature of the refrigerator was monitored in both medication storage rooms to ensure medications stored in the medication room refrigerator were maintained at the manufacturer's acceptable temperature range for storage. This practice had the potential to effect more than a minimum number of residents. Facility census: 102
Findings included:
a.) 100 Hall Medication Storage Room
An observation, with Licensed Practical Nurse (LPN #1), on 03/29/23 at 08:20 AM, revealed the refrigerator contained Insulin pens, the medications Orencia and Embrel with manufacture's instructions to store the medications at 36 to 46 degrees Fahrenheit.
A review of the temperature log for the refrigerator instructions, showed staff were to record temperatures twice each work day. After each month has ended, each months temperature log was to be saved for three (3) years, unless state/local jurisdiction require a longer period.
A review of the temperature log for the medication room on the 100 hall, for March 2023, showed the following dates and times where there was no evidence the temperatures were monitored to ensure safe storage for refrigerated medications:
- On 03/01/23, the PM shift had no refrigerator temperature recorded.
- On 03/02/23 the AM and PM shift had no refrigerators temperature recorded.
- On 03/06/23, the PM shift had no refrigerator temperature recorded.
- On 03/07/23, the AM shift had no refrigerator temperature recorded.
- On 03/10/23, the PM shift had no refrigerator temperatures recorded.
- On 03/11/23, the AM and PM shift had no refrigerator temperature recorded.
- On 03/12/23, the AM shift had no refrigerator temperature recorded.
- On 03/13/23 the AM shift had no refrigerator temperature recorded.
- On 03/15/23, the PM shift had no refrigerator temperature recorded.
- On 03/16/23, the AM and PM shift had no refrigerator temperatures recorded.
- On 03/17/23, the AM shift had no refrigerator temperature recorded.
- On 03/20/23, the PM shift had no refrigerator temperature recorded.
- On 03/21/23, the AM shift had no refrigerator temperature recorded.
- On 03/24/23, the PM shift had no refrigerator temperature recorded.
- On 03/25/23, the PM shift had no refrigerator temperature recorded.
- On 03/26/23, the AM and PM shift had no refrigerator temperatures recorded.
- On 03/27/23, the AM shift had no refrigerator temperature recorded.
An interview, on 03/29/23, at 09:22 AM, with the Director of Nursing (DON), verified temperatures were missed on several days in March 2023 and should have been completed and documented. It was also stated, the facility had identified staff had previously been in-serviced on the completion of temperature logs in the medication's rooms, but confirmed the temperatures were still not being conducted as required. At this time, additional refrigerator temperature logs were requested for February 2023 and March 2023 for the 300-hall medication room refrigerator and February 2023 refrigerator logs for the 100 hall.
An interview, with the Infection Preventionist, on 03/29/23 at 11:26 AM , revealed there were no temperature logs found for the 100 hall medication room refrigerator for 02/2023.
b) 300 Hall Medication Storage Room
Review of the temperature logs for 300 hall Medication room refrigerator, for February 2023, showed the following dates and times where there was no evidence the temperatures were monitored to ensure safe storage for refrigerated medications:
-- On 02/01/23, the PM shift had no refrigerator temperature recorded.
-- On 02/02/23, the PM shift had no refrigerator temperature recorded.
-- On 02/07/23, the AM shift had no refrigerator temperature recorded.
-- On 02/11/23, the PM shift had no refrigerator temperature recorded.
-- On 02/12/23, the AM and PM shift had no refrigerator temperature recorded.
-- On 02/16/23, the PM shift had no refrigerator temperature recorded.
-- On 02/17/23, the PM shift had no refrigerator temperature recorded.
-- On 02/18/23, the PM shift had no refrigerator temperature recorded.
-- On 02/19/23, the AM and PM shift had no refrigerator temperature recorded.
-- On 02/25/23, the PM shift had no refrigerator temperature recorded.
A review of the temperature logs for 300 hall Medication room refrigerator, for March 2023, showed the following dates and times where there was no evidence the temperatures were monitored to ensure safe storage for refrigerated medications:
- On 03/01/23, the AM and PM shift had no refrigerator temperatures recorded.
- On 03/02/23, the AM and PM shift had no refrigerator temperatures recorded.
- On 03/03/23, the AM and PM shift had no refrigerator temperatures recorded.
-- On 03/09/23, the PM shift had no refrigerator temperature recorded.
-- On 03/12/23, the PM shift had no refrigerator temperature recorded.
.-- On 03/13/23, the PM shift had no refrigerator temperature recorded.
-- On 03/14/23, the PM shift had no refrigerator temperature recorded.
.-- On 03/15/23, the AM and PM shift had no refrigerator temperature recorded.
-- On 03/16/23, the PM shift had no refrigerator temperature recorded.
-- On 03/17/23 the PM shift had no refrigerator temperature recorded
.-- On 03/18/23, the AM and PM shift had no refrigerator temperature recorded.
-- On 03/19/23, the AM and PM shift had no refrigerator temperature recorded.
- On 03/20/23, the AM shift had no refrigerator temperatures recorded.
- On 03/21/23, the AM and PM shift had no refrigerator temperatures recorded.
-- On 03/22/23, the PM shift had no refrigerator temperature recorded.
- On 03/23/23 and 03/24/23, the AM shift had no refrigerator temperatures recorded
-- On 03/25/23, the PM shift had no refrigerator temperature recorded.
-- On 03/26/23, the PM shift had no refrigerator temperature recorded.
-- On 03/27/23, the PM shift had no refrigerator temperature recorded.
-- On 03/27/23, the PM shift had no refrigerator temperature recorded.
An additional Interview, with the DON, on 03/29/23 at 11:35 AM, verified medications were being kept in the 100 hall medication room and 300 hall medication room during the months of 02/2023 and 03/2023, during which times temperatures were not taken as required.
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CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Menu Adequacy
(Tag F0803)
Could have caused harm · This affected multiple residents
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Based on observations, resident interviews, resident council meetings, and staff interview, the facility failed to provide notification of changes of the menu by not updating the menu and/or residen...
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Based on observations, resident interviews, resident council meetings, and staff interview, the facility failed to provide notification of changes of the menu by not updating the menu and/or residents were not notified of the change, when substituting foods. This had a potential to affect more than a limited number of residents receiving nourishment from the facility kitchen. Facility Census: 102
Findings Included:
a) Confidential Interviews
During an initial interview on 03/27/23 Confidential Resident stated the food is awful, we never get what the menu says or the meal tray ticket. The meal is always different from what they say. When you look forward to getting something and they don't have it on your tray its disappointing.
During an initial interview on 03/27/23 Confidential Resident stated the menus are not being followed, the new company is trying to save money. The menu in our rooms and the menus on our trays are not the same as what we receive. Last week the menu said meatloaf and we all received chicken.
b) Observation
During the tour of the kitchen on 03/27/23 at 8:06 AM the breakfast meal being served was
-Pancakes
-Ham
-Scrambled eggs
The menu in the hallway and the menu provided to the surveyor read as follows:
-Breakfast:
French Toast
Breakfast Ham
-Lunch
Kielbasa Sausage
Vegetable Blend
Baked Beans
Dinner Rolls
Carrot Cake with Cream Cheese Icing
During a lunch observation on 03/27/23 at 12:32 PM one Resident's lunch meal tray had Kielbasa, Baked Beans, Broccoli, pears and a very dense, unrisen roll.
The Food Service Director Acknowledged the meal and stated I did not know they were substituting the vegetable blend for broccoli. I could have ran to the store and bought the vegetable blend.
The rolls are small. I had to eat three to equal one. We don't have a proofer ( a piece of equipment designed with a specific temperature and relative humidity conditions to boost yeast activity) so we just set them out about an hour before she cooks them. The new company doesn't let us buy the pre-made ones, they are much easier
Another Resident's tray had Kielbasa, baked beans, broccoli, a very small dense square piece of plain cake with no icing and a very dense, unrisen roll.
The Food Service Director acknowledged the lunch meal and stated we did not have any carrots to make a carrot cake. Yes they are very small pieces. I don't know why they did not put any icing on the cake.
The Food Service Director stated the computer system does not let me change anything on the meal tickets when we have to substitute, so the residents doesn't know there is a change.
c) Resident Council
A Resident Council Meeting held on 03/28/23 at 10:00 AM , the following concerns were presented:
Confidential interviews with the Resident group found the following concern: they stated it is frequent that they do not get served what is on the menu.
A review of a Resident Council Meeting held on 12/07/22 , found the following concerns were presented:
Confidential interviews with the Resident group found the following concern stated the items on/from menu to tray card to his plate are all different.
A review of a Resident Council Meeting held on 10/05/22 , the following concerns were presented:
Confidential interviews with the Resident group found the following concerns:
-Menu does not match what is served
-Menu differs from what is being served on tray
-Items listed on tray card not matching what's on my plate.
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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, facility 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 f...
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Based on observation, facility 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 complete the daily refrigerator and freezer temperature log. In addition, the facility also documented food and drink temperatures prior to the meal being prepared. This has a potential to affect more than a limited number of residents receiving nourishment from the facility kitchen. Facility Census: 102
Findings Included:
A review of a facility policy titled Food Preparation with a revision date 09/2017 revealed the following.
Procedures
.14. Temperature for TCS foods will be recorded at time of service, and monitored periodically during meal service periods.
Another review of a facility titled Food Storage: Cold Foods with a revision date 04/2018 revealed the following.
Procedures
.4. An accurate thermometer will be kept in each refrigerator and freezer. Q written record of daily temperatures will be recorded.
On 03/27/23 at 8:06 AM during the initial tour with the Assistant Food Service Director (AFSD) the following issues were found:
a) Condiment Stand
-an open box of gluten free elbow macaroni no open or use by date
-an open box of gluten free spaghetti no open date or use by date
-an open box of gluten free crackers with an stamped manufacture date of 01/21/23.
The AFSD acknowledged the failure to label food items with a Date Opened and/or Use by Date and indicated the items needed to be discarded because they were out of date or not dated.
b) Drink Refrigerator
Observation of the Drink Refrigerator revealed the following issues:
-a plastic container with an employees lunch
-an opened 16 ounce mustard with no open or use by date
-a open jar of horseradish with no open or use by date
-two(2) jars of grape jelly with no open or use by date
-a opened jar of sauerkraut with a use by date of 03/03/23
-an opened carton of thicken orange juice dated 03/13/23 to 03/19/23
-a pitcher of juice with a use by date of 03/13/23
The AFSD acknowledged the failure to label food items with a Date Opened and/or Use by Date and indicated the items needed to be discarded because they were out of date or not dated.
c) Spice Rack
Observation of the spice rack revealed the following issues:
-an opened carton of black pepper no open date or use by date
-an opened carton of onion powder no open date or use by date
-an opened carton of garlic powder no open date or use by date
-an opened bottle of vanilla extract with no lid
-an opened bottle of vegetable oil with no open or use by date
-a storage bin of bread crumbs with use by date 03/07/23
The AFSD acknowledged the failure to label food items with a Date Opened and/or Use by Date and indicated the items needed to be discarded because they were out of date or not dated.
d) Walk-In Refrigerator
Observation of the Walk in Refrigerator revealed the following issues:
-a container labeled cabbage 03/22 to 03/25/23
-a container labeled sausage gravy 03/22/23 to 03/25/23
-a container labeled au gratin potatoes 03/21/23 to 03/24/23
-a container labeled cheese ravioli 03/23/23 to 03/26/23
-a container labeled chicken salad 03/23/23 to 03/26/23
-a container labeled ham salad 03/23/23 to 03/26/23
-a container labeled mechanical meat 03/23/23 to 03/26/23
-a container labeled pureed sausage 03/23/23 to 03/26/23
-an opened bag of mozzarella cheese with no open or use by date
-an open gallon of mayonnaise with no open or use by date
-an open 105 ounce container of mustard with no open or use by date
-eight (8) salads on a tray with a use by date of 03/26/23
The AFSD acknowledged the failure to label food items with a Date Opened and/or Use by Date and indicated the items needed to be discarded because they were out of date or not dated
The Food Service Director (FSD) was not present upon entering the facility. The Assistant Food Service director was in charge of the building during the above time and date.
During an interview on 03/27/23 at 8:35 AM the FSD stated they (kitchen staff) are educated on labeling and dating the food once opened. The FSD acknowledged several food items should have been disposed of due to expiration.
e) Food Temperature Record
The Daily Food Temperature Record for the 03/27/23 Lunch meal was completed at 8:06 AM with the following temperatures:
-Meat/Casserole 189
-Soups/Clear 188
-Potatoes 194
-Gravy 195
-Pasta 176
-Vegetable 169
-Ground Meat 167
-Pureed Meat 167
-Pureed Vegetable 167
-Regular Dessert Room
-Coffee 182
-Milk 36
-Juice 36
The AFSD acknowledged the cook documented the meal/drinks temperatures prior to the meal being prepared.
During an interview on 03/27/23 at 8:37 AM the FSD acknowledged the temperatures were documented prior to the meal being prepared.
f) Little Refrigerator
An observation on 03/27/23 revealed a refrigerator temperature log that was incomplete. Evidence revealed the temperature log was void of documentation for the following days:
-03/21/23 PM
-03/25/23 PM
-03/26/23 AM and PM
-03/27/23 AM
An immediate interview with AFSD acknowledged the refrigerator temperature log was incomplete and should have been completed daily.
g) Freezer
An observation on 03/27/23 revealed a freezer temperature log was incomplete. Evidence revealed the temperature log was void documentation for the following days:
-03/24/23 PM
-03/25/23 AM and PM
-03/26/23 AM and PM
-03/27/23 AM
An immediate interview with AFSD, confirmed the freezer temperature log was incomplete and should have been completed daily.
h) Milk Cooler #1
An observation on 03/27/23 revealed a Milk Cooler #1 temperature log was incomplete. Evidence revealed the temperature log was void documentation for the following days:
-03/25/23 PM
-03/26/23 PM
An immediate interview with AFSD, confirmed the Milk Cooler #1 temperature log was incomplete and should have been completed daily.
g) Milk Cooler #2
An observation on 03/27/23 revealed a Milk Cooler #1 temperature log was incomplete. Evidence revealed the temperature log was void documentation for the following days:
-03/25/23 PM
-03/26/23 PM
An immediate interview with AFSD, confirmed the freezer temperature log was incomplete and should have been completed daily.
During an interview on 03/27/23 at 8:35 AM the FSD stated they (kitchen staff) are educated to complete refrigerator/freezer temperature log daily and the food temperatures prior to food service.
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CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Garbage Disposal
(Tag F0814)
Could have caused harm · This affected multiple residents
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Based on observation and staff interview the facility failed to ensure garbage and refuse containers were in good condition. This deficient practice has the potential to affect more than a limited n...
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Based on observation and staff interview the facility failed to ensure garbage and refuse containers were in good condition. This deficient practice has the potential to affect more than a limited number of residents that reside in the facility. Facility Census: 102.
Findings Included:
a) Outside garbage receptacle
An observation on 03/28/23 at 10:26 AM, found two (2) of the facility's outside garbage receptacle were full of bagged trash reaching the top, one of them was missing a closure lid. Another garbage receptacle was full of bagged trash with a bent lid which was unable to close properly.
During an interview on 03/28/23 at 10:27 AM, Maintenance Assistance (MA) #1 acknowledge the missing closure lid and bend lid. The MA #1 stated I have called the (local Sanitary office name)several times to bring new lids, they have never brought them. I will call them again today.
During an interview on 03/28/23 at 3:23 PM, the Administrator stated we have called them several times for new lids, which we have never received. I should have just spray painted a cardboard box and changed it when it rains.
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CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Medical Records
(Tag F0842)
Could have caused harm · This affected multiple residents
.e) Resident #5
A review of medical records found the Physician Order for Scope of Treatment (POST) form was not signed by Medical Power of Attorney (MPOA). There is a verbal consent signed by Former ...
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.e) Resident #5
A review of medical records found the Physician Order for Scope of Treatment (POST) form was not signed by Medical Power of Attorney (MPOA). There is a verbal consent signed by Former Employee #134 on 11/12/2019.
During an interview on 03/28/23 at 1:34 PM, with Social Worker #91, SW #91 verified the verbal consent was not witnessed by two (2) nurses. In addition, she agreed a verbal consent completed on 11/12/19 should have been updated with a signature.
On 03/29/23 at 9:33 AM, the Administrator and Director of Nursing were informed of the above findings. The Administrator stated he did not understand the urgency of having the MPOA sign the POST form.
Based on record review and staff interview, the facility failed to ensure complete and accurate medical records. Physician Orders for Scope of Treatment (POST) forms were incomplete and/or inaccurate for five (5) of 26 records reviewed in the long-term care survey sample. Resident identifiers: #59, #60, #5, #27, and #96. Facility census: 102.
Findings included:
a) Resident #59
Review of Resident #59's Physician Orders for Scope of Treatment (POST) form showed that verbal consent was obtained from the resident's representative on 12/28/21. The consent was witnessed by two (2) staff members. However, the resident representative's actual signature was never obtained.
The 2021 POST form guidance titled, Using the POST Form: Guidance for Health Care Professionals, 2021 edition, available on-line, stated, If the incapacitated patient ' s MPOA [medical power of attorney] 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.
During an interview on 03/28/23 at 1:39 PM, the Social Worker confirmed Resident #59's representative had not signed the POST form even though verbal consent had been obtained over one (1) year previously.
No further information was provided through the completion of the survey process.
b) Resident #60
Review of Resident #60's Physician Orders for Scope of Treatment (POST) form dated 02/15/22 incorrectly listed the first name of the resident's medical power of attorney (MPOA).
During an interview on 03/28/23 at 1:36 PM, the Social Worker confirmed Resident #60's POST form incorrectly listed the first name of Resident #60's MPOA. She stated she would correct the form.
No further information was provided through the completion of the survey process.
c) Resident #27
During a record review on 03/27/23 at 3:15 PM, Resident # 27 medical records revealed a POST form with a verbal consent obtained from the resident representative on 08/31/18. The consent was witnessed by two (2) staff members. However, the resident representative's actual signature was never obtained.
During an interview on 03/28/23 at 1:36 PM, the Social Worker acknowledged the POST form had not been signed by the Resident's representative and should have been mailed for signature.
d) Resident #96
During an record review on 03/27/23 at 12:27 PM, Resident # 96 medical record revealed a POST form with a verbal consent obtained from the resident's representative on 01/24/23. The consent was witnessed by two (2) staff members. However, the resident representative's actual signature was never obtained.
During an interview on 03/28/23 at 1:36 PM the Social Worker acknowledged the POST form should have been signed by Resident#96's representative during his visitations.
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CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0868
(Tag F0868)
Could have caused harm · This affected multiple residents
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Based on facility document review and staff interview the facility failed have all required members of the Quality Assessment and Assurance (QAA) attended at least one meeting every quarter. This fa...
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Based on facility document review and staff interview the facility failed have all required members of the Quality Assessment and Assurance (QAA) attended at least one meeting every quarter. This failed practice had the potential to affect more than a limited number of residents that currently reside at the facility. Facility census 102.
Findings included:
While reviewing the attendance sign-in sheets for the QAA meetings it was noted that there was not an Infection Preventionist (IP) on record from January 2022 until June of 2022. In addition, there was not a Medical Director in attendance during the third quarter of the year 2022.
During an interview on 03/29/23 at 12:45 PM, the Administrator verified the Medical Director was not in attendance during the third quarter. The Administrator said the Director of Nursing (DON) was also the IP from 01/22 to 06/22. The administrator said it was hard to find staff. He confirmed the facility census was over 60 residents during this time frame.
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CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
d) Hand Hygiene
A dining observation on 03/28/23 beginning at 11:55 AM found the lunch meal trays arrived in the 200 Hall at 1...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
d) Hand Hygiene
A dining observation on 03/28/23 beginning at 11:55 AM found the lunch meal trays arrived in the 200 Hall at 12:03 PM.
Nurse Aide (NA) # 107 was observed passing three (3) lunch trays. During the observations hand hygiene was not offered to the residents prior to receiving their lunch trays. This surveyor intervened and inquired about hand hygiene.
Hand sanitizer wipes were not placed on the meal trays . There were no hand sanitizer bottles observed near the serving areas.
During an interview on 03/28/23 at 12:07 PM, NA #107 stated I just got here, I did not give any hand hygiene. No, I did not offer the Residents hand hygiene.
During an interview on 03/28/23 at 12:07 PM, Registered Nurse (RN) #104 acknowledged no hand hygiene was provided. RN #104 stated this hand hygiene is being cited at every facility I have been working at. RN #104, stated I just washed this resident's hands with wet paper towels before I served her tray, is that good enough? RN #104 stated How are we supposed to wash their hands.
During an interview on 03/28/23, the DON was informed of the hand hygiene not being performed prior to meals.
Based on facility documentation review, observation, staff interviews, and policy review, the facility failed to establish and 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. These failed practices were found in the care areas of: Water management, surveillance and tracking residents placed in Enhanced Barrier Precautions, cross contaminating meal trays, and failure to provide hand hygiene to residents prior to meals. These failed practices had the potential to affect more than a limited number of residents that currently reside at the facility. Facility census 102.
Findings included:
a) Water Management
During an interview on 03/29/23 at 9:07 AM, Maintenance #1 was asked for the information that includes a description of the building water systems using text and flow diagrams. Maintenance #1 said he did not have anything like that. Maintenance #1 stated the facility has a contract with a company outside of the facility that handles the water system.
On 03/29/23 at 11:07 AM, Maintenance #1 stated the contracted company cannot provide the documents previously asked for. He said the contracted company said the facility uses well water and that is what they monitor.
On 03/29/23/ at 1:27 PM, Administrator was informed the maintenance personal can not provide the text and flow diagrams of the facilities water system. In addition the maintenance personnel did not provide any testing or monitoring to ensure protocols remain in acceptable level within the facility's water systems.
b) Surveillance
During an interview with Infection Preventionist (IP) on 03/28/23 at 11:48 AM, he was asked if there were any residents currently in any type of Transmission Based Precautions (TBP)? The IP stated there was only one (1) resident and that resident was in room [ROOM NUMBER]-B and has Methicillin-resistant Staphylococcus aureus (MRSA).
During a tour of the facility on 03/28/23 at 12:30 PM, it was noted many rooms had Personal protective equipment (PPE) and a sign on the door. The signs read:
STOP,
Enhanced Barrier Precautions,
EVERYONE MUST:
Clean hands, including before entering and when leaving the room.
PROVIDERS AND STAFF MUST ALSO:
Wear gloves and a gown for the following High-Contact Resident care and activities.
Dressing
Bathing/showering
Transferring
Changing lines
Providing hygiene
Changing briefs or assisting with toileting
Device care or use:
Central line, Urinary catheter, feeding tubes, tracheostomy.
Wound care: any skin opening requiring a dressing.
The rooms noted to have these signs and PPE were:
103, 104, 107, 114, 116, 205, 206, 208, 217, 303, and 405.
On 03/28/23 at 12:38 PM, Nurse Aide #61 was asked why residents are in EBP? NA #61 stated she was not sure. Some are in EBP for something in their urine, I think.
During an interview with the IP on 03/29/23 at 8:00 AM, the IP was asked if he had documentation on a surveillance log listing which defines which Multidrug-resistant organisms (MDRO) the Residents have and the dates they were placed in EBPs. The IP said he would get that information.
By the close of the survey, the IP could not produce any documents about any of the residents in the rooms listed above.
On 03/29/23 at 3:30 PM, the DON was informed of the above information.
c) Resident #67
An observation on 03/27/23 at 12:55 PM, revealed Housekeeping (HK) staff #29 placed a dirty tray on the meal cart where Resident #67's meal tray was yet to be served.
An interview on 03/27/23 at 12:55 PM, with HK staff #29, revealed she assumed Resident #67 had finished the tray. At this time, HK staff #29 was informed by the surveyor, Resident #67 had not received the meal tray. HK staff #29 stated she was aware the dirty and clean trays should have not been together in the cart but was not sure why she thought Resident #67 had already been served her tray.
An observation, on 03/27/23 at 12:58 PM, revealed Nursing Assistant (NA) #61 walked to the tray cart and retrieved Resident #67's tray that was present with dirty trays. NA #61 proceeded to take the tray to the resident's room. At this time, the surveyor intervened to request a new tray for Resident #67.
An interview, on 03/28/23 01:17 PM, with the Director of Nursing (DON), verified it was not an acceptable practice to serve a prepared tray to a resident when dirty trays are in the same cart. The DON clarified no dirty trays should have been put back in the cart with unconsumed trays waiting to be served.
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CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0883
(Tag F0883)
Could have caused harm · This affected multiple residents
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Based on record review, staff interview, and policy review, the facility failed to follow the current recommendation from the Center for Disease Prevention and Control (CDC) guidance for the Pneumoc...
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Based on record review, staff interview, and policy review, the facility failed to follow the current recommendation from the Center for Disease Prevention and Control (CDC) guidance for the Pneumococcal vaccine. One (1) resident received the vaccine to soon, two (2) residents were not offered a pneumococcal immunization. This was true for three (3) out of five (5) residents reviewed for immunizations. Resident Identifiers: #44, #5, and #77. Facility census 102.
Findings included:
Facility Policy titled, Resident Pneumococcal Vaccines.
. Offer PCV20 if resident has received only PPSV23 greater than or equal to one (1) year ago.
a) Resident #44
Medical record found Resident #44 received the Pneumovax 23 (PPSV23) on 02/25/22 and Prevnar 20 (PVC 20) 11/18/22. The recommendation from the CDC is to wait at least one (1) year after receiving the PPSSV23 before giving the PVC20.
During an interview with facility Infection Preventionist (IP) on 03/29/23 at 8:00 AM, the IP stated he will report a medication error for giving Resident #44 the PCV 20 nine months after receiving the PPVS23, instead of waiting one year.
b) Resident #5
On 03/29/23 at 8:00 AM, the IP confirmed he failed to offer Resident #5 a PVC20.
Record review showed Resident #5 had not been offered a pneumococcal vaccine since 07/31/2015.
c) Resident #77
Record review found Resident #77 had not been offered a pneumococcal vaccine since 11/04/21.
On 03/29/23 at 8:00 AM, the IP confirmed he failed to offer Resident #77 a pneumococcal vaccine.
On 03/29/23 at 3:10 PM, the Administrator was informed of the above findings.
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CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0924
(Tag F0924)
Could have caused harm · This affected multiple residents
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Based on observation and staff interview, the facility failed to equip corridors with firmly secured handrails on each side. This was a random opportunity for discovery and the potential to affect a...
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Based on observation and staff interview, the facility failed to equip corridors with firmly secured handrails on each side. This was a random opportunity for discovery and the potential to affect a limited number of residents who reside in the facility. Facility census 102.
Findings included:
Observation on 03/28/23 at 4:23 PM, found multiple loose handrails on the 100 hall. This was verified at the time with Licensed Practical Nurse #110 and the Director of Nursing (DON). The DON stated she would have maintenance fix it right away.
On 03/29/23 at 3:10 PM, the Administrator was informed of the above findings.
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Oct 2021
12 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
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on observation, record review, and staff interview, the facility failed to ensure resident dignity was protected. Reside...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on observation, record review, and staff interview, the facility failed to ensure resident dignity was protected. Resident #68 required staff assistance in dressing. Staff failed to promote dignity by dressing Resident #68 in mismatched socks resulting in embarrassment. This was a random opportunity for discovery. Resident Identifier: #68. Facility census: 78.
Findings included:
a) Resident #68
On 10/04/21 at 9:41 AM, Resident #68 reported being dressed in mismatched socks which is somewhat embarrassing. Resident #68 pulled the blanket to the side to show the Surveyor her mismatched socks.
The quarterly Minimum Data Set (MDS) assessment, with an assessment reference date of 08/28/21, revealed Resident #68 required substantial/maximal assistance of staff to put on and take off socks.
During an interview with Resident #68, on 10/05/21 at 12:10 PM, an inventory of socks in the room resulted in the following findings:
-1 no show gray, pink, green, and white [NAME] sock that was missing a mate
-1 no show black, pink, white, and purple [NAME] sock that was missing a mate
-1 anklet sock with a purple line across the side that was missing a mate
-1 anklet sock with a blue line across the side that was missing a mate and
-1 pair of blue mid-calf socks.
Resident #68 stated staff would do the best they could and pair the two mismatched no show [NAME] socks together or the two mismatched anklet socks together as a solution.
On 10/05/21 at 1:30 PM, the Social Worker reported the staff assisting Resident #68 should have reported the four (4) socks having missing mates. The Social Worker will ask laundry to look for the mates and if they are not found, new socks will be purchased. The Social Worker also reported staff will be educated that dressing a resident in mismatched socks is a dignity issue.
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CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0558
(Tag F0558)
Could have caused harm · This affected 1 resident
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Based on record review, observation and interview, the facility failed to provide reasonable accommodations of residents needs and preferences for a resident who was visually impaired. This practice...
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Based on record review, observation and interview, the facility failed to provide reasonable accommodations of residents needs and preferences for a resident who was visually impaired. This practice affected one (1) of 19 sampled residents. Resident Identifier: Resident # 18. Census: 78
Findings included:
a) Resident #18
During an interview, on 10/04/21 at 10:00 AM, Resident #18 expressed he had a problem with vision and sometimes this caused problems when staff did not tell him where the food items were on his tray.
A record review, on 10/04/21 showed a comprehensive assessment dated , 07/10/21, noting Resident #18 required glasses for adequate vision under Section B1000 and B1200 of the Minimum Data Set (MDS),
An observation of Resident #18, during the noon meal, on 10/04/21 at 12:15 PM , revealed Resident #18 eating the lunch meal in bed, without glasses. Resident #18 was observed lifting the spoon with no food and bringing it to his mouth as if he was getting a bite of food. This was observed while Resident #18 was trying to eat chicken and pears.
On 10/04/21 at 12:15 PM, Resident #18 asked the surveyor where the milk was because he could not see it. There was a milk carton observed on the tray and a sippy cup of milk out of reach of Resident #18. Resident #18 requested assistance and the surveyor obtained assistance from a staff member at 12:20 PM.
On 10/04/21 at 12:20 PM, Nursing Assistant (NA #36) entered the resident's room and applied glasses on Resident #18 and verified the glasses should be on at all times and stated staff should have put his glasses back on or when they delivered the tray. NA #36 verified the milk was out of reach and continued to assist the resident.
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CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected 1 resident
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Based on review of resident council minutes, interview, and observation, the facility failed to honor the resident's right to a homelike environment. The facility failed to exercise reasonable care ...
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Based on review of resident council minutes, interview, and observation, the facility failed to honor the resident's right to a homelike environment. The facility failed to exercise reasonable care for the protection of Resident #18's property. This was true for one (1) of 19 sampled residents in the long-term care survey process. Resident identifier #18. Facility census: 78.
Findings included:
a) Resident #18
On 10/04/21 at 8:20 PM, a review of April 2021 thru September 2021 resident council minutes was completed. The July 2021 resident council minutes reported Resident #18 expressed, Roommate gets into things in middle of the night. The facility response to this concern was to install safety latches on Resident #18's dresser drawers.
During an interview, on 10/06/21 at 8:25 AM, Resident #18 reported the issue had not been resolved and the roommate was still getting into things. Resident #18 reported there may have been a week or two where the safety latches were effective, but that they no longer were. With resident's permission, the Surveyor inspected the dresser which had 4 drawers. The top two (2) drawers both had a safety latch attached, but the latches were not working. Surveyor was able to open the top two (2) drawers with no resistance. The third drawer had a safety latch that was broken off. Surveyor was able to open the third drawer with no resistance. Only the fourth drawer had a working safety latch which engaged when the Surveyor attempted to open the drawer.
On 10/06/21 at 9:00 AM, the Administrator explained if a certified nursing assistant (CNA) identified the broken latches as they were assisting Resident #18 to retrieve clothing, they should have reported it to a nurse who would have then put in a work order in the system. The Administrator acknowledged no work order had been entered and stated the issue would be addressed.
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CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Assessment Accuracy
(Tag F0641)
Could have caused harm · This affected 1 resident
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Based on record review and interview, the facility failed to assure each resident received an accurate assessment, reflective of the resident's status at the time of the assessment. The facility did...
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Based on record review and interview, the facility failed to assure each resident received an accurate assessment, reflective of the resident's status at the time of the assessment. The facility did not accurately code the Nursing Home Discharge Minimum Data Set (MDS) assessment for Resident #85. The facility assessed a resident as being discharged to an acute care hospital, when the resident was actually discharged to home. This was true for one (1) of three (3) closed records reviewed during the long-term care survey process. Resident Identifier: #85. Facility census: 78.
Findings included:
a) Resident #85
A record review, on 10/05/21 at 9:00 AM, revealed a nursing home discharge MDS, with an assessment reference date of 07/09/21. The MDS coded Resident #85's discharge status as an acute care hospital. Further record review revealed a nursing note, dated 07/09/21 at 10:30 AM, documenting Resident #85 was discharged to home.
During an interview, on 10/05/21 at 11:40 AM, the Minimum Data Set (MDS) Coordinator stated Resident #85 was coded as being discharged to an acute care hospital in error.
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CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on observation of medication administration, interview and record review of one (1) of three (3) closed records, the fac...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on observation of medication administration, interview and record review of one (1) of three (3) closed records, the facility failed to ensure care was provided within professional standards of practice relating to medication administration and disposition of medications of a discharged resident. This was a random opportunity for discovery and had the potential to affect a limited number of residents residing in the facility. Resident Identifier: Resident # 85. Census: 78
Findings included:
a.) Medication Administration
An observation of Medication Administration Pass, on 10/05/21 at 7:33 AM, revealed Licensed Practical Nurse (LPN) #112 at the medication cart preparing medications for a resident in room [ROOM NUMBER].
LPN #112 took the medications from the packaging and placed the medications in a medication cup. The medications included the following:
Biotin 5 mg
Centrum Silver
Folic acid 1000 mcg
Senna S
Methopredinisone 4mg (5 tablets)
Movantik 25 mg
Doxyclycline 100 mg
Dyazide 37-25 mg
Tylenol 300-30 for complaint of pain
and additional medications to include Flonase spray and Prednisone eye drops.
LPN #112 then handed the cup of medications with nasal spray and eye drops to LPN #113 who proceeded to enter the resident's room and administer the cup of medication while LPN #112 stayed at the medication cart.
While LPN #113 was in the resident's room, the resident requested something for nausea. LPN #113 requested LPN #112 to check to see if the resident in room [ROOM NUMBER] could have something for nausea. LPN #112 prepared Zofran 4 mg , opened the packaging and placed in a medication cup. LPN #112 handed the cup to LPN #113 and at 7:53 AM, LPN #113 administered the medication to the resident in room [ROOM NUMBER]A.
An interview, with LPN #112, on 10/05/21 at 7:57 AM revealed she enters the medication taken by pushing the save button on the electronic medication administration record which then shows LPN #112's initials as the staff that gave the medication when she did not actually administer the medications to the resident.
An additional observation was made of LPN #112 preparing medications for a resident in room [ROOM NUMBER]A on 10/05/21 at 8:00 AM. LPN #112 prepared the medications by taking them from the packaging and placing them in a medication cup. The medications included the following:
Multivitamin
Senna plus 1 tablet
Tylenol 325 2 tabs
Lisinopril 20 mg
Metformin 1000 mg
LPN #112 handed the pill cup to LPN #113 who administered them to the resident. LPN #112 stood by the medication cart and could not visualize LPN #113 ensuring medications were given.
An interview, with LPN #112, on 10/05/21 at 8:05 AM , revealed LPN #112 stated she would sign off after LPN #113 said the resident had taken the pill.
An interview with LPN #113, on 10/05/21 at 11:41 AM, revealed there was no directive for staff to administer the medications as observed during the medication administration pass on 10/05/21. The staff took it upon themselves to do the pass that way when they had two (2) nurses working on the unit. LPN #113 stated at this time, she administered medications she did not prepare herself to administer and did not sign that she was in fact the nurse who had administered the medication.
An interview was conducted with the Assistant Director of Nursing (ADON) on 10/05/21 at 12:50 PM to notify the faility of the two nurses sharing the pass for medication administration, with one nurse signing as given but did not administer the medication signed for. The ADON verified this should not be and that was not the standard of practice and absolutely should not be occurring.
During the interview, on 10/05/21 at 12:50 PM, the ADON provided a Clinical Competency Validation skill for Medication Administration which verified the practice of pouring and handing to another employee was not part of the skill set.
An interview, with the Director of Nursing (DON), on10/05/21 at 1:20 PM ,confirmed the practice of the facility was whoever is on the cart prepares and administers the medication and it was not acceptable to tag team.
b) Policy Review
The facility policy entitled, Discharge to Home Medication, dated 06/21/17, outlines the following:
Discharge medication information is entered on the Discharge Medication / Leave of Absence Release / Receipt Form to include:
a. Resident name
b. Date completed
c. Facility name
d. Check if leave of absence or discharge
e. Date and time leaving
f. List all medication giving to resident or responsible party Include:
-Name of medication, dosage, frequency (complete Physician's Order) or give copy of Medication Discharge Summary.
-Rx number
-Quantity given to resident or responsible party
-Check if medication instructions were given to resident or responsible party
-Check if medication instructions were understood by the resident or responsible party
-Check that resident or responsible party understands medications are not in child-resistant package.
The resident or responsible party is informed the container is not child-resistant. This is documented on the discharge instruction form or in the resident's medical record.
g. Original is given to resident or responsible party and copy is placed in the chart. Signatures as appropriate:
1. Resident signature (if able) and date
2. Responsible party signature and date
3. Nurse signature and date
b) Resident #85
A medical record review, completed on 10/05/21 at 10:05 AM, revealed Resident #85 had been assessed as having severely impaired cognition. A physician determination of capacity was on file reflecting Resident #85 did not have capacity to make medical decisions. The facility deferred to Resident #85's medical power of attorney (MPOA).
On 07/08/21, the facility reviewed the written Discharge Summary and the written Medication Discharge Summary with Resident #85's MPOA. The discharge summary noted Resident #85 was to have a planned discharge to home on the following day, on 07/09/21, and the Social Worker assisted with arranging the county (Name of home health service provider) to transport Resident #85 home. Medications were reviewed and explained to the MPOA. The MPOA signed and dated both forms on 07/08/21 at 5:10 PM. It is important to note the Medication Discharge Summary form did not document the quantity of each medication given.
On 07/09/21 at 10:30 AM, LPN #61documented the senior center wheelchair van arrived to take Resident #85 home. LPN #61 also documented a manilla envelope with medications was sent with resident.
During an interview, on 10/05/21 1:55 PM, the Assistant Director of Nursing (ADON) reported, It looks like the medications went with [Resident #85]. That's not good. The ADON acknowledged the responsible party/MPOA had signed the paperwork the day prior and was not present at the time of discharge. Resident #85 had remained in the building overnight and was picked up by the van driver the next day. Additionally, the ADON acknowledged if Resident #85 had ingested the medication during the wheelchair van drive home, there would have been no immediate way of emergency responders knowing how many pills were taken since the Medication Discharge Summary did not document the quantity of each medication given. The ADON stated the discharge was not aligned with professional standards of care.
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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 record review, and interview, the facilty failed to provide care and services , consistent with professional standards of practice to promote healing and prevent further infection and preve...
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Based on record review, and interview, the facilty failed to provide care and services , consistent with professional standards of practice to promote healing and prevent further infection and prevent new sores from developing for one (1) of three (3) residents reviewed who, based on the comprehensive assessment, had pressure ulcers. Resident Identifier: #64. Census: 78
Findings included:
a) Resident #64
A review of the facility's policy, on 10/06/21, titled , Skin Assessment, revision date of 05/03/21,
noted under section 7. (c), if wounds were observed, the staff were to initiate and complete a weekly wound assessment.
Record review for Resident #64, found on 07/20/21 Resident #64 was assessed to have developed an unstageable pressure ulcer on the right heel with measurements of 2x2.5 centimeters (cm) The documentation failed to address if exudate was present and failed to describe presence or absence of odor and failed to include the assessment of the condition of the tissue which as required of the weekly wound assessment according to policy.
Further review of the record for Resident #64, showed no evidence weekly wound assessments where completed for the following weeks:
July 26-30, 2021
August 1-7, 2021
August 8-14, 2021
August 15-21, 2021
August 22-28, 2021
September 12-18.
Progress notes reviewed during this time, did not address any wound assessment.
An interview with the Director of Nursing (DON), on 10/06/21 at 12:15 PM, revealed the employee that was responsible for performing the weekly skin assessments was off duty during those times and another employee was filling in. It was stated there was little time to complete the assessments and the documentation did not get done,
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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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Based on policy review, record review, observation, and interview, the facility failed to ensure supervision and assistive devices for one (1) of three (3) closed resident records reviewed and one (...
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Based on policy review, record review, observation, and interview, the facility failed to ensure supervision and assistive devices for one (1) of three (3) closed resident records reviewed and one (1) of 19 current sampled residents. When a senior center wheelchair van arrived to take Resident #85 home, a manilla envelope with medications was sent with Resident #85 despite the fact the facility had assessed Resident #85's cognitive ability as severely impaired. The facility failed to ensure #14 was wearing a soft helmet, geri sleeves, and hipsters per physician orders. Resident identifiers: #85 and #14. Facility census: 78.
Findings included:
a) Policy Review
The facility policy entitled, Discharge to Home Medication, dated 06/21/17, outlines the following:
Discharge medication information is entered on the Discharge Medication / Leave of Absence Release / Receipt Form to include:
a. Resident name
b. Date completed
c. Facility name
d. Check if leave of absence or discharge
e. Date and time leaving
f. List all medication giving to resident or responsible party Include:
-Name of medication, dosage, frequency (complete Physician's Order) or give copy of Medication Discharge Summary.
-Rx number
-Quantity given to resident or responsible party
-Check if medication instructions were given to resident or responsible party
-Check if medication instructions were understood by the resident or responsible party
-Check that resident or responsible party understands medications are not in child-resistant package. The resident or responsible party is informed the container is not child-resistant. This is documented on the discharge instruction form or in the resident's medical record.
g. Original is given to resident or responsible party and copy is placed in the chart. Signatures as appropriate:
1. Resident signature (if able) and date
2. Responsible party signature and date
3. Nurse signature and date
b) Resident #85
A medical record review, completed on 10/05/21 at 10:05 AM, revealed that Resident #85 had been assessed as having severely impaired cognition. A physician determination of capacity was on file reflecting the Resident #85 did not have capacity to make medical decisions. The facility deferred to Resident #85's medical power of attorney (MPOA).
On 07/08/21, the facility reviewed the written Discharge Summary and the written Medication Discharge Summary with Resident #85's MPOA. The discharge summary noted Resident #85 was to have a planned discharge to home on the following day, on 07/09/21, and the Social Worker assisted with arranging the county (name of local home health agency) to transport Resident #85 home. Medications were reviewed and explained to the MPOA. The MPOA signed and dated both forms on 07/08/21 at 5:10 PM. It is important to note the Medication Discharge Summary form did not document the quantity of each medication given.
On 07/09/21 at 10:30 AM, LPN #61 documented the senior center wheelchair van arrived to take Resident #85 home. LPN #61 also documented a manilla envelope with medications was sent with resident.
During an interview, on 10/05/21 1:55 PM, the Assistant Director of Nursing (ADON) reported, It looks like the medications went with [Resident #85]. That's not good. The ADON acknowledged the responsible party who had signed the forms was not present at the time of discharge. Additionally, the ADON acknowledged if Resident #85 had ingested the medication during the wheelchair van drive home, there would have been no immediate way of emergency responders knowing how many pills were taken since the Medication Discharge Summary did not document the quantity of each medication given.
c) Resident #14
A record review for Resident #14 showed the resident had current physician's orders for a soft helmet when out of bed in a chair, a current order for Hipsters on at all times and a current order for Geri sleeves to bilateral arms.
A review of facility documentation showed Resident #14 had been reported to have had 10 falls recorded from January 2021 through the review period of 10/06/21.
An observation made on 10/04/21 at 02:14 PM , revealed Resident #14 seated in the wheelchair in the resident's room. Resident #14 was not observed to have the soft helmet, the Geri sleeves or the Hipsters in place.
An interview with the Assistant Director of Nursing (ADON), on at 10/04/21 at 2:30 PM, verified Resident #14 did not have the devices in place to prevent injury due to falling. The ADON applied the helmet during the interview and stated the Geri sleeves and Hipsters would be applied as ordered.
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 and interview, the facility failed to provide oxygen therapy in accordance with professional standards and practices. The facility failed to ensure the flow rate of oxygen was a...
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Based on observation and interview, the facility failed to provide oxygen therapy in accordance with professional standards and practices. The facility failed to ensure the flow rate of oxygen was administered in accordance with physician's orders. This failed practice had the potential to affect one (1) of two (2) residents receiving oxygen therapy. Resident identifier: Resident #35. Census: 78
Findings included:
An observation on 10/04/21 at 3:09 PM , revealed Resident #35 receiving oxygen (O2) at 4 liters per minute.
An interview on 10/04/21 at 3:26 PM, with Licensed Practical Nurse (LPN) #111 verified the O2 flow rate was set at 4 liters per minute.
A record review for Resident #35 showed the resident had current physician orders for the oxygen flow rate to be 2 liters per minute and not the 4 liters that had been observed and verified with staff.
An interview with the Assistant Director of Nursing on 10/05/21 at 2:38 PM verified it was the facility policy to provide the correct flow rate and verified O2 should be administered in accordance with physicians orders.
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CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected multiple residents
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b) Resident #13
A review of the facility Grievance / Complaint log from 01/01//21 thru 10/04/21 found a grievance / complaint form dated 05/12/21 filed by Resident #13. The description of the compla...
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b) Resident #13
A review of the facility Grievance / Complaint log from 01/01//21 thru 10/04/21 found a grievance / complaint form dated 05/12/21 filed by Resident #13. The description of the complaint was Certified Nursing Assistant (CNA) #39 was rough when doing care, pulled and tugged on Resident #13's bad arm when providing incontinence care and bed mobility. The complaint was signed by the Administrator on 05/24/21.
The Director of Nursing (DON) met with Resident #13 to discuss the complaint, asked the following questions, and documented receiving the following answers:
-QUESTION: When the CNA assists with turning and positioning you in bed, does this cause any pain or discomfort? ANSWER: Yes. In attempts to turn me on my side, back and forth in bed, the CNA either pushes or pulls on my body. Pushing leaving red marks or pulls on stroke arm.
-QUESTION: When care is provided do you feel the CNA is using the appropriate action to prevent discomfort/pain? ANSWER. No.
-QUESTION: Does CNA announce self? ANSWER: Does not announce self. Sometimes I am startled out of a sleep. Second time it has happened.
The Social Worker met with Resident #13 to discuss the complaint and recorded the following details. Resident #13 told the Social Worker CNA #39 was rough when doing care. Resident #13 explained CNA #39 pulled and tugged on resident's bad arm. Resident #13 said the CNA was reminded it was his bad arm. Additionally, while changing Resident #13, the CNA would flop him from side to side which also hurts resident's bad arm.
Review of the facility's reportables revealed no evidence of the allegation being reported to state agencies as required.
The quarterly Minimum Data Set (MDS) assessment, with an assessment reference date (ARD) of 04/08/21, revealed Resident #13 required substantial/maximal assistance of staff to roll from lying on back to left and right side, and return to lying on back on the bed.
During an interview with the Administrator, on 10/06/21 at 11:40 AM, Surveyor questioned if Resident #13 reported it hurt when CNA #39 provided care why was it not reported. The Administrator stated he would have to get with the DON who was involved to clarify.
On 10/06/21 at 11:50 PM, the Social Worker stated, I cannot explain why that was not reported.
The DON, on 10/06/21 at 12:10 PM, reported CNA #39 was a new employee and had only worked a few weeks when Resident #13 expressed a complaint. The DON went on to explain CNA #39 was re-educated and Resident #13 didn't want anyone to get into trouble or get fired. The DON acknowledged any and all allegations should be reported to state agencies.
c) Resident #76
A review of the facility Grievance / Complaint log from 01/01/21 thru 10/04/21 found a grievance / complaint form dated 07/08/21 filed by Resident #76. The description of the complaint was Resident #76 was upset with night shift and had reported, At 5:00 AM I asked CNA twice for bed pan. They continued taking care of my roommate and ignored me. At 5:30 AM they came back in and complained that I had wet the bed. I was very angry because I felt that it was their fault. The complaint was signed by the Administrator on 07/23/21.
Review of the facility's reportables revealed no evidence of the allegation being reported to state agencies as required.
The quarterly MDS assessment, with an ARD of 06/17/21, revealed a Brief Interview for Mental Status (BIMS) score of 15 indicating Resident #76 was cognitively intact.
During an interview with the Administrator, on 10/06/21 at 11:42 AM, Surveyor questioned why the facility did not report the allegation. The Administrator responded by stating Resident #76 has a history of being accusatory.
On 10/06/21 at 11:50 PM, the Social Worker stated, I cannot explain why that was not reported.
d) Resident #71
Review of Resident #71's reportable incident showed Resident #71 had an unwitnessed fall on 8/7/21. Resident #71 was found on the floor in their room with a large laceration above the right side of their forehead. A large amount of blood was noted on Resident #71 and the surrounding area. Resident #71 was transported to (Name of local hospital). Resident was treated and required 12 staples to close the laceration.
Resident had a fall with a major injury on Saturday 08/07/21 and the Reportable was not completed until Monday 08/09/21. During an interview with the administrator on 10/06/21 at 10:20 AM, the administrator indicated the reportable was not completed within two (2) hours because, With the interpretation of the section of reporting an incident of a major injury, report only if the person fell with a fracture and report within two hours. This directive was per the facility's legal team. The legal team however did tell the administrator to go ahead and report Resident #71's incident even though it was not a fracture.
The administrator also stated, the legal team indicated it did not need to be reported within two hours because it was not a fracture. The Administrator stated, another facility within the company had an issue with reporting so, the Legal Team then made all facilities report the same way. Only report within two hours if its a fall with fracture. The incident involving Resident #71 was not reported in a two hour time frame because it was not a fracture.
The Administrator was asked on 10/06/21 at 11:15 AM to provide the guidance they used for reporting. The Administrator stated, I was advised to go by the Office of Health Facility Licensure and Certification Long Term Care Nursing Home Program Reporting Requirements dated 12/14/19.
Based on staff interview, document review of the facility's concern log and review of two (2) of four (4) residents reviewed for falls, the facility failed to report injuries in a timely manner. The failed practice was true for four (4) of nine (9) residents reviewed for falls and selected from the concern log. Resident identifiers: #7, #13, #71 and #76. Facility census: 78.
Findings included:
a) Resident #7
Record review of a nursing progress note and fall note both dated 12/09/20 showed Resident #7 had a fall on 12/06/20 at 10:34 AM. An x-ray was completed on 12/09/20 and showed Resident #7 had an acute distal femoral shaft impaction fracture, moderate size suprapatellar hemarthrosis.
Record review of the facility's December 2020 Reportables revealed, Resident #7's serious bodily injury of an acute distal femoral shaft impaction fracture was not reported.
During an interview on 10/06/21 at 11:45 AM, the Social Worker (SW), stated, any fall with major injury should be reported. SW stated, job requirements in the facility do not allow the social worker to report falls with major injuries or broken bones. SW stated, only the Director of Nursing (DON) or the Administrator reported the cases with serious bodily injuries.
During an interview on 10/06/21 at 12:05 PM, the Administrator, stated, no reportable was available for Resident #7 in December 2020. Administrator stated, being unaware of having to report cases with serious bodily injury and stated in December 2020 the facility did not have to report those cases. Administrator provided Surveyor a document titled, Long Term Care Nursing Home Program Reporting requirement dated for 12/04/19 that stated, report serious bodily injury to the Office of Health Facility Licensure and Certification (OHFLAC) and Adult Protective Services (APS) within two (2) hours of incident. Administrator stated, when the guidance came out the facility met with legal council and it was after the legal council consult that falls with major injuries began to be reported.
A document review of an administrative typed note dated 05/12/21 was provided by the Administrator for review. The administrative note showed, all incidents of falls resulting in a fracture or broken bones would need to be reported as a serious bodily injury within 2 hours of the incident. If a fall occurs with no immediate sign of serious bodily injury but later the x-ray revealed a fracture the timeline will begin with results.
During an interview on 10/06/21 at 12:51 PM, the Administrator, stated, the administrative note was discussed in Quality Assurance and Performance Improvement (QAPI) and education provided to staff to report all falls resulting in fracture or broken bones would need to be reported within 2 hours of incident. The Administrator, stated, as of 05/12/21 the facility began reporting all falls resulting in fracture or broken bones as a serious bodily injury. Administrator acknowledged the Long Term Care Nursing Home Program Reporting requirement dated for 12/04/19 was two (2) years old but stated the facility only began reporting falls with serious bodily injuries as of 05/12/21.
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CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Staffing Information
(Tag F0732)
Could have caused harm · This affected multiple residents
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Based on observation and staff interview the facility failed to ensure staffing information was for the correct date and was readily accessible to all residents in the facility. This was a random op...
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Based on observation and staff interview the facility failed to ensure staffing information was for the correct date and was readily accessible to all residents in the facility. This was a random opportunity for discovery. The failed practice had the potential to affect more than a limited number of residents currently residing in the facility. Facility census 78.
Findings included:
a) Daily Staff Posting
An observation, on 10/05/21 at 12:35 PM, revealed a daily staff posting dated 10/04/21 hung on the bulletin board near the nurses station on the 100 hall.
There was no daily staff posting was available for the 200 hall or 300 hall.
During an interview on 10/05/21 at 12:40 PM, the Director of Nursing (DON), stated, we had only been posting the staffing information at the front entrance of the facility. DON stated, the facility had a mock survey last week and it was recommended that daily staff postings be posted at all nurses stations so everyone could see the information. The DON stated, the facility had just failed to follow the recommendations of the mock survey by not posting or updating the daily staff postings where everyone could see the information. The DON also agreed the date of the posting on the 100 hall was for 10/04/21 and not up to date.
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CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0804
(Tag F0804)
Could have caused harm · This affected multiple residents
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Based on interview and observation, the facility failed to serve food at a safe palatable temperature. The facility was using a thermometer to test food temperatures which was inaccurate by 24 degre...
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Based on interview and observation, the facility failed to serve food at a safe palatable temperature. The facility was using a thermometer to test food temperatures which was inaccurate by 24 degrees. This practice had the potential to affect more than an isolated number of residents. Facility Census 78
Findings included:
A review of the facilities policy titled Calibrating Thermometers with revision date 05/03/21
states, Thermometers should be calibrated routinely and as needed (i.e.,after extreme temperature change,
or after dropping) to ensure accurate measurement of temperatures.
a) Test Tray Temperatures
During this survey some residents voiced cold food concerns.
Test trays were done on 100 Hall for both tray carts.
On 10/04/21 at 12:44 PM Test Tray for 100 Hall second Cart to 100 hall came on the hall at 12:06 PM. At 12:36 PM the Dietary Manager obtained the temperatures of the last tray on the cart at the time of service the following temperatures were obtained:
-- Nectar Coffee 137 degrees
-- Pureed Fruit 80.2 degrees
-- Chicken 140.2 degrees
-- Mashed Potatoes 132 degrees and
-- Cauliflower 134 degrees.
On 10/05/21 at 12:31 p.m. the DM obtained the temperatures on the last tray on the 100 hall cart at the time of the service and obtained the following temperatures:
-- Hot Chocolate 147 degrees
-- Lasagna 156 degrees
-- Mixed Vegetables 130 degrees
-- Fortified Mashed Potatoes 137 degrees
On 10/5/21 at 12:40 PM the DM came to this Surveyor with a full glass of ice water with all thermometers from Kitchen in the glass. The DM wanted to show the surveyor that the thermometer which had been used for obtaining the temperatures on the test trays on 10/04/21 and 10/05/21 needed to be calibrated and that is why the cold food were not at the appropriate temperature. The thermometer was inaccurate by 24 degrees and all food temperatures obtained on 10/04/21 and 10/05/21 would have been 24 degrees cooler than the temperatures obtained.
Considering this the following would be the true and accurate temperatures obtained:
Temperatures obtained on 10/04/21 were :
-- Nectar Coffee 137 degrees adjusted temperature 113 degrees.
-- Pureed Fruit 80.2 degrees adjusted temperature 56.2 degrees.
-- Chicken 140.2 degrees adjusted temperature 116.2 degrees.
-- Mashed Potatoes 132 degrees adjusted temperature 108 degrees, and
-- Cauliflower 134 degrees adjusted temperature 110 degrees.
Temperatures obtained on 10/05/21 were:
-- Hot Chocolate 147 degrees adjusted temperature 123 degrees.
-- Lasagna 156 degrees adjusted temperature 132 degrees.
-- Mixed Vegetables 130 degrees adjusted temperature 106 degrees.
-- Fortified Mashed Potatoes 137 degrees adjusted temperature 113 degrees.
When the DM was asked how often the thermometer should be calibrated she stated, I guess when I realized the temperatures were not reading right it should have been calibrated.
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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 and interview the facility failed to store, prepare and serve foods in accordance with professional standards for food service safety. This practice had the potential to affect ...
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Based on observation and interview the facility failed to store, prepare and serve foods in accordance with professional standards for food service safety. This practice had the potential to affect a more than a limited number of residents who receive nutrients from the kitchen. Facility Census 78
Findings include:
a) Food Service
On 10/04/21 at 8:53 AM during the initial tour of the kitchen with the dietary manager(DM) #16 the following issues were found:
-- A measuring cup on a shelf containing a white substance. The measuring cup was not covered or labeled to identify the contents or how long it had been there. The DM indicated the white substance was food thickener and it needed to be discarded because it was not covered or labeled.
-- Inside the walk in freezer was opened polish sausage with no date to indicate when the item was opened or when it should be discarded. The DM agreed the polish sausage needed to be discarded.
An observation of the 100 hall pantry refrigerator at 9:10 am on 10/04/21 found an opened box containing egg rolls which was not dated to indicate when it was opened. Also there were two (2) boxes of chicken [NAME] which was not labeled to indicate who it belonged to or when it was placed in the refrigerator. The DM agreed the items needed to be discarded.
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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
- "What changes have you made since the serious inspection findings?"
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • 44% turnover. Below West Virginia's 48% average. Good staff retention means consistent care.
Concerns
- • Multiple safety concerns identified: 1 life-threatening violation(s). Review inspection reports carefully.
- • 51 deficiencies on record, including 1 critical (life-threatening) violation. These warrant careful review before choosing this facility.
- • $15,593 in fines. Above average for West Virginia. Some compliance problems on record.
- • Grade F (36/100). Below average facility with significant concerns.
Bottom line: Trust Score of 36/100 indicates significant concerns. Thoroughly evaluate alternatives.
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About This Facility
What is Berkeley Springs Healthcare Center's CMS Rating?
CMS assigns BERKELEY SPRINGS HEALTHCARE CENTER 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 Berkeley Springs Healthcare Center Staffed?
CMS rates BERKELEY SPRINGS HEALTHCARE CENTER's staffing level at 3 out of 5 stars, which is average compared to other nursing homes. Staff turnover is 44%, compared to the West Virginia average of 46%. This relatively stable workforce can support continuity of care.
What Have Inspectors Found at Berkeley Springs Healthcare Center?
State health inspectors documented 51 deficiencies at BERKELEY SPRINGS HEALTHCARE CENTER during 2021 to 2025. These included: 1 Immediate Jeopardy (the most serious level, indicating potential for serious harm or death) and 50 with potential for harm. Immediate Jeopardy findings are rare and represent the most serious regulatory concerns. They require immediate corrective action.
Who Owns and Operates Berkeley Springs Healthcare Center?
BERKELEY SPRINGS HEALTHCARE CENTER is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility is operated by COMMUNICARE HEALTH, a chain that manages multiple nursing homes. With 120 certified beds and approximately 99 residents (about 82% occupancy), it is a mid-sized facility located in BERKELEY SPRINGS, West Virginia.
How Does Berkeley Springs Healthcare Center Compare to Other West Virginia Nursing Homes?
Compared to the 100 nursing homes in West Virginia, BERKELEY SPRINGS HEALTHCARE CENTER's overall rating (2 stars) is below the state average of 2.7, staff turnover (44%) is near the state average of 46%, and health inspection rating (2 stars) is below the national benchmark.
What Should Families Ask When Visiting Berkeley Springs Healthcare Center?
Based on this facility's data, families visiting should ask: "What changes have been made since the serious inspection findings, and how are you preventing similar issues?" "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 facility's Immediate Jeopardy citations.
Is Berkeley Springs Healthcare Center Safe?
Based on CMS inspection data, BERKELEY SPRINGS HEALTHCARE CENTER has documented safety concerns. Inspectors have issued 1 Immediate Jeopardy citation (the most serious violation level indicating risk of serious injury or death). The facility has a 2-star overall rating and ranks #100 of 100 nursing homes in West Virginia. Families considering this facility should ask detailed questions about what corrective actions have been taken since these incidents.
Do Nurses at Berkeley Springs Healthcare Center Stick Around?
BERKELEY SPRINGS HEALTHCARE CENTER has a staff turnover rate of 44%, 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 Berkeley Springs Healthcare Center Ever Fined?
BERKELEY SPRINGS HEALTHCARE CENTER has been fined $15,593 across 1 penalty action. This is below the West Virginia average of $33,235. While any fine indicates a compliance issue, fines under $50,000 are relatively common and typically reflect isolated problems that were subsequently corrected. Families should ask what specific issues led to these fines and confirm they've been resolved.
Is Berkeley Springs Healthcare Center on Any Federal Watch List?
BERKELEY SPRINGS HEALTHCARE CENTER is not on any federal watch list. The most significant is the Special Focus Facility (SFF) program, which identifies the bottom 1% of nursing homes nationally based on persistent, serious quality problems. Not being on this list means the facility has avoided the pattern of deficiencies that triggers enhanced federal oversight. This is a positive indicator, though families should still review the facility's inspection history directly.