SHENANDOAH CENTER
For profit - Corporation
78 Beds
GENESIS HEALTHCARE
Data: November 2025
3 Immediate Jeopardy citations
Trust Grade
0/100
#115 of 122 in WV
Photo by Shenandoah Center
Photo by Shenandoah Center
Photo by Shenandoah Center
1 / 5 photos
Last Inspection: July 2024
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
Shenandoah Center in Charles Town, West Virginia has received a Trust Grade of F, indicating poor performance with significant concerns. It ranks #115 out of 122 facilities in the state, placing it in the bottom half, and #3 out of 3 in Jefferson County, meaning only one local option is better. The facility's situation is worsening, with reported issues increasing from 3 in 2023 to 22 in 2024. While RN coverage is good, surpassing 95% of state facilities, staffing itself is below average with a 55% turnover rate, which is concerning. There have been serious incidents, including a resident being physically abused by a staff member and another receiving an incorrect insulin injection, both of which posed immediate risks to their health and safety.
- Trust Score
- F
- In West Virginia
- #115/122
- Safety Record
- High Risk
- Inspections
- Getting Worse
- Staff Stability ⚠ Watch
- 55% turnover. Above average. Higher turnover means staff may not know residents' routines.
- Penalties ○ Average
- $48,469 in fines. Higher than 71% of West Virginia facilities. Some compliance issues.
- Skilled Nurses ✓ Good
- Each resident gets 52 minutes of Registered Nurse (RN) attention daily — more than average for West Virginia. RNs are trained to catch health problems early.
- Violations ⚠ Watch
- 60 deficiencies on record. Higher than average. Multiple issues found across inspections.
0/100
Bottom 6%
Review needed
3 → 22 violations
★☆☆☆☆
1.0
Overall Rating
★★☆☆☆
2.0
Staff Levels
★★★★☆
4.0
Care Quality
★☆☆☆☆
1.0
Inspection Score
↔
Stable
2023: 3 issues
2024: 22 issues
The Good
-
4-Star Quality Measures · Strong clinical quality outcomes
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
Facility shows strength in quality measures, fire safety.
The Bad
1-Star Overall Rating
Below West Virginia average (2.7)
Significant quality concerns identified by CMS
Staff Turnover: 55%
Near West Virginia avg (46%)
Higher turnover may affect care consistency
Federal Fines: $48,469
Above median ($33,413)
Moderate penalties - review what triggered them
Chain: GENESIS HEALTHCARE
Part of a multi-facility chain
Ask about local staffing decisions and management
The Ugly 60 deficiencies on record
3 life-threatening 1 actual harm
Jul 2024
22 deficiencies
3 IJ (1 affecting multiple)
CRITICAL
(J)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Immediate Jeopardy (IJ) - the most serious Medicare violation
Free from Abuse/Neglect
(Tag F0600)
Someone could have died · This affected 1 resident
.
Based on record review and staff interview, the facility failed to provide an environment free from abuse and/or neglect from staff or other residents.
Resident #123 was physically abused by Licens...
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Based on record review and staff interview, the facility failed to provide an environment free from abuse and/or neglect from staff or other residents.
Resident #123 was physically abused by Licensed Practical Nurse (LPN) #91. This created an immediate jeopardy situation. The LPN admitted to losing her temper and backhanding a combative resident. The facility took all appropriate steps after the situation including terminating the LPN. This issue is being cited as past noncompliance.
Resident #23 was neglected by Nurse Aide (NA) #94.
These were random opportunities for discovery. Resident identifiers: #123, and #23. Facility Census: 71.
Findings included:
a) Resident #123
A record review on 07/25/24 at 12:30 PM of a Complaint #29751 revealed an incident where a Licensed Practical Nurse (LPN) #91 had struck Resident #123 in the face on 11/09/23 at approximately 11:30 PM.
Further record review revealed at the time of this incident Nurse Aides (NA) #45 and #55 were attempting to provide incontinence care to Resident #123. During care Resident #123 became combative with the NA. At this time, LPN #91 attempted to administer medication and water to the resident. Resident #123 spit at the LPN #91 and knocked the water out of her hands, and LPN #91 backhanded Resident #123(Typed as written.).
On 07/25/24 at 1:00 PM, an interview with the Administrator was held. The Administrator stated, I was not here but I do know about the incident. On 07/25/24 at 1:05 PM, the Administrator provided all paperwork in regards to this event.
The immediate fax reporting of the incident was dated 11/10/23 stating, I, (Name of previous Director of Nursing) received a call on 11/09/23 at 11:21 PM from CNA (certified nursing assistant) #94 reporting that another CNA #92 witnessed a nurse hit a resident in his room around 10:40 PM. I began to get dressed to head into the facility and I placed a call to the administrator, (Name of previous Administrator), as well as the facility social services director, (Name of social services director). (Name of social services director) and I agreed to meet at the facility to interview the staff and determine the situation. I arrived to the facility around 11:45 PM with (Name of social services director) and we began interviewing staff. We began by interviewing NA #92, followed by NA #45, NA #94, and then interviewed LPN #91. (Typed as written.)
NA #92 stated that she went to assist NA #45, LPN #91 and NA #55 with incontinence care for the Resident #123. NA #92 states the resident kicked NA #55 and when she entered the room, NA #55 was laying on the floor, crying in pain. NA #92 states she was assisting with changing the resident, NA #45 held his hands to prevent him from hitting, and NA #92 changed his brief. LPN #91 attempted to administer medications to the resident and the resident spit them out at her. The resident then allegedly attempted to hit LPN #91, and LPN #91 then reportedly pulled her arm back and struck the resident in the right side of his face while he was in bed. At this time, there were 3 (three) CNAs present in the room. NA #92, NA #55 and NA #45. NA #92 was the CNA that reported this incident by phone call at 11:21 PM to me. (Typed as written.)
'During the interview with LPN #91, LPN #91 admitted to myself and (Name of social services director) that she did lose her temper and backhanded him with an open fist. Upon completion of interviews, I counted both the narcotic drawers with LPN #91, walked her to the time clock and out of the building. (Typed as written.)
All state agencies, OHFLAC, Ombudsman, APS, Law Enforcement were notified of the incident. The immediate action to protect the resident(s) listed were investigation initiated, perpetrator suspended and Law Enforcement notified.
The five (5) day follow-up was dated 11/13/23.
The statement was completed by the previous Administrator, which stated, (Name of Resident #123) is a (age) (sex) admitted into the (Name of facility) with the following diagnosis: non-st elevation myocardial infarction, type 2 (two) diabetes, transient cerebral ischemic attack, hypertensive heart and chronic kidney disease with heart failure and with stage 5 (five) chronic kidney disease or end stage renal disease, personal history of transient ischemic attack and cerebral infarction without residual deficits, cerebral infarction, muscle weakness, lack of coordination, atherosclerotic heart disease of native coronary artery with unspecified angina pectoris, dementia, repeated falls, cardiomyopathy, weakness, osteoarthritis, proteinuria, chronic systolic heart failure, anemia in chronic kidney disease, benign prostatic hyperplasia without lower urinary tract symptoms, pain, hyperlipidemia, chronic kidney disease stage 3B, difficulty in walking and unspecified fall. (Typed as written.)
Resident is receiving the following medications: Milk of Magnesia, Atorvastatin, Aspirin, Docusate, Clopidogrel, Carvedilol, Famotidine, Mirtazapine, Flomax, Quetiapine and Acetaminophen. (Typed as written.)
An assessment completed on November 1, 2023 showed a BIMS (Brief Interview for Mental Status) score of 8 (eight) and a PHQ9 (Patient Health Questionnaire 9) of 0 (zero). The resident does not have capacity and (Name of Medical Power of Attorney) and was notified of the incident. (Typed as written.)
On November 9, 2023, at approximately 11:00 pm, the Director of Nursing, (Name of the Director of Nursing), was contacted and it was reported to her that a CNA witnessed LPN, #91, strike a resident in the face. Witness statement obtained from CNA #92, reported that while staff were attempting to provide care to the resident, the resident became combative and kicked another CNA who fell to the floor and had to be sent to the ER (emergency room) via ambulance. During the incident, the LPN attempted to give the resident water. The resident spit at the LPN and the LPN subsequently struck the resident in the face. The LPN admitted to striking the resident during her interview. (Typed as written.)
The Director of Nursing Services and the Director of Social Services entered the building to obtain statements and a report was made to OHFLAC (Office of Health Facility Licensure and Certification), APS (Adult Protective Services) ,Ombudsman and WV State Police (Incident #23-230449). The LPN was suspended pending investigation. (Typed as written.)
A report was made to the [NAME] Virginia LPN board by the Director of Nursing on November 10, 2023. (Typed as written.)
Skin check was performed on the resident following incident by the Director of Nursing, with no injuries observed. Skin checks were performed on November 11, 2023, by RN, on all non interviewable residents with no indicators of abuse found. (Typed as written.)
Interviewable residents were interviewed by the Recreation Director on November 11, 2023, asking if they were ever subjected to any form of abuse or witnessed any form of abuse, with none reported. (Typed as written.)
Re-education, with a post test, has been initiated with all employees regarding the process of reporting abuse as well as how to deal with a combative resident who is refusing care. (Typed as written.)
Medical Director ordered labs and a UA (urinalysis) on resident on November 10, 2023. (Typed as written.)
Based on the above, the allegation of abuse is substantiated. The LPN's employment is being terminated with the (Name of the facility) effective immediately. (Typed as written.)
A review of the facility policy, entitled Abuse Prohibition, was completed on 07/26/24. The Federal Definition of physical abuse includes hitting, slapping, pinching, kicking, etc., as well as controlling behavior through corporal punishment. (Typed as written.)
The surveyor interviewed various staff members on 07/26/24 at 10:00 AM from nursing and housekeeping regarding education on abuse. They knew the definitions of abuse and when to report. They also indicated they knew what to do if they became frustrated with a resident. This education was done to prevent other instances of physical abuse from staff to residents.
The State agency determined these failures placed the residents in an immediate jeopardy (IJ) situation for past non-compliance due to the potential of serious injury and/or death as a result of documented physical abuse by staff to a resident.
The State agency notified the Nursing Home Administrator of the immediate jeopardy at 2:17 PM on 07/25/24. The State agency verified the facility had completed their in-house plan on 12/09/23, which was verified by conducting staff interviews and providing education regarding abuse, on 07/26/24 at 10:00 AM.
b) Resident #23
According to a facility reported incident, on 04/07/24, it was alleged by Nurse Aide (NA) #62 that NA #94 left Resident #23 and his bed soiled with vomit, feces, and urine. NA #62 stated she noticed Resident #23 had vomit on his pants, dried feces on his legs, and his bed was soiled with urine and feces.
According to NA #62, NA #94 stated Resident #23 had thrown up and had vomit on his shirt and he had not changed the resident. An interview was conducted with Licensed Practical Nurse (LPN) #68, the nurse assigned to Resident #23 that night. LPN #68 confirmed Resident #23 was heavily soiled and had not been changed. According to a statement from NA #94, he did not change Resident #23 because he was attempting to use common sense by not waking up the resident due to the possibility of him becoming combative while receiving care.
The facility substantiated the allegation of abuse and terminated NA #94 on 04/12/2024. NA #94 did not return to work after being suspended pending investigation.
They did not have evidence of any education to the other staff or any other actions/plans to prevent recurrence of a situation like this.
CRITICAL
(J)
Immediate Jeopardy (IJ) - the most serious Medicare violation
Deficiency F0760
(Tag F0760)
Someone could have died · This affected 1 resident
.
Based on resident interview and record review the facility failed to ensure Resident #65 was free from significant medication errors. Resident #65 was administered an injection of 25 units of insuli...
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Based on resident interview and record review the facility failed to ensure Resident #65 was free from significant medication errors. Resident #65 was administered an injection of 25 units of insulin on 04/19/24 when the resident was not ordered any insulin nor was he a diabetic.
Giving a resident an insulin injection when they are not ordered the medication, nor a diabetic can cause serious consequences including serious harm and or death. The state agency (SA) determined this to be an Immediate Jeopardy (IJ) situation. The facility was notified of the IJ on 07/22/24 at 6:49 PM. The SA accepted the facility's Plan of Correction (POC) on 07/22/24 at 7:40 PM. After completing observations, record reviews, and staff interviews regarding the implementation of the POC the IJ was abated at 07/23/24 at 2:30 pm.
This failed practice was a random discovery and was true for Resident #65, but due to the systemic failures the failed practice had the potential to affect more than a limited number of residents. Resident identifier: 65. Facility Census: 71.
Findings include:
a) Resident #65
During an interview on 07/22/24 at approximately 3:45 PM, Resident #65 stated back in April 2024 a male nurse who he was unable to recall their name gave him an insulin shot and he was not a diabetic. The resident continued to state, the nurse did not verify who they were giving the insulin shot to.
Record review revealed a progress note dated 04/19/24 which read as follows: Resident was administered with 25 units of Lantus at 9pm by error. Residents had a room change from this shift from 401A to 107. Resident BS before the insulin was administered was 135. Resident was notified and he was upset because he was given the wrong medication. He said he never took any medications till he was admitted to the facility. On- call Dr called and initial orders were given to monitor resident BS Q for 15 minutes. Resident refused to have his blood sugar checked. At 10:30 after speaking to his wife he allowed a BS check and it was 118. On- Call (Dr Name) was notified and gave orders to check Blood Sugar (BS) at 5AM and Q shift for tomorrow.
The facility was unable to provide any documentation to prove they investigated and or implemented any process to ensure this failure never occurred again.
Further record review revealed the following change in condition Situation:
At the time of evaluation resident/patient vital signs, weight and blood sugar were:
- Blood Pressure: BP 112/75 - 4/19/2024 21:08 Position: Lying l/arm
- Pulse: P 78 - 4/19/2024 21:08 Pulse Type: Regular
- RR (respirations): R 18 - 4/19/2024 21:10
- Temp (Temperature): T 97.7 - 4/19/2024 21:10 Route: Forehead (non-contact)
- Weight: W 198.6 lb. - 4/10/2024 08:23 Scale: Wheelchair
- Pulse Oximetry: O2 97.0 % - 4/18/2024 22:59 Method: Room Air
- Blood Glucose: BS 118 - 4/19/2024 22:30
Nursing observations, evaluation, and recommendations were :No changes noted to resident at this time, will continue to monitor for changes.
Primary Care Provider Feedback: Primary Care Provider responded with the following feedback: Recheck Blood Sugar at 5:00 AM and every shift tomorrow. Continue to monitor all shifts.
During an interview with LPN#66 the LPN at approximately 4:30 PM stated, they had gotten report on a different resident and when he went to give the meds he didn't verify because he didn't know the residents had switched rooms.
An interview on 07/22/24 at approximately 6:00 PM with the facility Administrator revealed at the time of the error a one-to-one education/competency was completed with LPN#66 on 06/19/24, the error occurred on 04/19/24, at this time the DON stated LPN#66 is not full time and works part time or as needed.
b) Facility Plan of Correction
The facilities Plan of Correction (POC) read as follows.
The licensed nurse conducted a change in condition on 04/19/24 with notification to the medical provider for Resident#65.
All residents of the facility have the potential to be affected.
The Nurse Educator conducted an audit on 07/22/2024 of all licensed nurse's medication administration competencies to ensure all licensed nurses are competent with medication administration within the last 12 months with any corrective action immediately upon discovery.
The Administrator/Designee conducted an audit on 07/22/2024 for all residents to ensure they had a photo identification on the eMar with any corrective action immediately upon discovery. No residents were identified.
Re-education as provided by the DON/Designee to all licensed nurses starting on 7/22/24 on safe medication administration practices including verification of correct: Patient, drug, route, dose, time, special considerations, and expiration date with a POST test to validate understanding. Any licensed nurse not available during this time frame will be provided re-education, including post-test and return demonstration by DON/Designee prior to the beginning of the next shift to work.
New licensed nurses will be provided education, including post-test during orientation by DON/Designee. Annual in-servicing will be provided to licensed nurses regarding medication administration.
The unit managers(UM)/Designee will conduct observations starting on 7/22/24 to ensure all licensed nurses are passing medications with verification of right person, drug, route, dose, time, special considerations, and expiration dates across all shifts for two weeks, including holidays, then five times a week for four weeks, then three times a week for four weeks, then randomly thereafter.
Results of observations will be reported by the UM/designee monthly to the Quality Improvement Committee(QIC) for any additional follow-up and or in-servicing until the issue is resolved, then randomly thereafter determined by the QIC committee.
A review of the facility POST test was reviewed on 07/23/24 at 11:00 AM:
The following Licenses nurses were interviewed and confirmed they had got the training and took the posttest and understood what was being educated to them.
~Registered Nurse(RN)#31
~RN#20
~RN#13
~RN#21
~LPN#35
~LPN#48
~LPN#50
~LPN#52
IJ was abated 07/23/24 at 2:30 PM
CRITICAL
(K)
Immediate Jeopardy (IJ) - the most serious Medicare violation
Deficiency F0698
(Tag F0698)
Someone could have died · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on record review, observation and staff interview the facility failed to ensure Resident #9 who requires dialysis receiv...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on record review, observation and staff interview the facility failed to ensure Resident #9 who requires dialysis received such services, in accordance with professional standards of practice. Resident #9 had an arteriovenous (AV) fistula in their left arm. The facility on multiple occurrences documented they were obtaining the residents blood pressure in their left arm.
Obtaining blood pressure in the arm where the AV fistula is located may result in clots, clots that can dislodge, loss of use of the fistula and could cause a stroke. All of these things put the resident in an immediate risk of serious injury and/or death.
The state agency (SA) determined this failure to be an immediate jeopardy (IJ) situation. The facility was notified of the IJ on 07/25/24 at 11:09 am. The SA accepted the facility's plan of correction (POC) on 07/25/24 at 1:15 PM.
After observation of implementation of the POC the IJ was abated at 3:30 PM on 07/26/24. After the immediacy was removed a deficient practice remained for Resident #9 in regard to the completion of Post dialysis assessments at which time the Scope and severity was decreased form a K to an E.
These failed practices were true for one (1) of one (1) residents reviewed for the care area of dialysis during the long term care survey process. Resident Identifier: #9. Facility Census: #71.
Findings include:
a) Resident #9
A review of Resident #9's medical record on 07/25/24 at approximately 10:00 am found the following physician order:
A review of Resident #9's electronic medical record on 07/25/24 found under the blood pressure vital signs tab the following dates and times when facility staff documented they had taken Resident #9's blood pressure in his left arm:
-- 12/16/23 at 2:25 PM
-- 12/18/23 at 11:53 AM
-- 01/10/24 at 9:30 AM
-- 05/14/24 at :48 PM
-- 05/26/24 at 2:41 AM
-- 05/28/24 at 6:36 PM
-- 05/29/24 at 6:25 PM
-- 06/08/24 at 11:53 AM
-- 06/09/24 at 5:40 PM
-- 06/20/24 at 11:26 AM
-- 06/21/24 at 1:27 PM
-- 06/22/24 at 11:57 PM
-- 06/23/24 at 10:42 PM and
-- 06/25/24 11:50 PM.
Continued record review on 07/25/24 found an order stating, Monitor AV fistula.graft site to left arm for S/S infection, edema, bleeding and upon return from dialysis, notify primary care physician and dialysis if AV fistula/graft site is bleeding apply pressure for 15 minutes and notify MD/Physician if bleeding does not stop.
Record review of the Dialysis communication book revealed the facility was not completing POST dialysis assessments on Resident #9 after returning from dialysis.
Record review of Residents # 9's care plan revealed the following:
·- Do not take B/P in my left arm due to my AV
- Monitor for s/s of infection, edema, bleeding upon return from dialysis
An observation on 07/25/24 at approximately 10:30 AM, revealed Resident #9 had no signage in room stating not to take BP in left arm
Further observation of Resident #9 found his room and person was void of any signage and/or bracelet which would have brought awareness to the staff that Resident #9 had a restricted limb.
During an interview on 07/25/24 with LPN #68, stated they take blood pressure in the opposite arm of the AV fistula, Record review had previously revealed LPN #68 had documented having taken blood pressure in Resident #9's left arm.
On 07/25/24 at 11:30 AM, The Director of nursing (DON) stated, The orders and care plan should have been followed to not take a B/P in the left arm and complete the POST dialysis assessment in the resident's dialysis book.
b) Facility plan of correction (typed as written):
Resident #9 will be evaluated by the licensed nurse upon return to the facility.
All dialysis residents have the potential to be affected.
The Unit Managers/designee conducted an audit on 07/25/2024 for all residents on
dialysis with specific B/P orders to be taken and POST dialysis assessment is
completed upon return to the facility with any corrective action immediately upon discovery.
The Order for B/P not to be taken in the Left arm on Resident #9 will be added to the
Medication Administration Record in all Capital letters and will be added to the care
plan and [NAME] in capital letters.
The Director of Nursing(DON)/designee will reeducate all nursing staff with a posttest to
validate understanding regarding hemodialysis graft, fistula care, communication, and
documentation (as follows):
Procedure: 1. Verify orders and instructions from hemodialysis facility or hospital, if
patient is a new Admission.
2. Evaluate access site daily and on completion of hemodialysis (HD) or home hemodialysis (HHD) treatment. Observe for signs of complications.
2.1 Inspect fistula site for decrease or absence of vein dilation.
2.2 Palpate for distal thrill.
2.3 Auscultate for bruit.
2.4 Palpate skin around graft/fistula for warmth.
2.5 Evaluate skin around vascular access noting redness, swelling, local
warmth, exudate, tenderness.
3. Observe for presence of fever, chills, hypotension and notify physician/advanced practice provider (APP) and hemodialysis facility staff for.
3.1 Pain, numbness, swelling, redness, odor, bleeding or drainage at site;
3.2 Extreme warmth or coolness of extremity; 3.3 Blebs (ballooning or bulging) of the vascular access site;
3.4 Absence of pulses distal to access site;
3.5 Absence of bruit or thrill.
4. Protect access site from getting wet for several hours after HD or HHD treatment.
5. Avoid trauma or treatment procedures in the accessed extremity, such as:
5.1 Limit activity of extremity,
5.2 Blood pressure measurement,
5.3 Venipuncture, injection of any type,
5.4 Use of creams or lotions on the access site.
6. Instruct patient:
6.1 To avoid excessive pressure on the extremity or strain (e.g., laying on it or lifting heavy object with it).
6.2 In strengthening exercises to enhance blood flow such as squeezing
small rubber ball, if permitted by physician/APP and dialysis facility. 6.3 In proper care of fistula/graft.
7. Document:
7.1 Location of access site on admission assessment;
7.2 Status of access site in Nurses'
7.3 Status of pulses distal to access area;
7.4 Color and temperature of extremity;
7.5 Presence or absence of pain or numbness;
7.6 Status of bruit and thrill;
7.7 Notification and response of physician/APP and dialysis
facility, if indicated;
7.8 Patient education and family involvement; 7.9 Nursing
intervention.
Policy: Center staff will communicate with the certified dialysis facility regarding the
ongoing assessment of the patient's condition by monitoring for complications before
and after hemodialysis (HD) treatments received at a certified dialysis facility.
PURPOSE: To ensure ongoing communication and collaboration with the certified
dialysis facility regarding hemodialysis (HD) patient care and services.
1. Prior to a patient leaving the Center for HD, a licensed nurse will complete the top portion of the Hemodialysis Communication Record, or the state required form and send with the patient to his/her HD facility visit.
2. Following completion of the HD, the dialysis facility nurse should complete and return the form and return it or other communication to the Center with the patient.
3. Upon return of the patient to the Center, a licensed nurse will:
3.1 Review the certified dialysis facility communication;
3.2 Evaluate/observe the patient; and
3.3 Complete the post-hemodialysis treatment section on the Hemodialysis
Communication Record or state required form.
4. Notify the certified dialysis facility if the form is not returned with the patient and ask that it be faxed to the Center.
4.1 Document notification of certified dialysis facility regarding return of form or other
Communication.
5. Maintain the Hemodialysis Communication Record or state required
form in the patient's medical record.
Any licensed nurses not available during this time frame will be provided re-education,
including post-test and return demonstration by DON/designee prior to the beginning of
the next shift to work. New Licensed nurses will be provided education, including
post-test during orientation by the DON/designee. Annual in-servicing will be provided to
licensed nurses regarding medication administration.
The DON/designee will complete medication pass competencies quarterly x 2 quarters
to ensure physician orders are followed including ensuring B/P ' s are not taken in
restricted arm.
The Unit Managers (UM)/Designee will conduct observations starting on 7/25/2024 to
ensure all licensed nurses are taking B/P and the licensed nurse is completing the
dialysis communication sheets POST dialysis daily across all shifts for 2 weeks
including weekends and holidays, then 5 times a week for 4 weeks, then 3 times a
week for 4 weeks, then randomly thereafter.
Results of observations will be reported by the Unit Manager (UM)/designee monthly to
the Quality Improvement Committee (QIC) for any additional follow-up and or
in-servicing until the issue is resolved, then randomly thereafter as determined by the
QIC committee.
SERIOUS
(G)
Actual Harm - a resident was hurt due to facility failures
ADL Care
(Tag F0677)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on resident and staff interview and record review, the facility failed to provide showers and/or bed baths in accordance...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on resident and staff interview and record review, the facility failed to provide showers and/or bed baths in accordance with the residents' preference and/or plan of care. Residents stated the staff preferred to give them bed/sponge baths, rather than a shower, because it is less work. This was true for three (3) of six (6) residents reviewed for the care area of choices and for five (5) of seven (7) residents reviewed for the care area of Activities of Daily Living (ADL) during the long-term care survey process.
For Resident #42 the facility failed to provide a timely transfer from her chair to her bed causing the resident to become agitated and cry out for a period of 30 minutes. This resulted in actual psychosocial harm for Resident #42. Resident # 42 was a random opportunity for discovery. Resident Identifiers: #48, #40, #3, #51, #65, #22, #60, #63 and #42. Facility census: 71.
Findings Include:
a) Resident #42
During a night observation on 07/23/24 at 11:22 PM, Resident #42 was crying and saying over and over, Oh, God help me. Resident #42 would not talk to or acknowledge the surveyor.
During an interview on 07/23/24 at 11:29 PM, Licensed Practical Nurse (LPN) #48 stated, She gets upset because she doesn't like to wait. She is a lift. I have to wait on someone to help me.
Further observation at 11:32 PM, Resident #42 continued to cry out, Oh, God help me. (2) two nurses were sitting at the nurses' station.
The surveyor again went into Resident #42's room. Resident #42 would not talk to the surveyor.
Continued observation at 11:35 PM showed (2) nurses continuing to sit at the nurses' station.
During an interview on 07/23/24 at 11:41 PM, LPN #48 stated, She is like that a lot. She wants to be up all the time. If she doesn't get attended to in a timely manner she gets upset. Unfortunately, the other Certified Nursing Assistant (CNA) is talking to the surveyor and those (2) nurses are doing an admission.
An observation on 07/23/24 at 11:46 PM, found Resident #42 was continuing to cry out.
A final observation at 11:52 PM showed LPN #48 and CNA #39 going into the resident room with the mechanical lift.
b) Resident #48
During an interview with Resident #48 on 07/23/24 at 2:38 PM, he stated, the facility did not honor his request for showers. He stated he was scheduled for a shower two times a week, on Tuesday and Friday. He further stated he had not had a shower for over thirty (30) days.
A review of the resident's minimum data set (MDS) dated [DATE] at 3:20 PM, revealed under MDS Section F0400 for daily preferences, resident had responded to the question:
How important is it to you to choose between a tub bath, shower, bed bath, or sponge bath?
His response was - Somewhat important
Further review of resident's MDS dated [DATE] at 10:37 AM revealed, he had responded to the question:
How important is it to you to choose between a tub bath, shower, bed bath, or sponge bath?
His response was - Very Important
Record review of Resident #48's shower logs revealed the following:
For the month of January 2024, the resident received 13 bed/sponge baths, and no showers.
For the month of February 2024, the resident received 14 bed/sponge baths, and no showers
For the month of April 2024, the resident received two (2) bed/sponge baths, and one (1) shower. It was also noted, one bed/sponge bath was given on 04/03/24 and the next bed/sponge bath was given two (2) weeks later, on 04/17/24.
For the month of May 2024, the resident received 13 bed/sponge baths, and no showers. One bed/sponge bath was given on 05/16/24, and the next was given seven (7) days later, on 05/23/24.
For the month of June 2024, the resident received five (5) bed/sponge baths, and two (2) showers. One shower was given on 06/07/24, and the next bed/sponge bath was given six (6) days later, on 06/13/24. Another bed/sponge bath was given on 06/17/24, and the next bed/sponge bath was given six (6) days later, on 06/23/24. The bed/sponge bath on 06/23/24 was the last bed/sponge bath given for the month of June 2024.
The next bed/sponge bath was given 12 days later, on 07/05/24. A total of seven (7) bed/sponge were given as of 07/24/24.
c) Resident #40
An interview with Resident #40 on 07/23/24 at 2:55 PM, revealed the facility did not honor his request for showers. He stated he was scheduled for a shower two times a week, on Monday and Thursday. He further stated he had not had a shower for over thirty (30) days.
A review of the resident's MDS dated [DATE] at 10:58 AM, revealed under MDS Section F0400 for daily preferences the resident had had responded to the question:
How important is it to you to choose between a tub bath, shower, bed bath, or sponge bath?
Resident's response was - Not very important
Further review of resident's MDS dated [DATE] at 4:10 PM revealed, he had responded to the question:
How important is it to you to choose between a tub bath, shower, bed bath, or sponge bath?
Resident's response was - Somewhat Important
Record review of Resident #40's shower logs revealed the following:
For the month of January 2024, the resident received eight (8) bed/sponge baths, and no showers. The resident received one bed/sponge bath on 01/04/24 and the next bed/sponge bath 11 days later, on 01/15/24. It was further noted his next bed/sponge bath was seven (7) days later on 1/22/24.
For the month of February 2024, the resident received eight (8) bed/sponge baths, and no showers. One bed /sponge bath was given on 02/10/24, and the next bed/sponge bath was given 11 days later on 02/21/24.
For the month of March 2024, the resident received seven (7) bed/sponge baths, and no showers. It was also noted the resident had received no bed/sponge baths, or showers, for eight (8) days, from 03/10/24 to 03/18/24.
For the month of April 2024, the resident received four (4) bed/sponge baths, and no showers. A record review revealed the resident had received no bed/sponge baths or showers for fifteen (15) days, from 04/12/24 to 04/27/24.
For the month of May 2024, the resident received two (2) bed/sponge baths, and no showers. The resident received no bed/sponge baths, or showers for 18 days, from 04/27/24 to 05/15/24. Further, the resident also did not receive bed/sponge baths, or showers for 12 days, from 05/19/24 to 05/31/24.
For the month of June 2024, the resident received seven (7) bed/sponge baths, and one (1) shower. Further record review revealed the resident did not receive a bed/sponge bath, or shower for twelve (12) days, from 05/19/24 to 06/04/24, and for seven (7) days, from 06/13/24 to 06/20/24
For the month of July 2024, the resident received three (3) bed/sponge baths and no showers, as of 07/24/24. The resident received a bed/sponge bath on 07/08/24 and then received a bed/sponge bath ten days later, on 07/18/24. The resident also did not receive a bed/sponge bath, or shower for six (6) days, from 07/18/24 to 07/24/24.
d) Resident #3
An interview with Resident #3 on 07/23/24 at 2:49 PM, revealed the facility did not honor his request for showers. He stated he is scheduled for a shower two times a week, on Wednesday and Saturday. He further stated, he had not had a shower for over thirty (30) days.
A review of the resident's MDS dated [DATE], at 1:19 PM, revealed, under MDS Section F0400 daily preferences were not assessed.
Further review of the resident's MDS dated [DATE] at 4:10 PM revealed, he had responded to the question:
How important is it to you to choose between a tub bath, shower, bed bath, or sponge bath?
His response was - Very Important
Record review of Resident #3's shower logs reveal:
For the month of January 2024, the resident received three (3) bed/sponge baths, and no showers.
For the month of February 2024, the resident received three (3) bed/sponge baths, and no showers.
For the month of March 2024, the resident received three (3) bed/sponge baths, and one (1) shower. It was also noted the resident had received no bed/sponge baths, or showers for 17 days, from 2/29/24 to 3/18/24.
For the month of April 2024, the resident received one (1) bed/sponge baths, and no showers. A record review revealed the resident had received no bed/sponge baths or showers for 19 days, from 03/27/24 to 04/16/24.
For the month of May 2024, the resident received one (1) shower.
For the month of June 2024, the resident received four (4) bed/sponge baths, and one (1) shower. The resident's last shower in May was on 05/22/24, and his next shower was twenty (20) days later, on 06/11/24.
For the month of July 2024, the resident received eight (8) bed/sponge baths and no showers, as of 07/24/24.
e) Resident #51
On 07/24/24 at 1:28 PM a record review revealed, Resident #51 was admitted on [DATE] and has only received 1 shower.
On 07/24/24 at 1:36 PMm during an interview Resident #51 stated they don't give much showers here even if I ask.
Further review of the record on 07/24/24 revealed Resident #51 is care planned to have showers per preference.
During an interview with the Administrator on 7/25/24 at 11:00 AM she states they have identified some issues with showers and are currently working on getting those issues resolved.
f) Resident #65
On 07/22/24 at 3:36 PM, during an interview Resident #65 stated I don't get showers when I want one, it's been weeks since I have had a shower.
On 07/24/24 at 1:41 PM, a record review revealed Resident #65 has had two (2) showers and 13 bed baths from 04/01/24 through 06/31/24.
On 07/22/24 at 3:36 PM resident stated, I don't get showers when i want one, its been weeks since i have had a shower.
During an interview with the Administrator on 7/25/24 at 11:00 AM she states they have identified some issues with showers and are currently working on getting those issues resolved.
g) Resident #22
On 07/22/24 at 2:07 PM, during an interview Resident #22 stated I have not had a shower in two (2) weeks.
On 07/24/24 at 12:03 PM, a record review revealed Resident #22 has had one (1) shower on 07/03/24 in the past month from 06/24/24 to 07/24/24.
Further record review on 07/24/24 revealed Resident #22 had received four (4) showers from 04/01/24 through 06/31/24 and only seven (7) bed baths in this time frame.
On 07/24/24 at 1:20 PM, a review of Resident #22's care plan revealed the following care plan intervention, showers per preference and requires extensive assistance with showers/bathing.
During an interview with the Administrator on 7/25/24 at 11:00 AM she states they have identified some issues with showers and are currently working getting those issues resolved
g) Resident #60
During the initial interview on 07/22/24 at 1:22 PM, Resident #60 stated, I don't get showers often. Heck, I would be happy with at least a bed bath once a week. I was in an actual shower probably over a month ago. I have asked for showers and they say they will get to me as soon as they can and then end up doing a bed bath or not a bath at all.
A record review on 07/24/24 at 12:10 PM, revealed the following care plan:
Focus:
I need assistance with my ADL's due to
my physical limitations and history of
electrolyte imbalance and weakness
Intervention:
- Shower/bed bath scheduled per my preference. Monitor and document refusals.
Further record review showed, Resident #60 is scheduled to have a shower on Wednesday's and Saturday's. Resident #60 received the following showers and/or bed baths from 05/02/24 to present:
None noted for the month of May. No refusals noted from 05/02/24 to present.
06/11/24-Shower
06/19/24-Shower
06/22/24-Bed bath
06/23/24-Bed bath
06/25/24-Bed bath
06/26/24-Bed bath
06/27/24-Bed bath
06/29/24-Bed bath
06/30/24-Bed bath
07/04/24-Bed bath
07/11/24-Bed bath
07/18/24-Bed bath
07/21/21-Bed bath
During an interview on 07/24/24 at 11:53 AM, The Director of Nursing (DON) stated, We have identified this problem and are working on it. She later confirmed, Resident #60 had not had a shower since 06/19/24, and had not been bathed according to schedule.
h) Resident #63
During the initial interview on 07/22/24 at 1:46 PM, Resident #63 stated, The most recent shower I have had I believe was the fourth of July. They haven't offered. Well now that I think about it, I think the fourth of July was a bed bath. I have not had a shower since I have been in this room for about a month and a half.
A record review on 07/24/24 at 12:10 PM, revealed the following care plan:
Focus:
Resident/Patient is at risk for decreased
ability to perform ADL(s) in bathing,
grooming, personal hygiene, dressing, bed
mobility, transfer, locomotion, toileting
related to: left AKA with complications of, history of cerebral infarction,
spina bifida
Intervention:
-Provide resident/patient with substantial/maximal assist of staff for bathing. He
refuses at times.
Further record review showed that Resident #63 is scheduled to have a shower on Wednesday's and Saturday's. Resident #63 received the following showers and/ or bed bath from 05/02/24 to present:
No refusals are noted.
05/07/24-Shower
05/19/24-Bed bath
05/20/24-Bed bath
06/12/24-Bed bath
06/23/24-Bed bath
06/25/24-Bed bath
06/26/24-Bed bath
06/27/24-Bed bath
07/04/24-Bed bath
07/06/24-Bed bath
07/11/24-Bed bath
07/16/24-Bed bath
07/21/24-Bed bath
During an interview on 07/24/24 at 11:53 AM, The Director of Nursing (DON) stated, We have identified this problem and are working on it. She later confirmed that Resident #60 had not had a shower since 06/19/24 and had not been bathed according to schedule.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Transfer Notice
(Tag F0623)
Could have caused harm · This affected 1 resident
.
Based on record review and staff interview, the facility failed to notify the State ombudsman of a discharge for Resident #71. This was true for one (1) of two (2) residents reviewed under the care ...
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.
Based on record review and staff interview, the facility failed to notify the State ombudsman of a discharge for Resident #71. This was true for one (1) of two (2) residents reviewed under the care area of discharges. Resident identifier: 71. Facility Census: 71.
Findings Include:
a) Resident #71
On 07/23/24 at 9:45 AM, a record review was completed for Resident #71. The review found the resident had been discharged to another facility on 05/09/24. However, the facility could not provide evidence of the notification of discharge was sent to the State ombudsman.
On 07/23/24 at 1:00 PM, the Administrator was notified and stated, We do not have the notification to the Ombudsman regarding the discharge.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Assessment Accuracy
(Tag F0641)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on record review and staff interview, the facility failed to complete an accurate Minimum Data Set (MDS) regarding the d...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on record review and staff interview, the facility failed to complete an accurate Minimum Data Set (MDS) regarding the discharge destination for Resident #71 and #72. This was true for two (2) of two (2) residents reviewed under the care area of discharges. Resident identifiers: #71 and #72. Facility Census: 71.
Findings included:
a) Resident #71
On 07/23/24 at 12:29 PM, a record review was completed for Resident #71. The review found the resident was discharged on 05/09/24 to another long-term facility. The MDS dated [DATE] listed the discharge destination of home.
On 07/23/24 at 1:00 PM, the Administrator was notified and confirmed the MDS was incorrect. The Administrator stated, The resident did go to another facility .not home.
b) Resident #72
On 07/23/24 at 1:10 PM, a record review was completed for Resident #72. The review found the resident was discharged on 05/02/24 to home. The MDS dated [DATE] listed the discharge destination as short-term general hospital.
On 07/23/24 at 2:47 PM, the Administrator was notified and confirmed the discharge destination was incorrect on the MDS.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0657
(Tag F0657)
Could have caused harm · This affected 1 resident
.
Based on record review and staff interview the facility failed to ensure Resident #9's care plan was revised when the status of her pressure ulcer changed. This was true for one (1) of 34 sampled re...
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.
Based on record review and staff interview the facility failed to ensure Resident #9's care plan was revised when the status of her pressure ulcer changed. This was true for one (1) of 34 sampled residents reviewed during the long term care survey process. Resident Identifier: #42. Facility Census: 71.
Findings Include:
a) Resident #42
A record review on 07/23/23 at 9:48 AM revealed an order for Resident #42 which read as follows:
Cleanse Stage IV to right heel with wound cleanser and pat dry. Apply Calc alginate and cover with opti-foam heel protection every day. Every day shift.
Further record review showed a care plan for a Pressure Ulcer to the right heel staged as a stage 2 (two) pressure ulcer. The skin and wound evaluation effective 07/22/24 has the Pressure Ulcer to the right heal as an unstageable pressure ulcer.
During an interview on 07/26/24 at 10:00 AM, The Director of Nursing (DON) stated, Yes we have been having problems with this, Now, we have someone is looking at them and working on getting them all revised.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0679
(Tag F0679)
Could have caused harm · This affected 1 resident
Based on observation, record review, and staff interview the facility failed to provide an activity program to meet the needs and interest of the residents and failed to provide scheduled one-to-one v...
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Based on observation, record review, and staff interview the facility failed to provide an activity program to meet the needs and interest of the residents and failed to provide scheduled one-to-one visits for residents. This failed practice was found true for (1) one of (6) six residents reviewed for activities during the Long-Term Care Survey Process. Resident identifiers #27. Facility Census 71.
Findings include:
a) Resident #27
During the initial observation on 07/22/24 at 1:30 PM, Resident #27 was sitting in the Television Lounge in front of the TV.
Further observation at 3:45PM, showed Resident #27 sitting in the Television Lounge in front of the TV.
Further observation at 5:40PM , showed Resident #27 sitting in the Television Lounge in front of the TV.
A record review on 07/24/24 at 1:00 PM of Resident #27's Activity care plan read as follows:
Focus:
While in the facility, I state that it is
important that I have the opportunity to
engage in daily routines that are
meaningful relative to my preferences.
GOAL:
I receive one-to-one visits
three times/week as tolerated
through the next review.
INTERVENTIONS:
During one-to-one visits staff reads to her and provides hand massages.
I am of the Protestant religion. Please offer me bible readings during one-to-one
visits.
I receive visits from family and friends every few months. This is very important to
me.
It is important for me to choose what clothing to wear.
It is important for you to know which of my personal belongings I prefer to take care of
myself.
It is important for me to choose a shower.
I like to snack between meals and prefer ice cream.
It is important for me to choose my bedtime and I prefer to go to bed between 7-
9pm.
Further record review of Resident #27's Recreation Quarterly Progress Note and Care Plan Evaluation, under 2c. List Individual engagement opportunities reads as follows:
1:1, Sensory, morning visits.
Further record review of Resident #27's activity participation record for the months of 05/2024, 06/2024, and 07/2024 read as follows:
05/01/24 to 05/07/24- Two one-to-one visits were completed. No group activity.
05/08/24 to 05/15/24- Three one-to-one visits were completed. No group activity.
05/16/24 to 05/22/24- Two one-to-one visits were completed. No group activity.
05/23/24 to 05/31/24- Three one-to-one visits were completed. No group activity.
06/01/24 to 06/07/24- No one-to-one visits were completed. No group activity.
06/08/24 to 06/15/24- No one-to-one visits were completed. No group activity.
06/16/24 to 06/22/24- Two one-to-one visits were completed. No group activity.
06/23/24 to 06/30/24- One, one to one visit was completed. No group activity.
07/01/24 to 07/07/24- One, one-to-one visit was completed. No group activity.
07/08/24 to 07/15/24- One, one-to-one visit was completed. No group activity.
07/16/24 to 07/22/24- Five one-to-one visits were completed. No group activity.
07/26/24 at 12:31 PM, The Activity Director (AD), confirmed the one-to-one visits were not being done as scheduled.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0688
(Tag F0688)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on observation, record review, and resident and staff interviews, the facility failed to provide services and/or treatme...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on observation, record review, and resident and staff interviews, the facility failed to provide services and/or treatment to Resident #64 to prevent reduction in range of motion. This was true for one (1) of four (4) residents reviewed for limited range of motion during the survey process. Resident identifier: 64. Facility census: 71.
Findings include:
A) Resident #64
At approximately 9:16 AM on 07/23/24, an interview was conducted with Resident #64. During the interview, it was noted the resident seemed to have contractures in both knees, with his left knee being worse than the right. During the interview, Resident #64 states I don't remember much about when I came in, so I don't really remember when my knees got this way, I know they weren't like this when I came in, but I just don't remember when they got this way. Resident #64 stated no staff member helped him work on range of motion during times when care is being provided.
At approximately 10:30 AM on 07/23/24, during a review of Resident #64's medical record, it was noted that the Minimum Data Set (MDS), dated [DATE] indicated Resident #64's range of motion in his lower extremities was within normal limits.
Review of physical therapy evaluation and notes (dates of service 03/21/24-04/05/2024) and occupational therapy evaluation and notes (dates of service 03/22/24-04/08/24) indicated Resident #64's range of motion in lower extremities was within normal limits.
A review of the MDS for Resident #64 dated 06/26/24 indicated the resident has impairment on both lower extremities.
At approximately 12:40 PM on 07/23/24, an interview was conducted with Nurse Aide (NA) #58. During the interview, NA #58 states We don't have time to finish assignments with residents due to not having enough staff. We just don't have enough time with them and aren't able to do the things we should be doing, like working on range of motion with them while we are providing care. NA #58 stated the facility used to have restorative aides which would work with residents on such things, but the restorative aide position was removed from the building due to the facility not having enough staff to provide care.
At approximately 1:00 PM on 07/23/24, an interview was conducted with Registered Nurse (RN) #21, RN #20, and RN #31. During the interview, RN #21 stated staffing had not been an issue for nurses, but it had been a serious problem with the aides, knowing the aides were struggling getting assignments completed due to being short staffed, and not having enough time to spend with the residents. RN #31 stated the facility used to have a restorative program and has not used it in quite some time because they don't have enough staff.
At approximately 11:30 PM on 07/23/24, an interview was conducted with NA #39, who stated the aides are not able to work with residents like we should due to not having enough staff in the facility and not being able to spend the time we need to spend with the residents.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0725
(Tag F0725)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on observation, record review, and resident and staff interview, the facility failed to have sufficient staff to provide...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on observation, record review, and resident and staff interview, the facility failed to have sufficient staff to provide care for residents at the facility. This has the potential to affect all residents currently residing at the facility. Resident identifier: #64. Facility census: 71.
Findings include:
A) Resident #64
At approximately 9:16 AM on 07/23/24, an interview was conducted with Resident #64. During the interview, it was noted the resident seemed to have contractures in both knees, with his left knee being worse than the right. During the interview, Resident #64 states, I don't remember much about when I came in, so I don't really remember when my knees got this way, I know they weren't like this when I came in, but I just don't remember when they got this way. Resident #64 stated no staff member helped him work on range of motion during times when care is being provided.
At approximately 10:30 AM on 07/23/24 during a review of Resident #64's medical record, it was noted that the Minimum Data Set (MDS), dated [DATE] indicated Resident #64's range of motion in his lower extremities was within normal limits.
Review of physical therapy evaluation and notes (dates of service 03/21/24-04/05/24) and occupational therapy evaluation and notes (dates of service 03/22/24-04/08/24) indicated Resident #64's range of motion in lower extremities were within normal limits.
A review of the MDS for Resident #64 dated 06/26/24 indicates the resident has impairment on both lower extremities.
At approximately 12:40 PM on 07/23/24, an interview was conducted with Nurse Aide (NA) #58. During the interview, NA #58 states We don't have time to finish assignments with residents due to not having enough staff. We just don't have enough time with them and aren't able to do the things we should be doing, like working on range of motion with them while we are providing care. NA #58 stated the facility used to have restorative aides that would work with residents on such things, but the restorative aide position was removed from the building due to the facility not having enough staff to provide care.
At approximately 1:00 PM on 07/23/24, an interview was conducted with Registered Nurse (RN) #21, RN #20, and RN #31. During the interview, RN #21 stated staffing had not been an issue for nurses, but it had been a serious problem with the aides, knowing the aides were struggling getting assignments completed due to being short staffed, and not having enough time to spend with the residents.
RN #31 stated the facility used to have a restorative program and has not used it in quite some time because they don't have enough staff.
At approximately 11:30 PM on 07/23/24, an interview was conducted with NA #39, who stated the aides are not able to work with residents like we should due to not having enough staff in the facility and not being able to spend the time we need to spend with the residents.
b) Staff interviews
At approximately 12:40 PM on 07/23/24, an interview was conducted with NA #58. NA #58 stated the facility runs 4 aides during day shift pretty regularly. Very rarely do we have more than that. NA #58 stated weekends are worse than weekdays, although not every weekend has staffing issues. NA #58 stated they were asked to stay late almost all the time due to staffing issues at the facility. NA #58 states, I feel like I have to rush through providing care because we don't have enough staff, and the residents suffer because of it.
At approximately 1:00 PM on 07/23/24, an interview was conducted with RN #21, RN #20, and RN #31. During the interview, all three stated they were aware the staffing situation with the Nurse Aides was not good, as they were asked to pick up shifts as an aide regularly because they don't have enough. RN #21 stated I know they have asked for agency multiple times to get help with the situation, but they won't bring them in here.
At approximately 11:30 PM on 07/23/24, an interview was conducted with NA #39. During the interview, NA #39 stated, Very rarely do we have time to care for the residents the way we should because we don't have enough staff. When we come in we come bed strips, overflowing trash, trays left in the rooms, trash in the floor. People hanging their feet off the side of the bed because the last shift didn't do their rounds or didn't have time to do their rounds.
NA #39 states, We bring staffing concerns to management all the time, but they turn it around on us and make it out to be our fault, saying we call in too much. We have asked for agency, and we don't get it. People here don't get showers on day shift or evening shift because no one has time to do them.
NA #39 stated, I get three (3) to four (4) days off every week and every single one of those days I get a call from this place asking me to come in and work on my days off because we don't have enough people. When I am scheduled to work, I am constantly asked to come in early and stay late because of the staffing.
At approximately 11:45 AM on 07/25/24 an interview was conducted with the Administrator regarding staffing levels at the facility. The administrator stated the facility needs to have five (5) aides, at least, during day shift, but averages four (4) most days.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Medical Records
(Tag F0842)
Could have caused harm · This affected 1 resident
Based on record review and resident and staff interviews, the facility failed to accurately document the dental condition of Resident #227 on the admission assessment. This was a random opportunity fo...
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Based on record review and resident and staff interviews, the facility failed to accurately document the dental condition of Resident #227 on the admission assessment. This was a random opportunity for discovery. Resident identifier: #227. Facility census: 71.
Findings included:
a) Resident #227
At approximately 9:00 AM on 07/24/24 an interview was conducted with Resident #227. During the interview, the resident stated, I only have four (4) teeth and can't chew the food very well.
At approximately 9:30 AM on 07/24/24 a review of Resident #227's record was conducted. On the resident's clinical admission evaluation dated 07/19/24 at 4:24 PM, the box has own teeth was marked. However, the rest of the dental portion of the evaluation was incomplete.
At approximately 2:00 PM on 07/24/24 an interview was conducted with the Administrator regarding the incomplete assessment. The administrator reviewed the dental section of the assessment and confirmed it was incomplete.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0561
(Tag F0561)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on record review, staff interview and resident interview the facility failed to honor residents' preference for bed bat...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on record review, staff interview and resident interview the facility failed to honor residents' preference for bed bath/showers. This failed practice was found true for five (5) of (7) seven residents reviewed for the care area of choices during the Long-Term Care Survey Process. Resident identifiers: #60, #63, #40, #3 and #48. Facility Census: 71.
Findings included:
a) Resident #60
During the initial interview, on 07/22/24 at 1:22PM, Resident #60 stated, I don't get showers often. Heck, I would be happy with at least a bed bath once a week. I was in an actual shower probably over a month ago. I have asked for showers, and they say they will get to me as soon as they can and then end up doing a bed bath or not a bath at all.
A record review on 07/24/24 at 12:10 PM, revealed the following care plan:
Focus:
I need assistance with my ADL's due to my physical limitations and history of
electrolyte imbalance and weakness.
Intervention:
- Shower/bed bath scheduled per my preference. Monitor and document refusals.
Further record review showed Resident #60 was scheduled to have a shower on Wednesday and Saturday.
Resident #60 received the following showers from 05/02/24 to present:
-
06/11/24
-
06/19/24
During an interview, on 07/24/24 at 11:53 AM, the Director of Nursing (DON) confirmed Resident #60 had not had a shower since 06/19/24. She said, We are working on this problem.
b) Resident #63
During the initial interview on 07/22/24 at 1:46 PM, Resident #63 stated, The most recent shower I have had I believe was the fourth of July. They haven't offered. Well now I think about it, I think the fourth of July was a bed bath. I have not had a shower since I have been in this room for about a month and a half.
A record review on 07/24/24 at 12:10 PM, revealed the following care plan:
Focus:
'Resident/Patient is at risk for decreased ability to perform ADL(s) in bathing,
grooming, personal hygiene, dressing, bed mobility, transfer, locomotion, toileting
related to: left AKA with complications of, history of cerebral infarction,
spina bifida.'
Intervention:
-Provide resident/patient with substantial/maximal assist of staff for bathing. He
refuses at times.
Further record review showed Resident #63 is scheduled to have a shower on Wednesday's and Saturday's. Resident #63 received only one (1) shower on 05/07/24 for the time frame of 05/02/24 to current.
During an interview on 07/24/24 at 11:53 AM, The Director of Nursing (DON) stated, We have identified this problem and are working on it. She later confirmed Resident #63 had not had a shower since 05/07/24.
c) Resident #48
During an interview with Resident #48 on 07/23/24 at 2:38 PM, he stated the facility did not honor his request for showers. He stated he was scheduled for a shower two times a week, on Tuesday and Friday. He further stated he had not had a shower for over thirty (30) days.
A review of Resident #48's MDS dated [DATE] at 3:20 PM, revealed under MDS Section F0400 for daily preferences, resident had responded to the question:
How important is it to you to choose between a tub bath, shower, bed bath, or sponge bath?
His response was - Somewhat important
Further review of resident's MDS dated [DATE] at 10:37 AM revealed he had responded to the question:
How important is it to you to choose between a tub bath, shower, bed bath, or sponge bath?
His response was - Very Important
Record review of Resident #48's shower logs revealed :
January 2024
For the month of January 2024, the resident received only 13 bed/sponge baths, and no showers.
February 2024
For the month of February 2024, the resident received only 14 bed/sponge baths, and no showers
April 2024
For the month of April 2024, the resident received only two (2) bed/sponge baths, and one (1) shower. It was also noted one bed/sponge bath was given on 04/03/24 and the next bed/sponge bath was given two (2) weeks later, on 04/17/24.
May 2024
For the month of May 2024, the resident received only 13 bed/sponge baths, and no showers. One bed/sponge bath was given on 05/16/24, and the next was given seven (7) days later, on 05/23/24.
June 2024
For the month of June 2024, the resident received five (5) bed/sponge baths, and two (2) showers. One shower was given on 06/07/24, and the next bed/sponge bath was given six (6) days later, on 06/13/24. Another bed/sponge bath was given on 06/17/24, and the next bed/sponge bath was given six (6) days later, on 06/23/24. The bed/sponge bath on 06/23/24 was the last bed/sponge bath given for the month of June 2024.
The next bed/sponge bath was given twelve (12) days later, on 07/05/24. A total of seven (7) bed/sponge were given as of 07/24/24.
d) Resident #40
An interview with Resident #40 on 07/23/24 at 2:55 PM, revealed the facility did not honor his request for showers. He stated, he is scheduled for a shower two times a week, on Monday and Thursday. He further stated he had not had a shower for over thirty (30) days.
A review of Resident #40's MDS dated [DATE] at 10:58 AM, revealed under MDS Section F0400 for daily preferences resident had responded to the question:
How important is it to you to choose between a tub bath, shower, bed bath, or sponge bath? Resident's response - Not very important
Further review of resident's MDS dated [DATE] at 4:10 PM, revealed he had responded to the question:
How important is it to you to choose between a tub bath, shower, bed bath, or sponge bath? Resident's response was - Somewhat Important
Record review of Resident #40's shower logs revealed :
January 2024
For the month of January 2024, Resident #40 received eight (8) bed/sponge baths, and no showers. Resident received one bed/sponge bath on 01/04/24 and the next bed/sponge bath 11 days later, on 01/15/24. It was further noted his next bed/sponge bath was seven (7) days later on 1/22/24.
February 2024
For the month of February 2024, Resident #40 received eight (8) bed/sponge baths, and no showers. One bed /sponge bath was given on 02/10/24, and the next bed/sponge bath was given eleven (11) days later on 02/21/24.
March 2024
For the month of March 2024, Resident #40 received seven (7) bed/sponge baths, and no showers. It was also noted Resident #40 had received no bed/sponge baths, or showers, for eight (8) days, from 03/10/24 to 03/18/24.
April 2024
For the month of April 2024, Resident #40 received four (4) bed/sponge baths, and no showers. Record review revealed resident had received no bed/sponge baths or showers for 15 days, from 04/12/24 to 04/27/24.
May 2024
For the month of May 2024, Resident #40 received two (2) bed/sponge baths, and no showers. The resident received no bed/sponge baths, or showers for eighteen (18) days, from 04/27/24 to 05/15/24. Further, the resident also did not receive bed/sponge baths, or showers for twelve (12) days, from 05/19/24 to 05/31/24.
June 2024
For the month of June 2024, Resident #40 received seven (7) bed/sponge baths, and one (1) shower. Record review revealed resident did not receive a bed/sponge bath, or shower for 12 days, from 05/19/24 to 06/04/24, and for seven (7) days, from 06/13/24 to 06/20/24
July 2024
For the month of July 2024, Resident #40 received three (3) bed/sponge baths and no showers, as of 07/24/24.
Resident #40 received a bed/sponge bath on 07/08/24 and then received a bed/sponge bath 10 days later, on 07/18/24.Resident also did not receive a bed/sponge bath, or shower for six (6) days, from 07/18/24 to 07/24/24.
e) Resident #3
An interview with Resident #3 on 07/23/24 at 2:49 PM, revealed the facility did not honor his request for showers. He stated he was scheduled for a shower two (2) times a week, on Wednesday and Saturday. He further stated he had not had a shower for over thirty (30) days.
A review of Resident #3's MDS dated [DATE], at 1:19 PM, revealed under MDS Section F0400 daily preferences were not assessed.
Further review of resident's MDS dated [DATE] at 4:10 PM, revealed he had responded to the question:
How important is it to you to choose between a tub bath, shower, bed bath, or sponge bath? His response was - Very Important
Record review of Resident #3's shower logs revealed :
January 2024
For the month of January 2024, the resident received three (3) bed/sponge baths, and no showers.
February 2024
For the month of February 2024, the resident received three (3) bed/sponge baths, and no showers.
March 2024
For the month of March 2024, the resident received three (3) bed/sponge baths, and one (1) shower. It was also noted resident had received no bed/sponge baths, or showers for seventeen (17) days, from 2/29/24 to 3/18/24.
April 2024
For the month of April 2024, the resident received one (1) bed/sponge baths, and no showers. Record review revealed resident had received no bed/sponge baths or showers for nineteen (19) days, from 03/27/24 to 04/16/24.
May 2024
For the month of May 2024, the resident received one (1) shower.
June 2024
For the month of June 2024, the resident received four (4) bed/sponge baths, and one (1) shower. The resident's last shower was on 05/22/24, and his next shower was 20 days later, on 06/11/24.
July 2024
For the month of July 2024, resident received eight (8) bed/sponge baths and no showers, as of 07/24/24.
During an interview, on 07/24/24 at 11:53 AM, the Director of Nursing (DON) stated, We have identified this problem and are working on it.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0583
(Tag F0583)
Could have caused harm · This affected multiple residents
.
Based on observations and staff interviews the facility failed to keep residents' medical information confidential. Facility staff left a laptop open with resident information which was visible to t...
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.
Based on observations and staff interviews the facility failed to keep residents' medical information confidential. Facility staff left a laptop open with resident information which was visible to the public. This was a random opportunity for discovery and had the potential to affect more than a minimal number of residents residing in the Long-Term Care facility. Facility census :71
Findings include:
On 07/23/24 at 11:04 PM Licensed Practical Nurse (LPN) #48 was observed setting at the nurses' station on the computer.
On 07/23/24 at 11:08 PM a computer was observed sitting on top of the medication cart unattended by staff. On the screen was resident identifiable information.
During an interview on 07/23/24 at 11:12 PM, LPN #48 returned to the medication cart and locked the computer screen. He stated he was aware it was unlocked.
During an interview with the Director of Nursing(DON) on 07/24/24 at 10:00 AM, The DON stated the computer and med (Medication) cart should have been locked.
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** .
Based on observation, resident interview and staff interview, the facility failed to provide a comfortable, homelike environme...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on observation, resident interview and staff interview, the facility failed to provide a comfortable, homelike environment for residents residing in room [ROOM NUMBER], #202, #203, #303, #306, #309, #310, #312, #402, #404, #407, #408, #409, #410 and the slats of the packaged terminal air conditioner (PTAC) in Resident #60's room. These were random opportunities for discovery and had the potential to affect more than a limited number of residents. Facility Census: 71.
Findings included:
a) Resident Doors
On 07/23/24 at 11:25 PM, a tour of the facility was complete. The tour found the following resident doors had putty applied to the visible cracks and door frames with rough edges of wood:
--201
--202
--203
--303
--306
--309
--310
--312
--402
--404
--407
--408
--409
--410
On 07/24/24 at 9:55 AM, the Administrator was notified of issues found with the resident doors. The Administrator stated, I'll have maintenance check those.
b) Resident #60
During the initial observation on 07/22/24 at 1:40 PM, it was found the slats in the Packaged Terminal Air Conditioner (PTAC) unit in Resident #60's room were covered in a moldlike substance.
During an interview on 07/22/24 at 1:40 PM, Resident #60 stated, That could be why I have allergies. I can't remember if I am on allergy medicine.
During an interview on 07/24/24 at 1:30 PM, The Maintenance Supervisor (MS) stated, Yes it is mold. I will get cleaned.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on record review and staff interview the facility failed to develop and/or implement care plans related to Dementia, Anxi...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on record review and staff interview the facility failed to develop and/or implement care plans related to Dementia, Anxiety, Dialysis and showers. This failed practice was found true for seven (7) of 34 residents reviewed for care plan accuracy and implementation during the Long-Term Care Survey Process. Resident identifiers: #54, #22, #65, #51, #61, #9 and #71. Facility Census 71.
Findings included:
a) Resident #54
A record review on 07/23/24 at 12:30PM, of Resident #54's medial record revealed a diagnosis of Dementia with an onset date of 10/04/23.
Further record review showed no diagnosis of Dementia within the care plan.
During an interview on 07/24/23 at 1:30PM, The Director of Nursing (DON), confirmed the diagnosis of Dementia was not in Resident #54's care plan.
b) Resident #61
On 07/24/24 at 9:00 AM, a record review was completed of Resident #61's medical record. The review found the care plan had not been developed regarding the diagnosis of anxiety disorder. The resident was seen on two (2) occasions, listed as psychological telemedicine visits, dated 07/12/24 and 07/25/24 for Major Depressive Disorder and Generalized Anxiety Disorder as diagnoses.
On 07/24/24 9:46 AM, an interview was held with Resident #61. The resident stated, I am feeling good .I do have problems with anxiety at times but if I have a problem I will talk to the nurse.
On 07/24/24 at 1:23 PM, the Administrator was notified and confirmed the care plan was not developed for the diagnosis of anxiety.
c) Resident #71
On 07/23/24 at 11:44 AM, a record review was completed for Resident #71. The review found the care plan had not been developed regarding the focus areas of activities of daily living (ADLs), suspected/actual infection, and risk for skin breakdown. Multiple blanks were noted under each focus area.
On 07/23/24 at 1:00 PM, the Administrator was notified and confirmed the care plan had not been developed for the focus areas of ADLs, suspected/actual infection, and risk for skin breakdown.
d) Resident #51
On 07/24/24 at 1:28 PM, a record review of Resident #51's medical record revealed Resident #51 was admitted on [DATE] and has only received 1 shower.
On 07/24/24 at 1:36 PM, Resident #51 stated they don't give much showers here even if I ask.
A further review of Resident #51's medical record found the following care plan intervention related to the residents Activities of Daily Living focus, Shower/bed bath scheduled per my preference. Monitor and document refusals.
During an interview with the Administrator on 7/25/24 at 11:00 AM she stated they have identified some issues with showers and are currently working getting those issues resolved.
e) Resident #65
On 07/22/24 at 3:36 PM Resident #65 stated I don't get showers when I want one, it's been weeks since I have had a shower.
On 07/24/24 at 1:41 PM, A record review revealed Resident #65 has had two (2) showers and 13 bed baths from 04/01/24 through 06/31/24.
Further review of Resident #65's care plan found it was void of any interventions related to how many times Resident #65 perferred to be showered.
During an interview with the Administrator on 7/25/24 at 11:00 AM she stated they have identified some issues with showers and are currently working getting those issues resolved.
f) Resident #22
On 07/22/24 at 02:07 PM Resident #22 stated I have not had a shower in two weeks.
On 07/24/24 at 12:03 PM a Record review revealed Residen t#22 has had one (1) shower in the past month from 06/24/24 till 07/24/24. The one (1) shower was on 07/03/24.
Further record review on 07/24/24 revealed Resident#22 had received four (4) showers from 04/01/24 through 06/31/24 and only seven (7) bed baths in that time frame.
On 07/24/24 at 1:20 PM further review of care plan revealed Resident # 22 is care planned for getting showers per preference and requires extensive assistance with showers/bathing.
During an interview with the Administrator on 7/25/24 at 11:00 AM she stated they had identified some issues with showers and were currently working on getting those issues resolved.
g) Resident #9
A review of Resident #9's care plan found the following care plan intervention:
Do Not take B/P (blood pressure) in my left arm due to anterior [NAME] (AV).
Record review of weights/Vital summary revealed between 08/02/23 through 06/25/24, it is documented that resident #9 had a BP taken in the left arm on 17 different occasions.
On 07/25/24 at 11:30 AM, The Director of nursing (DON) stated, The orders and care plan should have been followed to not take a B/P in the left arm.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected multiple residents
.
Based on observation, policy review, and staff interview the facility failed to ensure the resident environment over which it had control was as free from accident hazards as possible. This was a ra...
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.
Based on observation, policy review, and staff interview the facility failed to ensure the resident environment over which it had control was as free from accident hazards as possible. This was a random opportunity for discovery and had the potential to affect more than a limited number of residents currently residing at the facility. Facility Census: 71.
Findings Include:
a) Treatment Cart
On 07/22/24 at 12:50 PM, an observation found an unlocked, unattended treatment cart in the resident tv room. The cart was in a place which was easily accessible allowing access to these medication/treatment supplies by residents, unauthorized persons, or visitors.
On 07/22/24 at 1:42 PM, during an interview with Registered Nurse (RN) #21, it was confirmand the Treatment cart was unlocked. RN #21 verified the treatment cart should not be unlocked when unattended. She closed and locked the cart at this time.
b) Resident #57
An observation on 07/22/24 at 1:23 PM found nystatin powder generic myconustatin 60 gm, at Resident #57's bed side, unsecured and unattended and allowing access to this medication by residents, unauthorized staff, or visitors.
During an interview on 07/22/24 at 1:28 PM, RN #21 confirmed, the nystatin powder generic myconustatin 60 gm, at Resident #57's bed side should not be left out in the room. RN #21 removed the nystatin powder at this time.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0730
(Tag F0730)
Could have caused harm · This affected multiple residents
Based on record review and staff interview, the facility failed to conduct yearly performance evaluations for each Nurse Aide. This was true for three (3) out of five (5) Nurse Aides reviewed during t...
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Based on record review and staff interview, the facility failed to conduct yearly performance evaluations for each Nurse Aide. This was true for three (3) out of five (5) Nurse Aides reviewed during the survey process. Staff identifiers: NA #34, NA #63, NA# 61. Facility census: 71.
Findings included:
A) Record review
At approximately 2:45 PM on 07/23/24 a review of yearly performance evaluations and educations were conducted for randomly selected Nurse Aides (NA). During review, it was discovered the facility was missing yearly performance evaluations for NA #34, NA #63, and NA #61.
B) Staff interviews
At approximately 3:30 PM on 07/23/24 an interview was conducted with the Administrator. During the interview, the administrator confirmed the absence of performance evaluations for the three (3) NAs. The administrator stated We knew there were some missing and we are aware of it. We are trying to get caught up on them.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Medication Errors
(Tag F0758)
Could have caused harm · This affected multiple residents
Based on record review and staff interview the facility failed to do behavior and side effect monitoring for psychotropic medications. This failed practice was found true for (1) one of (5) five resid...
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Based on record review and staff interview the facility failed to do behavior and side effect monitoring for psychotropic medications. This failed practice was found true for (1) one of (5) five residents reviewed for unnecessary medications during the Long-Term Care Survey Process. Resident identifier: #54. Facility Census 71.
Findings include:
a) Resident #54
Record review, on 07/24/24 at 4:00 PM, of Resident #54's orders revealed Resident #54 was ordered Lorazepam Oral Tablet 0.5 Milligrams (MG) on 12/22/23. It further read, (1) one tablet by mouth at bedtime for Anxiety. Monitor for Sedation, morning hangover, ataxia, nausea and report side effects to physician.
Further record review of Resident #54's Medication Administration Record (MAR) for behavior and side effect monitoring showed no monitoring for 12/2023, 01/2024, 02/2024, 03/2024, 04/2024, and 05/2024.
During an interview on 07/25/24 at 10:00 AM, The Director of Nursing (DON) stated, We did identify a problem and are now working on it. She later confirmed the behavior and side effect monitoring was not being done.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected multiple residents
Based on observation, record review and staff interview, the facility failed to record temperatures for the medication refrigerator. This was a random opportunity for discovery and had the potential t...
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Based on observation, record review and staff interview, the facility failed to record temperatures for the medication refrigerator. This was a random opportunity for discovery and had the potential to affect more than a limited number of residents. Facility Census: 71.
Findings Include:
On 07/25/24 at 9:25 AM, the medication room was observed. The observation found the medication refrigerator temperatures were not completed for March 2024 through July 2024. The following dates were not completed:
--03/16/24 PM
--03/17/24 PM
--03/18/24 PM
--03/19/24 PM
--03/20/24 PM
--03/21/24 PM
--03/22/24 PM
--03/23/24 AM
--03/25/24 PM
--03/26/24 PM
--03/28/24 PM
--03/29/24 AM
--03/29/24 PM
--03/30/24 PM
--03/31/24 AM
--04/01/24 PM
--04/02/24 PM
--04/04/24 PM
--04/05/24 PM
--04/06/24 PM
--04/08/24 PM
--04/09/24 PM
--04/10/24 PM
--04/11/24 PM
--04/12/24 AM
--04/13/24 PM
--04/14/24 PM
--04/15/24 AM
--04/15/24 PM
--04/16/24 PM
--04/17/24 PM
--04/18/24 PM
--04/19/24 PM
--04/21/24 PM
--04/22/24 PM
--04/23/24 AM
--04/23/24 PM
--04/24/24 PM
--04/25/24 AM
--04/25/24 PM
--04/26/24 PM
--04/27/24 PM
--04/28/24 PM
--04/29/24 PM
--04/30/24 PM
--05/01/24 PM
--05/02/24 PM
--05/03/24 PM
--05/04/24 AM
--05/05/24 AM
--05/06/24 PM
--05/07/24 PM
--05/08/24 AM
--05/09/24 PM
--05/10/24 AM
--05/10/24 PM
--05/11/24 AM
--05/11/24 PM
--05/12/24 AM
--05/13/24 PM
--05/14/24 PM
--05/15/24 PM
--05/16/24 PM
--05/17/24 PM
--05/20/24 PM
--05/21/24 PM
--05/22/24 AM
--05/22/24 PM
--05/23/24 AM
--05/23/24 PM
--05/24/24 AM
--05/24/24 PM
--05/25/24 PM
--05/26/24 PM
--05/27/24 PM
--05/28/24 PM
--05/29/24 PM
--05/30/24 PM
--05/31/24 PM
--06/01/24 AM
--06/01/24 PM
--06/04/24 AM
--06/04/24 PM
--06/05/24 AM
--06/05/24 PM
--06/07/24 AM
--06/07/24 PM
--06/11/24 AM
--06/11/24 PM
--06/12/24 AM
--06/13/24 PM
--06/15/24 AM
--06/15/24 PM
--06/16/24 AM
--06/17/24 PM
--06/18/24 PM
--06/19/24 AM
--06/19/24 PM
--06/20/24 AM
--06/21/24 PM
--06/24/24 AM
--06/25/24 PM
--06/26/24 AM
--06/27/24 PM
--06/29/24 PM
--06/30/24 PM
--07/01/24 AM
--07/02/24 AM
--07/03/24 AM
--07/05/24 PM
--07/06/24 PM
--07/07/24 PM
--07/08/24 PM
--07/09/24 PM
--07/10/24 PM
--07/11/24 PM
--07/13/24 PM
--07/15/24 PM
On 07/25/24 at 9:45 AM, the Administrator and the Director of Nursing (DON) were notified. The Administrator confirmed the medication refrigerator temperature logs were incomplete.
b) Policy
On 07/25/24 at 2:00 PM, the facility policy entitled, Medication and Vaccine Refrigerator/Freezer Temperatures was reviewed. Under the heading of Policy, the following was listed:
Refrigerators and freezers used to store medications and vaccines will operate within acceptable temperature range and will be checked twice a day for proper temperatures.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected multiple residents
Based on observation and staff interview the facility failed to ensure food was discarded after the expiration date. This failed practice had the potential to affect more than a limited number of resi...
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Based on observation and staff interview the facility failed to ensure food was discarded after the expiration date. This failed practice had the potential to affect more than a limited number of residents currently residing in the facility. Facility Census 71.
Findings included:
a) Kitchen
During the initial observation on 07/22/24 at 1:30 PM, the following items were found to be out of date and/or covered in an mold like substance in the kitchen:
1. Scalloped potatoes were wrapped in plastic wrap in the walk-in refrigerator with a discard date of 07/11/24.
2. There was a box of onions in the walk-in refrigerator with 8 onions in it, 4 of the onions were covered in what appeared to be mold.
During an interview on 07/22/24 at 1:40 PM, The Dietary manager in training (DMT) stated, Yes, those potatoes are out of date. I will get the potatoes and onions thrown out.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0919
(Tag F0919)
Could have caused harm · This affected multiple residents
.
Based on observation, and staff interview, the facility failed to ensure the resident call system was functioning as designed. This failed practice had the potential to affect more than a limited nu...
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.
Based on observation, and staff interview, the facility failed to ensure the resident call system was functioning as designed. This failed practice had the potential to affect more than a limited number of residents currently residing in the facility. Facility Census: 71.
Findings included:
a) Observation tour, on 07/22/24 at 2:30 PM, of the 200 and 300 halls, found the call light system turned off at the end of the halls. The volume was too low to be heard throughout the unit.
During an interview, on 07/23/24 at 12:26 PM, the Maintenance Assistant verified it was turned off at the end of the hall. At this time, he turned the audible switch back on. He stated the staff turned it off.
During an interview, on 07/23/24 at 12:33 PM, the Maintenance Director confirmed the call system was visual and audible. He stated all the call systems in the building were turned down and it had been that way since he started.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** An observation, on 07/23/24 at 11:16 PM, revealed a pair of soiled, discarded, gloves on the floor of the 300 hallway.
LPN #48 ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** An observation, on 07/23/24 at 11:16 PM, revealed a pair of soiled, discarded, gloves on the floor of the 300 hallway.
LPN #48 confirmed this was an infection control issue, and the gloves should have been discarded in the appropriate receptacle.
During an interview on 07/25/24 at 10:31 AM , LPN #68 stated soiled gloves were to be discarded the in trash can in the resident's room.
On 07/23/34 at 12:18 PM, NA #58 stated soiled dressings and gloves were to be discarded in the appropriate receptacle, in resident's room.
Based on observation, record review and staff interview, the facility failed to maintain an appropriate infection control program for disposal of soiled linen, not wearing proper personal protective equipment (PPE) in enhanced barrier precaution (EBP) rooms, storage of used bedpans, placing a dirty dinner tray on the cart of clean trays and disposal of soiled gloves. These were random opportunities for discovery and had the potential to affect more than an isolated number of residents. Facility Census: 71.
Findings included:
a) Soiled Linen
On 07/23/24 at 11:09 PM, an observation was made of linen laying on the PPE cart and soiled linen on the floor in room [ROOM NUMBER]. Registered Nurse (RN) #48 was notified and removed the soiled linen immediately.
On 07/24/24 at 9:55 AM, the Administrator was notified and confirmed soiled linen should be disposed of in the appropriate container.
b) Enhanced Barrier Precautions
On 07/23/24 at 11:55 PM, an observation was made of RN #48 and Nurse Aide (NA) #39 transferring Resident #42, who was in an EBP room, without wearing the proper PPE.
On 07/24/24 at 12:05 AM, a continued observation of NA #39 and NA #65 revealed they were providing incontinence care for Resident #42 without wearing the proper PPE.
On 07/24/24 at 12:08 AM, NA #39 was interviewed regarding PPE. NA #39 stated, they have those signs hanging everywhere. NA #65 stated, it could have been from the resident who was in the room before.
On 07/24/24 at 12:10 AM, RN #48 was interviewed regarding wearing PPE in EBP rooms. RN #48 nodded his head in regards PPE should be worn in EBP rooms.
On 07/24/24 at 9:58 AM, the Administrator was notified. The Administrator confirmed PPE should be worn in EBP rooms.
c) Door Signage
On 07/25/24 at 10:05 AM, a copy of the door signage entitled Enhanced Barrier Precautions was received. The door signage gives guidance of what PPE should be worn when caring for the residents. The following activities were listed:
--dressing
--bathing/showering
--transferring
--providing hygiene
--changing linens
--changing briefs or assisting with toileting
--device care or use of device
--wound care
On 07/25/24 at 10:06 AM, the Regional Nurse confirmed PPE should be worn in EBP rooms when providing the activities described on the door signage.
d) Meal service
On 07/22/24 at approximately 5:18 PM, Nurse Aide (NA) #60 removed a tray from the tray delivery cart on the 100 hall of the facility. NA #60 took the tray to a room and the resident refused the tray. NA #60 then proceeded to place the tray back onto the delivery cart. NA #60 acknowledged she placed the tray back onto the cart stating, I don't know what else to do with it.
e) Bedpan in floor
On 07/22/24 at 1:15 PM, three (3) bedpans were observed laying uncovered in the restroom of room [ROOM NUMBER].
On 07/22/24 at 2:25 PM, three (3) bedpans were laying uncovered in the restroom of room [ROOM NUMBER]
On 07/22/24 at 4:43 PM, Nurse Aide(NA) #64 confirmed the three (3) bedpans should not be on the floor uncovered and picked them up to throw away.
Jun 2023
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
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 record review and staff interviews the facility failed to provide care and services in accordance with professional sta...
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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 care and services in accordance with professional standards of practice. This was true for one (1) of four (4) residents reviewed for wound care during the Long-Term Care Survey Process for a complaint. The complaint investigation for Resident #277 indicated he did not receive the proper care for a surgical wound. Resident identifier: #277. Facility census: 76.
Findings included:
a) Resident #277
A record review on 06/13/23 revealed Resident #277 was admitted to the facility from an acute care hospital on [DATE] for rehabilitation services, following surgery for a left hip fracture, which he sustained at home. Resident #277 had surgery to repair the fracture to his left hip on 02/09/23.
Upon admission to the facility, he had a surgical incision with 17 staples still intact. The hospital discharge paperwork had an appointment for Resident #277 to be seen by an orthopedist on 02/22/23.
Resident #277 attended that appointment and returned from the appointment with the staples in place. Orders were faxed to the facility after the orthopedic appointment to obtain an x-ray. The x-ray was reviewed by the physician, which reported the fracture repair was healing properly.
The Wound Care nurse assessments on 02/23/23, 03/02/23 and 03/10/23 for the surgical incision and staples, reported the surgical incision was clean and dry, with no drainage or redness and the 17 original staples were still intact.
During all or most of the wound care rounds the nurse was accompanied by the wound care physician. The wound care nurse was required to report her findings to the wound care physician when he did not attend the weekly wound rounds. There was no evidence the wound care physician identified the long-time placement of the staples or made any recommendations regarding a time for the staples to be removed.
During interviews on 06/13/23 at 3:10 PM with the Nursing Home Administrator (NHA) and the Director of Nursing (DON), both agreed the staff failed to follow-up on the resident's staple removal. The NHA and the DON reported the staples were intact and no infection was present when he was discharged on 03/13/23.
Mar 2023
2 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected 1 resident
.
Based on record review, facility documentation of reportable occurrences review, and staff interview, the facility failed to ensure that all alleged violations of abuse and misappropriation of prope...
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.
Based on record review, facility documentation of reportable occurrences review, and staff interview, the facility failed to ensure that all alleged violations of abuse and misappropriation of property/funds, were reported immediately, and failed to ensure the results of the investigation were reported within five (5) working days of the occurrence, to other officials (including to the State Survey Agency and Adult Protective Services (APS) where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures. Resident #54 was identified as having an allegation of abuse and misappropriation that was not reported to all agencies as required. This deficient practice was identified through a random opportunity for discovery and had the potential to affect a limited number of residents. Resident identifier: Resident #54. Facility census: 75.
Findings included:
a) Policy and Procedure Review
A review of OPS300: Abuse Prohibition, with a revision date of 10/24/22, noted, under Section 7.3, and Section 7.4, the facility would report allegations to the appropriate state and local authorities involving neglect, exploitation, mistreatment, suspected criminal activity and misappropriation of patient property within 24 hours of the event if the event did not result in serious bodily injury. Under Section 7.5, the facility was to notify law enforcement as required.
Under Section 9, the policy showed the Administrator or designee would report all completed investigations within five (5) working days to the appropriate entity.
b) Resident #54
A review of the facility's reportable occurrences documentation, noted Resident #54 had made an allegation, on 11/04/22 at 9:30 AM, to the Social Service Department. The allegation noted Resident #54 stated her guardian continued to blame her, for receiving a discharge notification that had been received related to the resident had improved and no longer required nursing center care.
Resident #54 complained to the Social Work staff, the action of the Guardian was upsetting and the resident would prefer to be discharged home, then wait for an apartment to become available. Upon, checking with an apartment complex, the allegation also noted Resident #54 was denied because of credit issues. At this time, it was identified, the guardian had been residing in the resident's house and left the utilities in the resident's name. The allegation, noted the county had taken the house because the guardian had failed to pay the taxes. The allegation confirmed Resident #54 had not resided at the house for almost five (5) years.
A record review for Resident #54, revealed the resident had a Brief Interview for Mental Status (BIMS), conducted on 02/27/23 during a Significant change assessment, showed the resident to have intact cognition based on a score of 15.
An interview, with the Social Service Director and Administrator, on 03/01/23 at 9:00 AM, verified the Conservator for Resident #54 was court ordered on 03/12/18, to act as full guardian and full conservator without limitation, and was in effect on 11/04/22, when the allegation was made.
Further review of the reportable documentation, for the allegation made on 11/04/22, showed no evidence the facility notified the State Survey Agency or law enforcement of the allegations. Additionally, there was no evidence results of any investigation had been submitted as a five (5) day follow-up.
An additional interview, with the Administrator and Social Service Director, on 03/01/23 at 9:00 AM, revealed the State Survey Agency and local law enforcement had not been notified in accordance with the facility policy and State law and should have been. During this interview, the Administrator and Social Service Director, also confirmed no results of a five (5) day follow- up had been sent to any State agency.
.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Investigate Abuse
(Tag F0610)
Could have caused harm · This affected 1 resident
.
Based on record review, review of facility documentation of reportable incidents, and staff interview, the facility failed to ensure, in the response to allegations of abuse, misappropriation, explo...
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.
Based on record review, review of facility documentation of reportable incidents, and staff interview, the facility failed to ensure, in the response to allegations of abuse, misappropriation, exploitation or mistreatment, evidence that all alleged violations were thoroughly investigated. Resident #54 was found to have an allegation of abuse and misappropriation, that had been reported to facility staff on 11/04/22, but was not thoroughly investigated with evidence of the investigation maintained by the facility. This deficient practice was based on a random opportunity for discovery and had the potential to affect more than a limited number of residents residing in the facility. Resident identifiers: Resident #54. Facility census: 75.
Findings included:
a) Policy and Procedure Review
A review of the OPS300 Abuse Prohibition, with a revision date of 10/24/22, noted under Section 7.3, and Section 7.4, the facility would report allegations to the appropriate state and local authorities involving neglect, exploitation, mistreatment, suspected criminal activity and misappropriation of patient property within 24 hours of the event if the event did not result in serious bodily injury. Under Section 7.5, the facility was to notify law enforcement as required.
Under Section 8, the facility was required to initiate an investigation within 24 hours of the allegation that focused on whether the abuse occurred, interventions to prevent further injury and the investigation was to be thoroughly documented. The administrator designee was required to take necessary corrective action to prevent further harm during the investigation.
Under Section 9, the policy showed the Administrator or designee would report all completed investigations within five (5) working days to the appropriate entity.
b) Resident #54
A review of the facility's reportable occurrences documentation, noted Resident #54 had made an allegation on 11/04/22 at 9:30 AM, to the the Social Services Department regarding being upset due to feeling blamed, by the guardian of care, for a discharge notification. It was revealed during this time, the guardian that served as the conservator had failed to fulfill financial responsibilities, contributing to Resident #54 losing her home.
Further review of the reportable documentation or record review, showed no evidence a thorough investigation had been conducted based on the allegation received by Social Services on 11/04/22.
An interview, with the Social Service Director and Administrator, on 03/01/23 at 9:00 AM, verified the Conservator for Resident #54 was court ordered on 03/12/18, to act as full guardian and full conservator without limitation, and was in effect on 11/04/22, when Resident #54 made the allegation .
An additional interview, with the Administrator and Social Service Director, on 03/01/23 at 9:00 AM, revealed the facility had notified Adult Protective Services of the allegation, but failed to do a thorough investigation of the allegations of abuse and misappropriation alleged by Resident #54, and an investigation should have been completed
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Sept 2022
22 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0561
(Tag F0561)
Could have caused harm · This affected 1 resident
Based on resident interview, record review, and staff interview, the facility failed to ensure each resident had the opportunity to exercise autonomy regarding preferences that were important to their...
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Based on resident interview, record review, and staff interview, the facility failed to ensure each resident had the opportunity to exercise autonomy regarding preferences that were important to their life. The facility failed to honor a resident's preference to receive a shower in the morning. This was true for one (1) of 18 residents reviewed during the annual long-term care survey process. Resident identifier #64. Facility census: 74.
Findings included:
a) Resident #64
During an Interview on 09/27/22 at 9:00 AM, Resident #64 stated she would prefer to have a shower in the morning, but the facility frequently does not have enough staff to honor that request and she is told, We don't have anybody here to do it. Resident states she frequently refuses to shower later in the afternoon / evening hours simply because it is not her preference to shower later in the day. Resident reports she mostly gets bed baths as a result.
A record review, completed on 09/27/22 at 3:33 PM, revealed Resident #64 had not received a shower at any time from 09/06/22 - 09/27/22. Instead, Resident #64 received bed baths in the afternoon hours of the following dates:
--09/07/22
--09/09/22
--09/10/22
--09/13/22
--09/14/22
--09/17/22
--09/18/22
--09/26/22
During an interview on 10/03/22 at 11:08 AM, the Director of Nursing acknowledged Resident #64's request to be showered in the mornings and stated she would work with staff to ensure the facility honored Resident #64's preference.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Abuse Prevention Policies
(Tag F0607)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed implement written abuse and neglect policies and procedures for ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed implement written abuse and neglect policies and procedures for reporting in order to prevent all types of abuse. The facility failed to report an incident of neglect/mistreatment with Resident #221. This practice affected one (1) of two (2) residents reviewed using the abuse pathway in the survey process. Resident identifier: #221. Facility census: 74.
Findings included:
a) Facility Policy Review
Review of the facility's policy titled Abuse Prohibition, with a revision date of 05/01/22, revealed the center prohibits abuse, mistreatment, neglect for all patients. According to the policy employees are designated as mandated reporters and are obligated to immediately report any suspicions. The facility further defines mistreatment and neglect as:
--Mistreatment is defined as inappropriate treatment or exploitation of a patient.
--Neglect is defined as the failure of the Center, its employees, or service providers to provide goods and services to a patient that are necessary to avoid physical harm, pain, mental anguish, or emotional distress.
b) Resident #221
A review of facility grievances, completed on 09/28/22 at 9:15 AM, found a grievance from Resident #221. Details of the grievance outlined the following details:
--On 12/06/21 Resident #221 reported to the Social Worker that on Thursday, 12/02/21, the aide on the evening/night shift put an Attends [an adult incontinence brief] on her so they would not have to take her to the bathroom as frequent as she requests.
A subsequent review of Resident #221's Medicare 5 Day MDS, dated [DATE], reflected that the resident was continent of bowel and bladder but required a one person assist to make it safely to and from the bathroom.
A review of the facility reportables, completed on 09/28/22 at 11:45 AM, did not find a corresponding reportable to the appropriate state agencies. During an interview on 09/29/22 at 8:15 AM, the Assistant Director of Nursing (ADON) reported that the facility handled the resident's complaint about being put in a brief only as a facility grievance and the incident was not reported to state agencies as an allegation of mistreatment and neglect.
During an interview, on 10/03/22 at 11:00 AM, the Director of Nursing (DON) acknowledged the facility failed to identify the details of the incident as an allegation of mistreatment / neglect and stated the facility should have reported the incident to appropriate state agencies per facility policy.
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
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure a resident fall resulting in serious bodily injury and...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure a resident fall resulting in serious bodily injury and an allegation of neglect/mistreatment by staff, were reported in a timely manner to the appropriate state agencies. The failure to make a timely report was true for one (1) of five (5) sampled residents for falls and was true for one (1) of two (2) residents reviewed for abuse. Resident identifiers: #66 and #221. Facility census: 74.
Findings included:
a) Requirements for reporting seriously bodily injury.
The Federal regulation 483.12(c)(1) directs incidents involving serious bodily injury must be reported to the state survey agency within two (2) hours after the injury is noted.
The Office of Health Facility Licensure and Certification (OHFLAC) Long-Term Care Reporting Requirements guidance, dated December 4, 2019, instructs that OHFLAC and Adult Protective Services (APS) should receive the serious bodily injury report within two (2) hours. The guidance also instructs that OHFLAC and APS should receive an allegation of abuse report within two (2) hours.
b) Resident #66 - Fall Resulting in Serious Bodily Injury
Review of the facility's falls, on 09/28/22 at 2:23 PM, revealed Resident #66 experienced a fall with major injury on 08/15/22 at 11:20 PM. The note stated, Resident indicated that he could not put any weight on his left side. Left hip was noted to be out of place at this time.
Medical record review, completed on 09/28/22 at 2:40 PM, revealed Resident #66 was sent to the hospital for evaluation following his fall. A general progress note, dated 08/16/22 at 2:04 AM, reflected that the facility had been made aware Resident #66 was transferred to a different hospital due to a left displaced femoral head fracture [hip fracture]. A subsequent review of the facility's Reportables Log did not reveal the serious bodily injury had been reported to the appropriate state agencies.
During an interview on 10/03/22 at 10:52 AM, the Director of Nursing (DON) confirmed the facility failed to report the serious bodily injury within two (2) hours of having knowledge of the injury to the appropriate state agencies as required.
c) Resident #221
A review of facility grievances, completed on 09/28/22 at 9:15 AM, found a grievance from Resident #221. Details of the grievance outlined the following details:
--On 12/06/21 Resident #221 reported to the Social Worker that on Thursday, 12/02/21, the aide on the evening/night shift put an Attends [an adult incontinence brief] on her so they would not have to take her to the bathroom as frequent as she requests.
A subsequent review of Resident #221's Medicare 5 Day MDS, dated [DATE], reflected that the resident was continent of bowel and bladder but required a one person assist to make it safely to and from the bathroom.
A review of the facility reportables, completed on 09/28/22 at 11:45 AM, did not find a corresponding reportable to the appropriate state agencies. During an interview on 09/29/22 at 8:15 AM, the Assistant Director of Nursing (ADON) reported that the facility handled the resident's complaint about being put in a brief only as a facility grievance and the incident was not reported to state agencies as an allegation of mistreatment and neglect.
In an interview, on 10/03/22 at 11:00 AM, the Director of Nursing (DON) acknowledged the facility failed to identify the details of the incident as an allegation of mistreatment / neglect and stated the facility should have reported the incident to appropriate state agencies per facility policy.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Assessment Accuracy
(Tag F0641)
Could have caused harm · This affected 1 resident
Based on medical record review and staff interview, the facility failed to complete accurate Minimum Data Set (MDS) assessments for one (1) of 18 assessments reviewed during the Long-Term Care Survey ...
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Based on medical record review and staff interview, the facility failed to complete accurate Minimum Data Set (MDS) assessments for one (1) of 18 assessments reviewed during the Long-Term Care Survey Process (LTCSP). The MDS assessment for Resident #72 did not accurately reflect the resident's discharge status. Resident identifier: #72. Facility census: 74.
Findings included:
a) Resident #72
On 09/27/22 at 3:48 PM, a review of the electronic medical record was completed. Review of the Discharge MDS, with an Assessment Reference Date (ARD) of 07/21/22, revealed Section A was marked as Resident #72 being discharged to an acute hospital. However, the discharge plan documentation, dated 07/20/22, noted resident was scheduled for a discharge to home with family on 07/21/22 at 9:00 AM.
During an interview on 10/03/22 at 11:15 AM, the MDS Coordinator confirmed Resident #72 was discharged to home. The MDS Coordinator noted the MDS coding reflecting a discharge to an acute hospital was in error and stated, I will go in and correct that now.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0657
(Tag F0657)
Could have caused harm · This affected 1 resident
Based on medical record review and interview, the facility failed to revise person-centered comprehensive care plans for Resident #68's nutritional services and Resident #4's area of smoking. This pra...
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Based on medical record review and interview, the facility failed to revise person-centered comprehensive care plans for Resident #68's nutritional services and Resident #4's area of smoking. This practice affected two (2) of 18 Resident care plans reviewed during the Long-Term Care Survey Process (LTCSP). The failure to ensure the comprehensive care plan was reviewed and revised for the resident's highest practicable well-being placed the residents at risk of not receiving services that would meet their desires or wants and a decreased quality of life. Resident Identifiers #68 and #4. Facility census: 74.
Findings included:
a) Resident #68
On 09/27/22 a review of Resident (R#68's) medical records revealed, a physician's order:
--Patient to have pleasure foods, with the order date 09/02/22.
A review of the Resident #68's current care plan with the review date 09/02/22 with completion date 09/08/22 showed there was an active care plan addressing enteral feeding tube. The active goal, Resident is non-compliant with nothing by mouth (NPO) status and will take food from roommates and consume after repeated education on risks of eating food due to severe swallowing disorder. placing resident at high risk for aspiration.
Continued review revealed a second active care plan with the revision date 09/20/22.
The focus: I am non-compliant with my NPO order. Interventions: Staff will continue to educate on consequences of not complying with NPO status and NPO as ordered with ice chips upon request.
Subsequent review found and active care plan with the focus: I am at nutritional risk related to her need for a tube feeding. Intervention, NPO as ordered with ice chips upon request.
An interview with the Director of Nursing (DON), on 09/28/22 at 9:35 AM, verified that R #68's care plan was not revised to reflect the resident's current status of being able to consume food by mouth.
b) Resident #4
Record review of the facility's policy titled, Smoking; Resident, revised 12/15/11, showed A resident's smoking status - independent, supervised, or not permitted to smoke - will be documented in the service plan and updated as necessary.
On 09/26/22 at 12:32 PM an observation found, Resident #4 smoking outside independently with no staff present.
An observation on 09/28/22 at 12:53 PM found, Resident #4 was smoking outside independently with no staff present.
Review of Residents #4's care plan found a focus/problem:
The Focus:
--Resident may smoke with supervision per smoking assessment.
The goal associated with this problem:
--Resident will smoke safely with supervision through next review.
Interventions included:
-- Supervise resident with smoking in accordance with assessment needs.
Continued record review revealed a smoking evaluation completed 07/08/22
--Resident was able to smoke independently.
An interview with the Director of Nursing (DON), on 09/28/22 at 3:19 PM, verified Resident #4 was able to smoke independently. She verified the care plan was not revised to reflect the resident's current status of being able to smoke independently.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
Could have caused harm · This affected 1 resident
Based on observation, record review and staff interview the facility failed to ensure there was a current physician order to administer oxygen to a resident. This was a random opportunity for discover...
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Based on observation, record review and staff interview the facility failed to ensure there was a current physician order to administer oxygen to a resident. This was a random opportunity for discovery. Resident identifier: #38. Facility census: 74.
Findings included:
a) Policy Review
Record review of the facility's policy titled Oxygen: Nasal Cannula, revised on 01/01/04, showed directions and steps in administering oxygen to Residents. The first step to oxygen administration was to Verify order.
b) Resident #38
An observation on 09/26/22 at 9:44 AM, showed Resident # 38 laid in bed with oxygen being administered via nasal cannula at three (3) liters per minute.
Record review of Resident #38's medical record showed no current oxygen order.
An additional observation on 09/27/22 at 9:36 AM. Showed Resident #38 laid in bed with oxygen being administered via nasal cannula at three (3) liters per minute.
During an interview on 09/27/22 at 9:40 AM, the Director of Nursing (DON) stated Resident # 38 should be on oxygen and verified there was no current order for oxygen. The DON stated that she did not know why Resident #38's oxygen order was discontinued on 08/31/22.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0697
(Tag F0697)
Could have caused harm · This affected 1 resident
Based on resident interview, record review and staff interview the facility failed to ensure pain medications were administered in accordance with professional standards of practice. The failed practi...
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Based on resident interview, record review and staff interview the facility failed to ensure pain medications were administered in accordance with professional standards of practice. The failed practice was true for one (1) of four (4) Residents reviewed for pain. Resident identifier: #38. Facility census: 74.
Findings included:
a) Resident #38
During an interview on 09/26/22 at 9:45 AM, Resident # 38 stated that she was in pain a lot of the time. Resident #38 stated the facility only had pain medication scheduled as needed and some staff will give pain medication every 6 hours and others do not. Resident felt pain medication was administered inconsistently.
Record review of Resident #38's physician orders showed the following orders for pain medications:
OxyCODONE HCl Tablet 10 MG *Controlled Drug*- Give 1 tablet by mouth every 6 hours as needed for moderate to severe pain.
Acetaminophen Tablet 325 MG (Acetaminophen)-Give 2 tablet by mouth every 4 hours as needed for Mild Pain More than 3 doses in 48 hours, notify physician/advanced practice provider (APP) Do not exceed 3g/day. (standing order)
Further record review of Resident #38's medical record showed September 2022 Medication Administration record (MAR). The following inconsistencies were revealed:
Oxycodone was given for a zero (0) pain level on 09/12/22, 09/14/22, 09/20/22, and 09/25/22.
Oxycodone was given for a four (4) pain level on 09/12/22, 09/15/22, 09/16/22, 09/17/22, 09/18/22, 09/19/22, 09/21/22 and 09/25/22.
Acetaminophen was given for a pain level of five (5) on 09/01/22, 09/05/22, and 09/08/22.
Acetaminophen was given for a pain level of six (6) on 09/26/22.
During an interview on 09/27/22 at 2:35 PM, the Director of Nursing (DON) stated that parameters should have been part of the acetaminophen and oxycodone orders. The DON stated that a pain level of zero (0) should not have been administered Oxycodone as the pain level parameters are usually one (1)- four (4) for mild pain and five (5)-10 for moderate to severe pain.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected multiple residents
Based on observation, record review, resident interview, staff interview and facility documentation review facility failed to provide a resident transportation to a scheduled outside medical appointme...
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Based on observation, record review, resident interview, staff interview and facility documentation review facility failed to provide a resident transportation to a scheduled outside medical appointment. The facility failed to provide one (1) of two (2) residents reviewed for dialysis with transportation services to dialysis. The facility failed to obtain a physician order for a fall mat in place for one (1) of six (6) residents reviewed for falls. Resident identifiers: # 30, #33 and # 34. Facility census: 74.
Findings included:
A record review of the facility's policy titled, Dialysis: Hemodialysis- Communication and Documentation Policy, revised on 06/01/21, showed that the facility staff must assist Residents in making arrangements with safe transportation to and from the dialysis facility.
a) Resident #30
A review of Resident #30 ' s medical record showed a progress note dated 08/06/22 that stated, Resident up and ready for dialysis but their is no driver to take her. Called dialysis facility and let them know she will be unable to make it due to no available transportation.
Record review of the facility's Outpatient Dialysis Services Agreement dated
08/07/08, showed the Nursing Facility shall have the responsibilities for arranging suitable transportation of the resident to and from the Dialysis Center.
During an interview on 09/27/22 at 2:35 PM, Director of Nursing (DON) verified Resident #30 was not taken to dialysis because transportation was not available.
b) Resident #33
An observation on 09/26/22 at 10:00 AM, showed Resident #33 laid in bed with a fall mat on the floor beside bed.
An observation on 09/28/22 at 9:49 AM, showed Resident # 33 laid in bed in low position with fall mat beside bed.
A review of Resident #33's medical record showed no current physician order for the fall mat that was in place.
During an interview on 09/28/22 at 9:30 AM, Director of Nursing (DON) stated fall mats should have a physician order to be put in place. DON verified there was no current physician order for a fall mat for Resident # 33.
c) Resident #34
Review of the facility admission pack revealed - the center would arrange for residents transfer pursuant to the resident's attending physician. When the resident need to leave the center for medical or therapeutic reasons.
During an interview on 09/26/22 at 11:34 AM, Resident #34 stated that she was scheduled for a follow up appointment with her surgeon today. She stated that they got her up and ready to go to the appointment where her stepmother was waiting for her at the physician's office. Resident #34 stated the facility did not have anyone to take her, so she didn't get to go, and missed her appointment.
Medical record review on 09/27/22 revealed a physician's order for a follow up appt with a physician at a medical center wound care on 09/26/22 at 9:15 AM with the order date 9/12/22.
During an interview on 09/27/22 at 9:15 AM the Director of Nursing (DON), Verified Resident #34 missed her medical appointment because they did not have a transport person.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected multiple residents
Based on observation and staff Interview, the facility failed to ensure the facility was free from accident hazards in which it had control. Two (2) medication carts and one (1) treatment cart were le...
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Based on observation and staff Interview, the facility failed to ensure the facility was free from accident hazards in which it had control. Two (2) medication carts and one (1) treatment cart were left unlocked and unattended, allowing access to medications by residents and unauthorized persons. Additionally, the facility failed to lock and secure chemicals / disinfectant supplies. These were random opportunities for discovery and had the potential to effect more than a limited number of residents. Facility Census: 74.
Findings included:
a) 400 Hall Med Cart
An observation, on 10/02/22 at 5:10 PM, found the 400 Hall Med Cart unlocked and unattended. Surveyor remained with the unlocked cart until a staff member noticed the cart had been opened by Surveyor. During an interview, on 10/02/22 at 5:12 PM, Licensed Practical Nurse (LPN) #30 questioned, Did it just pop open? It's been acting up. LPN #30 then locked the cart.
b) Treatment Cart
An observation, on 10/02/22 at 5:15 PM, found the facility's Treatment Cart by the Director of Nursing's (DON's) office unlocked and unattended. LPN #41 immediately approached Surveyor and stated, That should be locked and then promptly locked the cart.
c) 200 Hall Med Cart
An observation, on 10/02/22 at 5:28 PM, found the 200 Hall med cart unlocked and unattended. Surveyor remained with the unlocked cart until a staff member noticed the cart had been opened by Surveyor. During an interview, 0n 10/02/22 at 5:31 PM, LPN #41 questioned, How did that get opened? I thought I pushed it [the lock] in. LPN #41 then locked the cart.
During an interview, on 10/02/22 at 6:04 PM, the DON was made aware of the med carts and treatment cart being unlocked. The DON confirmed that it is the facility's policy and a professional standard of practice for a nurse to secure all medications by locking the cart if it is going to be left unattended.
d) 100 Hall
An Observation on 10/02/22 at 5:44PM, found two (2) disinfectant supplies sitting on the handrail in reach of residents.
-Two (2) containers of Cavi Wipes with the warning :
Keep out of reach of Children
Skin: Wash skin with soap and water.
Eyes: Flush with water for 15 minutes. If irritation persists, seek
medical attention.
Inhalation: Remove to fresh air. If irritation persists, seek medical
attention.
Ingestion: Do not induce vomiting. Give large amounts of water.
Seek medical attention.
An interview with Licensed Practical Nurse (LPN) #30, on 10/02/22 at 5:52PM, revealed disinfectants should not be out in the reach of Residents.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0698
(Tag F0698)
Could have caused harm · This affected multiple residents
Based on medical record review and staff interview the facility failed to assess resident's conditions and monitor for complications before and after dialysis treatments. This was true for two (2) of ...
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Based on medical record review and staff interview the facility failed to assess resident's conditions and monitor for complications before and after dialysis treatments. This was true for two (2) of two (2) residents reviewed for dialysis treatment during the Long-Term Care Survey Process (LTCSP). Resident Identifiers #47 and #30. Facility census 74.
Findings Included:
a) Resident #47
Medical record review of resident #47s chart revealed there were no pre and post dialysis assessments completed in resident's active chart. Continued review found a physician's order: Dialysis center every Monday, Wednesday, and Friday with chair time at 11:30 am.
On 09/27/22 at 12:58 PM the facility staff were unable to locate Resident #47s dialysis communication book.
During an interview on 09/27/22 at 1:05 PM, the Assistant Director of Nursing (ADON) stated that Resident #47s dialysis communication book could have been left on the transportation bus yesterday when he went to the dialysis center. The ADON verified, staff would not be able to review residents' condition during the dialysis treatment or review the dialysis communications from the center for post dialysis from Resident #47 09/26/22 treatment.
On 09/27/22 at 1:48 PM the Director of Nursing (DON) brought all the Hemodialysis Communication Record that were found:
--10/15/21- Dialysis Center following dialysis treatment and post dialysis treatment sections not completed.
--04/08/22- Dialysis Center following dialysis treatment and post dialysis treatment sections not completed.
--05/09/22 - Dialysis Center following dialysis treatment and post dialysis treatment sections not completed.
--05/13/22 - Dialysis Center following dialysis treatment and post dialysis treatment sections not completed.
--08/19/22 - Dialysis Center following dialysis treatment and post dialysis treatment sections not completed.
--08/22/22 - Dialysis Center following dialysis treatment and post dialysis treatment sections not completed.
--08/24/22 - Dialysis Center following dialysis treatment and post dialysis treatment sections not completed.
--08/26/22 - Dialysis Center following dialysis treatment and post dialysis treatment sections not completed.
--08/31/22 - Completed, without receiving Licensed Nurse Signature.
--09/14/22 - Dialysis Center following dialysis treatment and post dialysis treatment sections not completed.
--09/26/22 - Completed, without receiving Licensed Nurse Signature.
-- Four (4) Hemodialysis Communication Record Incomplete with no date.
On 09/27/22 at 1:35 PM the Director of Nursing (DON) verified the Hemodialysis Communication Records are not being completed as ordered for Resident #47.
Based on medical record review and staff interview the facility failed to assess resident's conditions and monitor for complications before and after dialysis treatments. This was true for two (2) of two (2) residents reviewed for dialysis treatment during the Long-Term Care Survey Process (LTCSP). Resident Identifiers #47 and #30. Facility census 74.
Findings Included:
a) Resident #47
Medical record review of resident #47s chart revealed there were no pre and post dialysis assessments completed in resident's active chart. Continued review found a physician's order: Dialysis center every Monday, Wednesday, and Friday with chair time at 11:30 am.
On 09/27/22 at 12:58 PM the facility staff were unable to locate Resident #47s dialysis communication book.
During an interview on 09/27/22 at 1:05 PM, the Assistant Director of Nursing (ADON) stated that Resident #47s dialysis communication book could have been left on the transportation bus yesterday when he went to the dialysis center. The ADON verified, staff would not be able to review residents' condition during the dialysis treatment or review the dialysis communications from the center for post dialysis from Resident #47 09/26/22 treatment.
On 09/27/22 at 1:48 PM the Director of Nursing (DON) brought all the Hemodialysis Communication Records that were found:
--10/15/21- Dialysis Center following dialysis treatment and post dialysis treatment sections not completed.
--04/08/22- Dialysis Center following dialysis treatment and post dialysis treatment sections not completed.
--05/09/22 - Dialysis Center following dialysis treatment and post dialysis treatment sections not completed.
--05/13/22 - Dialysis Center following dialysis treatment and post dialysis treatment sections not completed.
--08/19/22 - Dialysis Center following dialysis treatment and post dialysis treatment sections not completed.
--08/22/22 - Dialysis Center following dialysis treatment and post dialysis treatment sections not completed.
--08/24/22 - Dialysis Center following dialysis treatment and post dialysis treatment sections not completed.
--08/26/22 - Dialysis Center following dialysis treatment and post dialysis treatment sections not completed.
--08/31/22 - Completed, without receiving Licensed Nurse Signature.
--09/14/22 - Dialysis Center following dialysis treatment and post dialysis treatment sections not completed.
--09/26/22 - Completed, without receiving Licensed Nurse Signature.
-- Four (4) Hemodialysis Communication Record Incomplete with no date.
On 09/27/22 at 1:35 PM the Director of Nursing (DON) verified the Hemodialysis Communication Records are not being completed as ordered for Resident #47.
b) Resident #30
Record review of Resident #30's medical record showed a medical diagnosis of End Stage Renal Disease and a physician order dated 05/17/22 that stated, Dialysis Center on Tuesday, Thursday, & Saturday at 11:45 am.
Record review of Resident #30's Dialysis Communication Book showed the following Hemodialysis Communication Records that had incomplete post dialysis information. The incomplete Hemodialysis Communication Records were dated as followed:
08/30/22
08/06/22
07/23/22
07/09/22
06/18/22
06/02/22
05/19/22
During an interview on 09/27/22 at 1:35 PM, Director of Nursing (DON) verified the Hemodialysis Communication Records were not completed.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Staffing Information
(Tag F0732)
Could have caused harm · This affected multiple residents
Based on observation and staff interview, the facility failed to post the daily nurse staffing. This was a random opportunity for discovery. Facility census 74.
Findings included:
a) No Daily Nurse St...
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Based on observation and staff interview, the facility failed to post the daily nurse staffing. This was a random opportunity for discovery. Facility census 74.
Findings included:
a) No Daily Nurse Staffing Posted
Observation on 10/02/22 at 5:05 PM, found the daily nurse staffing posted was dated 09/29/22. An immediate interview with Licensed Practical Nurse (LPN) #41 confirmed that the daily nurse staffing had not been posted for the following dates:
--Friday, 09/30/22
--Saturday, 10/01/22
--Sunday, 10/02/22
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Pharmacy Services
(Tag F0755)
Could have caused harm · This affected multiple residents
Based on observation, medical record review, and staff interview, the facility failed to provide routine and emergency drugs and biologicals to its residents as prescribed. This is true for 2 of 3 res...
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Based on observation, medical record review, and staff interview, the facility failed to provide routine and emergency drugs and biologicals to its residents as prescribed. This is true for 2 of 3 residents reviewed during medication administration. Resident identifiers: #120 and #62. Facility census: 74.
Findings include:
a) Resident (R) #120
The over the counter medication Zinc 220 milligrams (mg) was not available in the medication cart or the med storage room, during an observation of medication administration on 09/28/22 at 7:30 AM. Licensed practical Nurse (LPN) #60 acknowledged the Zinc was not available during the morning medication pass. LPN #60 stated it needed to be discontinued anyway, since the resident no longer has Covid.
A review of the medical record on 09/28/22 at 10:30 AM revealed an order was written to discontinue the Zinc at 09:17 AM on 09/28/22.
b) R #62
During an observation of medication administration on 09/28/22 at 08:00 AM, LPN #5 noted the prescribed supplemental medication Vitamin D3 400 units was not available in the facility to administer during the morning medication pass. LPN #5 reported Vitamin D3 is a stock med and needs to be reordered. LPN #5 added ordered stock meds are delivered every Thursday.
The DON reported stock meds are ordered by central supply twice a week after the nurse reports the medication needs reordered during an interview on 09/28/22 at 9:30 AM.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0802
(Tag F0802)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, food temperature checks, record review and staff interview the facility failed to ensure sufficient staff ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, food temperature checks, record review and staff interview the facility failed to ensure sufficient staff were employed to carry out the functions of the food and nutrition services in accordance with the facility assessment. These were random opportunities for discovery. The failed practice had the potential to affect more than a limited number of residents. Facility census: 74.
Findings included:
a) Kitchen staffing
An observation on 09/26/22 at 8:45 AM, during the initial tour showed only two (2) dietary staff working in the kitchen area.
During an interview on 09/26/22 at 9:15 AM, Resident # 40 stated most of the time Resident #40 does not eat because the food tastes bad and the food was cold.
During an interview on 09/26/22 at 10:04 AM, Resident #46 stated that food was always cold.
During an interview on 09/26/22 at 12:05 PM, Resident # 30 stated, the food is sucky. Resident # 30 stated the food tastes sucky and was always cold.
During an interview on 09/26/22 at 12:05 PM, Resident #4 stated that the food sucks, I'm going to have to buy my own food. The food is always cold.
An observation on at 09/26/22 at 1:10 PM, Resident # 30 was served lunch.
During an interview on 09/26/22 at 1:10 PM, Resident # 30 stated, I hate squash that's on the tray and did not want the chicken sandwich. Resident # 30 asked for the alternative.
A food tray temperature check of the last tray served on hallway 400, on 09/26/22 at 1:15 PM, revealed the following temperatures:
Chicken sandwich- 120 degrees
[NAME] Slaw- 65 degrees
Fresh Fruit- 58 degrees
During the interview on 09/26/22 at 1:15 PM, Dietary Manager (DM) that completed the temperature check stated the cold foods should have been under 55 and the hot foods should be at 120 degrees so chicken is good.
An observation on 09/26/22 at 1:55 PM, Resident # 30 received a chef salad as an alternative meal.
During an interview on 09/26/22 at 1:55 PM, Resident #30 stated the chef salad was pleasurable but he had to wait a while to get it. The resident waited from 1:10 pm until 1:55 pm which was 45 minutes after he requested the alternative.
An observation on 09/27/22 at 11:30 AM, showed only two (2) Dietary staff working in the kitchen with a facility census of 74.
During an interview on 09/27/22 at 11:30 AM, Dietary Manager (DM) stated food trays are started at 11:30 AM serving the dining room first and the expectation was food to be out to the halls and served within an hour after dining room was served. DM verified that the daily kitchen duties were staffed with just one (1) cook and one (1) aide on every shift.
An observation on 09/28/22 at 9:45 AM, showed only two (2) Dietary staff working in the kitchen with a facility census of 74.
Record review of the Facility Assessment updated on 07/13/22, showed, Dining Services Aides/Servers are scheduled to set-up, serve and clean up meals and snacks (1-3 per meal). As census or center needs change, staffing levels are adjusted.
Record review of the facility's census showed as of 09/27/22 the facility census was 74 Residents out of a total of 78 licensed beds.
During an interview on 09/28/22 at 11:25 AM, the Administrator stated the kitchen only runs with one (1) cook and one (1) aide per shift regardless of the census.
During an interview on 09/28/22 at 11:30 AM, the DM stated, I have a question for you, where did you get that paper at, that said dietary should have 1-3 aides per census, because I have never seen it before. DM stated was unaware of facility assessment dietary information. DM stated that the kitchen runs on one (1) cook and one (1) aide on each shift and that lunch begins at 11:30 AM in the dining room and then trays are served to the hallways after.
During an interview on 09/28/22 at 11:32 PM, the Administrator stated this was an easy fix that the facility assessment will just be changed to reflect only one (1) cook and one (aide) per shift.
An observation on 09/28/22 at 11:55 AM, showed only one (1) Resident had been served lunch in the dining room out of a total of six (6) Residents.
An observation on 10/02/22 at 5:23 PM, the first tray cart was announced to be on the floor.
During an interview on 10/02/22 at 5:30 PM, Dietary Staff (DS) #84 stated the food trays to the halls got a late start, after 5:00 PM, because the dietary staff were waiting for Residents to come to the dining room.
An observation on 10/02/22 at 5:36 PM Second tray cart was announced to the floor
An observation on 10/02/22 at 5:45 PM third tray cart was announced to the floor
An observation on 10/02/22 at 5:54 PM final tray cart was announced to the floor
A food tray temperature check of the last tray on hallway 400, on 10/02/22 at 6:08 PM, revealed the following temperatures:
Pepper Pot Soup- 112 degrees
Fish- 105.7 degrees
corn- 112.7 degrees
biscuit- 92.4 degrees
applesauce- 71 degrees
During an interview on 10/02/22 at 6:08 PM, Dietary Staff #84 verified the food temperatures were not good as hot food should be at 120 degrees and cold food should be 55 degrees or below.
An observation on 10/02/22 at 6:20 PM the last tray was served on 300-Hall.
During an interview on 10/02/22 at 6:30 PM, Licensed Practical Nurse (LPN) #30 stated dinner was a little late this evening and was usually served between 4:30 PM and 6:00 PM.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Menu Adequacy
(Tag F0803)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, staff interview, facility documentation, and resident council minutes the facility failed to provid...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, staff interview, facility documentation, and resident council minutes the facility failed to provide food in the amount for resident needs and preference. This affected [NAME] than a limited number of residents during the Long-Term Care Survey Process (LTCSP). Resident identifier #46. Facility census: 74.
Findings included:
a) Resident #46
During an interview on 09/26/22 at 10:04 AM Resident #46 stated the food is cold when they get it, and you don't get enough food when it's served.
Review of Grievance and Concerns found a concern dated 05/08/22 about the lunch meal: Residents received two (2) small pieces of hotdog in a crescent roll and pasta salad in a four (4) ounce condiment cup with lid.
A review from the Resident food committee on 05/10/22 at 10:30 AM revealed, Residents concerns about serving sizes.
A review of Resident Council Minutes revealed:
Resident Council 07/14/22: New Business -Meals and Dining,
--Portion sizes are small.
Resident Council 09/15/22: New Business -Meals and Dining,
--Cereal portion sizes are small.
During an Interview on 09/28/22 the Dietary Manager verified there has been resident council concerns about portion sizes.
b) Resident #120
During an interview on 10/02/22 at approximately 5:45 PM, Resident # 120 stated that she ordered chicken, but it tasted like fish.
An observation on 10/02/22 at approximately 5:45 PM, Resident #120's food tray card stated, Fresh Herb Roasted Chicken-1 each
During the food tray temperature check of the last tray on hallway 400, on 10/02/22 at 6:08 PM, showed fish was being served to Residents instead of chicken.
During an interview on 10/02/22 at 6:08 PM, Dietary Staff (DS) #84 verified fish was not on the menu. DS #84 stated fish was served instead of chicken this evening. DS #80 stated the kitchen did not have enough chicken to serve for this evenings dinner and for the chicken stew for lunch tomorrow. DS #80 stated that the dietary staff served fish instead and decided to hold on to the chicken for the chicken stew that everyone likes for lunch tomorrow. DS #80 stated that anyone who ordered chicken was served fish instead for dinner.
Review of the facility's dinner menu for 10/02/22, stated, Pepper Pot Soup, Parmesan Crusted Chicken, Seasoned Corn and Dinner Roll.
An observation on 10/03/22 at 10:19 AM, the daily Monday lunch menu was posted at the door by the dining room. The Lunch Menu stated, Garden Harvest Soup, Chicken Stew and Biscuit. as one (1) of the two (2) options for lunch choices this date.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0804
(Tag F0804)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interviews, observation and staff interviews the facility failed to serve food at an appetizing and preferable...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interviews, observation and staff interviews the facility failed to serve food at an appetizing and preferable temperature. This was a random opportunity for discovery. The failed practice had the potential to affect more than a limited number of Residents. Facility census: 74.
Findings included:
a) Food Tray Temperatures
During an interview on 09/26/22 at 9:15 AM, Resident # 40 stated most of the time Resident #40 does not eat because the food tastes bad and the food was cold.
During an interview on 09/26/22 at 10:04 AM, Resident #46 stated that food was always cold.
During an interview on 09/26/22 at 12:05 PM, Resident # 30 stated, the food is sucky. Resident # 30 stated the food tastes sucky and was always cold.
During an interview on 09/26/22 at 12:05 PM, Resident #4 stated that the food sucks, I'm going to have to buy my own food. The food is always cold.
A food tray temperature check of the last tray served on hallway 400, on 09/26/22 at 1:15 PM, revealed the following temperatures:
Chicken sandwich-120 degrees
[NAME] Slaw- 65 degrees
Fresh Fruit- 58 degrees
During the interview on 09/26/22 at 1:15 PM, Dietary Manager (DM) that completed the temperature check stated the cold foods should have been under 55 and the hot foods should be at 120 degrees so chicken is good.
An additional food tray temperature check of the last tray on hallway 400, on 10/02/22 at 6:08 PM, revealed the following temperatures:
Pepper Pot Soup- 112 degrees
Fish- 105.7 degrees
corn- 112.7 degrees
biscuit- 92.4 degrees
applesauce- 71 degrees
During an interview on 10/02/22 at 6:08 PM, Dietary Staff #84 verified the food temperatures were not good as hot food should be at 120 degrees and cold food should be 55 degrees or below.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0809
(Tag F0809)
Could have caused harm · This affected multiple residents
Based on record review, observation and staff interview the facility failed to ensure meals were served at times in accordance with resident's needs, preferences, and requests. This was a random oppor...
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Based on record review, observation and staff interview the facility failed to ensure meals were served at times in accordance with resident's needs, preferences, and requests. This was a random opportunity for discovery. The failed practice had the potential to affect more than a limited number of Residents. Facility census: 74.
Findings included:
a) Meal Serving Time
Record review of the facility's mealtimes were as followed:
Breakfast- 7:00 AM
Lunch- 11:30 AM
Dinner- 5:00 PM
During an interview on 09/26/22 at 12:05 PM, Resident # 30 asked, where was lunch? Resident #30 stated lunch should be here before noon and it is already 12:05 PM.
An observation on 09/26/22 at 1:10 PM, Resident # 30 was served lunch.
During an interview on 09/26/22 at 1:10 PM, Resident # 30 stated, I hate squash that's on the tray and did not want the chicken sandwich. Resident # 30 asked for an alternative.
An observation on 09/26/22 at 1:55 PM, Resident # 30 received chef salad as an alternative meal.
During an interview on 09/26/22 at 1:55 PM, Resident #30 stated the chef salad was pleasurable but had to wait a while to get it.
During an interview on 09/28/22 at 11:30 AM, Dietary Manager (DM) stated that the kitchen runs on one (1) cook and one (1) aide on each shift and that lunch begins at 11:30 AM in the dining room and then trays are served to the hallways after.
An observation on 09/28/22 at 11:55 AM, showed only one (1) Resident had been served lunch in the dining room out of a total of six (6) Residents.
An observation on 10/02/22 at 5:23 PM, the first tray cart was announced to be on the floor.
During an interview on 10/02/22 at 5:30 PM, Dietary Staff (DS) #84 stated the food trays to the halls got a late start, after 5:00 PM, because the dietary staff were waiting for Residents to come to the dining room. DS #84 stated dietary staff waited for residents to come to the dining room, but once it was discovered that no one was coming, that was the reason why the food trays were late going out to the hallways.
An observation on 10/02/22 at 5:36 PM Second tray cart was announced to the floor.
An observation on 10/02/22 at 5:45 PM third tray cart was announced to the floor.
An observation on 10/02/22 at 5:54 PM final tray cart was announced to the floor.
An observation on 10/02/22 at 6:20 PM the last tray was served on 300-Hall.
During an interview on 10/02/22 at 6:30 PM, Licensed Practical Nurse (LPN) #30 stated dinner was a little late this evening and was usually served between 4:30 PM and 6:00 PM.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected multiple residents
Based on observation and staff interview the facility failed to ensure the temperature logs were complete and up to date for the walk- in refrigerator, walk-in freezer, free standing refrigerator, and...
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Based on observation and staff interview the facility failed to ensure the temperature logs were complete and up to date for the walk- in refrigerator, walk-in freezer, free standing refrigerator, and dish machine. This was a random opportunity for discovery. The failed practice had the potential to affect more than a limited number of residents. Facility census: 74.
Findings included:
a) Temperature Logs
An observation on 10/02/22 at 5:20 PM, showed the October 2022 Walk-in Refrigerator Temperature Log, Walk-in Freezer Log, Dish Machine Log and Free-standing Refrigerator Temperature Logs were not completed for 10/01/22 and the morning of 10/02/22.
During an interview on 10/02/22 at 5:30 PM, Dietary Staff #84 verified the temperature logs for the walk-in refrigerator, walk-in freezer, free standing refrigerator, and dish machine were not completed for 10/01/22 or the morning of 10/02/22.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0838
(Tag F0838)
Could have caused harm · This affected multiple residents
Based on observation, record review and staff interview the facility failed to ensure the required thoroughness of the facility assessment to include the Dietary Manager as it related to food and nutr...
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Based on observation, record review and staff interview the facility failed to ensure the required thoroughness of the facility assessment to include the Dietary Manager as it related to food and nutritional services. This was a random opportunity for discovery. The failed practice had the potential to affect more than a limited number of Residents. Facility census: 74.
Findings included:
a) Dietary Staffing
An observation on 09/27/22 at 11:30 AM, showed only two (2) Dietary staff working in the kitchen with a facility census of 74.
During an interview on 09/27/22 at 11:30 AM, Dietary Manager (DM) stated food trays are started at 11:30 AM serving the dining room first and the expectation was food to be out to the halls and served within an hour after the dining room is served. DM confirmed that that daily kitchen duties were staffed with just one (1) cook and one (1) aide on every shift.
An observation on 09/28/22 at 9:45 AM, showed only two (2) Dietary staff working in the kitchen with a facility census of 74.
Record review of the Facility Assessment updated on 07/13/22, showed, Dining Services Aides/Servers are scheduled to set-up, serve and clean up meals and snacks (1-3 per meal). As census or center needs change, staffing levels are adjusted.
Record review of the facility's census showed as of 09/27/22 the facility census was 74 Residents out of a total of 78 licensed beds.
During an interview on 09/28/22 at 11:25 AM, Administrator stated that the kitchen only runs with one (1) cook and one (1) aide per shift regardless of the census.
During an interview on 09/28/22 at 11:30 AM, DM stated, I have a question for you, where did you get that paper at, that said dietary should have 1-3 aides per census, because I have never seen it before. DM stated he was unaware of facility assessment dietary information. DM stated that the kitchen runs on one (1) cook and one (1) aide on each shift and that lunch begins at 11:30 AM in the dining room and then trays are served to the hallways after.
During an interview on 09/28/22 at 11:32 PM, the Administrator stated this was an easy fix that the facility assessment will just be changed to reflect only one (1) cook and one (aide) per shift.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected multiple residents
Based on observation and staff interview, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and...
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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. The nurse failed to use a barrier during medication pass and touched the residents pills with her bare hands during medication prep. This was a random opportunity for discovery and was true for Resident #121. Resident identifier: #121. Facility census: 74.
Findings include:
a) Resident (R) #121
During an observation of medication preparation on 09/28/22 at 7:40 AM, Licensed Practical Nurse (LPN) #60 broke a B12 500 microgram tablet in half with her bare hands and thumb nail to administer the prescribed dose of 250 micrograms. LPN #60 dropped the lisinopril tablet on the medication cart, picked it up with her bare hand and placed it in the medicine cup with R #121's other meds. LPN #60 dropped the spirolactone tablet in the medication cart drawer, picked it up with her bare hand and placed it in the medication cup with the other medications for R #121. LPN #60 carried the medication cup, insulin injection pen, and blood pressure cuff into R #121's room. LPN #60 placed the insulin syringe on the window ledge without a barrier and the medication cup on the breakfast tray while she obtained his blood pressure (BP). LPN #60 reported R#121's BP was too low for his morning BP meds. She carried the medication cup, insulin pen and blood pressure cuff back to the medication cart. LPN #60 removed two tablets (lisinopril and metoprolol) from the medication cup with her bare hands. LPN #60 returned to R #121's room, administered the morning meds followed by the insulin injection. LPN #60 placed the insulin pen on the sink without a barrier while she washed her hands and returned the insulin injection pen to the medication cart without sanitizing it.
The Director of Nursing (DON) reported nurses are not to touch medications with their bare hands during an interview on 09/28/22 at 9:30 AM. The DON acknowledged medications such as an insulin injector pen should be placed on a barrier when carried into the resident's room to prevent contamination and the spread of infection.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0725
(Tag F0725)
Could have caused harm · This affected most or all residents
Based on deficiencies cited, resident interviews, resident representative interview, review of resident council minutes, resident council member interviews, review of the facility assessment, and faci...
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Based on deficiencies cited, resident interviews, resident representative interview, review of resident council minutes, resident council member interviews, review of the facility assessment, and facility staffing details, the facility failed to ensure sufficient qualified nursing staff were available at all times to provide nursing and related services to meet the residents' needs safely and in a manner that promoted resident rights, physical, mental and psychosocial well-being. This failed practice had the potential to affect all residents currently residing in the facility. Facility census: 74.
Findings Included:
a) Citations
During the facility's long-term care survey relevant citations included:
--See F561
--See F609
--See F657
--See F684
--See F689
--See F695
--See F697
--See F698
--See F727
--See F732
--See F755
--See F880
--See F885
b) Anonymous Resident Interviews
The first anonymous resident interview was conducted on 09/26/22 at 10:06 AM. Resident reported she feels there isn't enough staff to care for her.
The second anonymous resident interview was conducted on 09/26/22 at 10:16 AM. Resident reported there are many days she does not get enough food to eat but if she asks for more food, the staff say they do not have time to go get it.
The third anonymous resident interview was conducted on 09/26/22 at 12:14 PM. Resident reported, They take a long time to get to our lights. I have a BM [bowel movement] before they get here to take me to the bathroom.
c) Resident Representative Interview
An anonymous Resident Representative Interview was conducted on 09/26/22 at 2:48 PM. The resident representative stated the facility needs more help and the staff who do work are overwhelmed and overworked.
d) Meeting with Resident Council Members
Private interviews were conducted with Resident Council members throughout the long-term care survey process. Resident council members made the following statements regarding facility staffing and resident care:
-- Resident stated, There is not enough aides on day and evening shifts.
-- Resident stated she does not get the help and care she needs without waiting a long time. I wait for a long while and when they do come in, they will say I will come right back, but then don't return.
-- Resident stated she has waited over 40 minutes for her call light to be answered which resulted in resident having a bowel movement in her bed because she cannot make it to the bathroom without help.
-- Resident stated they don't have enough aides on weekends sometimes. The staff working do the best they can.
-- Resident stated, There have been many times over the last few months that help isn't available for long periods of time. I'm supposed to have help going to the bathroom for safety reasons. I fall a lot. Lots of times I wait so long for my call light to be answered that I will try to make it to the bathroom by myself before I have an accident. Then they will get mad at me for doing that.
e) Resident Council Minutes
On 09/26/22 at 7:21 PM, a review of resident council minutes from September 2021 - present found the following resident concerns:
--During a resident council meeting on 09/25/21, residents felt the facility could use more aides on evening shift.
--During a resident county meeting on 10/21/21, residents stated the facility needs more aides on evening shift.
--During a resident council meeting on 11/18/21, residents reported they felt some of the CNA's [certified nurse aides] need more training.
--During a resident council meeting on 12/16/21, residents reported their bed sheets were not changed on a regular basis. They also stated the facility had run out of wipes and briefs.
--During a resident council meeting on 01/20/22, residents reported showers were not being done twice a week. Residents stated there was not enough staff on days and evenings.
--During a resident council meeting on 02/17/22, residents reported showers were still not being done twice a week and remained a concern.
--During a resident council meeting on 03/17/22, residents stated the aides need to ask residents if they want food cut up. The necessary help was not being provided.
--During a resident council meeting on 05/19/22, residents reported some shifts run short.
--During a resident council meeting on 06/16/22, residents reported the facility did not have enough aides, especially on the weekends.
--During a resident council meeting on 07/14/22, residents were concerned about having two (2) nurses at a time.
--During a resident council meeting on 08/12/22, residents reported the aides turn off their call lights and leave the room saying they are coming back and then do not return.
--During a resident council meeting on 09/15/22, residents stated aides start care and leave saying they are coming back. Residents are left sitting with no clothes on, etc.
f) Review of Facility Grievances
A review of Facility Grievances from October 2021 - September 2022 was completed on 09/28/22 09:12 AM. The following grievances were related to facility staffing and resident care:
--An 11/16/21 grievance stated resident reported she felt staff are getting irritated with her when she puts her call light on for assistance. Staff education was completed and instructed staff to be mindful of their tone of voice and facial expressions.
-- A 12/06/21 grievance stated on 12/02/21 the aide on evening/night shift put an Attends [an adult incontinence brief] on her so they wouldn't have to take her to frequent bathroom requests.
--A 12/06/21 grievance stated on 12/03/21 on evening shift or night shift that she needed her bed changed due to sweating. She was given a new pillow by the aide who answered the call light, but the bedding remained unchanged.
--A 12/15/21 grievance stated resident and daughter reported that resident was soiled and had her light on for over an hour. Another CNA not assigned to resident answered light and changed resident.
--A 12/15/21 grievance stated resident was supposed to wear a leg brace BID [twice a day] but resident reported it was not put on over the weekend.
--A 02/15/22 grievance stated resident reported on 02/14/22 at approximately 8:00 PM she had her call light on for hours and no one came. She stated she was wet and needed changed.
--A 03/16/22 grievance stated resident put her call light on because she needed changed. Resident's light was not answered in a timely fashion. Staff education was completed and noted, We are again struggling with call lights being answered in a timely manner. Management gets frequent complaints regarding the time it takes to answer the call bell.
--A 05/02/22 grievance stated CNA [certified nurse aide] approached resident and asked if he needed his diaper changed. Resident and daughter were offended by the use of the term diaper instead of just asking if he needed changed.
-- A 06/01/22 grievance stated resident's daughter reported resident is not getting shaved and not getting up in his wheelchair.
-- A 07/02/22 grievance stated resident put her call light on and asked to be changed. Nurse answered call light and reported to resident that she notified the CNA. Resident reports she was not changed.
g) Review of the Facility Assessment and Record Review
The facility assessment (used to determine resources necessary to care for facility residents), documented a bed capacity of 78 with an average daily census of 75. The facility's staffing plan outlined the following staffing would be necessary to ensure sufficient staff to meet the needs of the residents at any given time:
Days
--3 LN [Licensed Nurses]
--1:16 CNA [Certified Nurse Aide] Ratio
Evenings
--3 LN
--1:16 CNA Ratio
Nights
--2 LN
--1:20 Ratio
A review of Nurse Staffing Information for six random weekend dates was completed on 09/26/22 at 2:56 PM.
Review of the Daily Time Detail by Department Report for 07/02/22 revealed:
--LN Staffing was two (2) for Day Shift
--LN Staff was two (2) for Evening Shift
--The CNA with Assignment 1 was assigned 20 residents
--The CNA with Assignment 2 was assigned 20 residents
--The CNA with Assignment 3 was assigned 20 residents
--The CNA with Assignment 4 was assigned 20 residents
Review of the Daily Time Detail by Department Report for 07/03/22 revealed:
--LN Staff was two (2) for Evening Shift
Review of the Daily Time Detail by Department Report for 08/20/22 revealed:
--LN Staff was two (2) for Evening Shift
Review of CNA Assignment Sheet for 08/21/22 from 10:30 AM - 2:30 PM revealed:
--The CNA with Assignment 1 was assigned 20 residents
--The CNA with Assignment 2 was assigned 20 residents
--The CNA with Assignment 3 was assigned 20 residents
--The CNA with Assignment 4 was assigned 20 residents
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0727
(Tag F0727)
Could have caused harm · This affected most or all residents
Based on record review and staff interview, the facility failed to ensure a Registered Nurse (RN) was present at the facility for at least eight (8) consecutive hours a day, seven (7) days a week. Thi...
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Based on record review and staff interview, the facility failed to ensure a Registered Nurse (RN) was present at the facility for at least eight (8) consecutive hours a day, seven (7) days a week. This was true for one (1) of six (6) randomly sampled dates from July 2022 - October 2022. This had the potential to affect all residents who currently reside at the facility. Facility census: 74.
Findings included:
a) RN Coverage
On 09/26/22 at 2:56 PM, a review of the staffing timesheets/schedules for RN coverage found one (1) occasion when RN coverage was not present in the facility. On Saturday, 07/02/22, RN coverage was 0.00 hours. There was no RN coverage in the facility.
On 10/03/22 at 10:45 AM, the Director of Nursing (DON) confirmed the facility timesheets did not reflect any RN coverage on Saturday, 07/02/22. The DON went on to report the nurse that would have normally been scheduled to work that particular day had been on vacation. The DON noted there must have been an oversight when making the schedule because normally the DON would have filled in for any opening in the schedule due to a call-off or scheduled vacation.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0885
(Tag F0885)
Could have caused harm · This affected most or all residents
Based on facility documentation and staff interview the facility failed to Inform residents, their representatives, and families of those residing in facilities by 5 PM the next calendar day following...
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Based on facility documentation and staff interview the facility failed to Inform residents, their representatives, and families of those residing in facilities by 5 PM the next calendar day following the occurrence of a confirmed infection of COVID-19. This failed practice had the potential to affect all residents in the facility. Facility Census: 74.
Findings included:
a) Covid-19 Notification
On 09/27/22 a facility documentation review revealed a confirmed case of Covid-19 for a resident in the facility on 09/17/22. Continued review found no residents, representatives or families were notified until 09/21/22.
During an interview on 09/27/22 at 2:38 PM The Director of Nursing (DON) confirmed no family, resident or representative was notified before 5 PM 09/18/22. She stated that she notified residents, their representatives, and families on 09/21/22.
Nov 2019
13 deficiencies
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 observation, record review, staff and family interview, the facility failed to ensure reasonable accommodations of choices related to daily menu selection. A resident who is Hispanic, canno...
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Based on observation, record review, staff and family interview, the facility failed to ensure reasonable accommodations of choices related to daily menu selection. A resident who is Hispanic, cannot read English nor Spanish is given daily menu written in English and asked to point to which menu selection he would like for his meal. This had the potential to effect one (1) of 18 resident reviewed for accommodation of needs. Resident Identifer #4. Facility census 76.
Findings included:
a) Resident #4
On 11/18/19 at 2:20 PM, Social Service Director (SSD)#26 was asked whether Resident #4 is capable of answering questions related to his life here at the facility. The SSD stated that Resident #4 would not know the date or year, but he is capable of answering questions related to his care.
An interview was conducted with Resident #4 on 11/19/19 at 8:38 AM, via the use of the Interpreter Services. Surveyor asked the translator to ask Resident #4, do you participate in activities here. The translator stated the resident said like what, I do not know how to read. The translator was given direction to ask the resident at 9:13 AM, does the staff know how to communicate with you. The resident replied, no staff communicates with him. Then the resident informed the translator, Well they talk to me in English and I don't know what they say. The interpreter service translated the question: Are there any communication system available at the bedside: cards, note pads, or any other items. Resident #4 replied to the translator by saying, No none of that cards, note pad, call translator- no. When his son is there he can communicate with the staff a little, maybe his son understands them. The resident was asked, if you wants something how do you get them to understand. The resident said I barely asked them for anything. The translator was informed to ask the resident does this work. Resident #4 replied by saying, I cannot do anything. The resident was asked, do they offer to call and ask the translator to help them when you do not understand them. The resident said, no.
Observation of Resident #4's room on 11/18/19, 11/19/19, and 11/20/19 found no cards or note pads as a way to communicate with the resident. The Interpreter services phone number was present on the wall behind the bed. During the three (3) days the surveyor was present there were no observation of the staff calling the phone interpreter service to assist them in communicating with Resident #4. The only time surveyor observed the staff calling the phone interpreter services was when the surveyor asked them to call in order to interview Resident #4.
During a random review of Resident #4's record finds on 11/19/19 at 2:30 PM, a care plan meeting transpired on 08/29/19. Resident #4's son attended the care plan meeting. The son wanted to know in the care plan meeting if the staff would provide a Spanish menu or have his meal preference offered in Spanish. There is no evidence Resident #4's son was provided with a menu written in Spanish until surveyor made a inquiry about the menu.
In an interview with the Food Service Supervisor (FSS) on 11/19/19 at 2:50 PM, was asked how do you ask Resident #4 what selection on the daily menu he preferes to have for his meals. The FSS stated that, the unit clerk's (UC) (name) #51 will ask the resident which selection on the menu he would like to have for his meal. The FSS handed surveyor Resident #4's dinner meal selection form for Tuesday November 19, 2019. The observation revealed the menu was written in English.
Selection #1 was circled as the meal Resident #4 had selected. The FSS was asked how does the staff determine what Resident #4 meal preference is for this menu. The FSS said you will have to ask UC #51, that he did not know how they ask the resident which meal he would prefer.
The FSS is unaware of how the staff member are asking Resident #4, what his meal selection preference is for his daily meals.
In an interview with UC #51 on 11/19/19 at 3:09 PM, she was asked how did you ask Resident #4 what his meal preferences is for tonight's dinner meal. The UC said she handed Resident #4 the daily menu selection and he points to what he wants. The UC was shown Resident #4's Tuesday 19, 2019's dinner meal. The UC was asked is this the menu you handed to Resident #4 to be able to choose which meal he would like to have tonight. The UC confirmed this was the menu selection form she had handed to Resident #4. The UC was asked whether she uses the phone Interpreter services to find out which menu selection the resident would like to receive. The UC stated, No. The UC was asked can Resident #4 read the menu in English and/or Spanish. The UC stated, I think he can read in English. The UC said she really did not know, she thought he could read both.
In an interview on 11/19/19 at 3:55 PM, the SSD was already informed the staff were offering the daily menu selection to Resident #4 written in English. The SSD said the resident is unable to read writing in English and Spanish in order to choose what food selection he would prefer to eat for his meal. The SSD was questioned at this time why the staff are not attempted to provide a menu in Spanish for Resident #4's son to be able to read the menu to his father, or use the phone Interpreter services. The SSD agreed the staff should have provided Resident #4 son a menus in Spanish to help the family be informed of what the meal will be and so the son can participate in helping the resident make choices about his menu selection. SSD said the staff have the translator form in the room and at the nursing station and she confirmed the staff are not picking up the phone, calling the Interpreter services so they can translate their menu selection to Resident #4. She said she will try to get the menu translated in Spanish for the family, give this to the FSS and educate the staff on using the translator in order for them to allow the resident to be able to make a selection from the menu for his meals. The SSD confirmed that Resident #4 is capable of make a decision about his meals preference if someone speaks what the menu selection is in Spanish.
In an interview with Resident #4's family member on 11/19/19 at 3:25 PM. The family member confirmed that Resident #4 was unable to read words written in English nor Spanish. The family member said Resident #4 Speaks in Spanish and the staff need to inform him what food is being offered to him in order for him to choose what he would like to eat.
In an interview with the Administrator on 11/19/19 at 4:00 PM, revealed she was informed by her staff that Resident #4 is unable to read writing in English nor Spanish. The Administrator also was aware that her staff have been handing Resident #4 menus written in English and asking him to point to the menu selection to determine what the resident wanted to consume for his meals. The Administrator said you are aware that Resident #4 has a low BIMS. Surveyor discussed with the Administrator, just because a resident has a low BIMS does not indicate that a resident cannot still make choices about his activity's of daily living (ADL'S), like making choices about what his preferences are for his meals.
The son had attended the care plan meeting on the afternoon of 11/19/19 and again the son posed the question of whether the staff would providing a menu in Spanish so that he could ask his father what meal choice he wanted on a weekly basis. The son made the statement to the staff members who had attended the care plan meeting that his father did not understand what he is being asked and he would answer eggs as a meal choice each time.
A review on 11/20/10 at 8:30 AM, of Resident #4's quarterly Minimum Data Set (MDS) with the Assessment Reference date (ARD) of 11/04/19 finds Resident #4 under section B, the resident is able to hear adequate, speech is clear, able to understand others and he can make himself understood. The resident's race/ethnicity is marked as being Hispanic or Latino. Resident #4 need and wants an interpreter to communicate with the doctor or health care staff. The resident preferred language is Spanish. Under section C is marked that a Brief Interview for Mental Status (BIMS) should be conducted. There is no BIMS score for Resident #4. The form says to enter 99 if the resident was unable to complete the interview. The BIMS form does contain the code 99 to indicate the resident was unable to complete the interview.
In an interview with Social Service assistant (SSA) #74 on 11/20/19 at 9:15 AM, revealed that she had completed Resident #4's quarterly MDS with the ARD of ( 11/04/19 ). The SSA said she had completed her assessment related to talking to the staff (Nurses Aide) about the staffing assessment and reading the nursing notes the nurses wrote to determine what the resident scored on his BIMS. The SSA was asked, did you call the interpreter to determine whether the resident can answer the BIMS questions. The SSA stated, No. The SSA point to the builten board and stated, We have an interpreter we could call. The SSA made no comment on why the BIMS form did not contain the code 99 to indicate the resident was unable to complete the interview.
The SSA did not attempt to notify the interpreter services in order to conduct an interview with Resident #4 to determine a complete an accurate BIMS score. The interpreter service was called on 11/20/19 at 9:26 AM, and SSD #26 completed a BIMS form.
The interpreter service was called on 11/20/19 at 9:26 AM. Resident #4, Surveyor, SSD , and the admission Director (AD) #14 was present for Resident #4's BIMS assessment. The assessment was completed by SSD. The SSD called the Interpreter services and the Interpreter number is # 353111 assisted the SSD with translating questions to Resident #4 in Spanish. Once the series of questions were asked the Resident's BIMS score was a 7.
The SSD asked the Interpreter #353111 to translate to Resident #4 on 11/20/19 at 9:36 AM, can you read Spanish or English. The translator asked Resident #4 this question and the Interpreter said the Resident #4 stated Nothing. The Interpreter translator to the resident if we show you a pictures of food would you understand, the resident responded back to the translator as yes.
The SSD asked the Interpreter to translate to Resident #4 on 11/20/19 at 9:39 AM, which menu selection for today (Wednesday), would he like meal. The interpreter translated Wednesday's menu selection to the resident and the interpreter said he had to rephrase the menu, but the resident stated that the resident selected the first selection for his meal.
Surveyor then asked SSD to ask the Interpreter to translate to Resident #4 the question does the staff give him a choice about what he wants to eat. The interpreter translated the above question. Resident #4 said he does not get a choice and whatever they give him he eats. Surveyor asked SSD to ask the Interpreter to ask the resident do you like the food you eat. The translator said the resident said sometimes yes, sometimes no. The SSD told the Interpreter to tell the resident they would give him a choice and the Interpreter said the resident said that is good.
The SSD on 11/20/19 at 9:50 AM, agreed that Resident #4 is cognitive enough of making decision about his activity of daily living (ADL's) menu selection.
In an interview with SSD on 11/20/19 at 10:00 AM, she said the staff have been told to call the interpreter so Resident #4 is allowed to make a choice on what he may want to eat for his meals. The SSD said that she is going to have a speech therapy evaluation the resident to determine his ability to understand picture. This may be something we can use to communicate with the resident. The SSD said that she will make sure that the FSS will translate the menu in Spanish for the family.
A progress note on10/14/19 at 5:54 PM, finds Resident #4 is alert and oriented to patient, place and time. Resident #4 has independent decision making skills for daily routine. On 11/16/19 the Certified Family Nurse Practitioner (C-FNP) reveales she is able to speak with resident, Few Spanish words.
On 11/20/19 at 11:30 AM, the FSS showed surveyor menus written in Spanish that he would start using from now on in order to obtain Resident #4's daily menu selection. The FSS said if the son is not available to go over the menu with the resident the staff will have to call the Interpreter services to obtain the resident's meal preferences.
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CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0655
(Tag F0655)
Could have caused harm · This affected 1 resident
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Based on resident interview, record review and staff interview the facility failed to initiate and/ or provide a baseline care plan within 48 hours of admission. This is true for one (1) of four (4)...
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Based on resident interview, record review and staff interview the facility failed to initiate and/ or provide a baseline care plan within 48 hours of admission. This is true for one (1) of four (4) residents reviewed. Resident identifier: #174. Facility census: 75.
Findings include:
a) Resident #174
On 11/18/19 at 3:25 PM Resident #174 expressed she was not sure if the facility staff discussed a baseline care plan with her and her daughter.
At 10:40 AM on 11/20/19 registered nurse (RN) #71 explained the resident care plan should occur within seventy-two (72) hours after admission. Often times this does not occur until five (5) to seven (7) days after admission. She explained an admitting base-line care plan is not reviewed with the resident.
The facility person-centered care plan policy with a revision date of 07/01/19 reveals, The Center must develop and implement a baseline person-centered care plan within 48 hours for each patient.
The facility could not provide evidence the care plan was reviewed with the resident within forty-eight hours after admission.
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CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on medical record review and staff interview, the facility failed to follow the care plan and monitor meal intakes for a...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on medical record review and staff interview, the facility failed to follow the care plan and monitor meal intakes for a resident identified with inadequate oral intake. This was true for one (1) of three (3) residents reviewed for nutrition. Resident identifier: 173. Facility census: 75.
Findings include:
a) Resident (R) #173
Review of the medical record on 11/20/19, revealed R #173 was admitted to the facility on [DATE] for therapy and intravenous antibiotics after a complicated prolonged hospital stay. The Dietician summary dated 11/07/19, states under section L. 1 .Inadequate oral intake. Interventions include liberalized regular diet with chopped meat, encourage intake, and coordinate care with the Interdisciplinary team (IDT). The goal was to maintain adequate intake to meet estimated nutritional needs and no significant changes in weight.
The care plan with a revision date of 11/11/19, identifies R #173's nutritional risk. Interventions include: Monitor intake at all meals, offer alternate choices as needed, alert dietician and physician to any decline in intake.
The ADL records for 11/06/19 through 11/19/19 contain multiple incomplete areas for meal intake since admission. Intakes for 12 of 42 meal opportunities were documented. four (4) of the 12 meals were refused, 2 meals were 25% consumed, 1 was 50% consumed, 3 meals were 75% consumed and 2 were 100% eaten.
During an interview on 11/20/19 at 11:00 AM, the Corporate Consultant (CC) #150, acknowledged R #173 lost 20 pounds since admission and agreed the Dietician admission note identifies inadequate intake. CC #150 reviewed the ADL records and confirmed staff are not following the care plan and documenting meal intakes.
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CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0679
(Tag F0679)
Could have caused harm · This affected 1 resident
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Based on record review and staff interview, the facility failed to allow preferences of each resident for their choice of activities designed to meet the interests of and support the physical, menta...
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Based on record review and staff interview, the facility failed to allow preferences of each resident for their choice of activities designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the community. A resident was identified that going outdoor was a very important activity, but this activity only occurred one (1) time in two (2) months and 17 days. Resident Identifier #4. Facility census 76.
Findings included:
a) Resident #4
A review of Resident #4's Annual Minimum Data set (MDS) with the Assessment Reference Date (ARD) of 02/07/19, under section F, while you are in this facility how important is it to you to go outside to get fresh air when the weather is good is identified as it is very important. This activity is identified as Resident #4's most highest important activity in the resident's life while he resides in this facility.
The quarterly MDS with the ARD of 11/04/19, finds under section E, Resident #4 is identified as having no wandering behaviors exhibited. Under Section G, reveals Resident #4 is steady at all times moving from a seated to a standing position, walking with assistive device, turning around and facing the opposite direction while walking, and no impairment in is upper and lower extremities. The resident uses a walker, wheelchair. The resident is continent of bowel and bladder. Under section P, Resident #4 has a wander/elopement alarm that is used daily.
A review of Resident #4's activity care plan does not identify going outside to get fresh air when the weather is good as an intervention in the resident's care plan.
A review of Residnet #4's progress note finds a recreation quarterly progress note and care plan dated 10/31/19, stating the resident participates in group engagement with the most frequently attended programs being bingo on occasion. The resident attends social, music programs and outdoors at a frequency of daily.
A review of Resident #4's participation record finds for the months of September, October and up to November 17, 2019, Resident #4 had only went outdoor one (1) time on 09/22/19.
In an interview on 11/19/19 at 1:41 PM, with the Activity Director (AD), she was asked what activities does Resident #4 likes to attend. The AD stated that, the resident likes to go to bingo, and listen to Spanish music. The AD did not mention going outdoor. When the AD was asked whether going outdoor is very important to Resident #4, the AD stated yes, the resident likes to go outdoor very much. When asked why has Resident #4 been identified that while he is in the facility it is very important for him to go outside to get fresh air when the weather is good on the resident's Annual MDS, and on the resident 's recreation quarterly progress note and care plan evaluation with the date of 10/31/19 reveals the resident is identified as going outdoor as his most frequently attended group program, but Resident #4 has only participated in going outdoor one (1) time on 09/22/19 for the months of September, October and up to November 17, 2019. The AD acknowledged that Resident #4 has not been assisted with activities of his preference, like being able to go outdoor.
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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 observation,record review and staff interview the facility failed to provide care in accordance with professional standards of practice. The facility failed to treat boggy heels, failed to ...
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Based on observation,record review and staff interview the facility failed to provide care in accordance with professional standards of practice. The facility failed to treat boggy heels, failed to date and initial intravenous antibiotic medications and a peripherally inserted central catheter, (PICC line). This is true for two (2) of eighteen (18) residents reviewed. Resident identifiers: #174 and #170. Facility census: 75.
Findings include:
a) Resident #174
The initial nursing assessment with a date of 11/14/19 reveals the resident was admitted with an integumentary issue of boggy heels.
Review of physician orders and plan of care found no evidence of treatment related to boggy heels.
The facility was unable to provide evidence of treatment for the boggy heels until the surveyor brought it to their attention on 11/19/19.
On 11/20/19 at 3:00 PM facility consultant #150 explained the new admission medical information should be reviewed by two nurses to prevent missing an intervention.
b) Resident #170
Resident #170 was admitted to the facility on Saturday 11/16/19.
I. During the initial tour of the facility on 11/18/19 at 1:00 PM Resident #170 was receiving oxygen at three and one half (3.5) liters per minute.
II. The intravenous (IV) medication which had been delivered and disconnected had no evidence of the time, the date or the person who started the medication.
III. The resident had a peripherally inserted central catheter (PICC) line, with no evidence of the date, the time and the person who placed the transparent dressing.
At 3:45 PM on 11/18/19 registered nurse (RN) #71 observed the same explained there was no order to give the resident oxygen, and the IV and PICC line sight were not labeled with the date, time and initials.
Review of the medical records found no evidence of an order to complete a normal saline flush before and after medication administration until 11/19/19.
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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
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on medical record review and staff interview the facility failed to ensure a resident maintains adequate nutritional sta...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on medical record review and staff interview the facility failed to ensure a resident maintains adequate nutritional status, to the extent possible, to ensure each resident is able to maintain the highest practicable level of well-being. The Interdisciplinary team (IDT) failed to ensure meal intakes were monitored and failed to implement new interventions to address continued weight loss. This was found for one (1) of three (3) residents reviewed for nutrition. Resident identifier: 173. Facility census: 75.
Findings include:
a) Resident (R) #173
Review of the medical record on 11/20/19, revealed R #173 was admitted to the facility on [DATE] for therapy and intravenous antibiotics after a complicated prolonged hospital stay. The admission nursing note dated 11/05/19 identifies a recent spinal fusion complicated by infection, a history of liver disease, a daily or almost daily consumption of alcohol and tobacco in the past year, total assistance with all activities of daily living (ADL) except eating independently, and the absence of edema.
The Dietician summary dated 11/07/19, states R #173 reported losing approximately 13 pounds during his recent hospitalization, notes his current intake is less than his estimated needs and identifies his history of alcohol use. The Dietician's nutritional assessment states under section L. 1 .Inadequate oral intake. Interventions include liberalized regular diet with chopped meat, encourage intake, and coordinate care with the Interdisciplinary team (IDT). The goal was to maintain adequate intake to meet estimated nutritional needs and no significant changes in weight.
**The medical records lack any other dietary notes from admission until this record was reviewed on 11/20/19.
The computerized records note the following weights:
--11/05/19 -- 157 pounds
--11/07/19 -- 157 pounds
--11/13/19 -- 143 pounds
--11/17/19 -- 137 pounds
The ADL records for 11/06/19 through 11/19/19 contain multiple incomplete areas for meal intake since admission. Intakes for 12 of 42 meal opportunities were documented. four (4) of the 12 meals were refused, 2 meals were 25% consumed, 1 was 50% consumed, 3 meals were 75% consumed and 2 were 100% eaten.
During an interview on 11/20/19 at 11:00 AM, the Corporate Consultant (CC) #150, acknowledged R #173 lost 20 pounds since admission according to his last weight of 137 pounds on 11/17/19, agreed he has no history of edema/fluid loss to account for the large weight loss, and agreed the Dietician admission note identifies inadequate intake. CC #150 reviewed the ADL records and confirmed staff are not monitoring and documenting meal intakes. At the end of this interview, CC #150 reported the dietician was currently reviewing R #173's nutritional needs.
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CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Medical Records
(Tag F0842)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
c) Resident #270
On 11/19/19 at 1:00 PM a medical record review revealed Resident #270 was admitted to the facility on [DATE]....
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
c) Resident #270
On 11/19/19 at 1:00 PM a medical record review revealed Resident #270 was admitted to the facility on [DATE]. Her diagnosis included; Central cord syndrome at unspecified level of cervical spinal cord, Spinal instabilities, Occipito-Atlanto-Axial region muscle weakness, Chronic Obstructive Pulmonary disease and paralytic syndrome.
Resident #270 requires total dependence for bed mobility, transfers, locomotion. dressing, eating, personal hygiene, and bathing.
Review of the ADL (activities of daily living) record for the months of September and November 2019 found multiple dates and shifts lacking documentation of provided care.
After review of the ADL sheets for September and November on 11/19/19 at 2:00 PM, the NHA stated, Yes there are multiple blank areas without any documentation. I will check to see if there is some documentation somewhere else.
On 11/20/19 at 9:30 AM, the NHA reported no other documentation was found and it is an incomplete medical record.
Based on medical record review and staff interview, the facility failed to maintain complete and accurate medical records. Activity of Daily Living (ADL) Records were incomplete for three (3) of 18 residents reviewed. Resident Identifiers: #62, #11, and #270. Facility census: 75.
Findings include:
a) Resident (R) #62
Review of the medical record on 11/19/19, revealed R #62 has limited communication skills, a history of wandering and is dependent on staff for all aspects of ADL care. The ADL records for the period of 11/01/19 through 11/18/19, were incomplete in the following areas :
--Bed Mobility - Night shift (N) 11/10, 11/16; Day shift (D) 11/1, 11/4, 11/7, 11/9 through 11/11, 11/15, 11/17, 11/18; Evening shift (E) 11/2, 11/11 and 11/16.
--Transfers - N 11/10, 11/16; D 11/1, 11/4, 11/7, 11/9 through 11/11, 11/15, 11/17, 11/18; E 11/2, 11/11, and 11/16.
--Eating - N 11/10, 11/16; D 11/1, 11/4, 11/7, 11/10, 11/11, 11/15, 11/17, 11/18; E 11/2, 11/9, 11/11, and 11/16.
--Toilet use - N 11/10, 11/16; D 11/1, 11/4, 11/7, 11/9 through 11/11, 11/15, 11/17, 11/18; E 11/2, 11/11, and 11/16.
--Locomotion (on unit) - N 11/10, 11/16; D 11/1, 11/4, 11/7, 11/10, 11/11, 11/15, 11/17, 11/18; E 11/2, 11/9, 11/11 and 11/16.
--Locomotion (off unit) - N 11/10, 11/16; D 11/1, 11/4, 11/7, 11/10, 11/11, 11/15, 11/17, 11/18; E 11/2, 11/9, 11/11 and 11/16.
--Dressing - N 11/10, 11/16; D 11/1, 11/4, 11/7, 11/10, 11/11, 11/15, 11/17, 11/18; E 11/2, 11/9, 11/11 and 11/16.
--Personal Hygiene - N 11/10, 11/16; D 11/4, 11/7, 11/10, 11/9 through 11/11, 11/15, 11/17, 11/18; E 11/2, 11/11, and 11/16.
--Meal intakes - Breakfast 1/1, 1/4, 1/9, 11/11, 11/15, 11/17, 11/18; Lunch 11/1, 11/4, 11/7, 11/9, 11/11, 11/15, 11/17, 11/18.; Dinner 11/1, 11/2, and 11/9 through 11/11.
--Bladder - N 11/10, 11/16; D 11/1, 11/4, 11/7, 11/9, 11/11, 11/15, 11/17, 11/18; E 11/1, 11/2, 11/9, 11/11, and 11/16.
--Bowel - N 11/10, 11/15, 11/16; D 11/1, 11/4, 11/7, 11/9 through 11/11, 11/15, 11/17, 11/18; E 11/1, 11/2, 11/9, 11/11, and 11/16.
The Interim Director of Nursing (DON) confirmed the ADL records were incomplete during an interview on 11/19/19 at 10:00 AM.
b) Resident (R) #11
Review of the medical record on 11/19/19, revealed R#11's has a diagnosis of Alzheimer's Dementia. She is dependent on staff for all ADLs and wanders at times. The ADL record was reviewed for the period of 11/01/19 through 11/18/19 and revealed the following incomplete areas:
--Bed mobility - Night shift (N) 11/10, 11/16; Day shift (D) 11/1, 11/4, 11/11, 11/15, 11/17, 11/18; Evening shift (E) 11/2, 11/9, 11/11, and 11/16.
--Transfers - N 11/10 and 11/16; D 11/1, 11/4, 11/11, 11/15, 11/17, 11/18; E 11/2, 11/9, 11/11, and 11/16.
--Eating - N 11/10 and 11/16; D 11/1, 11/4, 11/11, 11/14, 11/17, 11/18; E 11/2, 11/9, 11/11 and 11/16.
--Toilet use - N 11/10 and 11/16; D 11/1, 11/4, 11/11, 11/15, 11/17, 11/18; E 11/2, 11/9, 11/11 and 11/16.
--Dressing - N 11/10 and 11/16; D 11/1, 11/4, 11/11, 11/17 and 11/18; E 11/2, 11/9, 11/11, 11/16.
--Personal Hygiene - N 11/10 and 11/16; D 11/1, 11/4, 11/9, 11/15, 11/17 and 11/18; E 11/2, 11/9, 11/11, and 11/16.
--Meal intake - Breakfast and Lunch 11/1, 11/4, 11/9, 11/11, 11/15, 11/17 and 11/18. Dinner 11/1, 11/2, 11/9 through 11/11, and 11/16.
--Bladder N- 11/10, 11/11, 11/16; D 11/1, 11/4, 11/9, 11/11, 11/15, 11/17, 11/18; E 11/2, 11/9 through 11/11, 11/14 and 11/16.
--Bowel - N 11/11 and 11/16; D 11/1, 11/4, 11/9 through 11/11, 11/15, 11/17, 11/18; E 11/2, 11/9 through 11/11, and 11/16.
The Interim Director of Nursing (DON) confirmed the ADL records were incomplete during an interview on 11/19/19 at 10:00 AM.
.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Pharmacy Services
(Tag F0755)
Could have caused harm · This affected multiple residents
.
Based on record review and staff interview, the facility failed to maintain complete and
accurate drug records to ensure an account of all controlled medications (medications
which fall under US D...
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.
Based on record review and staff interview, the facility failed to maintain complete and
accurate drug records to ensure an account of all controlled medications (medications
which fall under US Drug Enforcement Agency (DEA) Schedules II-V, and have a potential for
abuse, ranging from low to high, and may also lead to physical or psychological dependence). This was found for two (2) of three (3) medication carts and has the potential to affect all residents residing in the facility. Facility census: 75.
Findings include:
a) On 11/19/19 at 3:00 PM, a review of the controlled substance shift to shift reconciliation log on medication cart #3, with Licensed Practical Nurse (LPN) #82 revealed incomplete records. Nursing signatures were missing in the coming on duty section for 09/20, 9/28, 10/4, 10/8, 10/15, 10/18, 11/5, 11/7, 11/10 and 11/11/19. Nursing signatures were also missing on the going off duty section for 9/20, 9/28, 10/9, 10/16, 10/18, 11/1, 11/5, 11/10 and 11/11. LPN #82 reported two nurses are to count the controlled medications at the change of every shift and both sign the record. LPN #82 confirmed there were multiple signatures missing for medication cart #3 for the period of 09/20/19 through 11/19/19.
The shift to shift reconciliation records for medication cart #1 were reviewed with LPN #72 on 11/19/19 at 3:15 PM. LPN #72 confirmed the shift to shift count records lacked signatures for the coming on duty section on 11/8, and 11/12 and the going off duty section for 11/8, 11/12, 11/14, 11/15, and 11/16/19.
On 11/20/19 at 9:30 AM, the Consultant Pharmacy summary for September, October and November 2019 were reviewed with Corporate Consultant #150. She confirmed the pharmacist identified missing shift change signatures on all three summaries.
.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on record review and staff interview, the facility failed to store and prepare food in a safe and sanitary manner. The f...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on record review and staff interview, the facility failed to store and prepare food in a safe and sanitary manner. The facility failed to monitor temperatures of potential hazard foods that may not be prepared properly, food temperature documentation was reviewed and it was revealed that there were days the dietary department did not have the temperatures of any food items for the whole meal. Additionally, food was found in the freezer unlabeled and undated of when the items were opened, and one item was open exposed to the air inside the freezer. This had the potential to affect more than a limited number of residents who are served meals from this central location. Facility census 76.
Findings included:
a) Initial tour of the kitchen
During the initial tour of the facility with the Food Service Supervisor (FSS) who is a Certified Dietary Manager (CDM) found on 11/18/19 at 1:35 PM, there were three (3) Italian sausage in the freezer in a clear bag unlabeled and undated of when the sausage was first removed from it's original box and opened. There were a half of a bag of pepperoni open exposed to the air in the freezer unlabeled and undated. The CDM said the staff are to label, date, and make sure the bag of food are closed.
The facility's policy states all food are labeled with the name of product and the date received and used by date once opened.
A review of the temperatures logs for the daily menus' for food found in the kitchen on 11/18/19 at 1:40 PM, found no temperatures were recorded on the 11/13/19- lunch, 11/14/19- lunch, 11/14/19- dinner, 11/15/19 dinner, 11/16/19 dinner. The FSS confirmed the cooks did not checks the food temperature on the above dates. The FSS said the cook is to check the temperatures prior to the food being served and document each food temperature on the production count worksheet. The following dates and the food on the menu is listed below:
11/13/19 lunch -mixed garden salad with signature dressing, mixed garden salad with vinaigrette dressing, shredded lettuce salad with signature dressing, mixed garden salad/dressing, gluten free (GF) - Shepherd's pie, lactose free Shepherds pie, plain shrimp salad on roll, Shepherds pie one (1) square and and six (6) ounzes (OZ), shrimp salad on roll, smooth yogurt, margarine, shredded lettuce and diced tomato for garnish, plain potato salad, red bliss potato salad, dinner roll, soft dinner roll, warm bread, shredded lettuce for garnish, piña colada fruit cup, plain piña colada fruit cup in half (1/2) cup and three (3) OZ, two (2) percent % milk , Whole milk, coffee, unsweetened iced tea.
11/14/19 lunch- creamy cucumber salad 1/2 and three (3) OZ, vegetable soup, three-fourth (3/4 cup and six (6) OZ, classic sub and a moisten classic sub, egg salad on wheat and puree bread. GF egg salad sandwich, molasses barbeque chicken, smooth yogurt, marinated cauliflower salad, plain marinated cauliflower salad-chopped, calico beans in 1/2 cup, and 1/3 cup, and low sodium calico beans in 1/2 cup, corn muffins, dinner roll, two (2) Percent % milk, whole milk, coffee, unsweetened ice tea.
11/14/19 dinner - beef lasagna in six (6) OZ and one (1) square, low sodium (LS) beef lasagna, shredded pork, tomato meat sauce GF pasta, smooth yogurt, LS marinara sauce, margarine, marinara sauce, egg noodles, yellow rice, broccoli florets, broccoli florets chopped, garlic bread, GF garlic bread, pan biscuits, soft pan biscuit, pears in half (1/2) cup and three (3) OZ, vanilla ice cream, two (2) percent % milk, whole milk, coffee, unsweetened ice tea.
11/15/19 dinner - herded fish, oven fried fish - one (1) each and a three (3) OZ, oven fried fish moisten, roast beef, roast beef moisten, smooth yogurt, brown gravy, lemon mayonnaise, LS [NAME] gravy, margarine, Remoulade sauce, garlic mashed potatoes, Harvard beets, oriental blended vegetables, oriental blended vegetable chopped, seasoned beets, Herb dinner rolls, GF pudding, vanilla ice cream, two (2) percent % milk, whole milk, coffee, unsweetened ice tea.
11/16/19 dinner - chicken and dumpling, chicken ground and dumplings, maple glazed ham and pork, roasted chicken, smooth yogurt, margarine, parslied noodles, butter roasted cauliflower with pimentos, buttered roasted cauliflower with pimentos chopped, parslied potatoes, dinner roll, soft dinner rolls, warm bread, two (2) percent % milk, whole milk, coffee, unsweetened ice tea, sliced carrots.
The facility's policy states holding temperature for all food and cold foods are taken and recorded on the production worksheet prior to meals being served.
.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Drug Regimen Review
(Tag F0756)
Could have caused harm · This affected most or all residents
.
Based on policy review and staff interview, the facility failed to develop and maintain
policies and procedures for the monthly drug regimen review that include, but are not
limited to, time frame...
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.
Based on policy review and staff interview, the facility failed to develop and maintain
policies and procedures for the monthly drug regimen review that include, but are not
limited to, time frames for the different steps in the monthly medication regimen review
process. This practice has the potential to affect all residents. Facility census: 75.
Findings included:
a) The facility policy titled 9.1 Medication Regimen Review with an effective date of
11/28/16, states the Medication Regimen Review (MRR) of each resident must be reviewed at
least once a month by a licensed pharmacist.
Section 6 of the procedure states: The pharmacist will address copies of residents' MRRs to the Director of Nursing and/or attending physician and to the Medical Director.
Section 7 states: Facility should encourage Physician/Prescriber or other responsible parties receiving the MRR and the Director of Nursing to act upon the recommendations contained in the MRR .
Section 11 states: The attending physician should address the consultant pharmacist's recommendations no later than their next scheduled visit to the facility to assess the resident, either 30 or 60 days per applicable regulation.
Except for the identified urgent irregularities, the policy lacks time frames for the
various steps in the process.
After reviewing the facility policy titled 9.1 Medication Regimen Review on 11/19/19 at 2:10 PM, the Nursing Home Administrator (NHA) verified the pharmacy policy lacks specific time frames for the
various steps in the MRR review process. Upon inquiry if the facility had it's own individual MRR policy, informed the corporate consultant is searching for one as we speak.
On 11/19/19 at 3:18 PM, Corporate Consultant #150 provided facility policy titled Medication Regimen Review with an effective date of 02/01/07 and revision date of 11/01/19. After review
Corporate Consultant #150 acknowledged the policy lacks specific time frames for the
various steps in the MRR review process.
.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
QAPI Program
(Tag F0867)
Could have caused harm · This affected most or all residents
.
Based on observation, record review and staff interview the facility's quality assessment and assurance (QA&A) committee failed to identify and act upon quality deficiencies during the daily operati...
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.
Based on observation, record review and staff interview the facility's quality assessment and assurance (QA&A) committee failed to identify and act upon quality deficiencies during the daily operation of the facility, in which it had, or should have had knowledge. Systematic problems were identified related to the failure to maintain an accurate account of controlled substances, failed to establish//implement an infection control program to include surveillance with tracking and trending of facility infections, failed to conduct an ongoing review for antibiotic stewardship, and failed to provide treatment in accordance with professional standards. This has the potential to effect all. Resident identifiers: #174 and #170. Facility census: 75
Findings included:
a) Cross reference findings at F755
b) Cross reference findings at F880
c) Cross reference findings at F881
d) Cross reference findings at F684
.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected most or all residents
.
Based on record review and staff interview the facility failed to establish and/or implement an infection prevention and control program (IPCP) to include an ongoing system of tracking and trending ...
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.
Based on record review and staff interview the facility failed to establish and/or implement an infection prevention and control program (IPCP) to include an ongoing system of tracking and trending surveillance designed to identify possible communicable diseases or infections in the facility. In addition failed to establish and/or implement a system for identifying, reporting, investigating, and controlling infections and communicable diseases for all residents. This practice has the potential to affect all residents. Facility census: 75.
Findings include:
a) Review of the Infection control Monthly Line Listing on 11/19/19 at 1:30 PM for March 2019 to present revealed multiple blank areas. Inconsistent and/or absence of infection onset, culture or x-ray dates, site of infection, results of culture or x-ray and if infection resolved.
No provided evidence of the trending of facility infections.
During an interview on 11/19/19 at 3:33 PM, Employee #18 reported only being employed in the position for two (2) weeks and still currently doing corporation education required for the position. She explained within her employment has not had the time to review the previous nurse's information.
After review of the Infection control Monthly Line Listing for March 2019 to present, Employee #18 verified the monthly line listings were not accurate and incomplete. She stated, the line listing surveillance is lacking information to be considered a line listing.
On 11/20/19 at 11:00 AM Employee #18 reported unable to find evidence of trending for facility infections for 2019.
.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Antibiotic Stewardship
(Tag F0881)
Could have caused harm · This affected most or all residents
.
Based on medical record review and staff interview, the facility's Infection Control Prevention Team (ICPT) failed to develop an Antibiotic Stewardship program that promotes the appropriate use of a...
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.
Based on medical record review and staff interview, the facility's Infection Control Prevention Team (ICPT) failed to develop an Antibiotic Stewardship program that promotes the appropriate use of antibiotics. Actions were not implemented to improve antibiotic use and reduce adverse events associated with antibiotics, including the development of antibiotic-resistant organisms. Antibiotic use protocols and assessment tools were not utilized prior to the prescribing and administration of antibiotics. This practice has the potential to affect all residents residing in the facility. Facility
census: 75.
Findings included:
a) During an interview on 11/19/19 at 3:33 PM, Employee #18 reported only being employed in the position for two (2) weeks and still currently doing corporation education required for the position. She explained within her employment has not had the time to review the previous nurse's information.
She reported utilizing algorithms and assessment tools prior to the initiation of an antibiotic. No evidence was provided to verify the Minimum Criteria for Initiation of Antibiotics in Long-Term Care Residents.
The facility policy titled Antibiotic Stewardship Program (ASP) with a revision date of
11/07/17, states under section 5 of the Core Elements .Monitor measurements of antibiotic
use by auditing available reports and patient medical records for adherence to .(Company
name) specific algorithms for assessing and treating patients including optimizing
diagnostic tests for specific infections .
During the survey no evidence was provided to show adherence to specific algorithms for assessing and treating patients including optimizing diagnostic tests for specific infections .
.
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?"
- "What safeguards are in place to prevent abuse and neglect?"
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • Licensed and certified facility. Meets minimum state requirements.
Concerns
- • Multiple safety concerns identified: Federal abuse finding, 3 life-threatening violation(s), 1 harm violation(s), $48,469 in fines. Review inspection reports carefully.
- • 60 deficiencies on record, including 3 critical (life-threatening) violations. These warrant careful review before choosing this facility.
- • $48,469 in fines. Higher than 94% of West Virginia facilities, suggesting repeated compliance issues.
- • Grade F (0/100). Below average facility with significant concerns.
Bottom line: This facility has a substantiated abuse finding. Extreme caution advised. Explore alternatives.
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About This Facility
What is Shenandoah Center's CMS Rating?
CMS assigns SHENANDOAH CENTER an overall rating of 1 out of 5 stars, which is considered much 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 Shenandoah Center Staffed?
CMS rates SHENANDOAH CENTER's staffing level at 2 out of 5 stars, which is below average compared to other nursing homes. Staff turnover is 55%, compared to the West Virginia average of 46%.
What Have Inspectors Found at Shenandoah Center?
State health inspectors documented 60 deficiencies at SHENANDOAH CENTER during 2019 to 2024. These included: 3 Immediate Jeopardy (the most serious level, indicating potential for serious harm or death), 1 that caused actual resident harm, and 56 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 Shenandoah Center?
SHENANDOAH 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 GENESIS HEALTHCARE, a chain that manages multiple nursing homes. With 78 certified beds and approximately 73 residents (about 94% occupancy), it is a smaller facility located in CHARLES TOWN, West Virginia.
How Does Shenandoah Center Compare to Other West Virginia Nursing Homes?
Compared to the 100 nursing homes in West Virginia, SHENANDOAH CENTER's overall rating (1 stars) is below the state average of 2.7, staff turnover (55%) is near the state average of 46%, and health inspection rating (1 stars) is much below the national benchmark.
What Should Families Ask When Visiting Shenandoah 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?" "What safeguards and monitoring systems are in place to protect residents from abuse or neglect?" "Can you walk me through typical staffing levels on day, evening, and night shifts?" "Can I visit during a mealtime to observe dining assistance and food quality?" These questions are particularly relevant given the facility's Immediate Jeopardy citations, the substantiated abuse finding on record, and the below-average staffing rating.
Is Shenandoah Center Safe?
Based on CMS inspection data, SHENANDOAH CENTER has documented safety concerns. The facility has 1 substantiated abuse finding (meaning confirmed case of resident harm by staff or other residents). Inspectors have issued 3 Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death). The facility has a 1-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 Shenandoah Center Stick Around?
SHENANDOAH CENTER has a staff turnover rate of 55%, which is 9 percentage points above the West Virginia average of 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 Shenandoah Center Ever Fined?
SHENANDOAH CENTER has been fined $48,469 across 4 penalty actions. The West Virginia average is $33,564. 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 Shenandoah Center on Any Federal Watch List?
SHENANDOAH 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.