MEADOWBROOK ACRES
For profit - Corporation
60 Beds
NURSING CARE MANAGEMENT OF AMERICA
Data: November 2025
Trust Grade
70/100
#33 of 122 in WV
Last Inspection: April 2025
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
Meadowbrook Acres in Charleston, West Virginia, has a Trust Grade of B, indicating it is a solid choice for families seeking care (not the top but still good). It ranks #33 out of 122 facilities in the state, placing it in the top half, and #3 out of 11 in Kanawha County, meaning only two local options are better. However, the facility is experiencing a worsening trend, with reported issues increasing from 1 in 2024 to 11 in 2025. Staffing is rated 4 out of 5 stars, which is promising, but the turnover rate is 51%, which is average for the area. Notably, there have been concerns, such as the absence of a full-time qualified nutrition professional and a lack of compliance in maintaining a safe environment, including unlocked medication and janitor closets, which raises safety risks. Overall, while there are strengths in staffing and no financial fines, the increasing number of issues and some safety concerns should be taken into consideration.
- Trust Score
- B
- In West Virginia
- #33/122
- Safety Record
- Low Risk
- Inspections
- Getting Worse
- Staff Stability ⚠ Watch
- 51% turnover. Above average. Higher turnover means staff may not know residents' routines.
- Penalties ✓ Good
- No fines on record. Clean compliance history, better than most West Virginia facilities.
- Skilled Nurses ✓ Good
- Each resident gets 47 minutes of Registered Nurse (RN) attention daily — more than average for West Virginia. RNs are trained to catch health problems early.
- Violations ⚠ Watch
- 51 deficiencies on record. Higher than average. Multiple issues found across inspections.
70/100
Top 27%
No red flags
1 → 11 violations
★★★★☆
4.0
Overall Rating
★★★★☆
4.0
Staff Levels
★★★★★
5.0
Care Quality
★★★☆☆
3.0
Inspection Score
↔
Stable
2024: 1 issues
2025: 11 issues
The Good
-
4-Star Staffing Rating · Above-average nurse staffing levels
-
5-Star Quality Measures · Strong clinical quality outcomes
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
Facility shows strength in staffing levels, quality measures, fire safety.
The Bad
Staff Turnover: 51%
Near West Virginia avg (46%)
Higher turnover may affect care consistency
Chain: NURSING CARE MANAGEMENT OF AMERICA
Part of a multi-facility chain
Ask about local staffing decisions and management
The Ugly 51 deficiencies on record
Apr 2025
11 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Resident Rights
(Tag F0550)
Could have caused harm · This affected 1 resident
Based on observation, and staff interview the facility failed to treat each resident with respect and dignity regarding meal service. This was a random opportunity for discovery. Resident identifier: ...
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Based on observation, and staff interview the facility failed to treat each resident with respect and dignity regarding meal service. This was a random opportunity for discovery. Resident identifier: # 211. Facility census: 54.
Findings included:
a) Resident #211
During an observation of meal services on 04/08/25 at 12:08 PM revealed Resident #211's sitting in the dining room at a table with 2 other residents and a visitor that was eating their lunch. Resident #211 watched as everyone around consumed their lunch.
Continued observation revealed seven more tables were served, prior to surveyor intervention.
During an interview on 04/08/25 at 12:20 PM the Director of Nursing (DON) verified that Resident #211 should have been served when the other residents at the table received their meal.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0552
(Tag F0552)
Could have caused harm · This affected 1 resident
Based on record review, and staff interview, facility failed to ensure residents and/or their medical representatives were given the right to be informed of participate in the decision to initiate a p...
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Based on record review, and staff interview, facility failed to ensure residents and/or their medical representatives were given the right to be informed of participate in the decision to initiate a psychotropic medication. This was true for one (1) of five (5) reviewed for unnecessary medications. Resident identifier #23. Facility census: 54.
Finding included:
a) Resident #23
A review for Unnecessary Medication for Resident #23 on 04/14/25 found, Physician order for:
Zoloft oral tablet 50 MG (Sertraline HCI) Give one (1) tablet by mouth one time a day related to anxiety disorder.
Continued review found no consent form for Zoloft in the medical record.
During an interview on 04/14/25 at 4:15 PM the Director of Nursing (DON) stated that there was no signed consent form for Zoloft for Resident #23
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0582
(Tag F0582)
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 provide evidence that the required Notification of Medicare N...
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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 provide evidence that the required Notification of Medicare Non-Coverage (NOMNC) notice was issued in a timely fashion for one (1) of three (3) residents reviewed for beneficiary protection notification. This failure had the potential to place the resident at risk of not being informed of their rights prior to the end of Medicare Part A covered services. Resident identifier: #4 . Facility census: 54.
Findings included:
a) Resident #4
On 04/10/25 at 11:30 AM, a review was completed regarding the beneficiary protection notification liability notice given for the following resident who was discharged home following the last covered day of Medicare Part A services:
-Resident #4's last covered day of Part A Services was on 01/08/25.
-Resident #4 was discharged to home on [DATE]; however, the NOMNC was only issued 24 hours prior on 01/07/25 .
The Form Instructions for the Notice of Medicare Non-Coverage (NOMNC) CMS-10123 state: The NOMNC must be delivered at least two (2) calendar days before Medicare covered services end . The instructions also state: A NOMNC must be delivered even if the beneficiary agrees with the termination of services.
The Business Office Manager (BOM) Employee #39 confirmed the Beneficiary Protection Notification Review was outside of the notification date range of only 24 hours as opposed to required minimal 48 hours notice.
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
Abuse Prevention Policies
(Tag F0607)
Could have caused harm · This affected 1 resident
Based on observation, staff interviews, electronic medical record and policy review the facility failed to ensure they implemented their policy regarding the training of nurse aide staff following a s...
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Based on observation, staff interviews, electronic medical record and policy review the facility failed to ensure they implemented their policy regarding the training of nurse aide staff following a substantiation of allegations of neglect. This is true of one (1) of six (6) residents reviewed for abuse and neglect. Resident identifier: #161. Facility census: 54.
Findings included:
a) Resident #161
A record review found an allegation from 05/07/24 where Nurse Aide NA #94 and NA #114 did not follow the plan of care and did not use the lift during a transfer causing a skin tear to Resident # 161's arm.
A medical record review revealed the following care plan:
Focus:
(Name) has a ADL self-care performance deficit related to Dementia, blindness and limited functional mobility as well as generalized muscle weakness.
Goal:
Resident will maintain the current level of function in ADLs through the review date
Interventions:
Transfers: require two (2) staff assistance using a full body Hoyer lift and placing him in a Rock and Go Chair.
A reportable was completed with action notes:
NA's involved will be re-educated/disciplined. All other NA's will be re-educated.
Continued review found NA's #94 and #114 were re-educated. No other documentation could be provided for education with all other NA's.
During an interview the Administrator verified that all NA's were not re-educated.
Subsequent record review found that an allegation from 05/21/24 where Nurse Aide NA #8 and NA #91 did not follow the plan of care and did not use the lift during a transfer causing pain into Resident #161s leg.
A reportable was completed with action notes:
NA's involved will be re-educated / disciplined. All other NA's will be re-educated.
Continued review found NA's #8 and #91 were re-educated. No other documentation could be provided for education with all other NA's.
Record review of the facility's policy titled, Abuse, neglect, and exploration, showed:
Report allegations to appropriate state and local authorities involving neglect, exploitation or mistreatment (including injuries of unknown source), suspected criminal activity, and misappropriation of patient property not later than two (2) hours after the allegation is made if it does result in serious bodily injury.
Report allegations to appropriate state and local authorities involving neglect, exploitation or mistreatment (including injuries of unknown source), suspected criminal activity, and misappropriation of patient property not later than (24) hours after the allegation is made if it does not result in serious bodily injury.
Taking all necessary actions as a result if the investigation, which may include, but not limited to, the following:
Analyzing the occurrence to determine abuse, neglect, misappropriation of resident property or exportation occurred, and what changes are needed to prevent further occurrences.
Define how care provision will be changed and /or improved to protect residents receiving services.
Training of staff on changes made and demonstration of competency after training is implemented.
The expected date for implementation; and Identification of staff responsible for monitoring and implementation of the plan.
During an interview the Administrator verified that all NA's were not re-educated.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected 1 resident
Based on record review, and staff interview. The facility failed to assist dependent residents with activities of daily living (ADL's) in accordance with the residents assessed needs for care. This wa...
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Based on record review, and staff interview. The facility failed to assist dependent residents with activities of daily living (ADL's) in accordance with the residents assessed needs for care. This was true for one (1) of one (1) residents reviewed for ADL care. Resident identifier:164. Facility census: 54.
Findings included:
a) Resident #164
A record review revealed Resident #164 was covered in feces on 11/17/24 and reported to the facility by her son.
Statement from Nurse Aide #113 revealed Resident #164 was covered in dried feces from head to toe.
Statements from Registered Nurse #87 confirmed that dried feces was all over the resident and the bed.
Continued record review found the incident was reported to appropriate state and local authorities for neglect. The allegations were found substantiated by the facility and the NA assigned to Resident #164 was suspended and resigned at that time.
An interview with the Director of Nursing on 04/14/25 at approximately 2:10 PM confirmed that Resident #164 did not get ADL care timely.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Drug Regimen Review
(Tag F0756)
Could have caused harm · This affected 1 resident
Based on record review and staff interview, the facility failed to ensure two (2) monthly pharmacy reviews were reviewed by the facility physician for Resident #35. This was true for one (1) of five (...
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Based on record review and staff interview, the facility failed to ensure two (2) monthly pharmacy reviews were reviewed by the facility physician for Resident #35. This was true for one (1) of five (5) residents reviewed under the care area of unnecessary medications. Resident identifier: #35. Facility Census: 57.
Findings Include:
a) Resident #35
On 04/09/25 at 1:03 PM, a record review was completed for Resident #35. The review found two (2) monthly pharmacy reviews, 03/2024 and 01/2025, were not signed by the facility physician. The pharmacy reviews had no indication if the facility physician agreed or disagreed with the pharmacy recommendations.
On 04/14/25 at 10:32 AM, the Administrator confirmed neither of the two (2) pharmacy reviews were signed by the facility physician.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0757
(Tag F0757)
Could have caused harm · This affected 1 resident
Based on record review, and staff interview, facility failed to ensure residents was free from unnecessary medications in regard to psychotropic medication. This was true for one (1) of five (5) revie...
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Based on record review, and staff interview, facility failed to ensure residents was free from unnecessary medications in regard to psychotropic medication. This was true for one (1) of five (5) reviewed for unnecessary medications. Resident identifier #23. Facility census: 54.
Finding included:
a) Resident #23
A review for Unnecessary Medication for Resident #23 on 04/14/25 found, Physician order for:
Zoloft oral tablet 50MG (Sertraline HCI) Give one (1) tablet by mouth one time a day related to anxiety disorder.
Continued review found no consent form for Zoloft in the medical record.
During an interview on 04/14/25 at 4:15 PM the Director of Nursing (DON) stated that there was no signed consent form for Zoloft for Resident #23
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 staff interview, the facility failed to ensure an accurate and complete record for Resident #35. This was true for one (1) of five (5) residents reviewed under the care area...
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Based on record review and staff interview, the facility failed to ensure an accurate and complete record for Resident #35. This was true for one (1) of five (5) residents reviewed under the care area of unnecessary medications. Resident identifier: #35. Facility Census: 57.
Findings Included:
a) Resident #35
On 04/09/25 at 10:00 AM, a record review was completed for Resident #35. The review found two (2) medications without diagnoses.
The medication is as follows:
--Eye Scrubs External Pad apply to eyes topically every day, which started on 11/07/24.
--Metoprolol Tartrate 25mg (milligram) by mouth twice daily, which started on 03/08/25.
On 04/09/25 at 4:00 PM, the Administrator and the Director of Nursing (DON) confirmed the medication did not have diagnoses.
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 interviews, 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 d...
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Based on observation and interviews, 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 of a resident smoking in non-designated areas, a medication cart and janitor closet unlocked and unattended. Resident identifier: #5. Facility census: 54.
Findings included:
a) An observation on 04/08/25 at 12:20 PM of an unlocked janitors closet on the B hall.
A second observation on 04/08/25 at 1:00 PM of the unlocked janitors closet on the B hall found:
-Clorox Clean-up
-Sani-Clean 2 spray
-Odor Neutral
-Clorox bleach germicidal wipes
-Glass Cleaner
-DNA bath cleaner
-Clorox urine cleaner
-Sun burst neutral cleaner
An interview on 04/08/25 at 1:08 PM with the Maintenance Assistant revealed the closet should always be locked and the lock was broken. He stated he was unsure how long the lock had been broken.
An observation on 04/09/25 at 9:55 AM found the Medication Cart on the B Hall was unlocked and unattended.
An interview with Licensed Practical Nurse (LPN #33) on 04/09/25 at 10:00 AM revealed that the medication cart should not be unlocked when unattended.
c) Resident #5
On 04/08/25 at 6:47 PM, a review of the list of resident smokers was completed. The review found one (1) resident listed as a smoker. Resident #5 smoked a vape (electronic cigarette). The resident was allowed to smoke at designated times and places with a staff member. The designated times were 9:00 AM, 11:00 AM, and 1:30 PM. The designated area was in the outer gazebo at the side of the building. A smoking assessment was completed on 03/24/25. The smoking assessment stated, Smoking safety note: Electronic cigarette to be used with staff supervision during scheduled smoke breaks. Electronic cigarette to be stored in med (medication) cart and charged by nurse as needed.
On 04/09/25 at 9:05 AM, the resident was being pushed in a wheelchair by a staff member; and, before the resident exited the door of the lobby, the resident began smoking the vape. Nurse Aide (NA) # 91 was the staff member pushing the resident's wheelchair. An interview was held with NA #91 at 9:30 AM. NA #91 was asked, Does the resident usually use the vape prior to exiting the building? NA #91 stated, Not normally, but I did tell her not to smoke it before we got out of the building NA #91 was then asked, Does the resident usually hold the vape prior to exiting the building? NA #91 stated, She normally doesn't smoke until we are outside the building.
On 04/09/25 at 9:40 AM, the Administrator confirmed the resident should not be vaping before she got outside to the designated smoking area. The Administrator stated, Maybe the staff member should hold on to the vape until they get to the designated spot.
On 04/09/25 at 10:00 AM, a review of the facility policy was completed. Under the heading of Policy Explanation and Compliance Guidelines: Number 7 stated, Any resident who is exempt from the Smoke Free Facility policy, in accordance with his/her right to self-determination and participation, will be allowed to smoke in designated smoking areas (weather-permitting), at designated times, and in accordance with his/her care plan.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Pharmacy Services
(Tag F0755)
Could have caused harm · This affected multiple residents
Based on observation, record review and staff interview it was determined the facility failed to ensure proper reconciliation of the narcotic medication logbook was performed. Facility census: #54
Fin...
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Based on observation, record review and staff interview it was determined the facility failed to ensure proper reconciliation of the narcotic medication logbook was performed. Facility census: #54
Findings include:
a) A Hall
On 04/09/25 at 8:24 AM during the medication administration observation process, it was noted that the narcotic medication logbook reconciliation was not completed properly for each daily shift change.
The current narcotic medication logbook on hand begins on 02/18/25 through 04/09/25.
The following dates were not reconciled as required as explained by the Administrator.
02/21/25 no entry for 7 PM - 7 AM shift
02/22/25 no entry for 7 AM - 7 PM shift
02/23/25 no entry for 7 PM - 7 AM shift
02/28/25 no entry for 7 PM - 7 AM shift
03/01/25 no entry for 7 AM - 7 PM shift
03/01/25 no entry for 7 PM - 7 AM shift
03/06/25 no Nurse signature for going off duty for 3 PM shift
03/08/25 no Nurse signature for going off duty for 7 PM - 7 AM shift
03/09/25 no entry for 7 PM - 7 AM shift
03/12/25 no Nurse signature for going off duty for 7 PM - 7 AM shift
03/17/25 no Nurse signature for going off duty for 1:30 PM shift change
03/18/25 no Nurse signature for going off duty for 7 PM - 7 AM shift
03/19/25 no Nurse signature for going off duty for 3 PM shift change
03/20/25 no Nurse signature for going off duty for 7 PM - 7 AM shift
03/27/25 no Nurse signature for going off duty for 1 PM shift change
03/28/25 no entry for 7 PM - 7 AM shift
03/31/25 no Nurse signature for going off duty for 7 AM - 7 PM shift
04/02/25 no Nurse signature for going off duty for 7 PM - 7 AM shift
04/04/25 no entry for 7 PM - 7 AM shift
04/07/25 no Nurse signature for going off duty for 7 AM - 7 PM shift
The above missing entries were confirmed on 04/09/25 at 10 AM with the Administrator who agreed the reconciliation process had failed on these dates.
b) B Hall
On 04/09/25 at 8:24 AM during the medication administration observation process, it was noted that the narcotic medication logbook reconciliation was not completed properly for each daily shift change.
The current narcotic medication logbook on hand begins on 02/18/25 through 04/09/25.
The following dates were not reconciled as required as explained by the Administrator.
02/21/25 no entry for 7 AM - 7 PM shift
02/21/25 no entry for 7 PM - 7 AM shift
02/27/25 no Nurse signature for coming on duty for 7 AM - 7 PM shift
02/28/25 no entry for 7 PM - 7 AM shift
03/09/25 no entry for 7 AM - 7 PM shift
03/14/25 no Nurse signature for coming on duty for 7 AM - 7 PM shift
03/16/25 no entry for 7 AM - 7 PM shift
03/16/25 no Nurse signature for going off duty for 7 PM - 7 AM shift
03/17/25 no Nurse signature for going off duty for 7 PM - 7 AM shift
03/20/25 no Nurse signature for coming on duty for 7 AM - 7 PM shift
03/20/25 no entry for 7 PM - 7 AM shift
03/21/25 no entry for 7 AM - 7 PM shift
03/21/25 no Nurse signature for going off duty for 7 PM - 7 AM shift
03/25/25 no Nurse signature for going off duty for 7 PM - 7 AM shift
03/26/25 no Nurse signature for coming on duty for 7 AM - 7 PM shift
04/01/25 no Nurse signature for coming on duty for 7 AM - 7 PM shift
04/01/25 no Nurse signature for going off duty for 3 PM shift change
04/09/25 no entry for 7 AM - 7 PM shift
The above missing entries were confirmed on 04/09/25 at 10 AM with the Administrator who agreed the reconciliation process had failed on these dates.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected multiple residents
Based on observation and staff interview the facility failed to store plate lids in accordance with professional standards for food service safety related to storage. This could have affected all resi...
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Based on observation and staff interview the facility failed to store plate lids in accordance with professional standards for food service safety related to storage. This could have affected all residents that received their nutrition from the kitchen. Facility Census: 54
Findings included:
a) Kitchen
During the initial kitchen tour on 04/08/25 at 9:48 AM, an observation revealed a rack of plate lids stored up against the dirty open utility-room door. There was a mop sink, dirty mops, rags, and chemicals stored in the utility room.
During an interview with the Dietary Manager (DM) on 04/08/25 at 9:49 AM, DM stated that they probably should not be stored there with the door open.
May 2024
1 deficiency
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected multiple residents
.
Based on record review and staff interview the facility failed to develop and implement a comprehensive person-centered care plan with measurable objectives for each resident related to resident's b...
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.
Based on record review and staff interview the facility failed to develop and implement a comprehensive person-centered care plan with measurable objectives for each resident related to resident's behaviors. This is true for two (2) of two (2) residents reviewed for behavioral care plans. Resident Identifiers: Resident #43 and Resident #6. Facility Census: 59
Findings Include:
a)Resident #43
During a review of the reportable dated 04/08/24, Resident #43's incident was as follows:
Reported to this nurse per restorative aide that resident was sitting in quiet lounge beside another resident (2935) touching her, when he put his hand in her face and she bit him on the pointer finger. Residents separated, small red bite mark to pointer finger on 2935 has since dissipated. (Physician name) made aware and verbalized understanding. POA( Power of Attorney) (name) contacted and verbalized understanding.
Further review of the care plan with an initiated date 12/20/22 and revision date 01/11/13 no behavioral focus, goal or interventions were implemented after the 04/08/24 incident.
During an interview on 05/06/24 at 11:40 AM,the Administrator acknowledged the care plans did not reflect appropriate behavioral interventions.
b) Resident #6
A review of the reportable dated 04/30/24, reported the following:
CNA reported to this nurse that while resident was in A hallway by clean linen door, she punched resident #52 in the right stomach/hip area. Per report from CNAs resident #6 stated after she punched the other resident that They are thieves. Residents were immediately separated. Residents went separate directions down the hall. Resident sitting in wheelchair in quiet lounge conversing with another resident at this time, will continue with current plan of care. Residents' hands assessed at this time and noted to be per baseline for resident. No increased pain or swelling noted at this time, will continue with current plan of care.
Further review of the care plan initiated on 08/24/22 and revised on 02/22/24, found there were no behavioral focus, goal or interventions were implemented after the 04/30/24 incident.
During an interview on 05/06/24 at 11:40 AM, the administrator acknowledged the care plans did not reflect appropriate behavioral interventions.
Aug 2023
3 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
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
.
Based on observation, record review, and staff interview, the facility failed to ensure a care plan was implemented for one (1) of three (3) residents reviewed for the care area of accidents. Reside...
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.
Based on observation, record review, and staff interview, the facility failed to ensure a care plan was implemented for one (1) of three (3) residents reviewed for the care area of accidents. Resident identifier: #52. Facility census: 56.
Findings included:
a) Resident #52
Review of the medical record found the following:
Review of the medical record found the current care plan:
The care plan addressed the following:
Resident is at risk of falls related to poor safety awareness related to dementia.
The goal associated with the care plan:
Resident will have no further falls through review date, revised on 8/8/23
Interventions included:
Fall mat to left side of bed, dated 05/30/23
Observation at 12:25 PM on 08/29/23, with Registered Nurse #27, and Nurse Aides (NA) #67 and #49 found the fall mat was on the resident's right side of the bed. RN #27 said, well if you were standing at the foot of the bed the fall mat is on the left side of the bed. Both NA's stated they believed when an order says to place something on the right or left side, it is the Resident's right and left side, not the onlookers right and left side.
At 2:30 PM, the Administrator stated the order has been corrected.
.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
.
Based on record review and staff interview, the facility failed to ensure one (1) of four (4) residents reviewed for accidents received adequate assistive devices to prevent accidents. Resident iden...
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.
Based on record review and staff interview, the facility failed to ensure one (1) of four (4) residents reviewed for accidents received adequate assistive devices to prevent accidents. Resident identifier: #54. Facility census: 56.
Findings included:
a) Resident #54
Record review found the Resident was care planned for:
Additional falls related to a history of frequent falls, impaired cognition/poor safety awareness, impaired strength/balance/coordination, incontinence, adverse reaction of medications.
Further review found the resident had the following falls since 05/01/23:
05/04/23
05/11/23
06/15/23
07/30/23
Review of the medical record found a nursing note dated 05/01/23:
I walked into the resident's room to find (name of resident) sitting on the floor with her back against the wardrobe undressing. I had just been in and woke her for her 0600-medication administration. There did not seem to be incontinence at that time due to no smell being noted. The fall mat was down but she was between the mat and the bed. Legs were in front of her as she was taking off her depends, already having removed her hipsters. She was incontinent of a large amount of liquid stool. Her alarm was not placed on her when she was put into bed last evening and therefore was not sounding.
Assessment of (name of resident) indicated no injuries and I called a CNA (certified nursing assistant)in to assist with placing her in the WC (wheelchair) after we put on nonskid socks. She initially was barefoot from sleeping. She was immediately taken into the shower after the initial Neuro checks were obtained and noted to be within normal limits for residents. Upon return from the shower, she was placed back into bed, per her request, and is resting quietly with tab alarm in place. MPOA (Medical Power of Attorney) was notified via telephone and informed of the fall. (Name of medical director) was notified via telephone and message left on voice mail.
On 8/29/23 at 2:45 PM, the Administrator was asked if there was any investigation completed regarding the alarm not being placed on the resident's bed? The Administrator stated, the Nurse Aide was terminated around that date for an unrelated issue.
.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Grievances
(Tag F0585)
Could have caused harm · This affected multiple residents
.
Based on record review and staff interview the facility failed to establish and implement a grievance policy to ensure prompt resolution of grievances. The facility's policy indicated they would kee...
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.
Based on record review and staff interview the facility failed to establish and implement a grievance policy to ensure prompt resolution of grievances. The facility's policy indicated they would keep evidence of the resolution of all grievances for a period of three (3) years from the date the grievance was filed. The facility was unable to provide evidence of the prompt resolutions of grievances for the previous six (6) months. This failed practice had the potential to affect more than a limited number of residents. Facility Census: 56.
a) Policy Review
A review of the facility's policy titled; Grievances found the following:
.Documentation: The facility will keep evidence of the resolution of all grievances for a period of three (3) years from the date the grievance decision is issued.
This policy was not dated.
a) Grievances
In the afternoon of 08/28/23 the grievances and concerns for the previous six months were requested from the Nursing Home Administrator (NHA).
Upon leaving the building on 08/28/23 at approximately 4:00 PM the NHA was reminded we were still waiting for the grievances and concerns to review. The NHA stated, I cannot find them, but I will tear this place apart tonight looking for them.
On 08/29/23 at 1:26 PM, the NHA was asked if she had found the grievances and concerns for the previous six (6) months. She stated, No I cannot find them. I know we had them, but I can't find them. She agreed her policy indicated they would keep evidence of the resolution of all grievances for a period of three (3) years from the date the grievance decision was issued.
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Apr 2023
19 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
Resident Rights
(Tag F0550)
Could have caused harm · This affected 1 resident
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Based on observation, resident interview, and record review, the facility failed to ensure all residents were treated with dignity and respect. This was a random opportunity for discovery during the...
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Based on observation, resident interview, and record review, the facility failed to ensure all residents were treated with dignity and respect. This was a random opportunity for discovery during the Long Term Care Survey Process, and was only true for Resident #37. Resident identifier #37. Census 55.
Findings Included:
a) Resident #37
Resident #37 was observed sitting outside of the conference room, in the hallway, with what appeared to be urine soaked pants on. A member of the survey team notified an unidentified staff member who stated she would take the resident to the nurses station and get someone to assist the resident with getting cleaned up. This occurred on 04/17/23 at approximately 2:30 PM.
At 2:55 PM the same day, the resident was again observed in her scoot chair sitting at the nurses station. The resident was still wearing the same pants which were soaked with what appeared to be urine. There were numerous staff members at the nurses station. When the staff noticed the surveyor looking at the resident's clothing, Nursing Assistant (NA) #25 was instructed to take the resident to her room and clean her up.
At 3:31 PM the same day an additional observation found Resident #37 was in her room wearing the same shirt, but now had on a different pair of pants which were clean and dry. An interview with Resident #37 confirmed it had been about three (3) hours since she had been changed prior to NA #25 changing resident at 2:55 PM.
Record review of Resident #37's Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 02/08/23, was coded to reflect the resident was frequently incontinent. Resident #37's Activities of Daily Living (ADL) care plan intervention for toilet use states the resident .requires staff assistance/check and assist every couple of hours while awake .
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CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0604
(Tag F0604)
Could have caused harm · This affected 1 resident
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Based on observation, record review, policy review and staff interview the facility failed to ensure each resident was free from physical restraints which are not required to treat the resident's me...
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Based on observation, record review, policy review and staff interview the facility failed to ensure each resident was free from physical restraints which are not required to treat the resident's medical symptoms. This was true for one (1) of one (1) residents reviewed for the care area of restraints during the long term care survey process. Resident Identifier: #21 Facility Census: 55
Findings included:
a) Resident #21
A review of Resident #21's medical record on 04/17/23 at 1:20 PM shows a current order dated 03/29/23 which read Seat belt to WC (wheelchair) to minimize risk of unassisted ambulation/falls related to a history of falling.
A Progress note on 03/10/23 at 2:10 PM reads: Was able to notify POA (Power of attorney) by telephone of residents fall without injuries. Spoke with her regarding a seatbelt potentially being placed on the WC for keeping her in her WC. After explaining how it would work and our policy for it she was in agreement and stated that she'd rather see the seatbelt then hear that the resident has fallen and gotten seriously injured. I stated I would notify her if and when the decision for the seat belt was made. Signed by Registered Nurse Supervisor #61.
There is no documentation of a consent by the Power of Attorney (Residents daughter) to apply the seat belt. This was confirmed with the Administrator on 04/19/23 at 10:00 AM. She states they have not had a restraint for a long time and really did not know what to do with it, did not know she needed a consent.
The care plan reads: 03/30/23 Seat belt applied to WC to minimum risk for unassisted ambulation with potential falls. Interventions included 1) Seat belt to be released every 2 hours for toileting and assisted ambulation. 2) Seat belt to WC to minimize risk for unassisted ambulation and potential falls.
Review of the Treatment Administration Record (TAR) for 03/30/23 through 04/19/23 documents the seat belt was applied daily.
There is no documentation of the seat belt being released every two hours as directed by the care plan. This was confirmed with the Administrator on 04/19/23 at 10:00 AM.
Their Restraint Free Environment Policy (not dated) states under Compliance Guidelines:
. #2 Physical restraints may be used in emergency care situations for brief periods to permit medically necessary treatment that has been ordered by a practitioner, unless the resident previously made a valid refusal of the treatment in question. Falls do not constitute self injurious behavior or a medical symptom that warrants the use of a physical restraint.
#5. Before a resident is restrained, the facility will determine the presence of a specific medical symptom that would require the use of restraints, and determine:
a. How the use of restraints would treat the medical symptom.
b. The length of time the restraint is anticipated to be used to treat the medical symptom, who may apply the restraint, and the time and frequency that the restraint will be released.
c. The type of direct monitoring and supervision that will be provided during the use of the restraint.
d. How the resident will request staff assistance and how his/her needs will be met while the restraint is in place.
e. How to assist the resident in attaining or maintaining his or her highest practicable level of physical and psychosocial well-being.
#6. Medical symptoms warranting the use of restraints should be documented in the residents medical record. The resident's record needs to include documentation that less restrictive alternatives were attempted to treat the medical symptom but were ineffective, ongoing re-evaluation of the need for the restraint, and the effectiveness of the restraint
The medical record was void of any information to suggest the facility's policy was implemented correctly in regards to the use of Resident # 21's restraint. The facility failed to show they implemented any of the aforementioned steps as outlined in the policy.
Observation of Resident #21 on 04/17/23 through 04/19/23 shows the resident had the seat belt on when she was in the wheelchair. Observation of the afternoon meal on 04/18/23 at 12:23 PM, shows the resident had the seat belt on the entire meal, which in case of emergency, such as choking, would hinder medical care.
Observation on 04/18/23 at 2:06 PM, found Resident #21 was unable to release the seat belt on command.
The above information was reviewed, discussed and confirmed with the Administrator on 04/18/23 at 2:37 PM.
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CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Transfer Notice
(Tag F0623)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on record review and staff interviews, the facility failed to notify the resident and/or the resident's representative, ...
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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 notify the resident and/or the resident's representative, in writing, of the reason for the transfer/discharge to the hospital or to send a copy to the ombudsman for one (1) of four (4) residents reviewed for the category of hospitalization, during the long term care survey. Resident identifier #55. Census 55.
Findings Included:
a) Resident #55
A review of Resident #55's medical record on 04/18/23 , found the resident was sent to the hospital on [DATE]. The transfer/discharge notice was requested from facility staff on multiple occasions for this transfer beginning at 11:15 am on 04/18/23.
At 4:14 PM Medical Records #67 presented a copy of the resident's facesheet, medication administration record (MAR), and physician orders for scope of treatment (POST) which were sent with the resident when she went to the hospital. The notice of transfer/discharge was again requested. Medical Records #67 stated, she isn't sure they will have that but she will look for it.
No further documentation was provided to the surveyor by the time of survey exit.
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CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0625
(Tag F0625)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on record review and staff interviews, the facility failed to notify the resident and/or the resident's representative o...
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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 notify the resident and/or the resident's representative of the facility policy for bed hold, including reserve bed payment for one (1) of four (4) residents reviewed for the category of hospitalization, during the long term care survey. Resident identifier #55. Census 55.
Findings Included:
a) Resident #55
A review of Resident #55's medical record on 04/18/23 , found the resident was sent to the hospital on [DATE]. Evidence of the bed hold policy being sent with the resident was requested from facility staff on multiple occasions for this transfer beginning at 11:15 am on 04/18/23.
At 4:14 PM Medical Records #67 presented a copy of the resident's facesheet, medication administration record (MAR), and physician orders for scope of treatment (POST) which were sent with the resident when she went to the hospital. The bed hold policy was again requested. Medical Records #67 stated, she isn't sure they will have that but she will look for it.
No further documentation was provided to the surveyor by the time of survey exit.
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CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0657
(Tag F0657)
Could have caused harm · This affected 1 resident
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Based on resident interviews, staff interview, and record review, the facility failed to allow residents to be involved in developing their care plan and making decisions about his or her care for t...
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Based on resident interviews, staff interview, and record review, the facility failed to allow residents to be involved in developing their care plan and making decisions about his or her care for two (2) of 24 residents reviewed for the category of care planning, during the long term care survey. Resident identifiers #45 and #7. Census 55.
Findings Included:
a) Resident #7
An interview with Resident #7 on 04/17/23 at 11:32 AM, resulted in the resident stating he has never heard of a care plan meeting nor has he ever been invited to his care plan meeting.
On 04/18/23 at 10:56 AM, a staff interview was conducted with social worker (SW) #56. SW #56 stated resident #7 has been invited to his care plan meetings in the past but it's probably been a long time since he has been invited. This is because he usually cusses the staff and wants his wife to do everything. SW #56 does agree that he could participate in his care plan meetings.
On 04/18/23 a record review found, the resident's care plan notes were void of any documentation showing the resident was invited to participate in his care plan meetings and declined.
B) Resident #45
On 04/17/23 at 11:34 AM a resident interview was conducted. The resident stated, he had not been to a care plan meeting. The resident said, he has never seen an invitation and never heard of this meeting.
A staff interview with SW #56 on 04/18/23 at 10:56 AM, resulted in SW #56 stating Resident #45 has not been invited to his care plan meetings but probably should be.
c) Anonymous residents at Resident Council
During a resident council meeting was held on 04/19/23 at 1:30 PM, the when asked if they participated in their care plan meetings and none of the eight (8) attendees had ever heard of care plan meetings. The surveyor explained who might attend and the type of things that would be discussed in a care plan meeting, but none of the residents had attended a meeting of this type. When asked if any of them had received an invitation to their care plan meeting, they said they had not. The members of the resident council stated they are going to bring this issue up to the staff because they feel like they should be a part of their care plan meeting.
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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 follow physician orders for heel protectors. This was true for one (1) of three (3) residents reviewed for the care are...
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Based on observation, record review and staff interview the facility failed to follow physician orders for heel protectors. This was true for one (1) of three (3) residents reviewed for the care area of pressure ulcers during the long term care survey process. Resident Identifier: #2 Facility Census: 55
Findings Included:
a) Resident #2
On 04/18/23 at 9:10 AM, 12:40 PM and 3:58 PM Resident #2 was observed with no heel protectors on.
Record review found an order dated 03/02/23 which reads Resident to have bilateral heel protectors in place (may remove for personal hygiene) every shift for skin breakdown prevention.
At 3:58 pm on 04/18/23 the Director of Nursing (DON) confirmed Resident #2's heel protectors were not on as ordered by the physician.
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CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
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Based on Medical record review and staff interview the facility failed to ensure the resident environment over which it had control was as free from accident hazards as possible. A quarterly smoking...
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Based on Medical record 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. A quarterly smoking assessment was not completed for Resident #9 who is the facility's only smoker. This was true for one (1) of one (1) residents reviewed for the care area of smoking during the long term care survey process. Resident Identifiers: # 9. Facility census: 55.
Findings Included:
a) Policy Review
Record review of the facility's policy titled, Resident Smoking, showed:
-All Residents will be asked about tobacco use during the admission process, and during each quarterly or comprehensive MDS assessment process.
--Residents that smoke will be further assessed, using the Resident Safe Smoking Assessment, to determine whether or not supervision is required for smoking, or if Resident is safe to smoke at all.
--A safe smoking assessment will be completed on all residents using e-cigarettes.
b) Resident #9
An observation on 04/17/23 at 12:14 PM found Resident #9 smoking a Vape cigarette (e cigarette) at the scheduled smoke break time.
A medical record review revealed the last smoking evaluation for Resident #9 was completed on 11/01/23 which included the following:
--Electronic cigarette to be used as (Name of Resident #9) is no longer safe to hold regular cigarette. (Name of Resident #9) is safe to smoke with supervision.
During an interview on 04/19/23 at 9:33 AM the Director of Nursing (DON) and Administrator verified Resident #9s quarterly smoking assessment was not completed as required by their policy to ensure Resident #9 was still safe to use an E-cigarette.
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CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0692
(Tag F0692)
Could have caused harm · This affected 1 resident
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Based on observation, resident interview, staff interview, and record review, the facility failed to provide hydration care and services for one (1) of 24 residents reviewed for hydration, during th...
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Based on observation, resident interview, staff interview, and record review, the facility failed to provide hydration care and services for one (1) of 24 residents reviewed for hydration, during the long term care survey. Resident identifier #7. Census 55.
Findings Included:
a) Resident #7
Observation on 04/17/23 at 11:32 AM, found the resident did not have a water pitcher or cup at bedside.
A resident interview on 04/17/23 at 11:32 AM, confirmed he did not have anything to drink. He stated, I normally has a pitcher of water.
Staff interview on 04/17/23 at 11:40 AM, with Licensed Practicing Nurse (LPN) #24, confirmed the resident did not have any water at bedside. LPN #24 said the resident recently changed to thickened liquids and the staff must have taken his cup away with his breakfast tray. LPN #24 stated the resident is supposed to have a pitcher and a cup with a handle, with thickened liquids at bedside.
Record review of Resident #7's care plan indicates the resident is to have nectar thick liquid, and a blue cup with spout to be used for water/fluids at bedside.
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CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
Could have caused harm · This affected 1 resident
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Based on observation, policy review and staff interview the facility failed to follow their policy to store the nebulizer mask in a sanitary manner. This was true for one (1) of one (1) resident rev...
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Based on observation, policy review and staff interview the facility failed to follow their policy to store the nebulizer mask in a sanitary manner. This was true for one (1) of one (1) resident reviewed for the oxygen care area during the long term care survey process. Resident Identifier: #44 Facility Census: 55
Findings Included:
a) Resident #44
An observation on 04/17/23 at 11:35 AM, found Resident #44's nebulizer mask was on the bedside table and not stored in a sanitary manner. This was confirmed with Licensed Practical Nurse #16 on 04/17/23 at 11:40 AM.
The Oxygen Administration Policy (not dated) states under the Policy Explanation and Compliance Guidelines: #5 Staff shall perform hand hygiene and don gloves when administering oxygen or when in contact with oxygen equipment. Other infection control measures include: (e) Keep delivery devices covered in plastic bag when not in use.
This was confirmed with Licensed Practical Nurse #16 on 04/17/23 at 11:40 AM.
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CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Medication Errors
(Tag F0758)
Could have caused harm · This affected 1 resident
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Based on record review and staff interview the facility failed to evaluate residents for an acceptable diagnosis for the use of psychotropic medications. This was true for two (2) of five (5) reside...
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Based on record review and staff interview the facility failed to evaluate residents for an acceptable diagnosis for the use of psychotropic medications. This was true for two (2) of five (5) residents reviewed for the care area of unnecessary medications during the long term care survey process. Resident identifier: #9 and #36. Facility census: 55.
Findings included:
a) Resident #9
A review of Resident #9's medical record on 04/18/23 found the following pharmacist recommendations:
-- Review dated 01/19/23 Resperidone not in new guidelines to be given for bipolar.
-- Review dated 02/06/23 Resperidone not recommended for bipolar. The physician had signed this recommendation but no rational for using bipolar a diagnosis was provided.
A further review of the medical record found a current order for Resperidone for a diagnosis of bipolar.
During an interview on 04/18/23 at 11:20 AM the Director of Nursing (DON) verified these pharmacy recommendations there is no documentation for Physician responses from the pharmacy reviews and the resident still had the diagnosis of bipolar for the use resperidone.
b) Resident Identifier #36
An electronic record review on 04/18/23 at 12:00 PM, revealed two (2) pharmacy recommendations, one dated 02/06/23 (signed by the physician on 02/14/23) and one dated 01/11/23 (signed by the physician on 01/19/23). Both of these pharmacy recommendation forms state, .This resident is currently on the drug LITHIUM with the diagnosis of AUTISM SPECTRUM DISORDER. According to new guidelines, appropriate diagnosis for antipsychotic medication in the LTC setting include: Schizophrenia, Psychosis, or Dementia with Delusions or Psychosis. Please consider changing to an appropriate diagnosis or titrating off this medication .
The electronic record review also indicated that the resident has an order dated 12/14/22, for Lithium Carbonate Oral Capsule 150 milligrams (mg), with directions to give one (1) capsule by mouth two (2) times a day for Autism Spectrum Disorder.
A staff interview with the Administrator on 04/18/23 at 2:28 PM, confirmed the diagnosis for the resident's Lithium had not been changed as recommended by the pharmacist on two (2) occasions, nor had the physician provided a rationale as to why the diagnosis should not be changed.
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CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0804
(Tag F0804)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on observation, recipe review and staff interview the facility failed to provide food prepared by methods that conserve ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on observation, recipe review and staff interview the facility failed to provide food prepared by methods that conserve the nutritive value and the appearance of the food. This practice had the potential to affect an isolated number of residents who receive their nutrition from the kitchen. Facility census 55.
Findings Included:
a) Brussels Sprouts
During a tour of the kitchen on 04/17/23 at 11:45 AM, while obtaining the temperatures on the steam table there was a roundish, shriveled up vegetable which was brown in color.
This surveyor asked Is that mushrooms, to clarify what the vegetable was.
The Certified Dietary Manager (CDM) stated, no that is our substitute vegetable, Brussels sprouts.
This surveyor then stated, but they are brown not green.
The CDM stated She [NAME] them in the oven, that is probably why.
The CDM acknowledged the Brussels sprouts were not appealing in appearance and probably had no nutritive value.
On 04/17/23 the CDM provided the Brussels sprouts recipe, the recipe was as follows:
-Frozen Brussels Sprouts
-Water
-Margarine
1. Steam or boil Brussels sprouts until tender. Drain off excess water.
2. Toss lightly with margarine.
Cook to a minimum internal temperature of 140 degrees.
The Administrator was informed of Brussels sprouts on 04/17/23, and no other information was provided.
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CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0810
(Tag F0810)
Could have caused harm · This affected 1 resident
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Based on observation, medical record review and staff interview the facility failed to provide a spouted cup for Resident #25 at meal time. This was a random opportunity for discovery during the obs...
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Based on observation, medical record review and staff interview the facility failed to provide a spouted cup for Resident #25 at meal time. This was a random opportunity for discovery during the observation of the noon time meal on 04/17/23. Resident Identifier: Resident # 25. Facility Census: 55
Findings Included:
a) Resident #25
During a dining observation on 04/17/23 at 12:35 PM. Resident #25's lunch meal tray ticket was reviewed. This review revealed the following:
.Texture: Regular 4
Adaptive Equipment: Spouted Cup.
Resident #25 had his meal tray in front of him and there was no spouted cup on the tray.
During an interview on 04/18/23 at 12:36 PM Nurse Aide (NA) #1 acknowledged the spouted cup was not on the lunch meal tray and should have been.
During an interview on 04/18/23 at 12:37 PM Licensed Practical Nurse (LPN) #5 stated its dietary's responsibility to provide the assistive equipment for meals on the trays.
During a record review on 04/17/23 at 2:30 PM, Resident #25's medical record revealed a physician diet order dated 10/04/22 regular texture, thin consistency, spouted cup for beverages.
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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
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Based on record review and staff interview, the facility failed to maintain a complete and accurate medical record for one (1) of 24 sampled residents during the Long-Term Care Survey Process. Speci...
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Based on record review and staff interview, the facility failed to maintain a complete and accurate medical record for one (1) of 24 sampled residents during the Long-Term Care Survey Process. Specifically, the facility failed to accurately accept verbal consent on a Physician Orders for Scope of Treatment (POST) form by not having a witness to the consent. Resident identifiers: #19. Facility census: 55.
Findings included:
a) Resident #19
A medical record review, completed on 04/03/23 at 1:52 PM, revealed the following details:
-There was a Physician Orders for Scope of Treatment (POST) form on file for Resident #19.
-A verbal consent from Resident #19's Health Care Surrogate (HCS). The verbal consent was accepted on 04/23/21. No witness to the verbal consent and no follow-up signature was obtained.
Review of instructions on how to complete the POST form from Using the POST Form: Guidance for Healthcare Professionals 2021 Edition, page 20, outlined: If the incapacitated patient's MPOA [Medical Power of Attorney] representative or Health Care Surrogate [HCS] is unavailable at the time of form completion, this section can be signed by two witnesses for verbal confirmation of agreement from the patient's MPOA representative or Health Care Surrogate [HCS]. The form should be signed at the earliest available opportunity.
During an interview on 04/18/23 at 11:22 AM the Director of Nursing (DON) verified there was no follow-up to obtain the resident's Representative's Signature on the Post form.
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CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected multiple residents
Deficiency Text Not Available
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Deficiency Text Not Available
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Drug Regimen Review
(Tag F0756)
Could have caused harm · This affected multiple residents
Based on record review and staff interview, the facility failed to ensure each resident's drug regimen was reviewed at least once monthly by a licensed pharmacist or failed to ensure when the drug reg...
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Based on record review and staff interview, the facility failed to ensure each resident's drug regimen was reviewed at least once monthly by a licensed pharmacist or failed to ensure when the drug regimen was reviewed, and an irregularity was identified, the resident's physician responded with a rationale for the response made after review. This was true for four (4) of (5) residents reviewed for the unnecessary medication review care area during the Long-Term Survey Process (LTCSP).
Resident identifiers: Resident #108, #4, #9 and #27. Census: 55.
Findings included:
a) Resident #108
A record review, for Resident #108, showed no evidence the licensed pharmacist had reviewed the resident's drug regimen on a monthly basis. Drug regimen reviews (DRRs) were reviewed from 04/2022 through 03/2023. This review found no evidence the resident's drug regimen had been reviewed by a licensed pharmacist for 04/2022, 08/2022, 09/2022, 10/2022, 11/2022, 12/2022, 01/2023, 2/2023 and 3/2023.
An interview, with the Director of Nursing (DON), on 04/18/23 02:33 PM, confirmed no DRR had been completed for 04/2022, 08/2022, 09/2022, 10/2022, 11/2022, 12/2022, 01/2023, 2/2023 and 3/2033 and verified that only three (3) DRRs had been completed from 04/2022 through 03/2023.
b) Resident #27
A record review, for Resident #27, showed no evidence the licensed pharmacist had reviewed the resident's drug regimen on a monthly basis. Drug regimen reviews (DRRs) were reviewed from 04/2022 through 03/2023. This review found no evidence the resident's drug regimen had been reviewed, by a licensed pharmacist, for the months of 05/2022, 08/2022, 09/2022, 10/2022, 11/2022, 12/2022, 01/2023, or 2/2023.
An interview, with the Director of Nursing (DON), on 04/18/23 02:33 PM, confirmed the DRR had not been reviewed or completed, by a licensed pharmacist, for Resident #27 for the months of 05/2022, 08/2022, 09/2022, 10/2022, 11/2022, 12/2022, 01/2023, or 2/2023 and should have been done on a monthly basis.
c) Resident #4
On 04/18/23 at approximately 10:30 AM, the surveyor requested pharmacy recommendations from the Administrator for the time frame of 04/2022 through current. A review of the pharmacy recommendations provided found on the following months no DRRs were completed: 06/2022, 08/2022, 10/2022, 12/2022 and 03/2023.
An interview with the Administrator on 04/18/23 at 2:28 PM, confirmed Resident #4's drug regimen was not reviewed monthly.
d) Resident #9
A review for Unnecessary Medication for Resident #9 on 04/18/23 found the record did not contain medication regimen reviews for March 2023, January 2023, November 2022, October 2022, and August 2022.
During an interview on 04/18/23 at 11:20 AM the Director of Nursing (DON) verified the facility was unable to find documentation to indicate the pharmacy reviews were completed.
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CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected multiple residents
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Based on observation and staff interview the facility failed to store food in accordance with professional standards for food safety. The facility failed to label and date food items which were open...
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Based on observation and staff interview the facility failed to store food in accordance with professional standards for food safety. The facility failed to label and date food items which were open and failed to dispose of expired food items. The facility also failed to keep an accurate refrigerator temperature log. The facility also failed to distribute and serve food and ice in a safe and sanitary manner. This failed practice had the potential to affect more than a limited number of residents currently receiving nourishment from the facility's kitchen and ice from the B hall Ice chest. Facility Census: 55
Findings Included:
a) Walk In Refrigerator
During the initial tour of the kitchen with the Certified Dietary Manager (CDM) beginning on 04/17/23 at 10:30 AM, the following items were found in the walk-in refrigerator:
-A pan of Chicken with the tin foil ripped exposing the chicken.
-4 rolls of hamburger thawing on a rolling cart with no date as to when it was placed in the refrigerator for thawing.
The Dietary Manager acknowledged the failure to label food items with a Date Opened and/or Use by Date. Also indicated the items needed to be discarded because they were open and exposed or not dated.
b) Walk in Freezer
During the initial tour of the kitchen with the CDM beginning on 04/17/23 at 10:30 AM, the following items were found in the walk-in freezer:
-Ice build up in the freezer, on the shelving units and on the floor leaking from the intake fan. Ice build up was on several boxes of food including an opened box of frozen fruit and an opened bag of garlic bread sticks.
The CDM stated I cleaned the freezer on Friday before I left, and came in this morning to it frozen again.
-An opened box of Fish with no open or use by date.
-An opened bag of garlic bread sticks with no open or use by date.
-An opened box of skillet frittatas with no open or use by date.
The Dietary Manager acknowledged the failure to label food items with a Date Opened and/or Use by Date. Also indicated the items needed to be discarded because they were open and exposed or not dated.
c) Condiment Shelf:
During the initial tour of the kitchen with the CDM beginning on 04/17/23 at 10:30 AM, the following issues were found on the Condiment shelf:
-three (3) bowls of cornflakes not labeled to indicate the contents and had no open or use by date
-an opened bag of cornflakes with no open or use by date
The Dietary Manager acknowledged the failure to label food items with a Date Opened and/or Use by Date. Also indicated the item needed to be discarded because they were open and/or not dated.
d) Prep Station:
During the initial tour of the kitchen with the CDM beginning on 04/17/23 at 10:30 AM, the following issues were discovered on the Prep Station:
-an opened bottle of Pancake Syrup with an open date of 04/11 with no use by date.
-an opened carton of dried chopped onion with no open or use by date.
-an opened box of pancake mix with no open or use by date
-an opened loaf of marble bread with no open or use by date
The CDM acknowledged the failure to label food items with a Date Opened and/or Use by Date. Also indicated the item needed to be discarded because they were open and exposed and/or not dated.
-two (2) plastic storage containers with scoops and cooking utensils the handles were not facing the same direction or turned in the same way which increased the risk for exposure to contaminants.
The CDM acknowledged the failure to place utensils in the same direction and turned them facing all the same direction.
e) Stockroom Freezer:
During the initial tour of the kitchen with the CDM beginning on 04/17/23 at 10:30 AM, the following issues were found in the stockroom freezer:
-four (4) open boxes of popsicles with no open or use by date
-one (1) open bag of popsicles with no open or use by date
The Dietary Manager acknowledged the failure to label food items with a Date Opened and/or Use by Date. Also indicated the items needed to be discarded because they were open and not dated.
f) Stockroom:
During the initial tour of the kitchen with the CDM beginning on 04/17/23 at 10:30 AM, the the following issues were found in the Stockroom:
-an open bag of white rice with no open or use by date.
-an open bag of ziti with no open or use by date
-an open bag of egg noodles no open or use by date
-an open bag of elbow noodles with no open or use by date
The Dietary Manager acknowledged the failure to label food items with a Date Opened and/or Use by Date. Also indicated the items needed to be discarded because they were open and/or not dated.
g) Spice Rack in the Office
During the initial tour of the kitchen with the CDM beginning on 04/17/23 at 10:30 AM, the following issues were found on the spice rack:
-a bottle of Taco Seasoning with a use by date of 03/23/23
-a storage container with a unknown spice with no label of contents nor an open or use by date
-an open bag of dry milk with a date of 09/06 with no year or use by date
The Dietary Manager acknowledged the failure to label food items with a Date Opened and/or Use by Date. Also indicated the item needed to be discarded because they were open and/or not dated.
h) Stockroom Freezer Temperature Log
A review of the April 2023 Stockroom Freezer Temperature Log on 04/17/23 at 10:45 AM, revealed the documentation was incomplete. The following dates did not have temperatures checked and logged for the freezer. The following dates on the temperature log were incomplete included:
-On 04/12/23 AM was void temperature
-On 04/13/23 AM was void temperature
-On 04/14/23 AM was void temperature
-On 04/15/23 AM was void temperature
-On 04/16/23 AM and PM was void temperatures
-On 04/17/23 AM was void temperature
The CDM acknowledged the temperature log was incomplete and should have been completed daily.
i) Main Dining Room Observation
During a dining observation on 4/17/23 starting 11:35 AM the main dining room revealed the following issues:
-Activity Assistant #60 removed the Resident's slice of bread from the bag touching the bread with her bare hands and placed it on the plate.
- Activity Assistant #59 removed the Resident's slice of bread from the bag touching the bread with her bare hands to place it on the plate.
An immediate interview Activity Assistant #59 stated how am I supposed to get the bread out, I have to touch it.
During an interview on 04/17/23 at 12:10 PM the Activity Director #48 acknowledge the slice of bread should not be touched with bare hands.
j) Ice Scoop
During a dining observation on 04/17/23 at 12:13 PM the B hall ice chest had a mesh holder for the ice scoop, exposing the ice scoop to contaminants.
During an interview on 04/17/23 at 03:06 PM, the Director of Nursing stated I feel it should be in a plastic container, to prevent contamination.
During an interview on 04/17/23 at 3:13 PM, the CDM stated the ice scoop needs to be in a plastic container with a covered lid.
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CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected multiple residents
Based on observation, record review, and staff interview, the facility failed to establish and maintain an effective infection prevention and control program designed to provide a safe, sanitary and c...
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Based on observation, record review, and staff interview, the facility failed to establish and maintain an effective 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 facility failed to ensure, residents with physician orders and care plan approaches for Enhanced Barrier Precautions, were implemented, placing all residents at risk for transmission of infections. In addition, the facility failed to ensure residents were provided hand hygiene prior to meals and failed to ensure the proper storage of linens to prevent the spread of infection. This practice had the potential to affect more than a limited number of residents. Resident Identifiers: Resident #31, # 108, #44, #29, #49, #19, and #53. Census: 55.
Findings included:
a) Resident #31
A record review, for Resident #31, showed a current physician's order for Enhanced Barrier Precaution related to MDRO: ESBL(Multi drug resistant organism: Extended Spectrum Beta Lactamase). Observation of the resident's room, on 04/17/23 at 10:45 AM, showed no designation of any special precaution in place for the care of the resident.
An observation, on 04/18/23 at 08:45 AM, revealed Nursing Assistant (NA #26) was assisting Resident #31 with the breakfast meal. The resident indicated she needed to go to the restroom and was assisted by NA #26 and Licensed Practical Nurse (LPN #5). Both NA #26 and LPN #5 failed to don the Personal Protective Equipment (PPE) used when assisting a resident with a high contact resident care activity such as toileting.
Further review of the electronic medical record showed a Minimum Data Set (MDS), dated with a target date of 02/20/23, this MDS, under Section G, Item I., Toileting, Resident #31 required extensive assistance with this task and required two (2) plus persons to assist.
An interview and observation, with the Infection Preventionist (IP), on 04/19/23 at 01:23 PM, verified Resident #31 had a current order for Enhanced Barrier Precautions and did not have any instruction to staff and visitors, posted at the room, as to what PPE would be required to visit or care for the resident. During the interview, the IP provided the information that was to be posted on each room of any resident in Transmission Based Precautions including Enhanced Barrier Precautions.
Review of the Enhanced Barrier Precautions required PPE included the following:
Wear gloves and a gown for the following activities:
Dressing, Bathing//shower, Transferring, changing linens, providing hygiene, changing briefs or assisting with toileting, device or wound care.
b) Resident #108
A record review, for Resident #108, showed a current physician's order for Enhanced Barrier Precaution related to MDRO: MRSA (multi -drug resistant organism: Methicillin Resistant Staphylococcus aureus). Observation of the resident's room, on 04/17/23 at 10:50 AM, showed no information of any special precaution in place for additional PPE to be donned, necessary for the care of the resident.
An interview and observation, with the Infection Preventionist (IP), on 04/19/23 at 01:23 PM, verified Resident #31 had a current order for Enhanced Barrier Precautions and did not have any instruction to staff and visitors, posted at the room, detailing what PPE would be required to visit or care for the resident. During the interview, the IP provided the information that was to be posted on each room of any resident in Transmission Based Precautions including Enhanced Barrier Precautions.
Review of the Enhanced Barrier Precautions included the following:
Wear gloves and a gown for the following activities:
Dressing, Bathing//shower, Transferring, changing linens, providing hygiene, changing briefs or assisting with toileting, device or wound care.
c) Resident #44
On 04/17/23 at 1:15 PM a record Review for Resident #44 found an order for Enhanced Barrier precaution related to Multidrug Resistant Organisms (MDRO): Extended Spectrum Beta-Lactamase (ESBL) and Device Care: Feeding tube.
Observation on 04/17/23 at 1:20 PM found no signage for isolation or instruction to staff or visitors as to what personal protective equipment should be worn for infection control prevention.
This was confirmed with the Infection Preventionist #60 on 04/17/23 at 1:40 PM.
d) Resident #29
On 04/17/23 at 1:15 PM, a record review for Resident #29 found an order for Enhanced Barrier precaution as related to MDRO: Methicillin-resistant Staphylococcus aureus (MRSA)<ESBL<Carbapenem-resistant Enterobacterales (CRE)<Vancomycin-resistant Enterococci (VRE) and Wound care: Stage IV Pressure injury.
Observation on 04/17/23 at 1:20 PM found no signage for isolation or instruction to staff or visitors as to what personal protective equipment should be worn for infection control prevention.
This was confirmed with the Infection Preventionist #60 on 04/17/23 at 1:40 PM.
e) Resident #49
A review of Resident #49's medical record review on 04/18/23 found a physician order for:
-- Enhanced Barrier Precaution related to Device care: Peg-tube
every shift for transmission precautions with a start date 10/24/22.
Continued review found the following care plan:
--Focus
-Enhanced Barrier Precautions (EBP) related to increased risk of developing infections secondary to history of Multidrug-Resistant Organisms (MDRO): Methicillin-resistant Staphylococcus aureus (MRSA) and Device: percutaneous endoscopic gastrostomy (Peg Tube.)
--Goal
-Resident #49 will remain free of complications from infection secondary to history of MRSA and other devices: Peg Tube through next review.
--Interventions/Task
-Staff to use PPE gowns and gloves to minimize risk of spreading directly/indirectly for high contact resident care activities: Dressing, Bathing /Showering, transferring. Providing hygiene, changing linens, changing briefs or assisting with toileting and devices Peg tube and foley catheter care.
An observation of Resident #49's room on 04/18/23 found no signage for isolation or instruction to staff or visitors as to what personal protective equipment should be worn for infection control prevention.
During an interview on 04/19/23 at 11:19 AM the Infection Preventionist verified enhanced barrier precautions are not being done at this time, no precautions signs are in place on the doors. She confirmed there are orders and a care plan for Enhanced Barrier Precautions for Resident #49.
f) Resident #53
A review of Resident #53's medical record on 04/18/23 found the following physician order:
-- Enhanced Barrier Precaution related to Device care: Peg-tube
every shift for transmission precautions with a start date 01/20/23.
Continued review found the following care plan:
--Focus
-Enhanced Barrier Precautions (EBP) related to increased risk of developing infections secondary to history of Multidrug-Resistant Organisms (MDRO): Methicillin-resistant Staphylococcus aureus (MRSA) and Device: percutaneous endoscopic gastrostomy (Peg Tube.)
--Goal
-Resident #53 will remain free of complications from infection secondary to history of MRSA and other devices: Peg Tube through next review.
--Interventions/Task
-Staff to use PPE gowns and gloves to minimize risk of spreading directly/indirectly for high contact resident care activities: Dressing, Bathing /Showering, transferring. Providing hygiene, changing linens, changing briefs or assisting with toileting and devices Peg tube and foley catheter care.
An observation of Resident #53's room found no signage for isolation or instruction to staff or visitors as to what personal protective equipment should be worn for infection control prevention.
During an interview on 04/19/23 at 11:19 AM, the Infection Preventionist verified enhanced barrier precautions are not being done at this time, no precautions signs are in place on the doors. She confirmed there is orders and a care plan for Enhanced Barrier Precaution for Resident #53.
g) Resident #19
A review of Resident #19's medical record on 04/18/23 found the following physician order:
-- Enhanced Barrier Precaution related to Multidrug-Resistant Organisms (MDRO): Methicillin-resistant Staphylococcus aureus (MRSA) every shift for transmission precautions with a start date 10/03/22.
An observation of Resident #19's room found no signage for isolation or instruction to staff or visitors as to what personal protective equipment should be worn for infection control prevention.
During an interview on 04/19/23 at 11:19 AM the Infection Preventionist verified enhanced barrier precautions are not being done at this time, no precautions signs are in place on the doors. She confirmed there is orders for Enhanced Barrier Precaution for Resident #19.
h) Hand Hygiene
A dining observation on 04/17/23 beginning at 11:35 AM in the main dining room revealed the following Nurses Aides (NA) had not performed hand sanitization before delivering the next resident's lunch meal.
-Nurse Aide (NA) # 8 no hand hygiene prior to delivering a Resident's tray
-Activity Assistant #59 no hand hygiene prior to delivering a resident's tray after assisting another resident with their meal
- NA #24 no hand hygiene prior to delivering a drink and touching a resident plate.
During an interview on 04/17/23 at 12:10 PM the Activity Director acknowledged the need for hand hygiene prior to delivering another resident's tray.
i) Clean Linen Carts
An observation on 04/17/23 at 12:13 PM of the A-Hall clean linen cart revealed the following issues:
-three (3) opened bags of undergarments
-two (2) bags of disposable bed chux pads
During an interview on 04/17/23 at 12:15 PM Licensed Practical Nurse (LPN ) #5 acknowledged the undergarments and chux pads were on the clean linen cart. And stated I will remove all the linen from the cart and restock it.
During an observation on 04/17/23 at 12:19 PM of the B-Hall clean linen revealed several unpackaged undergarments laying on the clean linen.
During an interview on 04/17/23 at 12:19 PM LPN #5 acknowledged the undergarments on the clean linen cart and stated they know better to than to put anything on the clean linen cart besides linen. I will get everything removed and restocked.
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CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Room Equipment
(Tag F0908)
Could have caused harm · This affected multiple residents
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Based on observation and staff interviews the facility failed to maintain equipment in safe operating conditions. The steam table drain was leaking around a shut off valve. The steamer was leaking w...
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Based on observation and staff interviews the facility failed to maintain equipment in safe operating conditions. The steam table drain was leaking around a shut off valve. The steamer was leaking water around the seal when opened. The walk-in freezer had ice build up on the shelving unit, on boxes of frozen food and on the floor. This failed practice had the potential to affect more than a limited number of residents currently receiving nutrition from the facility kitchen. Facility Census: 55
Findings Included:
a) Steam table drain
During the initial tour of the kitchen beginning on 04/17/23 at 10:30 AM with the Certified Dietary Manager (CDM) an observation of the steam table drain shut off valve had water dripping into a pan.
During an immediate interview the CDM stated, Maintenance has tried to fix it, I think the whole thing needs replaced.
During an interview on 04/17/23 at 1:40 PM the Maintenance helper #73 stated I did not know it was leaking, looks like someone just spilled water from the steam table. It's not leaking now.
b) Steamer
During the initial tour of the kitchen beginning on 04/17/23 at 10:30 AM with the CDM an observation of a white blanket that was noticeably dirty under the door of the steamer.
During an immediate interview the CDM stated the steamer is leaking when you open it. It is the seal. The evening shift changes the towel daily.
During an interview on 04/17/23 at 1:42 PM the Maintenance helper stated another company takes care of the steamer, we don't touch it.
c) Walk-in freezer
During the initial tour of the kitchen with the CDM beginning on 04/17/23 at 10:30 AM, the walk-in freezer had ice build-up on the shelving units and on the floor leaking from the intake fan. Ice build up was also on several boxes of food including an opened box of frozen fruit and an opened bag of garlic bread sticks.
During an immediate interview, the CDM stated I cleaned the freezer on Friday before I left, I came in this morning to it all frozen again.
During an interview 04/17/23 at 1:41 PM, the Maintenance helper #73 stated they did not know it was leaking, it's where they turn off the freezer and it leaks and freezes up. They need to quit turning the freezer off when they are stocking.
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MINOR
(B)
Minor Issue - procedural, no safety impact
Garbage Disposal
(Tag F0814)
Minor procedural issue · This affected multiple residents
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Based on observation and staff interview the facility failed to ensure waste was properly contained and covered in the outside garbage receptacle. The lids of the dumpster's were left open, exposing...
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Based on observation and staff interview the facility failed to ensure waste was properly contained and covered in the outside garbage receptacle. The lids of the dumpster's were left open, exposing bags of garbage and boxes. This deficient practice had a potential to affect more than an isolated number of residents residing in the nursing facility. Facility Census: 55.
Findings Included:
a) Garbage Receptacles
During an observation on 04/17/23 at 11:52 AM, there were two (2) outside garbage receptacles, the lids to the dumpster's were open exposing bags of garbage and boxes.
During an interview on 04/17/23 at 11:54 AM, the Certified Dietary Manager acknowledged the dumpster lids need to be closed.
During an interview on 04/17/23 at 1:43 PM, the Maintenance helper #73 stated the lids on the trash blow up all the time because they don't break down the boxes. That is what makes the garbage overfill because they just throw the whole boxes in the trash.
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Mar 2022
17 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Resident Rights
(Tag F0550)
Could have caused harm · This affected 1 resident
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Based on observation and staff interview, the facility failed to care for a resident in a respectful manner to protect their dignity. Resident #2's urinary catheter drain bag was laying uncovered on...
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Based on observation and staff interview, the facility failed to care for a resident in a respectful manner to protect their dignity. Resident #2's urinary catheter drain bag was laying uncovered on the fall and visible from the hallway. This was a random opportunity of discovery. Resident identifiers: # 2. Facility census: 54.
Findings Included:
a) Resident #2
An observation on 03/15/22 at 2:15 PM found Resident # 2's urinary catheter drain bag was not in a privacy cover and was laying in the floor.
During an interview on 03/15/22 at 2:16 PM Licensed Practical Nurse (LPN) #30 acknowledged the urinary catheter bag was uncovered and laying in the floor.
On 03/15/22 at 2:37 PM the Director of Nursing (DON) was notified of the urinary catheter bag was not in a privacy cover and the catheter bag was laying on the floor, no further information was provided.
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CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0552
(Tag F0552)
Could have caused harm · This affected 1 resident
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Based on record review and staff interview the facility failed to notify the Physician and the Resident's Medical Power of Attorney (MPOA) timely of a change in the resident's condition for one (1) ...
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Based on record review and staff interview the facility failed to notify the Physician and the Resident's Medical Power of Attorney (MPOA) timely of a change in the resident's condition for one (1) of one (1) resident reviewed for a change in condition. Resident Identifier #205. Facility census 54.
Findings included:
a) Resident #205
A review of the medical record found Resident #205 developed a fever on 09/04/21 at 11:16 PM. Resident coughing and running a temperature of 102.1 temporal (non-touch). The facility failed to notify Resident # 205's Physician regarding the change in condition until 09/07/21 at 5:41 PM . The facility failed to notify Resident #205's MPOA regarding the change in condition until 09/07/21 at 6:05 PM.
The facility was not able to provide a policy regarding Resident Change in Condition documentation or notification.
An interview at 10:15 AM on 03/17/22, with the Director of Nursing (DON), confirmed the Resident's Physician and MPOA should have been notified at the time the change in condition occurred.
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CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Assessment Accuracy
(Tag F0641)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on medical record review and staff interview, the facility failed to ensure the Minimum Data Set (MDS) was complete and ...
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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 the Minimum Data Set (MDS) was complete and accurate. This was true for one (1) of 25 residents reviewed during the survey process. Resident Identifier: #52. Facility Census: 54.
Findings Included:
a) Resident #52
On 03/16/22 at 11:55 AM, the MDS dated [DATE] section L Oral/Dental Status was reviewed. The section was was coded indicating there were no dental issues.
A consultation dated 11/16/21 from a local denture company stated recommend extracting teeth 23, 24, 25, 26 and roots 28 and 29 with an oral surgeon.
After a review of the medical record and resident interview on 03/16/22, the resident's teeth and roots had not been extracted as recommended. The resident stated I really want them out .
On 03/16/22 at 11:43 AM, Social Worker (SW) #23 confirmed the resident's teeth and roots had not been extracted as recommended and section L of the MDS was incorrect. We are waiting on a pre-authorization before she [the resident] can have them extracted.
No further information was obtained during the survey process.
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CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0657
(Tag F0657)
Could have caused harm · This affected 1 resident
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Based on record review and staff interview, the facility failed to revise the care plan with new interventions after Resident #25 and #205 had additional falls. This was true for two (2) of two (2) ...
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Based on record review and staff interview, the facility failed to revise the care plan with new interventions after Resident #25 and #205 had additional falls. This was true for two (2) of two (2) residents reviewed during the long-term care survey. Resident identifier #25 and #205. Facility Census: 54.
Findings Included:
a) Resident #205
A record review found Resident #205 was admitted to the facility 08/20/19. A care plan for risk for falls ., and risk of fracture during falls ., was initiated 08/22/2019, and canceled on 09/23/21 (upon discharge). A review of August 2021 and September 2021 incident reports for Resident #205 found she fell six (6) times (08/02/21, 08/08/21, 08/27/21, 09/01/21, 09/15/21, 09/19/21). The only revision to interventions for the .risk for falls . care plan for Resident #205 during August 2021-September 2021 (other than canceling the interventions upon discharge) was resolving RNP scheduled toileting program as ordered on 09/15/21.
An interview with both the Director of Nursing (DON) and Administrator on 03/16/22 at 12:30 PM
confirmed Resident #205's fall care plan interventions were not updated.
B) Resident #25
On 03/14/22 at 3:55 PM, the resident was noted with a fall with possible head injury. The note states Recreation aide had him outside. He wanted to come inside and did not wait for staff to help him. He attempted to wheel himself through the closed door and fell backwards in his wheelchair, hitting his head. [Typed as written.]
On 03/05/22 at 4:06 PM, after speaking with the facility physician the resident was sent to an acute care hospital to be evaluated. The progress note stated Spoke to [name of facility physician and received order to send to ER. Also spoke with brother and told him we were sending resident out for CT [computerized tomography] related to fall. He voiced understanding. [Typed as written.]
On 03/05/22 at 8:30 PM, the resident returned to the facility with the following notation, Resident returned to facility from [name of the acute care facility] d/t [due to] fall. New diagnosis of pneumonia with prescription for Doxycycline Hyclate 100mg PO BID for ten days. [Name of facility physician] notified of residents return and of new orders. Attempted to notify [Name of Medical Power of Attorney], MPOA, with no answer. [Typed as written.]
A progress note dated 03/07/22 at 9:44 AM stated IDT [interdisciplinary team] reviewed incident. [Name of resident] has poor safety awareness and impulsiveness. He has had increased confusion and behaviors. He currently has diagnosis of Pneumonia. Anti-tippers to be placed on wheelchair. Will also refer to psychologist for eval. [Typed as written.]
A review of the care plan did not list the intervention of anti-tippers to be placed on the wheelchair under the focus of at risk for falls as indicated.
On 03/16/22 at 10:11 AM, the Director of Nursing (DON) confirmed the intervention of anti-tippers was not added to the care plan.
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CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
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Based on record review and staff interview the facility failed to provide adequate supervision and interventions to prevent accidents. Resident #205 sustained two (2) falls which resulted in injurie...
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Based on record review and staff interview the facility failed to provide adequate supervision and interventions to prevent accidents. Resident #205 sustained two (2) falls which resulted in injuries to her head and no interventions were put into place after each fall. This is true for one (1) of 1 resident reviewed for the care area of accidents during the long term care survey process. Resident identifier #205. Facility census 54.
Findings Included:
A) Resident #205
A review of Resident #205's medical record found she sustained a fall on 08/27/21 at 2:45 am. Resident #205 fell out of bed and sustained a wound to her left forehead that required medical intervention and was transferred to a local hospital for treatment. Resident #205 required sutures to her left forehead and developed a hemotoma.
A review of Resident #205's medical record and the incident report for her fall on 08/27/21 found no interventions were put in place after this fall to prevent further injury should another fall occur.
Further review of Resident # 205's medical record found she was found on the floor beside her bed on 09/19/21 at 2:25 AM. Resident #205 again suffered an injury to her head requiring medical intervention and transfer to a local hospital for treatment.
Resident #205's progress notes following incident found {typed as written} this resident will be admitted to hospital waiting on a bed on the floor DX brain bleed neuro has seen resident and order another CT SCAN.
Both the Director of Nursing (DON) and Administrator were interviewed on 03/16/22 at 12:30 PM.
When questioned about interventions for the resident's falls, or witness statements not being present on the incident report, neither the Administrator or DON could offer any additional information.
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CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
Could have caused harm · This affected 1 resident
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Based on observation, medical record review and staff interview the facility failed to provide necessary respiratory care consistent with professional standards of practice. This was true for one (1...
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Based on observation, medical record review and staff interview the facility failed to provide necessary respiratory care consistent with professional standards of practice. This was true for one (1) of one (1) residents reviewed for respiratory services during the Long Term Care Survey Process. Resident identifier: #54. Facility Census: 54
Findings Included:
a) Resident #54
An observation on 03/14/22 at 4:00 PM, found Resident #54's portable oxygen was set on 2 liters per minute, Activity Supervisor #67 acknowledged it was set on 2 liters per minute.
An observation on 03/15/22 at 10:00 AM, Resident #54 oxygen concentrator was not turned on with no oxygen flowing.
During an interview on 03/15/22 at 10:00 AM LPN #72 acknowledged the oxygen concentrator was not turned on.
On 03/15/22 at 10:03 AM LPN #72 monitored her oxygen saturation at 83.
On 03/15/22 at 10:04 AM stated (Resident's name's) oxygen saturation are usually between 96-98, I am unsure how long the oxygen has been off.
On 03/15/22 at 10:05 AM LPN #72 monitored her oxygen saturation was between 90-91.
On 03/15/22 at 10:07 AM LPN #72 monitored her oxygen saturation was 94.
A review of the Physician orders dated 02/18/22 Oxygen (O2) via nasal cannula every shift 3 liters/nasal cannula.
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CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected 1 resident
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Based on observation, policy review and staff interview the facility failed to ensure medication were labeled in accordance with accepted professional principles. The facility failed to label a bag ...
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Based on observation, policy review and staff interview the facility failed to ensure medication were labeled in accordance with accepted professional principles. The facility failed to label a bag of intravenous(IV) fluid of Normal Saline and intravenous tubing when it was put into use for Resident #35. This was a random opportunity for discovery. Resident Identifiers: #35. Facility Census: 54.
Findings Included:
a) Resident #35
An observation on 03/14/22 at 2:50 PM , found a bag of IV fluids was being administered to Resident #35 with no date or order information on the bag or no date on the IV tubing.
An interview on 03/14/22 at 2:55 PM, with Licensed Practical Nurse (LPN) # 30, comfirmed (LPN #72's name) is her nurse today she is on lunch. I know that 2 bags of fluids was to be given per report.
During an interview on 03/14/22 at 2:55 PM LPN #30 confirmed no label on the normal saline or IV tubing.
During an interview on 03/14/22 at 3:00 PM the Director of Nursing (DON) acknowledged there was no date on tubing and no date or information on IV fluids of normal saline being administered to Resident #35.
On 03/14/22 at 3:12 PM DON Presented policy stated our policy doesn't say anything about labeling the med's. This surveyor showed the DON their policy that stated, medications are to be labeled in accordance with state and federal requirements, is it not a state or federal requirement to label the medication before administering. The DON stated I guess your right.
A review of the facility policy titled Infusion therapy products-general information with a revision date of 01/18 found the following.
.D. All infusion therapy including piggyback solutions of less than 250 ml, are labeled in accordance with state and federal requirements .
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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
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Based on record review and staff interview the facility failed to keep an accurate medical record for Resident #205 and #37. This is true for two (2) of 25 sampled residents reviewed during the long...
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Based on record review and staff interview the facility failed to keep an accurate medical record for Resident #205 and #37. This is true for two (2) of 25 sampled residents reviewed during the long term care survey process. Resident identifiers #205 and #37. Facility Census 54.
Findings Included:
a) Resident #205
A review of the medical record found a Progress Note written 09/05/21 at 12:07 am {typed as written} Staff reported that resident was coughing and had a temperature of 102.1 Resident was given a PRN Covid test. Results of test are negative. Gave resident Tylenol 325mg x2 tabs and temperature is now 99. Lung sounds are clear. Will continue to observe resident and report these findings to morning nurse. Resident appears to have yellow drainage from left eye. No redness or swelling to forehead. Stitches are dry and intact.
A record review of the Medication Administration Record (MAR) for September 2021 found no Tylenol (Acetaminophen) administered to Resident #205 on 09/05/21.
An interview at 10:15 am on 03/17/22 with the Director of Nursing (DON) verified if a medication was given, it should be signed as given on the MAR.
b) Resident #37
A record review of weekly wound charting for Resident #37 's unstageable pressure area on his right ear, showed assessments on 02/24/22, 03/03/22, and 03/10/22 stating Skin prep and sponge ear protectors for nasal cannula as special equipment/preventative measures.
A review of the Physicians Orders for February 2022 and March 2022 found no physician order for skin prep.
In an interview at 10:15 am on 03/17/22 with the Director of Nursing (DON), verified there was no physician order for the skin prep that was documented in the Weekly Wound Charting.
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CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0578
(Tag F0578)
Could have caused harm · This affected multiple residents
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Based on medical record review and staff interview the facility failed to ensure the Physician Orders for Scope of Treatment (POST) forms were completed per directions specified by the [NAME] Virgin...
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Based on medical record review and staff interview the facility failed to ensure the Physician Orders for Scope of Treatment (POST) forms were completed per directions specified by the [NAME] Virginia Center for End of Life Care. This is true for seven (7) of seven (7) residents reviewed during the Long Term Care Survey Process. Resident Identifiers: Resident # 39, #35, #2, #54, #17, #25 and #45. Facility Census: 54.
Findings Included:
a) #39
On 03/14/22 at 4:20 PM the POST form for Resident #39 was reviewed. The POST form was signed and dated by the physician on 08/05/21. The POST form was missing the physician's printed full name and telephone number which were left blank.
During an interview on 03/16/22 at 11:41 AM Social Worker (SW) #23 acknowledged the POST form was incomplete. SW #23 stated I will definitely work on the POST forms.
b) #35
On 03/14/22 at 4:31 PM the POST form for Resident #35 was reviewed. The POST form was signed and dated by the physician on 02/20/22. The POST form was missing the physician's printed full name and telephone number which were left blank.
During an interview on 03/16/22 at 11:41 AM Social Worker (SW) #23 acknowledged the POST form was incomplete. SW #23 stated I will definitely work on the POST forms.
c) #2
On 03/14/22 at 4:03 PM the POST form for Resident #2 was reviewed. The POST form was signed and dated by the physician on 03/01/22. The POST form was missing the physician's printed full name and telephone number which were left blank.
During an interview on 03/16/22 at 11:41 AM Social Worker (SW) #23 acknowledged the POST form was incomplete. SW #23 stated I will definitely work on the POST forms.
d) #54
On 03/14/22 at 4:31 PM the POST form for Resident #54 was reviewed. The POST form was signed and dated by the physician on 07/27/21. The POST form was missing the physician's printed full name and telephone number which were left blank.
During an interview on 03/16/22 at 11:41 AM Social Worker (SW) #23 acknowledged the POST form was incomplete. SW #23 stated I will definitely work on the POST forms.
e) Resident #17
On 03/14/22 at 2:15 PM, the Physician Orders for Scope of Treatment (POST) Scope form was reviewed. The POST form was signed and dated by the physician on 08/12/21. The POST form was missing the physician's printed full name and telephone number which were left blank.
During an interview on 03/16/22 at 11:41 AM, Social Worker (SW) #23 acknowledged the POST form was incomplete. SW #23 stated I will definitely work on the POST forms.
f) Resident #25
On 03/14/22 at 2:15 PM, the POST form was reviewed. The POST form was singed and dated by the physician on 09/07/21. The POST form was missing the physician's full printed name, license number and telephone number which were left blank.
During an interview on 03/16/22 at 11:41 AM, Social Worker (SW) #23 acknowledged the POST form was incomplete. SW #23 stated I will definitely work on the POST forms.
g) Resident #45
On 03/14/22 at 2:15 PM, the Physician Orders for Scope of Treatment (POST) Scope form was reviewed. The POST form was signed and dated by the physician on 11/11//21. The POST form was missing the physician's printed full name and telephone number which were left blank.
During an interview on 03/16/22 at 11:41 AM, Social Worker (SW) #23 acknowledged the POST form was incomplete. SW #23 stated I will definitely work on the POST forms.
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CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on medical record review and staff interview, the facility failed to report falls with serious bodily injury to state an...
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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 report falls with serious bodily injury to state and other appropriate agencies as required within two (2) hours of discovering the serious bodily injury. This was true for four (4) of four (4) records reviewed during the Long Term Care Survey. Resident Identifiers: # 46, #205, #25, and #34. Facility Census: 54
a) Resident # 46
According to a record review, Resident #46 had two (2) unwitnessed falls on 07/27/21.
The Resident fell on [DATE] and on 08/02/21 Licensed Practical Nurse (LPN) #71 notified the Physician of swelling to the right knee and a new order for an X-ray of the right knee was obtained.
On 03/16/22 at 02:20 PM this was confirmed with LPN #71.
On 08/03/21 when the Physician assessed the Resident and upon observing the right knee being swollen, the Resident was transferred to a local hospital emergency room on [DATE] at approximately 10:45 AM according to hospital records.
Based on record review from the hospital the Residents right knee was swollen and she could not straighten her leg out. The Physician determined from their right femur x-rays, the Resident had an acute displaced fracture involving the distal metadiaphysis of the right femur. This was documented as an impacted distal femur fracture resulting in a right knee replacement.
The facility never reported this serious bodily injury to officials in accordance with State law, including adult protective services where state law provides for jurisdiction in long-term care facilities.
During an interview on 03/16/22 at 9:47 AM the Director of Nursing (DON) and the Administrator confirmed the fall was not reported or investigated.
b) Resident # 205
A review of Resident #205's medical record found Resident # 205 fell out of bed 08/27/21 at 2:45 AM resulting in a wound to her left forehead which required medical intervention and a transfer to a local hospital for treatment. Resident #205 required sutures to her left forehead and developed a hematoma (bruise).
A further record review found Resident #205 was found on the floor beside her bed 09/19/21 at 2:25 AM again requiring medical intervention and transfer to a local hospital for treatment. Resident #205's progress notes following incident found {typed as written} this resident will be admitted to hospital waiting on a bed on the floor DX brain bleed neuro has seen resident and ordered another CT SCAN.
A review of the facility incident report #2176 dated 08/27/21 and report #2186 found no witnesses and no investigation completed for either incident. A review of the facility reportable log found no evidence the incident resulting in serious bodily injury was reported to the appropriate state agencies.
Interview with both the Director of Nursing (DON) and Administrator on 03/16/22 at 12:30 PM verified that neither the 08/27/21 or 09/19/21 fall had been reported to appropriate state agencies. When questioned about interventions for the resident's falls, or witness statements not being present on the incident report, neither the Administrator or DON could offer any additional information.
c) Resident #25
A progress note dated 03/05/22 at 2:57 PM stated Recreation aide had him outside. He wanted to come inside and did not wait for staff to help him. He attempted to wheel himself through the closed door and fell backwards in his wheelchair, hitting his head. [Typed as written.]
The record review revealed the resident had a fall with a serious injury on 03/05/22 at 2:57 PM. The
A review of progress notes continue with a notation dated 03/05/22 at 4:06 PM Spoke to [name of facility physician] and received order to send to ER. Also spoke with brother and told him we were sending resident out for CT [computerized tomography] related to fall. He voiced understanding. [Typed as written.]
The progress notes continue with a notation on 03/05/22 at 8:30 PM stating Resident returned to facility from [name of acute care facility] d/t fall. New diagnosis of pneumonia with prescription for Doxycycline Hyclate 100mg PO BID for ten days. l notified [name of facility physician] of residents return and of new orders. Attempted to notify [name of medical power of attorney] MPOA, with no answer. [Typed as written.]
On 03/07/22 at 9:44 AM the interdisciplinary team [IDT] reviewed the incident for the cause of the fall. IDT reviewed incident. [Name of resident] has poor safety awareness and impulsiveness. He has had increased confusion and behaviors. He currently has diagnosis of Pneumonia. Anti-tippers to be placed on wheelchair. Will also refer to psychologist for eval [evaluation]. [Typed as written.]
The Discharge Instructions dated 03/05/22 from [acute care facility] stated final diagnosis fall, resides in skilled nursing facility, closed head injury, atrial fibrillation, anticoagulated, pneumonia. [Typed as written.]
On 03/16/22 at 9:30 AM, the Administrator confirmed the closed head injury was not reported to the appropriate state agencies.
d) Resident #34
During an interview on 03/14/22 at 2:37 PM with the Resident #34's family member they stated she fell recently and hit her head.
During a Medical record review of incident reports on 03/15/22 revealed Resident #34 had an unwitnessed fall on 02/26/22.
A Nurses Note dated 02/26/22 at 6:07 AM RN #104 [typed as written] CNA walked into room at approximately 5:45 and saw her on the floor in front of her room mates bed. There was a small and very deep laceration to the eye. Bleeding was stopped and she was assessed with no other injuries noted. She was assisted back to bed. Doctor was called, order to send to ER (Emergency Room)obtained. POA (Power of Attorney) was informed. 911 Called to pick her up. v/S (vital signs) obtained prior to leaving.
A Nurses Note dated 02/26/22 at 8:10 AM RN #104 [typed as written] Received report from ER. CT (Computed Tomography) negative, labs looked good. Eye sutured. Tetanus shot given. Will be coming back. Communicated above to floor nurse.
There was no reporting to the appropriate agencies associated with this incident.
During an interview on 03/16/22 at 9:47 AM the Director of Nursing (DON) and the Administrator confirmed the fall was not reported or investigated.
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CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Investigate Abuse
(Tag F0610)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on medical record review and staff interview the facility failed to thoroughly investigate falls with serious bodily inj...
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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 thoroughly investigate falls with serious bodily injury as required. This was true for four (4) of four (4) records reviewed. Resident Identifiers: # 46, #205, #25, and #34. Facility Census: 54
a) Resident # 46
According to record review, Resident #46 had two (2) unwitnessed falls on 07/27/21.
The Resident fell on [DATE] and on 08/02/21 Licensed Practical Nurse (LPN) #71 notified the Physician of swelling of the right knee and a new order for an X-ray of the right knee was obtained.
On 08/03/21 when the Physician assessed the Resident and upon observing the right knee being swollen, the Resident was transferred to a local hospital emergency room on [DATE] at approximately 10:45 AM according to hospital records.
Based on record review from the hospital the Residents right knee was swollen and she could not straighten her leg out. The Physician determined from their right femur x-rays, the Resident had an acute displaced fracture involving the distal metadiaphysis of the right femur. This was documented as an impacted distal femur fracture resulting in a right knee replacement.
The facility has no evidence this serious bodily injury was thoroughly investigated.
On 03/16/22 at 02:20 PM an interview with the Nursing Home Administrator confirmed this incident was not thoroughly investigated.
b) Resident # 205
A review of the medical record found Resident # 205 fell out of bed 08/27/21 at 2:45 AM resulting in a wound to her left forehead that required medical intervention and a transfer to a local hospital for treatment. Resident #205 required sutures to her left forehead and developed a hematoma (bruise).
A further review found Resident #205 was found on the floor beside her bed on 09/19/21 at 2:25 AM again requiring medical intervention and transfer to a local hospital for treatment. A review of Resident #205's progress notes following incident found {typed as written} this resident will be admitted to hospital waiting on a bed on the floor DX brain bleed neuro has seen resident and order another CT SCAN.
A review of the facility incident report #2176 dated 08/27/21 and report #2186 found no witnesses and no investigation completed for either incident. A review of the facility reportable log found no evidence the incident resulting in serious bodily injury was reported to the appropriate state agencies.
An interview with both the Director of Nursing (DON) and Administrator on 03/16/22 at 12:30 PM verified that neither the 08/27/21 or 09/19/21 fall with serious bodily injury had been reported to appropriate state agencies as required. When questioned about interventions for the resident's falls, or witness statements not being present on the incident report, neither the Administrator or DON could offer any additional information.
c) Resident #25
A progress note dated 03/05/22 at 2:57 PM stated Recreation aide had him outside. He wanted to come inside and did not wait for staff to help him. He attempted to wheel himself through the closed door and fell backwards in his wheelchair, hitting his head. [Typed as written.]
The record review revealed the resident had a fall with a serious injury on 03/05/22 at 2:57 PM. The
A review of progress notes continue with a notation dated 03/05/22 at 4:06 PM Spoke to [name of facility physician] and received order to send to ER. Also spoke with brother and told him we were sending resident out for CT [computerized tomography] related to fall. He voiced understanding. [Typed as written.]
The progress notes continued with a notation on 03/05/22 at 8:30 PM stating Resident returned to facility from [name of acute care facility] d/t fall. New diagnosis of pneumonia with prescription for Doxycycline Hyclate 100mg PO BID for ten days. l notified [name of facility physician] of residents return and of new orders. Attempted to notify [name of medical power of attorney] MPOA, with no answer. [Typed as written.]
On 03/07/22 at 9:44 AM the interdisciplinary team [IDT] reviewed the incident for the cause of the fall. IDT reviewed incident. [Name of resident] has poor safety awareness and impulsiveness. He has had increased confusion and behaviors. He currently has diagnosis of Pneumonia. Anti-tippers to be placed on wheelchair. Will also refer to psychologist for eval [evaluation]. [Typed as written.]
The Discharge Instructions dated 03/05/22 from [acute care facility] stated final diagnosis fall, resides in skilled nursing facility, closed head injury, atrial fibrillation, anticoagulated, pneumonia. [Typed as written.]
On 03/16/22 at 9:30 AM, the Administrator confirmed the fall resulting in a closed head injury was not investigated.
d) Resident #34
During an interview on 03/14/22 at 2:37 PM with Resident #34's family member they stated she fell recently and hit her head.
A medical record review of incident reports on 03/15/22 revealed Resident #34 had an unwitnessed fall on 02/26/22.
A Nurses Note dated 02/26/22 at 6:07 AM read as follows; Registered Nurse (RN) #104 [typed as written] NA walked into room at approximately 5:45 and saw her on the floor in front of her room mates bed. There was a small (centimeters)long and very deep. Bleeding was stopped and she was assessed with no other injuries noted. She was assisted back to bed. Doctor was called, order to send to ER (Emergency Room)obtained. POA (Power of Attorney) was informed. 911 Called to pick her up. v/S (vital signs) obtained prior to leaving.
A Nurses Note dated 02/26/22 at 8:10 AM RN #104 [typed as written] Received report from ER. CT (Computed Tomography) negative, labs looked good. Eye sutured. Tetanus shot given. Will be coming back. Communicated above to floor nurse.
There was no investigation associated with this incident.
During an interview on 03/16/22 at 9:47 AM the Director of Nursing (DON) and the Administrator confirmed the fall was not reported or investigated.
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CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on observation, record review and staff interview the facility failed to provide care and services according to professi...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on observation, record review and staff interview the facility failed to provide care and services according to professional standards of care and the resident's plan of care. This is true for five (5) of 25 residents reviewed during the long term care survey process. Resident Identifiers #54, #205, #46, #44, and #35. Facility census 54.
Findings Included:
a) Resident #54
An observation of the medication pass on the A hallway at 9:20 am on 03/16/2022 found Licensed Practical Nurse (LPN ) # 56 administered a Symbicort (a steroid inhaler) to Resident #54. After administration of the steroid inhaler Resident #54 was not asked to rinse her mouth.
Review of the facility policy Medication Administration failed to advise to have the resident to rinse their mouth after administering a steroid inhaler. According to the Symbicort manufacturers guideline: After using your SYMBICORT inhaler: Put the cover back on, Rinse your mouth with water and spit it out, Don't swallow the water.
An interview with the Director of Nursing (DON) at 10:15 am on 03/16/22 confirmed Resident # 54 should have been offered to rinse their mouth after receiving their Symbicort inhaler.
b) Resident #205
A review of the medical record found Resident #205 developed a fever on 09/04/21 at 11:16 PM (typed as written) Resident coughing and running a temperature of 102.1 temporal (non-touch). The facility failed to notify Resident # 205's Physician regarding the change in condition until 09/07/21 at 5:41 PM . The facility failed to notify Resident #205's Medical Power of Attorney (MPOA) regarding the change in condition until 09/07/21 at 6:05 PM.
Further review of the medical record found Resident #205 was sent to the local hospital for evaluation and treatment on 09/10/21 .due to WBC (white blood cells) 21.1 . [NAME] Blood Cell (WBC) normal range is 4.5-11. A progress note dated 09/11/21 at 1:09 PM {typed as written}Called (area hospital name) for update. Resident is being admitted to telemetry floor for observation. She is being treated with ABX (antibiotics) for pneumonia. Made nurse aware she is in APS (adult protective services) custody.
The facility was not able to provide a policy regarding Resident Change in Condition documentation or notification.
In an interview at 10:15 am on 03/17/22 with the Director of Nursing (DON), agreed the Resident's Physician and MPOA should have been notified at the time the change in condition occurred and a delay in treatment occurred.
c) Resident #46
According to record review, Resident #46 had two (2) unwitnessed falls on 07/27/21. One was at 07:00 AM and again at 10:45 PM. These were assessed as no apparent injury. Due to the falls being unwitnessed, neurological assessments were initiated.
On 07/28/21 at 07:04 AM there was a pain assessment completed that showed the resident had no complaints of pain. There were no other documented pain assessments completed.
The Resident had scheduled Norco 5-325 mg, one (1) tablet three times a day related to other chronic pain. From 07/01/21 through 07/28/21 the Resident only complained of pain three (3) times which was rated as a one (1) twice, a two (2) once and a three (3) once. On 07/28/21, the day after the falls, the Resident complained of pain rating it as a three (3) and then a five (5). She also complained of pain on 08/2/21, 08/3/21 and 08/04/21, each day her pain increasing to a pain level of 6. There was no documentation as to where the pain was located nor the effectiveness of the pain medication. This increase of pain was never relayed to the Physician.
During a staff interview on 08/16/21 at 02:10 PM Licensed Practical Nurse (LPN) #71 states that on 08/02/21 she removed the Residents' blanket and noticed her right knee was swollen. She states this swelling had never been reported to her nor had she noticed any swelling. She reported the swelling to the Physician on 08/02/21 with new orders to obtain a two (2) view X-ray to the right knee and one (1) liter of Sodium Chloride via subcutaneous due to depleted fluid volume.
The Resident fell on [DATE] and 08/02/21 is the first documentation that the Physician was notified of swelling of the right knee. The X-ray report at 1:53 PM on 08/02/21 showed a fracture to the right femur. LPN #71 reported the X-ray results to the Physician on 08/02/21 at 3:06 PM with new orders were received to consult Orthopedics and the Physician would see the Resident on 08/03/21.
On 08/03/21 when the Physician assessed the Resident and observed the right knee swollen, new orders were given to discontinue the Orthopedic consult and transfer the Resident to the emergency room. The Resident was transferred to a local hospital emergency room on [DATE] at approximately 10:45 AM according to hospital records.
Based on record review from the hospital the Residents right knee was swollen and she could not straighten her leg out. The Physician determined from their right femur x-rays, the Resident had an acute displaced fracture involving the distal metadiaphysis of the right femur. This was reported as an impacted distal femur fracture resulting in a right knee replacement.
An interview with the Director of Nursing (DON) and Nursing Home Administrator (NHA) on 03/16/22 at 2:20 pm confirmed the Residents increased pain level after her fall was no assessed for location or if the pain medication was effective in controlling her pain. They agreed the resident was no sent to the hospital until 08/03/21 as a result of the fall she sustained on 07/27/21.
d) Resident #44
On 03/14/22 at 3:20 PM Resident #44 was observed wearing a left wrist brace. According to record review the Resident had an order for a left hand/wrist brace to be on four (4) hours per day for left sided weakness.
According to the Point Of Care Response History from 02/25/22 through 03/15/22 documentation shows the brace was applied nine (9) times and the Resident refused 3 (three) times.
This documentation shows that the brace was not applied the remaining seven (7) days of the nineteen (19) days available for applying the brace. These seven (7) days were documented as non applicable (NA).
During an interview with the Administrator on 03/15/22 at 01:54 PM no additional information concerning the brace was provided.
e) Resident #35
An observation on 03/14/22 at 2:50 PM found Resident #35 had a water pitcher cup with a straw and a regular drinking cup containing pink substance on her bedside table.
An observation on 03/15/22 at 9:17 AM found Resident #35 had a regular drinking cup of water with a straw on her bed side table.
During an interview on 03/15/22 at 10:00 AM Nurse Aide (NA) #82 stated this is her 10:00 snack, its a strawberry milkshake.
An observation on 03/15/22 at 10:01 AM, found NA #82 giving Resident #35 her milkshake in a regular drinking cup which contained a straw, NA #82 placed the straw in Resident #82's mouth, Resident did not drink.
An observation on 03/15/22 at 10:55 AM, found Licensed Practical Nurse (LPN) #72 was preparing Resident #35's medication in pudding with a regular drinking cup of water with a straw. LPN #72 placed the straw to Resident #35's mouth, resident did not take a drink. This surveyor intervened and asked LPN #72 to check Resident #35's orders. LPN #72 verified the order of No straws with beverages and provide one handled mug with beverages per Medical Power of Attorney (MPOA) request. LPN also verified there was another physician order for Kennedy cup with all liquids.
A review of Resident #35's physicians orders dated 03/09/22; Regular diet pureed texture, thin consistency, requires total feeding assistance. No straw with beverages and provide one handled mug with beverages per MPOA (Medical Power of Attorney) request.
A review of Resident #35 physicians orders dated 03/11/22, found an order for Kennedy cup with all liquids.
An interview on 03/15/22 at 11:14 AM with the speech therapist revealed Resident #35 was not recognizing the straw but would drink from the cup when she felt the liquid touch her lips. She was not aspirating or strangling on fluids. She has had a massive decline recently.
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CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Pharmacy Services
(Tag F0755)
Could have caused harm · This affected multiple residents
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Based on observation, record review and staff interview, the facility failed to complete an accurate and complete record of controlled substances in the narcotic count book. This was a random opport...
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Based on observation, record review and staff interview, the facility failed to complete an accurate and complete record of controlled substances in the narcotic count book. This was a random opportunity for discovery and had the potential to affect more than an isolated number of residents. Facility Census: 54.
a) Narcotic Count Book
The Controlled Substance Administration and Accountability Policy was reviewed and states in section 3 (three) ordering and receiving controlled substances in subsection e, The medications delivered are immediately recorded on the appropriate drug disposition record .
On 03/16/22 at 9:12 AM, Licensed Practical Nurse (LPN) #71 confirmed the index of the Narcotic Count Book was blank. The Index did not list the name of the residents, medications, dosages and page number for each controlled substance.
On 03/16/22 at 9:15 AM, the the Director of Nursing (DON) confirmed the index of the Narcotic Count Book was blank. The Index did not list the name of the residents, medications, dosages, and page numbers for each controlled substance.
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CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected multiple residents
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Based on observation, policy review and staff interview the facility failed to store, label and date food in a sanitary manner in accordance with professional standards for food service safety. The ...
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Based on observation, policy review and staff interview the facility failed to store, label and date food in a sanitary manner in accordance with professional standards for food service safety. The facility also failed to correctly document dishwasher temperatures. This deficient practice has the potential to affect a limited number of residents who receive nutrients from the kitchen. Facility Census: 54
Findings Included:
a) Initial Tour of the kitchen
An initial tour of the kitchen with the Dietary Supervisor(DS) #1 on 03/14/22 at 12:50 PM revealed the following failed practices:
The Walk in Freezer:
--Pork Chops box lid was opened and exposing the meat to the elements
--Raisin Bread was opened and not labeled with a date
--5 Hamburger patties with no open date or use by date
The DS indicated the pork chops, raisin bread and hamburger patties needed to be discarded.
The Walk in Refrigerator:
--a bag of liquid scrambled eggs which was open with no date to indicate when they were opened or needed to be discarded.
The DS indicated the eggs needed to be discarded.
Spice Rack:
--Ground Nutmeg with an open date of 12/20
--Ground Ginger with an open date of 10/08/20
--Ground Cinnamon with an open date of 10/20/20
--Taco Seasoning no open date
--Onion Powder no open date
The DM indicated the Ground Nutmeg, Ground Ginger, Ground Cinnamon, taco Seasoning and the Onion Powder needed to be discarded.
The Reach in Freezer:
-- 2 bags of tortellini with no date as to when it was with no date
The Food Pantry:
--A plastic container of sprinkles dated 10/20/20
DS stated I guess they need thrown away, we don't use them.
--A plastic container of thickener the lid was not shut properly.
DS stated stated I guess that needs closed better.
A review of the facility policy titled Date Marking for Food Safety with a copyright date 2021 found the following.
.2. The food shall be clearly marked to indicate the date or day by which the food shall be consumed or discarded.
b) Nourishment Room
A tour of the nourishment room on 03/15/22 at 12:00 PM with DS #1 found the following failed practices in the freezer. A local restaurant milkshake with a room number but no brought in date and 3 bags of frozen corn with a room number and no brought in date.
Upon leaving the nourishment room this surveyor noticed the DS #1 putting the frozen corn and milkshake back in the freezer.
A review of the facility policy titled Use and Storage of Food Brought in by Family or Visitors with a copyright date 2021 found the following.
.2. All food items that prepared by family or visitor brought in must be labeled with a content and dated.
c) Dishwasher temperature monitoring
On 03/14/22 at 1:11 PM the dishwasher temperature log was already completed for the dinner section with the following temperatures:
--wash temperature: 125
--rinse temperature: 130
--Chlorine ppm(parts per million):75
--Sani bkts (sanitation buckets) 70
The DS #1 stated the dishwashing is her only the job, she only does the dishes, she came in at 8:00 this morning, so she probably knew it would be ok and just signed it for the evening. Nobody else does the dishes. The temperatures never change.
On 03/15/22 at 11:45 AM another tour of kitchen with the DS #1 revealed the dishwasher temperature log for 03/15/22 was void of temperature for the breakfast and lunch section.
The DS #1 stated the Temperature for the dishwasher are to be recorded before breakfast, before lunch and before dinner.
A review of the facility policy titled Dishwasher Temperature with a copyright date 2021 found the following.
.6. Water temperatures shall be measured and recorded prior to each meal and/or after the dishwasher has been emptied or refilled for cleaning purposes.
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CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected multiple residents
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Based on observation, staff interview and record review, the facility failed to maintain appropriate infection control standards during medication administration by using a barrier with the inhaler ...
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Based on observation, staff interview and record review, the facility failed to maintain appropriate infection control standards during medication administration by using a barrier with the inhaler for Resident #27, popping a pill into bare hands for Resident #33, not providing hand hygiene to residents prior to a meal and not bagging an inhaler in the drawer of the medication cart for Resident #54. These were random opportunities for discovery and had the potential to affect more than an isolated number of residents. Resident identifiers: #27, #33 and #54. Facility Census: 54.
Findings Included:
a) Resident #27
On 03/16/22 at 8:45 AM, Licensed Practical Nurse (LPN) #71 was observed during medication administration. LPN #71 did not use a barrier between Resident #27's nasal spray and the sink.
On 03/16/22 at 9:05 AM, LPN #71 stated I'm sorry I was nervous.
On 03/16/22 at 10:20 AM, the Director of Nursing (DON) confirmed using a barrier between the medication and the furniture in a resident's room was a professional standard of care for the prevention of infections. The DON confirmed the Medication Administration policy does not address using a barrier when administering metered dose inhalers.
b) Resident #33
On 03/16/22 at 8:50 AM, an observation of LPN #71 found she popped a pill from the medication card into her bare hand before placing it into the medication cup and administering it to Resident #33.
The Medication Administration policy number 13 was reviewed and states remove medication from source, taking care not to touch medication with bare hand. [Typed as written.]
On 03/16/22 at 9:05 AM, LPN #71 stated I'm sorry .I was nervous.
On 03/16/22 at 10:20 AM, the DON confirmed not touching pills during medication preparation was a professional standard of care for the prevention of infections and is addressed in the Medication Administration policy.
c) Noontime Meal
On 03/15/22 at 11:50 AM during observation of the lunch meal in the dining room and on the B Hall, found there was no hand hygiene measures provided for the residents.
An interview on 03/15/22 at 12:15 PM with Nurse Aide (NA) #63, confirmed they do not get hand wipes on the trays and provide nothing for hand hygiene to the residents. During an additional interview with the Administrator at 03/15/22 at 02:23 PM she confirmed they most likely do nothing for hand hygiene.
No further information provided prior to ending the survey on 03/17/22.
d) Resident #35
An observation on 03/15/22 at 2:15 PM Resident # 2 urinary catheter bag was not in a privacy cover and was laying in the floor.
During an interview on 03/15/22 at 2:16 LPN #30 acknowledged the urinary catheter bag was uncovered and was laying in the floor. She picked the bag up and placed in on the side of the bed in the privacy bag.
e) Resident #54
An observation of the medication cart on the A hallway at 9:20 am on 03/16/22 found Resident #54's inhaler and spacer in the bottom drawer of the medication cart with other residents' inhalers the inhaler and space was not in a sealed plastic bag to prevent the spread of infection .
An interview with Licensed Practical Nurse (LPN) #56 on 03/16/22 at 9:17 am confirmed the inhaler and spacer should be sealed in a plastic bag prior to placing it in the drawer of the medication cart.
An interview with the Director of Nursing (DON) at 10:15 am on 03/16/22 confirmed the inhaler and spacer must be stored in a plastic bag in the medication cart.
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CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0801
(Tag F0801)
Could have caused harm · This affected most or all residents
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Based on observation and staff interview the facility failed to employ a clinically qualified nutrition professional on a full time basis to manage the daily function of the kitchen. This had the po...
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Based on observation and staff interview the facility failed to employ a clinically qualified nutrition professional on a full time basis to manage the daily function of the kitchen. This had the potential to affect all the residents that receive nutrition from the kitchen. Facility Census: 54
Findings Included:
During an interview on 03/14/22 on 12:50 PM, the Dietary supervisor (DS) #1, which was hired on 03/15/21, stated he was not a Certified Dietary Manager (CDM). He indicated he took the CDM class in 2015 and was supposed to test the day COVID hit. He further confirmed he has not rescheduled to take the test yet.
During an interview on 03/15/22 at 9:32 AM DS #1 was asked how often the Registered Dietician visits the facility. DS #1 replied the RD #21 visits on Wednesday and Fridays.
During an interview on 03/15/22 at 12:05 PM the Administrator stated the RD works 16-20 hours a week. She is not sure why DS #1 has not taken his test, we will get it scheduled. He has worked in several other facilities before coming to this one.
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CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0882
(Tag F0882)
Could have caused harm · This affected most or all residents
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Based on record review and staff interview, the facility failed to employee an Infection Preventionist (IP)who met all required qualifications. This failed practice has the potential to affect all r...
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Based on record review and staff interview, the facility failed to employee an Infection Preventionist (IP)who met all required qualifications. This failed practice has the potential to affect all residents currently residing in the facility.
Findings Included:
During record review it was determined the IP, RN #6 did not have the required certification on file.
During an interview with RN #6 on 03/16/22 at 02:59 PM she states she has been in the IP position since 02/18/22 but is not yet been certified. She registered on 03/15/22 for the class and will be fulfilling the qualifications soon.
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Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated
K - Pattern
L - Widespread
Actual Harm
G - Isolated
H - Pattern
I - Widespread
Potential for Harm
D - Isolated
E - Pattern
F - Widespread
No Harm (Minor)
A - Isolated
B - Pattern
C - Widespread
Questions to Ask on Your Visit
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • No major safety red flags. No abuse findings, life-threatening violations, or SFF status.
- • No fines on record. Clean compliance history, better than most West Virginia facilities.
Concerns
- • 51 deficiencies on record. Higher than average. Multiple issues found across inspections.
Bottom line: Mixed indicators with Trust Score of 70/100. Visit in person and ask pointed questions.
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About This Facility
What is Meadowbrook Acres's CMS Rating?
CMS assigns MEADOWBROOK ACRES an overall rating of 4 out of 5 stars, which is considered above average nationally. Within West Virginia, this rating places the facility higher than 99% of the state's 100 nursing homes. This rating reflects solid performance across the metrics CMS uses to evaluate nursing home quality.
How is Meadowbrook Acres Staffed?
CMS rates MEADOWBROOK ACRES's staffing level at 4 out of 5 stars, which is above average compared to other nursing homes. Staff turnover is 51%, compared to the West Virginia average of 46%.
What Have Inspectors Found at Meadowbrook Acres?
State health inspectors documented 51 deficiencies at MEADOWBROOK ACRES during 2022 to 2025. These included: 50 with potential for harm and 1 minor or isolated issues. While no single deficiency reached the most serious levels, the total volume warrants attention from prospective families.
Who Owns and Operates Meadowbrook Acres?
MEADOWBROOK ACRES 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 NURSING CARE MANAGEMENT OF AMERICA, a chain that manages multiple nursing homes. With 60 certified beds and approximately 56 residents (about 93% occupancy), it is a smaller facility located in CHARLESTON, West Virginia.
How Does Meadowbrook Acres Compare to Other West Virginia Nursing Homes?
Compared to the 100 nursing homes in West Virginia, MEADOWBROOK ACRES's overall rating (4 stars) is above the state average of 2.7, staff turnover (51%) is near the state average of 46%, and health inspection rating (3 stars) is at the national benchmark.
What Should Families Ask When Visiting Meadowbrook Acres?
Based on this facility's data, families visiting should ask: "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" "Can I speak with family members of current residents about their experience?"
Is Meadowbrook Acres Safe?
Based on CMS inspection data, MEADOWBROOK ACRES has a clean safety record: no substantiated abuse findings (meaning no confirmed cases of resident harm), no Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death), and is not on the Special Focus Facility watch list (a federal program monitoring the lowest-performing 1% of nursing homes). The facility has a 4-star overall rating and ranks #1 of 100 nursing homes in West Virginia. While no facility is perfect, families should still ask about staff-to-resident ratios and recent inspection results during their visit.
Do Nurses at Meadowbrook Acres Stick Around?
MEADOWBROOK ACRES has a staff turnover rate of 51%, which is 5 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 Meadowbrook Acres Ever Fined?
MEADOWBROOK ACRES has no federal fines on record. CMS issues fines when nursing homes fail to meet care standards or don't correct problems found during inspections. The absence of fines suggests the facility has either maintained compliance or corrected any issues before penalties were assessed. This is a positive indicator, though families should still review recent inspection reports for the full picture.
Is Meadowbrook Acres on Any Federal Watch List?
MEADOWBROOK ACRES 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.