RIVER OAKS HEALTHCARE CENTER
For profit - Limited Liability company
120 Beds
COMMUNICARE HEALTH
Data: November 2025
Trust Grade
40/100
#114 of 122 in WV
Photo by Gruen Agency HCR - ManorCare
Photo by Gruen Agency HCR - ManorCare
Photo by Gruen Agency HCR - ManorCare
1 / 5 photos
Last Inspection: December 2024
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
River Oaks Healthcare Center in Clarksburg, West Virginia, has a Trust Grade of D, indicating below-average performance with some concerning issues. It ranks #114 out of 122 facilities in the state, placing it in the bottom half, and #6 out of 6 in Harrison County, meaning only one local option is better. The facility is showing signs of improvement, reducing issues from 30 in 2024 to just 1 in 2025. Staffing is rated below average at 2 out of 5 stars, with a 55% turnover rate, which is concerning as it suggests staff may not be very stable. On the positive side, there have been no fines recorded, indicating compliance with regulations, and while RN coverage is average, there were troubling incidents reported, such as a multi-resident medication error where an RN failed to administer prescribed medications to ten residents over several nights and a concerning lack of pest control, with gnats noted throughout the facility. Overall, while there are some strengths, the issues present a mixed picture for families considering this nursing home.
- Trust Score
- D
- In West Virginia
- #114/122
- Safety Record
- Low Risk
- Inspections
- Getting Better
- Staff Stability ⚠ Watch
- 55% 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 ○ Average
- Each resident gets 30 minutes of Registered Nurse (RN) attention daily — about average for West Virginia. RNs are the most trained staff who monitor for health changes.
- Violations ⚠ Watch
- 76 deficiencies on record. Higher than average. Multiple issues found across inspections.
40/100
Bottom 7%
No red flags
30 → 1 violations
★☆☆☆☆
1.0
Overall Rating
★★☆☆☆
2.0
Staff Levels
★★★★☆
4.0
Care Quality
★☆☆☆☆
1.0
Inspection Score
↔
Stable
2024: 30 issues
2025: 1 issues
The Good
-
4-Star Quality Measures · Strong clinical quality outcomes
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
Facility shows strength in quality measures, fire safety.
The Bad
1-Star Overall Rating
Below West Virginia average (2.7)
Significant quality concerns identified by CMS
Staff Turnover: 55%
Near West Virginia avg (46%)
Higher turnover may affect care consistency
Chain: COMMUNICARE HEALTH
Part of a multi-facility chain
Ask about local staffing decisions and management
The Ugly 76 deficiencies on record
Apr 2025
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident interview, and staff interview, the facility failed to ensure that residents received treatment...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident interview, and staff interview, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice. Soiled briefs were being left in residential rooms following staff providing incontinence care. This was true for two (2) out of (2) residents reviewed. Resident identifiers: #92 and #78. Facility census: 115.
Findings included:
a) Resident #92
Record review completed on Monday, 04/07/25 at 1:30 PM revealed a resident grievance dated 01/16/25. Resident #92 alleged Nurse Aides do not pick up after themselves. Her roommate's soiled briefs are being left on the floor. The facility's Infection Preventionist and Social Service Designee #5 investigated the allegation and reported their findings to the Director of Nursing (DON). Nurse Aide #133 was re-educated, and the incident was logged as a teachable moment.
Further review of Resident #92's electronic medical record revealed:
-A physician determination of capacity, dated 05/20/24, stating resident had capacity to make decisions.
-A quarterly MDS, dated [DATE], revealed the resident had a Brief Interview for Mental Status (BIMS) score of 15, indicating that resident was cognitively intact.
During an interview on 04/09/24 at 12:05 PM, Resident #92 reported that her roommate's soiled briefs are still being left in the room. Resident #92 stated that the issue had improved but there were still a few staff members who were not picking up after themselves and are leaving briefs in the room which leaves an undesirable odor for her to endure.
b) Resident #78
A record review completed on Monday, 04/07/25 at 2:15 PM revealed a resident grievance had been filed on 02/10/25. Resident #78 reported that nursing staff would change a brief and discard it in the room rather than removing it. The DON and Assistant DON investigated this allegation. The facility provided staff education regarding the proper way to complete incontinence care which would include removing soiled briefs from the resident room.
Further review of Resident #78's electronic medical record revealed:
-A physician determination of capacity, dated 01/03/25, stating resident had capacity to make decisions.
-A quarterly MDS, dated [DATE], revealed the resident had a Brief Interview for Mental Status (BIMS) score of 13, indicating that resident was cognitively intact.
During an interview on 04/09/24 at 9:40 AM, Resident #78 reported that her roommate's soiled briefs are still being left in the room. Resident #78 stated that the issue had improved but there were still a few staff members who were not picking up after themselves and are leaving briefs in the room which leaves an undesirable odor for her to endure. In fact, it just happened again the other day, the resident stated. Resident #78 reported she found it necessary to bag the brief herself and place it outside of her room in the hallway for staff to pick up so her room would not smell so bad.
c) Anonymous Staff Interviews
Anonymous staff interviews were conducted on 04/08/25 with the following results:
-Staff Member #55 reported that briefs are still being left in resident trash cans within their rooms.
-Staff Member #121 reported that even though it had been a lot worse many months ago, that briefs were still occasionally being left in resident rooms and not being removed as per facility protocol.
-Staff Member #56 reported that she sometimes finds briefs left in resident rooms throughout the course of her shift.
-Staff Member #13 reported that briefs are still being left in resident rooms despite the re-education that has been given to staff.
Dec 2024
30 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0559
(Tag F0559)
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 honor the residents right to receive written notice, includi...
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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 honor the residents right to receive written notice, including the reason for the change, before the resident's room or roommate in the facility was changed. Resident identifier: #90 and #39. Facility census: 107.
Findings included:
a) Resident #39
A review of Resident #39's medical record found he was transferred from room [ROOM NUMBER] to room [ROOM NUMBER] on 11/16/24. No written notice was given prior to the room move.
b) Resident #90
A review of Resident #90's medical record found he was transferred from room [ROOM NUMBER] to room [ROOM NUMBER] on 11/29/24. No written notice was given prior to the room move.
During an interview on 12/5/24 at 11:20 AM the Social Worker confirmed no written notice was given to Resident #39 or #90 prior to them being transferred to different rooms.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0561
(Tag F0561)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and resident and staff interviews, the facility failed to ensure Resident #32 received showers in accorda...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and resident and staff interviews, the facility failed to ensure Resident #32 received showers in accordance with her preferences. This was true for one (1) of six (6) residents reviewed for Activities of Daily Living (ADLs) during the survey process. Resident identifier: 32. Facility census: 107.
Findings include:
a) Resident #32
At approximately 3:30 PM on 12/02/2024, an interview was conducted with Resident #32. During the interview, the resident stated Sometimes you have to [NAME] them before they will give you a shower, and even then, I don't get showers when I want them so, sometimes, I just tell them I don't want them.
At approximately 10:00 AM on 12/04/2024, a review of Resident #32's record revealed she had refused showers on 11/20/2024 at 6:59 AM, 11/27/24 at 6:59 AM, 11/28/2024 at 10:16 PM, and 12/06/2024 at 6:59 AM, according to the bathing task sheet for the past thirty (30) days. A review of the progress notes for these days do not indicate a reason for refusals.
At approximately 3:55 PM on 12/09/2024, an interview was conducted with Resident #32 regarding her refusals. Resident #32 has a Brief Interview for Mental Status (BIMS) score of fifteen (15), which indicated she was cognitively intact, and has been deemed capacitated by a physician.
During the interview, the resident recalled refusing showers on 11/20/2024, 11/27/2024, and 12/06/2024, stating It 's too cold of the mornings and if I take a shower then, when I leave for dialysis my hair will be wet, and I'll have to go out in the cold with wet hair, I don't want that. Resident #32 then recalled refusing her shower on 11/28/2024 stating, It was too late to take one then. Who wants to take a shower late at night? I have told them before, I want to take showers in the afternoons and I want to take an extra shower on Sundays so I will be clean when I leave for dialysis on Mondays. So, I should be getting showers on Sunday, Tuesday, and Thursday. Resident #32 was asked if she had voiced her preferences for showers to staff and she stated I have, I have told my nurses and aides but nothing has ever changed. Resident #32 is currently scheduled for showers on Tuesdays and Thursdays for the facility's night shift, which runs from 7:00 PM through 7:00 AM.
At approximately 10:00 AM on 12/10/2024, an interview was conducted with Nurse Aide (NA) #73 at the nurses station. During the interview, all present staff were asked if Resident #32 had ever expressed interest in switching her shower times from night shift to day shift. NA #73 spoke up and stated Yes, she has told me and I have heard her tell other staff members as well.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Transfer Notice
(Tag F0623)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to provide evidence a resident/resident's representative...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to provide evidence a resident/resident's representative was provided with a written Notice of Transfer for an acute hospital transfer. This was true for two (2) out of three (3) residents reviewed for hospitalizations during the long-term care survey process. Resident identifiers: #71 and #89. Facility census: 107.
Findings included:
a) Resident #71
A record review, completed on 12/04/24 at 2:00 PM revealed Resident #71 was hospitalized on [DATE]. The electronic medical record did not have evidence that a Notice of Transfer / Discharge had been issued informing the resident of her right to appeal the decision if she so desired.
During an interview on 12/04/24 at 9:55 AM, the Assistant Director of Nursing (ADON) reported the facility could not produce evidence that a Notice of Transfer / Discharge had been given.
b) Resident #89
A record review, completed on 12/04/24 at 2:20 PM revealed Resident #89 was hospitalized on [DATE]. The electronic medical record did not have evidence that a Notice of Transfer / Discharge had been issued informing the resident of her right to appeal the decision if she so desired.
During an interview on 12/04/24 at 9:58 AM, the ADON reported the facility could not produce evidence that a Notice of Transfer / Discharge had been given.
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 medical record review and staff interview, the facility failed to provide evidence a resident/resident's representative...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to provide evidence a resident/resident's representative was provided with a written Bed Hold Notice for an acute hospital transfer. This was true for two (1) out of three (3) residents reviewed for hospitalizations during the long-term care survey process. Resident identifier: #71. Facility census: 107.
Findings included:
a) Resident #71
A record review, completed on 12/04/24 at 2:00 PM revealed Resident #71 was hospitalized on [DATE]. The electronic medical record did not have evidence that a Bed Hold Notice had been issued.
During an interview on 12/04/24 at 9:55 AM, the Assistant Director of Nursing (ADON) reported the facility could not produce evidence that a Bed Hold Notice had been given.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0645
(Tag F0645)
Could have caused harm · This affected 1 resident
Based on record review and staff interview, the facility failed to ensure the resident's Pre-admission Screening (PAS) reflected pre-admission diagnoses. This was true for one (1) out of two (2) resid...
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Based on record review and staff interview, the facility failed to ensure the resident's Pre-admission Screening (PAS) reflected pre-admission diagnoses. This was true for one (1) out of two (2) residents reviewed for the category of PASARR (Pre-admission Screening and Record Review, during the Long-Term Care Survey Process. Resident identifier #52. Facility census: 107.
Findings included:
a) Resident #52
A medical record review, completed on 12/04/24 at 8:48 AM, revealed Resident #52 had the following diagnoses:
-A Major Depression Disorder diagnosis
-An Epilepsy diagnosis
A PAS, completed on 05/20/21, marked NONE under Section III Question 30 entitled, Current Diagnosis (Check all that apply). Addionally, Section V Question 40 entitled, Major Mental Illness (MI) or Suspected MI only listed major depression.
During an interview on 12/04/24 at 9:15 AM, the Director of Social Services reported that resident's Epilepsy diagnosis had not been captured on the PAS.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
c) Resident #68
On 12/02/24, at approximately 9:29 AM, during an interview with Resident #68, she responded to questions about her vision by stating that she was unable to see anyone clearly and could...
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c) Resident #68
On 12/02/24, at approximately 9:29 AM, during an interview with Resident #68, she responded to questions about her vision by stating that she was unable to see anyone clearly and could only see shadows. Although the resident was able to locate her call light, which she had placed under her pillow, she was unaware of the location of items on her bedside table. Furthermore, she mentioned that she enjoys listening to music but does not participate in activities due to her vision problems.
During an interview with Social Worker #30 on 12/04/24, at approximately 10:18 AM, the social worker stated that Resident #68 has a care plan in place for her impaired vision. The social worker also mentioned that the resident is encouraged to participate in various activities, including music programs, entertainment, bands, church services, snacks, socializing, listening to television, playing word games, and having stories read to her due to her blindness.
A review of Resident #68's care plan revealed the following:
**FOCUS**
The resident has impaired visual function due to being legally blind.
**Date Initiated:** 01/24/2023
**Last Revision:** 01/12/2024
**INTERVENTIONS/TASKS**
1. Arrange a consultation with an eye care practitioner as needed.
**Date Initiated:** 01/24/2023
2. Organize the resident's room and personal items to promote independence and safety.
**Date Initiated:** 01/24/2023
3. Observe, document, and report any acute eye problems to the medical provider.
**Date Initiated:** 01/24/2023
4. During room visits and one-on-one sensory interactions, check the floor in the resident's room for any obstacles that could contribute to falls due to her visual impairment.
**Date Initiated:** 09/20/2024
**Last Revision:** 10/23/2024
A detailed review of Resident #68's care plan revealed that it did not include specific interventions. For example, it lacked guidance on how to arrange and place food on meal trays, as well as how to organize belongings and frequently used items for easy access.
Additionally, from 12/02/24, to 12/05/24, Resident #68 was observed in bed, listening to the television. During this time, the resident did not participate in any activities and was not engaged by staff, who did not read to her or involve her in any word games.
Based on record review and staff interview, the facility failed to follow the care plan of Resident #66 by failing to monitor for behaviors, and to include Resident #33 's history of physical aggression with other residents into her care plan. This was true for three (3) of 54 care plans reviewed during the survey process. Resident identifiers: #66, #33, and #68. Facility cesus: 107.
Findings include:
A) Resident #66
At approximately 11:00 AM on 12/04/2024, a review of Resident #66's care plan was conducted. Resident #66 had orders for behavior monitoring. Behaviors included being tearful, refusal of care, self isolation, aggressiveness, calling out. This was also included on the resident's care plan.
According to the Medication Administration Record (MAR), where the facility monitors for behaviors, behaviors were not monitored on 10/18/2024, 11/05/2024, and 11/16/2024.
At approximately 2:30 PM on 12/10/2024, an interview was conducted with the Director of Nursing (DON). During the interview, the DON confirmed behaviors were not monitored on those dates.
b) Resident #33
A record review completed on 12/10/24 at 9:44 AM, revealed the following details regarding a resident-to-resident altercation:
-The resident-to-resident incident occurred on 11/07/24 at 7:00 AM.
-The incident occurred in the resident's room.
-Description of incident: Resident #33 was seen grabbing a foot rest from a wheelchair and hitting her roommate (Resident #16) in the left arm. Resident #16 had a bruise to the left wrist and outer left forearm.
-Review of Resident #33's care plan did not reflect a history of resident-to-resident physically aggressive behaviors.
During an interview on 12/10/24 at 10:40 AM, the Director of Nursing confirmed that Resident #33's care plan had not been updated to include a history of physically aggressive behaviors toward other residents.
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 resident and staff interviews and record review the facility failed to provide the necessary services for residents who are unable to carry out activities of daily living (showers) to maintai...
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Based on resident and staff interviews and record review the facility failed to provide the necessary services for residents who are unable to carry out activities of daily living (showers) to maintain good grooming, and personal hygiene. This was true for two (2) of four (4) records reviewed for showers. Resident Identifiers: #58 and #92. Facility Census: 107.
Findings Include:
a) Resident #58
On 12/03/24 at 10:01 AM Resident #58 states he prefers a shower over a bed bath but does not get his showers as ordered. According to the shower schedule provided by the facility Resident #58 should receive his showers on day shift every Monday and Friday.
On 12/05/24 at 1:10 PM record review of showers given for the last thirty (30) days shows Resident #58 had eight (8) opportunities for a shower. He received five (5) of the eight (8) showers. There were no refusals documented. The care plan was reviewed and Resident #58 is not care planned for a history of refusing showers.
According to the schedule he was scheduled a shower on the following dates:
11/11/24
11/15/24
11/18/24
11/22/24
11/25/24
11/29/24
12/02/24
12/06/24
He received a shower on the following dates:
11/15/24
11/18/24
11/22/24
12/02/24
12/06/24
This documentation shows that Resident #58 went nine (9) days without a shower from 11/22/24 until 12/02/24 with no refusals.
On 12/05/24 at 2:20 PM the above information was confirmed with the Director of Nursing.
b) Resident #92
On 12/03/24 at 9:57 AM Resident #92 states he prefers a shower over a bed bath but does not get his showers as ordered. According to the shower schedule provided by the facility Resident #92 should receive his showers on evening shift every Tuesday and Friday.
On 12/05/24 at 1:10 PM record review of showers given for the last thirty (30) days shows Resident #92 had eight (8) opportunities for a shower. He received two (2) of the eight (8) showers. There is documentation that Resident #92 refused his shower two (2) times on 11/20/24 and 11/23/24.
According to the schedule he was scheduled a shower on the following dates:
11/12/24
11/15/24
11/19/24
11/22/24
11/26/24
11/29/24
12/03/24
12/06/24
He received or refused a shower on the following dates:
11/16/24 received
11/20/24 refused
11/23/24 refused
12/04/24 received
This documentation shows that Resident #92 went seventeen (17) days without a shower from 11/16/24 until 12/04/24.
On 12/05/24 at 2:20 PM the above information was reviewed with the Director of Nursing.
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
Pressure Ulcer Prevention
(Tag F0686)
Could have caused harm · This affected 1 resident
Based on observation, record review and staff interview the facility failed to turn and reposition an immobile resident according to standard practice of nursing care to prevent new or worsening press...
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Based on observation, record review and staff interview the facility failed to turn and reposition an immobile resident according to standard practice of nursing care to prevent new or worsening pressure ulcers. Resident Identifier: #72 Facility Census: #107
Findings Include:
a) Resident #72
On 12/05/24 at 2:18 PM observation and record review identified Resident #72 has a stage III pressure ulcer to her left back. Record review and Licensed Practical Nurse #26 confirmed the wound was first identified 08/29/24.
Current orders for wound care to her back are:
1) WOUND CARE: Monitor Stage 3 pressure injury to thoracic spine. Notify medical provider if presence of complications (e.g. increased redness, swelling, drainage, abnormal odor, new or worsening pain/discomfort.
WOUND CARE: Cleanse Stage 3 pressure injury to left back with wound cleanser, apply hydrogel with silver to wound bed, cover with bordered gauze.
On 12/05/24 at 3:10 PM record review of Resident #72's care plan and current orders show there are no interventions or tasks for turning and repositioning the resident to prevent worsening of the stage III pressure ulcer to her back.
On 12/05/24 at 3:20 PM during an interview with Certified Nurse Aide (CNA) #10 and CNA #61 they stated they do not routinely have a place to chart for turning but they do turn some residents. CNA #10 identified Resident #72 as a resident that she turns from side to side. Further record review shows a charting task for rolling left and right for this resident.
Record review of task documentation shows Resident #72 is totally dependent with one to two or more helpers for turning. Resident #72 is non-verbal and immobile. She has contractures and can not roll herself from side to side.
According to the Director of Nursing in an interview on 12/09/24 at 3:36 PM it is standard practice of nursing care to prevent a new or worsening pressure ulcer that an immobile resident should be turned from side to side or to the back every two (2) hours.
Documentation review for thrifty (30) days from 11/10/24 through 12/08/24 shows the following number of times Resident #72 was turned and repositioned in a 24 hour period.
11/10/24 two times
11/11/24 two times
11/12/24 once
11/13/24 two times
11/14/24 three times
11/15/24 once
11/16/24 two times
11/17/24 two times
11/18/24 three times
11/19/24 two times
11/20/24 two times
11/21/24 no documentation of turning/repositioning
11/22/24 two times
11/23/24 two times
11/24/24 no documentation of turning/repositioning
11/25/24 once
11/26/24 three times
11/27/24 once
11/28/24 three times
11/29/24 once
11/30/24 two times
12/01/24 three times
12/02/24 two times
12/03/24 once
12/04/24 two times
12/05/24 two times
12/06/24 once
12/07/24 once
12/08/24 two times
If a resident was turned every two (2) hours there are twelve (12) opportunities a day to turn and reposition the resident. In a thrifty (30) day time period there would be 360 opportunities to turn and reposition a resident.
Documentation shows Resident #72 was turned and repositioned fifty one (51) times during this thirty (30) day record review.
On 12/09/24 at 3:46 PM the DON confirmed Resident #72 had not been turned and repositioned according to standard practice of nursing care to prevent a new or worsening pressure ulcer.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0692
(Tag F0692)
Could have caused harm · This affected 1 resident
Based on record review and staff interview the facility failed to maintain adequate nutritional status, to the extent possible, to ensure the resident is able to maintain the highest practicable level...
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Based on record review and staff interview the facility failed to maintain adequate nutritional status, to the extent possible, to ensure the resident is able to maintain the highest practicable level of well-being. This was true for one (1) of three (3) records reviewed for weight loss. Resident identifier: #59 Facility Census: #107.
Findings Include:
a) Resident #59
On 12/03/24 at 9:15 AM record review of weights for Resident #59 found there had been a significant weight loss of 10.3% in one month.
Documentation showed Resident #59 weighed 208 pounds on 10/11/24 and dropped to 186.6 pounds on 11/11/24. This reflects a weight loss of 10.3% of her weight in 30 days.
A significant weight loss is defined as:
5% change in weight in 1 month (30 days)
7.5% change in weight in 3 months (90 days)
10% change in weight in 6 months (180 days)
Resident #59 has the following active orders:
Regular diet Regular texture, Regular consistency, Diabetic Condiments No Salt Packet
and Weight times 4 weeks upon admission on e time a day every Sun for Baseline Weight for 4 Weeks AND every day shift every 30 day(s) for Weight.
There were no supplements, snacks or additional protein sources ordered.
A record review of meal intake percentages show Resident #59 usually ate between 51-100% of her meals.
Record review of dietary assessments and notes show the last dietary nutritional assessment was dated 10/21/24 and dietary progress notes for 10/31/24 and 11/07/24. There have been no dietary nutritional assessments or dietary progress notes since the last entered weight on 11/11/24 which reflected the 10.3% weight loss.
The facility Dietitian was not available for an interview. The Director of Nursing confirmed the above weight loss and had no input as to why there has not been a dietary assessment due to the weight loss.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0710
(Tag F0710)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility failed to ensure that the physician or delegate responded to a new onset of symptoms, in a resident's condition, in...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility failed to ensure that the physician or delegate responded to a new onset of symptoms, in a resident's condition, in a timely manner. This failed practice had the potential to cause more than minimal harm. Resident Identifier: #103. Facility Census:107.
Findings included:
a) Resident #103
During a closed record review on 12/03/24 at approximately 2:15 PM, a nursing note entered by Licensed Practical Nurse (LPN) #117 on 11/06/24 at 4:29 AM revealed the following:
Nursing Assistant (NA) informed this nurse that there was blood in residents catheter bag. This nurse assessed residents' catheter and found no abnormalities. Resident has no c/o pain or discomfort with catheter. Secure messaged Nurse Practitioner (NP) #120, and Medical Director (MD) #121. And attempted to reach Medical Power of Attorney (MPOA). No concerns at this time, will continue to monitor this shift.
Further record review on 12/03/24 at 2:25 PM revealed that neither MD #121, nor NP #120, had responded to the LPN's message.
During an interview with the Director of Nursing (DON) on 12/04/24 at approximately 08:29 AM, the DON stated that while NP #120 had not responded to LPN #117's message, NP #120 had visited the resident on 11/08/24 at 7:23 PM, as evidenced by the following note:
Date of Service: 11/08/2024
Visit Type: Acute
[Resident #103] is a [AGE] year old male resident who is seen today for acute hypoxia. His wife is a resident in his room. She came to hallway to alert that something is wrong with [Resident]. Upon entering his room he hypoxic with Cheyne-Stokes respiration. He has cyanosis of the lips and tongue. His respirations continue to become more shallow, respiration ceased within 10 minutes of entering his room.
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 a physician responded to recommendations made by a licensed pharmacist for Resident #66, and to ensure the physician provided ...
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Based on record review and staff interview, the facility failed to ensure a physician responded to recommendations made by a licensed pharmacist for Resident #66, and to ensure the physician provided a rationale for the use of a medication Resident #38 had a documented allergy to. This was true for two (2) of six (6) residents reviewed for unnecessary medications during the survey process. Resident identifiers: #66, #38. Facility census: 107.
Findings include:
a) Resident #66
At approximately 12:30 PM on 12/04/2024, a review of the physician ' s responses to pharmacy recommendations was conducted with the Assistant Director of Nursing (ADON). During the review, the following recommendations were noted:
05/28/2024- Reassess the PRN order for Lorazepam
05/28/2024- Possible duplicate orders for Tramadol 50 mg and Ativan 0.5 mg
06/06/2024- Reassess the PRN order for Lorazepam
There are no options marked for agree, disagree, or other. There was no rationale provided for any decision made. There was no physician's signature or date to indicate the physician ever acknowledged the recommendation.
This was acknowledged by the ADON at approximately 12:30 PM on 12/04/24.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0806
(Tag F0806)
Could have caused harm · This affected 1 resident
Based on observation and staff interview, the facility failed to offer the opportunity to receive a substitute when residents refused food items during the morning meal. This was a random opportunity ...
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Based on observation and staff interview, the facility failed to offer the opportunity to receive a substitute when residents refused food items during the morning meal. This was a random opportunity for discovery. Resident identifiers: #7 and #61. Facility census: 107
Findings included:
a) During observation of the 400 Hall breakfast meal delivery on, 12/04/24 at 7:20 AM, Resident #7 and Resident #61 refused their breakfast trays by stating, No thanks. CNA #71 removed the meals from their room but did not offer an alternative. When questioned as to how CNAs are trained to serve meals, CNA #71 reported, I didn't offer an alternative because we know she (Resident #7) only likes sweets for breakfast. If it had been something like a cinnamon roll, she would have said yes.
During an interview with the Director of Nursing on 12/04/24 at 8:12 AM, she stated that all aides are trained to offer residents the opportunity to receive a substitute if they are unhappy with the meal served.
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 maintain an accurate medical record for three (3) out of four (4) records reviewed for accurate POST forms. Resident identifiers: #16...
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Based on record review and staff interview, the facility failed to maintain an accurate medical record for three (3) out of four (4) records reviewed for accurate POST forms. Resident identifiers: #16, #29, and #33. Facility census: 107
Findings included:
a) Resident #16
An electronic medical review, completed on 12/03/24 at 11:17 AM, found a scanned Physician Orders for Treatment (POST) form in Resident #16's electronic chart that left Section F completely blank. Section F should have the Physician's signature, phone number and license number.
On 12/03/24 at 2:40 PM, a review of the Residents' POST Binder which is kept at the nurses' station, found the original POST form did not have the physician's signature, phone number, and license number.
During 12/03/24 at 3:30 PM, the Director of Social Services confirmed without the physician's signature, phone number and license number, the form could not be considered a valid POST.
b) Resident #29
An electronic medical review, completed on 12/03/24 at 2:32 PM, found a scanned POST form in Resident #29's electronic chart that did not have the physician's phone number.
On 12/03/24 at 2:46 PM, a review of the Residents' POST Binder which is kept at the nurses' station, found the original POST form did not have the physician's phone number listed.
During an interview on 12/03/24 at 3:30 PM, the Director of Social Services confirmed the form was incomplete and did not identify a way to reach the physician should their be a discrepancy that needed to be resolved in a timely manner.
c) Resident #33
An electronic medical review, completed on 12/03/24 at 11:36 AM, found a scanned POST form in Resident #33's electronic chart that accepted verbal consent from the resident's legal decision maker.
On 12/03/24 at 2:50 PM, a review of the Residents' POST Binder which is kept at the nurses' station, found the original POST form reflected verbal consent was accepted on 04/17/23, but an original signature had never been obtained. An additional record review revealed the legal representative had participated in care conference meetings on 07/16/24 and 10/16/24 where the POST form had been reviewed.
During an interview on 12/03/24 at 3:30 PM, the Director of Social Services confirmed the facility had failed to follow-up on obtaining an original signature from the legal decision-maker.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Resident Rights
(Tag F0550)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** d) Resident #68
During an interview on 12/03/24, at approximately 9:35 AM, Resident #68 reported experiencing an upset stomach a...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** d) Resident #68
During an interview on 12/03/24, at approximately 9:35 AM, Resident #68 reported experiencing an upset stomach and diarrhea. At around 9:38 AM, she used her call light to request assistance. Nursing Assistant (NA) #41 responded at approximately 9:57 AM. When interviewed, NA #41 explained that there were 32 rooms in the hallway and that all the NAs were occupied providing care.
In a further interview with Licensed Practical Nurse (LPN) #14 on 12/03/24, at approximately 11:30 AM, LPN #14 stated that the NA coverage was adequate, as four (4) NAs were assigned to the hallway.
Additionally, during interviews with Resident #47 and Resident #13, both indicated that the response time for assistance could be as long as 30 minutes. Resident #47 mentioned that he was fortunate to have a catheter; otherwise, he would not have been able to avoid soiling his bed.
b) Overflow Dining Room Lunch Service
At approximately 12:00 PM on 12/02/2024, during meal service observation in the lounge (which is used as the overflow dining room), all residents eating lunch in the overflow dining room had their plates and drinks placed on serving trays, and were eating their meals off of the serving trays, as the staff did not remove the items after serving the residents.
At approximately 12:05 PM on 12/02/2024, an interview was conducted with Nurse Aide (NA) #73. NA #73 was asked if the residents regularly ate off of the serving trays in the overflow dining room, to which she replied Yes, it 's like this every day.
c) Observations on 12/03/24 at 11:48 AM revealed the following residents were sitting at the large table: Resident #16, #101, #50, #74, #30, #40, #23, #76, #42, and #27.
Resident #16 was eating her lunch meal. No other residents at the table had their food yet. Beginning at 12:10 PM, the lunch meal was delivered to Resident # 's 101, #50, #74, #30, #40, #23 and #76.
Resident #42 was crying and asking for food. She was crying and saying, I want some food, please give me some food She did not receive her meal until 12:30 PM.
Resident #27 was sitting at the end of the table with her arms crossed and head down. At 12:20 PM, she asked why she did not receive her food. Her meal tray was served at 12:30 PM.
These issues were discussed with the Administrator on 12/03/24 at 2:10 PM.
Based on observation, resident interview, and staff interview, the facility failed to protect and promote a dignified dining experience and failed to answer a resident's call light on a timely basis. These were random opportunities for discovery. Resident identifiers: #24, #71, #37, #45, #68, #27, #42, and #51. Facility census: 107.
Findings included:
a) During an interview on 12/03/24 at 10:30 AM, Residents #24 and Resident #31 reported that they had gone to the dining room for their Thanksgiving meal. They reported that one of the more confused residents from the 400 hall, Resident #45, had a soiled brief in her lap as she wheeled into the dining room. Resident #45 reportedly lifted the soiled brief, spread it on the table in front of her, and started playing in the feces as though she was finger painting. Both residents reported two activity aides were in the room but failed to do anything to intervene. They reported that Resident #71 went to the [NAME] hallway to ask staff to address it, and was told, Hey, that's not our problem. When asked what they thought that meant, both residents reported that Resident #45 was a resident on the [NAME] Fort 400 Hallway and the [NAME] hallway staff expected the other unit to handle the problem. After that, Resident #31 wheeled herself down the [NAME] Fort 400 hallway and was successful in finding CNA #83 who agreed to help and accompanied the resident to the dining room to take care of Resident #45. Both residents reported that they recalled Resident #37 was also in the dining room.
During an interview on 12/04/24 at 11:30 AM, Resident #71 reported she recalled being in the dining room when the above-mentioned incident happened during the Thanksgiving meal. She reported she went to the [NAME] hallway to ask for staff assistance and was told, Hey, that's not our problem. She wheeled herself back into the dining room and reported she had not been successful in getting a staff member to help. That was when Resident #31 left to go get help from the 400 hallway. Resident #71 reported that there were two (2) activity staff in the room but that they did not intervene in any way.
During a telephone interview on 12/04/24 at 12:42 PM, CNA #83 confirmed that Resident #31 had come and asked for her assistance in the dining room during the Thanksgiving meal. CNA #83 reported as she entered the dining room, Resident #45 had the dirty brief on the table and was playing in the feces. CNA #83 reported two activity staff members (#49 and #92) were present and sitting at the first table when she entered the room. Additionally, CNA #83 reported that CNA #10 assisted in helping clean Resident #45 up in the bathroom once they were back on the 400 hall. It was at this time that they identified Resident #45 had a brief on and that they could not be sure WHOSE dirty brief Resident #45 had been playing in while in the dining room.
During an interview on 12/09/24 at 3:18 PM, Resident #37 confirmed her presence in the dining room during the Thanksgiving meal when the incident occurred. A subsequent record review found that Resident #31, Resident #24, Resident #71 and Resident #37 were all cognitively intact and would be able to accurately recall the events in the dining room and the fact that it did not provide a dignified dining experience to anyone that was present. The record review also determined that Resident #45 had severely impaired cognitive function. Using a reasonable person concept, one could determine that the facility failed to protect Resident #45's dignity when staff did not immediately intervene when she began playing in the dirty brief in a public setting.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0565
(Tag F0565)
Could have caused harm · This affected multiple residents
]Based on record review, resident interviews, and staff interviews, the facility failed to ensure resident council grievances, issues, and concerns were acted upon promptly and provide a rational resp...
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]Based on record review, resident interviews, and staff interviews, the facility failed to ensure resident council grievances, issues, and concerns were acted upon promptly and provide a rational response. This had the potential to affect more than an isolated number of residents. Facility census: 107.
Findings included:
a) On 12/03/24 Resident Council minutes were received upon entry. It was noted that concerns and issues were brought up at the meetings but these previous grievances, concerns, and issues were not listed in the minutes.
Review of the Resident Council minutes revealed the following: All Grievances, concerns, and issues are documented and given to the appropriate manager to complete and then they are given to the Administrator to file.
During the resident council meeting with the resident council president and 3 others on 12/04/2024 at 10 AM, the council president stated the activities coordinator writes down the issues and concerns, but nothing is ever done and they do not get any feedback in future meetings.
During an interview with the activities coordinator on 12/03/2024 at approximately 11:45 AM, She stated she lists the concerns and issues from the meeting and passes them on to the Nursing Home Administrator. They are not typed into the meeting minutes.
During an interview with the Nursing Home Administrator on 12/03/2024 at approximately 2:30pm, the surveyor requested copies of the documented grievances, concerns and issues.
On 12/04/2024, at 9:45 AM, during an interview with the NH Administrator he said the statement on the minutes was a general statement and that the grievances were given to the appropriate department managers. He did not have them but said he would look for them.
On 12/5/2024 at approximately 1:30 PM during a follow up interview with the administrator, he stated that he could not locate the concerns, issues, and grievances from past or present resident council meetings.
During a resident council meeting, on 12/03/24 at 10:00 AM, Residents #31, #37, #70, and #80 confirmed that during every resident council meeting over the last several months the request has been made to have the Soup of the Day placed back on the menu. They reported never hearing back about their request.
During an interview on 12/04/24 at 10:09 AM, Resident #71 also reported that she has requested to have the Soup of the Day placed back on the menu but never heard back about her request.
A subsequent review of the facility's grievance log did not reveal Resident #24, Resident #31, Resident #37, Resident #70, Resident #80, and Resident #71's concerns had been recorded on facility grievance forms. Each resident's medical chart reflected that the resident was cognitively intact and would be able to accurately remember such details clearly.
During an interview on 12/04/24 at 11:44, the Administrator reported that he was not aware of the residents' request to have the Soup of the Day put back on the menu. The Administrator reported it had never come up during the time he was part of the resident council meeting, noting that he only attends a small portion of the meeting. The Administrator also confirmed there was no written grievance regarding the requests.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0583
(Tag F0583)
Could have caused harm · This affected multiple residents
Based on observation and staff interview, the facility failed to secure and keep confidential residents' medical information. The facility failed to safeguard private information that was placed in a ...
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Based on observation and staff interview, the facility failed to secure and keep confidential residents' medical information. The facility failed to safeguard private information that was placed in a clear acrylic wall file holder located outside of the medical records office. This was a random opportunity for discovery. Resident identifiers: #305, #155, #357, #30, #308, #28, and #100. Facility census: 107
Findings included:
a) An observation on 12/02/24 at 11:40 AM revealed diagnosis sheets and mini nutritional assessments placed in an acrylic wall file holder outside the Medical Records office.
There were diagnosis sheets for Resident #305, Resident #155, Resident #357, Resident #30, Resident #308, and Resident #28.
Additionally, there were mini nutritional assessments for Resident #28 and Resident #100. All the forms had been printed by Minimum Data Set (MDS) RN #55.
During an interview on 12/02/24 at 11:50 AM, the Medical Records Coordinator #17 confirmed the diagnosis sheets and mini nutritional assessments were accessible to any passerby and had confidential information on them.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected multiple residents
Based on observation and staff interview, the facility failed to provide a safe, clean, comfortable, and homelike environment. The facility failed to keep the dining room temperature at a comfortable ...
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Based on observation and staff interview, the facility failed to provide a safe, clean, comfortable, and homelike environment. The facility failed to keep the dining room temperature at a comfortable temperature level. This was a random opportunity for discovery and had the potential to affect more than an isolated number of residents Residenti Identifiers: #45, #95, #37, and #8. Facility census: 107.
Findings included:
a) An Observation, on 12/03/24 at 11:30, identified the following:
-Resident #45 shivered and stated she was cold. The Activities Director left the dining room to obtain a sweater for the resident.
-Resident #95 stated, Wow, I'm cold.
-Resident #37 was wearing a sweatshirt and a wrap around her shoulders. The resident also had a folded blanket on the back of her wheelchair. She smiled and stated, I came prepared.
-Resident #8 had a blanket wrapped around her.
Surveyor requested that a maintenance staff member come to the dining room to test the temperature to see if it met the minimum of 71 degrees Fahrenheit. The Maintenance Director took the temperature in the dining room on 12/03/24 at 11:37 AM. The ambient temperature was found to be 65.5 degrees Fahrenheit. He then checked to see if the air conditioner was on. The Maintenance Director said, Sometimes staff turn it on because they are running hot.
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
b) Resident #32
At approximately 3:30 PM on 12/02/2024, an interview was conducted with Resident #32. During the interview, Resident #32 stated she has shirts and other clothing items missing. The res...
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b) Resident #32
At approximately 3:30 PM on 12/02/2024, an interview was conducted with Resident #32. During the interview, Resident #32 stated she has shirts and other clothing items missing. The resident stated she told housekeeping and laundry staff she had missing items but they were never found, nor were her concerns followed up on by the facility.
A review of the facility's grievance and concern log was conducted and no grievances were noted regarding missing items for Resident #32.
At approximately 11:55 AM on 12/04/2024, an interview was conducted with Housekeeper #106. Housekeeper #106 confirmed Resident #32 had brought concerns about missing items to her attention on multiple occasions. Housekeeper #106 confirmed she never filled out grievance forms, nor did she forward the concerns on to anyone else at the facility.
Based on resident interview, record review, and staff interview, the facility failed to make prompt efforts to resolve verbal grievances. The facility failed to act on verbal grievances related to bringing back the Soup of the Day to the menu and failed to act on a verbal grievance regarding burnt food, gnats, and food not being removed from the resident's room for three (3) days. Additionally, the facility failed to act on a verbal grievance regarding a resident's missing personal property. Resident identifiers: #24, #71, #31, #37, #70, #80, #29, and #32. Facility census: 107.
Findings included:
a) Soup of the Day
During an interview on 12/02/24 at 11:34 AM, Resident #24 stated that residents, including herself, requested that the Soup of the Day be put back on the menu at every resident council meeting but the residents never heard back about their request. She stated the only soup that was available to residents was tomato soup and many people were sick of having it.
During a resident council meeting, on 12/03/24 at 10:00 AM, Residents #31, #37, #70, and #80 confirmed that during every resident council meeting over the last several months the request has been made to have the Soup of the Day placed back on the menu. They reported never hearing back about their request.
During an interview on 12/04/24 at 10:09 AM, Resident #71 also reported that she has requested to have the Soup of the Day placed back on the menu but never heard back about her request.
A subsequent review of the facility's grievance log did not reveal Resident #24, Resident #31, Resident #37, Resident #70, Resident #80, and Resident #71's concerns had been recorded on facility grievance forms. Each resident's medical chart reflected that the resident was cognitively intact and would be able to accurately remember such details clearly.
During an interview on 12/04/24 at 11:44, the Administrator reported that he was not aware of the residents' request to have the Soup of the Day put back on the menu. The Administrator reported it had never come up during the time he was part of the resident council meeting, noting that he only attends a small portion of the meeting. The Administrator also confirmed there was no written grievance regarding the requests.
b) Resident #29
During an interview on 12/04/24 at 11:05 AM, Resident #29 reported she had resorted to killing the gnats in her room (on the 400 hall) with a fly swatter. Resident #29 also stated she had met with the Administrator to discuss the gnats as well as her dissatisfaction with burnt food on her dinner tray, the fact that the garbage in her room had not been taken out for three (3) days, and that she had resorted to bagging it up herself and placing it in the hallway. The resident stated she never received verbal or written follow-up from the Administrator regarding her concerns. A subsequent review of the facility's grievance log did not reveal Resident #29's concerns had been recorded on a facility grievance form. Resident #29's medical record reflected that she was cognitively intact and would be able to remember such details clearly.
During an interview on 12/04/24 at 11:09 AM, the Administrator stated that he and Resident #29 talk pretty routinely and that the housekeeping concern does register with me. The Administrator could produce no grievance form noting the resident's concerns and could produce no evidence the issues had been addressed.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0657
(Tag F0657)
Could have caused harm · This affected multiple residents
Based on medical record review and staff interview, the facility failed to revise the comprehensive care plan in the area of showers, wound care and turning and repositioning. Resident identifiers: #2...
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Based on medical record review and staff interview, the facility failed to revise the comprehensive care plan in the area of showers, wound care and turning and repositioning. Resident identifiers: #20, #22, #58, #72 and #92. Facility census: 107.
Findings include:
a) Resident #20
On 12/03/24 at 11:11 AM Resident #20 states he prefers a shower over a bed bath but does not get his showers as ordered. According to the shower schedule provided by the facility Resident #20 should receive his showers on the evening shift every Wednesday and Saturday.
On 12/05/24 at 1:00 PM review of the comprehensive care plan under the focus of Activities of Daily Living (ADL) is not resident specific in relation to specifying Resident #20's choice for a shower versus a bed bath.
In addition, the care plan does not relay that Resident #20 has refusals for a shower in the past. Review of the task for showers/baths for the last thirty (30) days show Resident #20 has refused a shower three (3) times on 11/10/24, 12/01/24 and 12/05/24.
On 12/05/24 at 2:10 PM Nurse Aide # 62 confirmed Resident #20 prefers showers over baths.
On 12/05/24 at 2:20 PM the above information was confirmed with the Director of Nursing who agreed the care plan should be revised to reflect Resident #20's choice of a shower.
b) Resident #58
On 12/03/24 at 10:01 AM Resident #58 states he prefers a shower over a bed bath but does not get his showers as ordered. According to the shower schedule provided by the facility Resident #58 should receive showers on day shift every Monday and Friday.
On 12/05/24 at 1:10 PM review of the comprehensive care plan under the focus of Activities of Daily Living (ADL) is not resident specific in relation to specifying Resident #58's choice for a shower versus a bed bath.
On 12/05/24 at 2:10 PM Certified Nurse Aide #62 confirmed Resident #58 prefered showers over baths.
On 12/05/24 at 2:20 PM the above information was confirmed with the Director of Nursing who agreed the care plan should be revised to reflect Resident #58's choice of a shower.
c) Resident #92
On 12/03/24 at 9:57 AM Resident #92 states he prefers a shower over a bed bath but does not get his showers as ordered. According to the shower schedule provided by the facility Resident #92 should receive his showers on evening shift every Tuesday and Friday.
On 12/05/24 at 1:10 PM review of the comprehensive care plan under the focus of Activities of Daily Living (ADL) is not resident specific in relation to specifying Resident #92's choice for a shower versus a bed bath. The care plan does not reflect what level of care Resident #92 is for a shower/bath.
In addition, the care plan does not reflect Resident #92 has refusals for a shower in the past. Review of the task for showers/baths for the last thirty (30) days show Resident #92 has refused his shower two (2) times on 11/20/24 and 11/23/24.
On 12/05/24 at 2:10 PM Certified Nurse Aide #62 confirmed Resident #92 prefers showers over baths and does refuse at times.
On 12/05/24 at 2:20 PM the above information was confirmed with the Director of Nursing who agreed the care plan should be revised for reflect Resident #92's choice of a shower, his level of assistance for showers/baths and refusals of showers.
d) Resident #22
On 12/02/24 at 8:24 AM observation shows Resident #22 was on a speciality mattress. The facility matrix revealed she has a Stage IV pressure.
On 12/03/24 at 10:00 AM record review reflects Resident #22 has an active order dated 11/12/24 for:
1) Wound care: Monitor stage IV pressure injury to sacrum. Notify medical providers of presence of complications (e.g increased redness, swelling, drainage, abnormal odor, new or worsening pain/discomfort every shift.
2) Wound Care: Cleanse stage IV pressure ulcer to sacrum with wound cleanser, pat dry, apply collagen particles to wound bed, cover with bordered foam every day shift.
On 12/04/24 at 10:10 AM it was observed and confirmed with Licensed Practical Nurse #26 that Resident #22 does have a Stage IV pressure ulcer to her sacrum.
Review of Resident #22's care plan found under the focus of skin integrity it identifies skin tears, unstagable to the left ear and unstagable pressure ulcer to the sacrum. It does not identify the stage IV pressure ulcer that she has on her sacrum nor does it identify interventions or tasks for wound care.
On 12/03/24 at 1:34 PM the above was confirmed with the Regional Director of Clinical Operations #400 who agreed the care plan is not current and needs revised to reflect the above information.
e) Resident #72
On 12/05/24 at 2:18 PM observation and record review identified Resident #72 has a stage III pressure ulcer to her left back.
Current orders for wound care to her back are:
1) WOUND CARE: Monitor Stage 3 pressure injury to thoracic spine. Notify medical provider if presence of complications (e.g. increased redness, swelling, drainage, abnormal odor, new or worsening pain/discomfort.
WOUND CARE: Cleanse Stage 3 pressure injury to left back with wound cleanser, apply hydrogel with silver to wound bed, cover with bordered gauze.
Resident #72 is non-verbal and immobile. She has contractures and can not roll herself from side to side.
On 12/05/24 at 3:10 PM record review of Resident #72's care plan shows there are no interventions or tasks for turning and repositioning the resident to prevent worsening of the stage III pressure ulcer to her back.
On 12/05/24 at 3:20 PM during an interview with Certified Nurse Aide (CNA) #10 and CNA #61 they stated they do not routinely have a place to chart for turning but they do turn some residents. CNA #10 identified Resident #72 as a resident that she turns from side to side. Further record review shows a charting task for rolling left and right for this resident.
According to the Director of Nursing in an interview on 12/05/24 at 4:00 PM it is standard practice of nursing care to prevent a new or worsening pressure ulcer, an immobile resident should be turned from side to side to the back every two (2) hours. She also confirmed the care plan should reflect the turning and repositioning under the skin integrity focus.
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
Quality of Care
(Tag F0684)
Could have caused harm · This affected multiple residents
Based on record review and staff interview the facility failed to identify and provide needed care and services that are resident centered, in accordance with the resident's preferences and profession...
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Based on record review and staff interview the facility failed to identify and provide needed care and services that are resident centered, in accordance with the resident's preferences and professional standards of nursing practice for more than a limited number of residents. Resident Identifiers: #19, #25, #30, #43, #64, #69, #77, #255, #256, #258, #59, #89. Facility Census: 107
Findings Include:
a) Resident #19, #25, #30, #43, #64, #69, #77, #255, #256, and #258
On 12/04/24 at 11:23 AM a facility reported incident concerning a multi-resident medication error was reviewed.
The incident report alleged Registered Nurse (RN) #404 failed to pass Physician ordered medications to ten (10) residents. This occurred on each night shift from 04/06/24 through 04/09/24.
On 12/09/24 at 9: 05 AM during an interview with the Director of Nursing (DON), she stated the error was identified when a random audit of the medication cart was performed by herself. It was found that the dated medication packets which come from pharmacy were still in the medication cart, unopened. She then performed an audit of the Medication Administration Report (MAR) and found that the medication had been documented as given.
The MAR was compared to the medications in the packets and it was determined that the RN had not administered medications to ten (10 Residents.
The facility policy and procedure for NS-1197-05 Nursing Medication Administration states on page seven of seven (7 of 7) as follows: IV. Documentation a. Documentation of medication will be current for medication administration. b. Documentation of medications will follow accepted standards of nursing practice.
A review of the Medication Administration Report (MAR) for the ten (10) residents identified as missing medications were reviewed. The following medications/dosages were identified as not being administered on each of the dates of alleged errors (04/06/24 - 04/09/24).
Resident #19
Mirtazapine 7.5 milligram (mg) for dementia
Singular 10 mg for allergies
Nifedipine 0.2% cream for hemorrhoids
Nutritional supplement for weight loss
Ocusoft lid scrub to both eyes for dry eyes
Systane Ultra Solution 0.4-0.3% 2 drops in both eyes for dry eyes
Sulfasalazine 500 mg for inflammation
Resident #25
Catapres-TTS-s transdermal patch weekly for hypertension
Lantus insulin 50 units for diabetes
Levothyroxine 25 micrograms (mcg) for hypothyroidism
Lipitor 20 mg for hyperlipedemia
Resident #30
Eliquis 5 mg for Atrial fibrillation
Entresto 49-51 mg for congestive heart failure
Med pass supplement for weight loss 90 ml for weight loss
Resident #43
Celexa 40 mg for depression
Senna-S 8.6-50 mg for constipation
Acetaminophen 1000 mg for pain
Eliquis 5 mg for anticoagulation
Fluticasone Proprionate Suspension 50 mcg 1 spray in each nostril for congestion
Quetiapine Fumarate 100 mg for schizophrenia
Seroquel 125 mg for schizophrenia
Symbicort Inhalation Aerosol 160-45 mcg for COPD
Tegretol 100 mg/5 ml for delusions
Resident #64
Lipitor 20 mg for hyperlipedemia
Refresh Ophthalmic Ointment 1 application in each eye for dry eyes
Spiriva inhalation 18 mcg for COPD
Trazodone 50 mg for depression
Tylenol Extra Strength 10000 mg for pain
Eliquis 5 mg for Atrial fibrillation
Norco 10-325 mg for pain
Requip 1 mg restless leg syndrome
Rewetting eyedrops 2 drops in both eyes for dry eyes
Resident #69
Med pass product 90 ml for weight loss
Rivaroxaban 2.5 mg for circulation
Tylenol 1000 mg for pain
Resident #77
Celexa 20 mg for anxiety and depression
Sennosides 8.6 mg for constipation
Med Pass product 90 ml for supplement
Metoprolol Tartrate 25 mg for hypertension
Pantoprazole 40 mg for GERD
Tegretol-XR 100 mg for anxiety
Tramadol 50 mg for pain
Ativan 0.5 mg for anxiety
Carafate 1 gram for digestive aid
Resident #255
Acetazolamine 250 mg for kidney disease
Budesonide inhalation solution 0.5 mg/2 ml for COPD
Guaifenesin ER 600 mg for mucus
Ipratropium Albuterol Solution 05.-2.5 mg/3 ml for COPD
Pantoprazole Sodium 40 mg for reflux
Spironolactine 25 mg for congestive heart disease
Torsemide 20 mg for congestive heard disease
Ipratropium Albuterol solution 0.5-2.5 mg/ml for COPD
Resident #256
Levothyroxine 125 mcg for hypothyroidism
Senna 8.6-50 mg for constipation
Famotidine 20 mg for acid indigestion
Lantus insulin 35 units for diabetes
Meclizine 12.5 mg for dizziness
Resident #258
Atrovastatin 10 mg for hyperlipedemia
Metformin 500 mg for diabetes
Pantoprazole 40 mg for acid indigestion
Tamsulosin 0.4 mg for urinary health
Trazadone 50 mg for depression
Carvedilol 25 mg for hypertension
Magnesium Oxide 400 mg for supplement
On 12/10/24 at 9:10 AM the above findings were discussed with the DON and the Regional Director of Clinical Operations #400 who confirmed the residents listed above did not receive their medications during the time period of 04/06/24 through 04/09/24 for the night shift.
b) Resident #59
On 12/03/24 at 9:15 AM record review of weights for Resident #59 found there has been a significant weight loss of 10.3% in one month.
Documentation shows Resident #59 weighed 208 pounds on 10/11/24 and dropped to 186.6 pounds on 11/11/24. This reflects a weight loss of 10.3% of her weight in 30 days.
A significant weight loss is defined as:
5% change in weight in 1 month (30 days)
7.5% change in weight in 3 months (90 days)
10% change in weight in 6 months (180 days)
Resident #59 has the following active orders:
Regular diet Regular texture, Regular consistency, Diabetic Condiments No Salt Packet
Weight times 4 weeks upon admission on e time a day every Sun for Baseline Weight for 4 Weeks AND every day shift every 30 day(s) for Weight.
The facility policy and procedure for Resident Height and Weight states on page three (3) of three (3), Procedure for obtaining weight B. Weight Procedure (3) Compare weight to previous weight obtained. If a variance of five (5) pounds more or less is noted,reweigh resident to verify weight.
A review of Resident #59 weights show the following documentation where on two (2) occasions the resident should have been re-weighed due to a five (5) pound fluctuation in her weight.
10/11/24 208 pounds
10/13/24 200.8 pounds
10/27/24 195.4 pounds
11/03/24 186 pounds
The Director of Nursing confirmed their policy and stated that is standard practice of nursing are as well. She confirmed the above weight documentation and the resident should have been re-weighed on both instances listed above.
c) Resident #89
A record review completed on 12/04/24 at 9:30 AM, revealed the following physician order: Five times a day 90ml pre & post each enteral feeding.
During an Interview on 12/04/24 at 12:14 PM, the DON was asked to described what would be 90ml pre and post each enteral feed. The DON initially replied, That would be the Jevity (a calorically dense, fiber-fortified therapeutic nutrition that provides complete, balanced nutrition for long- or short-term tube feeding). The DON then corrected herself by explaining that would be the water for the tube flush.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, the facility failed to ensure the resident environment over which it had control was a...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, the facility failed to ensure the resident environment over which it had control was as free from accident hazards as possible. Three (3) medication carts and a treatment cart were unlocked and unattended. This was a random opportunity for discovery. This deficient practice had the potential to affect more than a limited number of residents. Facility Census: #107
Findings include:
a) Medication carts
On 12/04/24 at 4:50 AM it was observed at the nurses station on the 100/200 hallways there were two (2) medication carts that were unattended and unlocked.
At 4:52 AM Licensed Practical Nurse (LPN) #87 returned to the medication cart and confirmed the medication cart she was responsible for on the 100 hallway was left unlocked and unattended. posing an accident threat to residents on the 100 and 200 hallways.
At 4:57 AM LPN #70 returned to the medication cart and confirmed the medication cart she was responsible for on the 200 hallway was left unlocked and unattended. posing an accident threat to residents on the 100 and 200 hallways.
On 12/04/24 at 7:45 AM the above information was provided to the Director
On 12/09/24 at 12:10 PM observation of a medication cart at the nurses station on the 100 hallway found it to be unlocked and unattended. This was confirmed with LPN #26 who also identified the medication cart was the responsibility of LPN #57.
b) Treatment cart
On 12/04/24 at 11:40 AM during observation of tracheostomy care in room [ROOM NUMBER]-2 Licensed Practical Nurse #53 retrieved the appropriate supplies from the treatment cart. At that time she entered the room and closed the door to the room and left the treatment cart unlocked and unattended posing an accident threat to residents that may come on the 400 hallway.
This was confirmed with the Regional Director of Clinical Operations #400 on 12/04/24 at 1:47 PM who agreed the treatment cart should remain locked when unattended.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0725
(Tag F0725)
Could have caused harm · This affected multiple residents
Based on record review and staff interview, the facility failed to deploy sufficient direct care staff to meet the care needs of all residents in the facility, based on the facility assessment. This h...
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Based on record review and staff interview, the facility failed to deploy sufficient direct care staff to meet the care needs of all residents in the facility, based on the facility assessment. This has the potential to affect all residents residing in the facility. Facility census: 107.
Findings include:
A) Facility staffing
At approximately 11:30 AM on 12/10/2024, a review was conducted of the facility assessment and staffing for the following days: 07/10/24, 08/13/24, 09/21/24, 11/30/24, 12/1/24. According to the facility assessment, the facility would deploy between ten (10) and twelve (12) Nurse Aides on day shift and between eight (8) and ten (10) on night shift to sufficiently meet the needs of the residents who reside at the facility.
Punch in and out reports were conducted for above days, which showed every employee that clocked in and out of the facility for those days. The review of the punch in and out reports revealed the following:
7/10/24- Nine (9) Nurse Aides were in the facility on day shift.
8/13/24- Eight (8) Nurse Aides were in the facility for dash and four (4) were present for night shift.
9/21/24- Seven (7) Nurse Aides were in the facility for dash and six (6) for night shift
11/30/24- Six (6) Nurse Aides were present for dayshift
12/1/24- Six (6) Nurse Aides were present for dayshift
During the survey issues were found with the following: Dependent residents (Resident #58 and #92) were dependent for activities of daliy living (ADLs) and were not getting showers.
Resident #32 was not getting showered at the preferred time of day.
Issues were also found with turning and repositionging not being doen for Resident #72 who had a Stage III pressure ulcer. Resident #59 had signficant weight loss with no interventions.
At approximately 1:30 PM on 12/10/2024, an interview was conducted with the Director of Nursing (DON). During the interview, the DON acknowledged the requirements the facility set forth in the facility assessment and the days the facility fell short of those requirements, based on the punch in and out reports provided by the facility.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0757
(Tag F0757)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** b) Resident #38
During record review on 12/03/24 at approximately 12:15 PM, the following entries were noted in the resident's c...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** b) Resident #38
During record review on 12/03/24 at approximately 12:15 PM, the following entries were noted in the resident's chart:
An order by Nurse Practitioner (NP) #120 on 11/26/24 at 9:00 PM for Doxycycline Hyclate Oral Tablet 100 MG (Doxycycline Hyclate). Give 1 tablet by mouth two times a day for cellulitis left breast for 10 Days
Further record review of Resident #38's medical record on 12/03/24 at approximately 2:30 PM revealed the following allergies listed:
Doxycycline, Penicillins, Bees, Latex, Iodine
It was also noted that a nursing note by Licensed Practical Nurse (LPN ) #117 on 11/26/24 at 12:47 AM stated:
The system has identified a possible drug allergy for the following order: Doxycycline Hyclate Oral Tablet 100 MG (Doxycycline Hyclate) Give 1 tablet by mouth two times a day for cellulitis left breast for 10 Days
Review of the pharmacist recommendations showed that the Consultant Pharmacist had completed the medication review at 8:33 PM on 11/26/24, and missed the irregularity, because the medication order had been placed, after the review, at 9:00 PM on 11/26/2024.
The consultant pharmacist's review stated:
No apparent medication irregularities noted at this time
During an interview with the Director of Nursing (DON) on 12/04/24, at 9:48 AM, the DON confirmed that the facility had not notified the physician about the resident's allergy. Additionally, the physician had not documented a rationale for using this specific medication, despite the resident having a documented allergy to it.
Based on record review and staff interviews, the facility failed to ensure the medication regimens for Residents #307, #38,#22, and #64 were free from unnecessary medications. This was true for four (4) of six (6) residents reviewed for unnecessary medications during the survey process. Resident identifiers: #307, #38, #22, #64. Facility census: 107.
Findings include:
a) Resident #307
At approximately 3:30 PM on 12/03/2024, a review of Resident #307 ' s medical record was conducted during the review, the following orders were noted:
Donepezil HCl Oral Tablet 5 MG (Donepezil Hydrochloride)
Give 1 tablet by mouth at bedtime for dementia
Active
11/27/2024 21:00
traZODone HCl Oral Tablet 50 MG (Trazodone HCl)
Give 1 tablet by mouth at bedtime for depression
Active
11/27/2024 21:00
The following diagnoses were noted on the resident's diagnosis list during the review:
ACUTE ON CHRONIC SYSTOLIC (CONGESTIVE) HEART FAILURE
TYPE 2 DIABETES MELLITUS WITH DIABETIC CHRONIC KIDNEY DISEASE
CHRONIC OBSTRUCTIVE PULMONARY DISEASE, UNSPECIFIED
ESSENTIAL (PRIMARY) HYPERTENSION
TYPE 2 DIABETES MELLITUS WITH DIABETIC NEUROPATHY, UNSPECIFIED
HYPOTHYROIDISM, UNSPECIFIED
CHRONIC ATRIAL FIBRILLATION, UNSPECIFIED
HYPERLIPIDEMIA, UNSPECIFIED
OLD MYOCARDIAL INFARCTION
ATHEROSCLEROTIC HEART DISEASE OF NATIVE CORONARY ARTERY WITHOUT ANGINA PECTORIS
GASTRO-ESOPHAGEAL REFLUX DISEASE WITHOUT ESOPHAGITIS
PRESENCE OF AUTOMATIC (IMPLANTABLE) CARDIAC DEFIBRILLATOR
Resident #307 was admitted to the facility on [DATE]. Discharge paperwork from the hospital, prior to the admission to the facility was reviewed, and there was no indication the resident had ever been diagnosed with dementia or depression.
The initial pharmacy recommendations were reviewed for Resident #307. The recommendation from 11/28/2024 mentions the resident was admitted to the facility with an order for trazodone but did not have the appropriate indication for use. The recommendation was for the physician to verify indication and update the system with a diagnosis to support continued use. The Nurse Practitioner (NP) signed the recommendation on 12/02/2024, circled trazodone and wrote depression beside it.
Notes from following visits between the physician and Resident #307 were reviewed and there were no indications of the resident being diagnosed with depression or dementia.
At approximately 11:25 AM on 12/04/2024, an interview was conducted with the Director of Nursing (DON) regarding the orders and diagnoses. The DON acknowledged the resident was prescribed donepezil for dementia, but lacked the diagnosis of dementia. The DON also acknowledged the resident was prescribed trazodone for depression, but lacked the diagnosis of depression. The DON also acknowledged the absence of physician notes stating the resident had been diagnosed with either.
c) Resident #22
On 12/09/24 at 10:30 AM record review for Resident #22 found a current order for Levetiraetam Oral Solution 100 MG/ML (Levetiracetam) Give 5 ml via PEG-Tube two times a day for Seizures.
Review of Resident #22's current diagnosis did not find a current diagnosis for seizures or epilepsy.
The care plan was reviewed and found no focus for seizures.
On 12/09/24 at 12:45 PM the Director of Nursing confirmed that Resident #22 does not have a current diagnosis of epilepsy.
d) Resident #64
On 12/09/24 at 10:30 AM record review for Resident #64 found a current order for Zonisamide Oral Capsule 100 MG (Zonisamide) Give 100 mg orally one time a day for seizures.
Review of Resident #64's current diagnosis did not find a current diagnosis for seizures or epilepsy.
The care plan was reviewed and found no focus for seizures.
On 12/09/24 at 12:45 PM the Director of Nursing confirmed that Resident #64 does not have a current diagnosis of epilepsy.
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
Menu Adequacy
(Tag F0803)
Could have caused harm · This affected multiple residents
b) Resident #88
On 12/02/24 01:23 PM Resident #88 said the food was terrible. The resident said he was supposed to get a chicken thigh on this date but he got pork. He said they had no rolls and no ma...
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b) Resident #88
On 12/02/24 01:23 PM Resident #88 said the food was terrible. The resident said he was supposed to get a chicken thigh on this date but he got pork. He said they had no rolls and no maragarine.
12/03/24 09:16 AM Resident #88 said he had put orange juice on cereal this morning due to the facility having no milk.
12/04/24 at 8:00 AM an observation revealed the resident did not receive milk for cereal. The tray ticket said, Cereal of choice each day.
Based on observation, resident and staff interviews, the facility failed to ensure they were able to follow menus by not having the food items needed for the preperation of the meal. This had the potentital to affcet more than a limited number of residents. Facility census: 107.
Findings included:
a) Resident #88
During an Interview on 12/02/24 at 1:23 PM. Resident #88 stated the facility runs out of food all the time and must send us whatever they have. She stated that they, Haven't had milk for days. She continued to say that they sent her chocolate milk with her cold cereal this morning and they had ran out of bread also. She stated that she never gets what's on the menu.
During an interview with the dietary manager on 12/02/24 at 230 PM he stated that if they do not have a menu item or run out of something, they just tell the Nurse Aides. When ask if they post changes in menus any where for the residents to see, he stated, No.
A medical record review for Resident #88 revealed, a diet order for a regular diet.
A review of the facility menu on 02/02/24 for lunch was kielbasa sausage, capri vegetables, baked beans, dinner roll /bread. An alternate menu marinated chicken thigh, seasoned greens, mashed potatoes.
An observation on 02/02/24 at 12:48 PM of Resident #88 lunch meal ticket listed marinated chicken thighs, capri vegetables, baked beans, dinner roll /bread and brownie. She received on her tray pork roast, capri vegetables, and baked beans. No chicken thigh, roll or brownie.
An observation on 02/03/24 at 8AM of Resident #88 meal ticket listed scrambled eggs, cold cereal, ginger pear cake, milk. On her tray she received scrambled eggs, cold cereal, ginger pear cake and orange juice. No milk was received.
During an interview with the assistant Dietary Manager on 02/03/24 at 8:30 PM, she stated that the truck was coming today with milk. She verified they had been out of milk. She stated that she would send the van driver to get milk now.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected multiple residents
Based on observation, staff interview, and equipment manual review the facility failed to have a clean, sanitized kitchen, store food in the refrigerator, freezer, and dry storage in accordance with p...
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Based on observation, staff interview, and equipment manual review the facility failed to have a clean, sanitized kitchen, store food in the refrigerator, freezer, and dry storage in accordance with professional standards for food service safety. The facility also failed to keep the ice machine and dishwasher in safe operating condition. This has the ability to affect all residents that get their nutrition from the kitchen, and also attends food related activities. Facility Census: 107
Findings included:
a) Initial Kitchen tour.
During the initial kitchen tour with the Kitchen Account Manager on 12/02/24 at 11:54 AM, an observation found
--Walk-in refrigerator - One container of cottage cheese, opened, not labeled, or dated.
and 6 heads of lettuce brown / spoiled.
-- Walk -in the freezer - Boxes of hamburger patties, waffles and french toast, open to air.
-- Dry storage - 4 dented cans (peaches and soups) in circulation.
--The microwave had dried food debris throughout the inside of it.
-- The floors under the stove and sink area had food and debris.
--The stove and outside of refrigerators and freezers were unclean.
During an interview on 12/02/24 at 11:54 AM and throughout the kitchen the Kitchen Account Manager confirmed all issues during tour.
b) Dishwasher
A review of facility records on 12/02/24, found the dishwasher's final rinse temperature had been below the recommended 180 degrees since 11/03/24.
On 11/15/24 through 11/21/24 education was given to the dietary staff on logging the dishwasher temperatures and the protocol to hand wash dishes if the machines wash temperature is below 150 or the rinse temperature is below 180.
The documentation continued to show that the machine was not working properly and the dietary staff continued to use the dish machine.
During an interview on 12/02/24 at 12:16 PM the Kitchen Account Manager confirmed that the machine was not working adequately. He continued to say there was a part ordered for the machine.
c) Ice Machines
On 12/03/24 at 1:15 tour of the pantry's with the Maintenance Director found the ice machine located in the nutrition rooms room had no required air gap on the ice machine drains. The drain pipes were touching the drains.
On 12/03/24 at around 1:25 PM, the Maintenance Director also confirmed the pipe should not be touching the drain. He stated both brackets were broken.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** d) Resident #56
During an observation of wound care, and assessment, performed on Resident #56 on 12/03/24 at approximately 1:45...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** d) Resident #56
During an observation of wound care, and assessment, performed on Resident #56 on 12/03/24 at approximately 1:45 PM, by Nurse Practitioner (NP) #122, and Licensed Practical Nurse (LPN) #26, it was observed that Resident # 56's room did not have Enhanced Barrier Precautions (EBP) notices posted.
The NP and LPN failed to don PPE upon entering the room, and prior to performing wound care. Resident $56 had venous stasis ulcers on his right lower extremity, a diabetic foot ulcer to his right great toe, and an abscess to the posterior aspect of his neck. NP #122 assessed the wounds and collected pictures, after which LPN #26 performed wound care.
On 12/04/24 at approximately 5:29 AM during an interview with LPN #57, she stated that Resident #56 should be on Enhanced Barrier Precautions (EBP). LPN further stated that Resident #56 had been moved from a different hallway because the facility was being renovated, and his EBP signage had not come with him. LPN stated that an order for EBP would be obtained immediately.
Record review on 12/04/24 at approximately 2:00 PM revealed the following order dated 12/04/24 at 5:28 AM:
Enhanced barrier precautions related to:
When dressing/bathing, showering/transferring in room or therapy gym/personal hygiene, changing linen, providing hygiene, changing briefs or assisting with toileting.
Record review revealed the following orders:
09/30/24 at 7:28 AM
WOUND CARE: Cleanse abscess to neck wound cleanser, pat dry, apply 1/4-inch packing strip, cover with bordered gauze. Every day shift
09/30/24 at 7:28 AM
WOUND CARE: Cleanse arterial ulcer to left posterior lower leg with wound cleanser, pat dry, apply xeroform, cover with bordered gauze. Every day shift
09/30/24 at 7:35 AM
WOUND CARE: Cleanse diabetic foot ulcer to right foot second toe with wound cleanser, pat dry, apply betadine and leave open to air. Every day shift
However, further record review on 12/04/24 at approximately 7:30 AM showed no previous orders for enhanced barrier precautions for Resident #56.
b) Morning Observation
At approximately 4:55 AM on 12/04/2024, a trash barrel was observed at the end of the 100 hallway with the lid off, overflowing with trash. Another barrel, containing soiled linen, was beside the trash barrel, overflowing, with the lid off. This was confirmed by Nurse Aide (NA) #40. NA #40 stated They have been here for a couple of hours.
At approximately 5:00 AM on 12/04/2024, dirty linens were observed in the floor, by the door at room [ROOM NUMBER]. Licensed Practical Nurse (LPN) #87 acknowledged the linens on the floor and confirmed they were soiled.
Based on observation, resident interview, and staff interview, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Resident #45 was allowed to play in feces until other residents intervened, wound care for a resident under enhanced barrier precautions was provided without staff wearing the appropriate personal protective equipment (PPE), linens were on the floor and a linen barrel was overflowing. These were random opportunities for discovery. Resident identifiers: #45 and #56. Facility census: 107.
Findings included:
a) Resident #45
During an interview on 12/03/24 at 10:30 AM, Residents #24 and Resident #31 reported that they had gone to the dining room for their Thanksgiving meal. They reported that one of the more confused residents from the 400 hall, Resident #45, had a soiled brief in her lap as she wheeled into the dining room. Resident #45 reportedly lifted the soiled brief, spread it on the table in front of her, and started playing in the feces as though she was finger painting. Both residents reported two activity aides were in the room but failed to do anything to intervene. They reported that Resident #71 went to the [NAME] hallway to ask staff to address it, was told, Hey, that's not our problem. When asked what they thought that meant, both residents reported that Resident #45 was a resident on the [NAME] Fort 400 Hallway and the [NAME] hallway staff expected the other unit to handle the problem. After that, Resident #31 wheeled herself down the [NAME] Fort 400 hallway and was successful in finding CNA #83 who agreed to help and accompanied the resident to the dining room to take care of Resident #45. Both residents reported that they recalled Resident #37 was also in the dining room.
During an interview on 12/04/24 at 11:30 AM, Resident #71 reported she recalled being in the dining room when the above-mentioned incident happened during the Thanksgiving meal. She reported she went to the [NAME] hallway to ask for staff assistance and was told, Hey, that's not our problem. She wheeled herself back into the dining room and reported she had not been successful in getting a staff member to help. That was when Resident #31 left to go get help from the 400 hallway. Resident #71 reported that there were two (2) activity staff in the room but that they did not intervene in any way.
During a telephone interview, on 12/04/24 at 12:42 PM, CNA #83 confirmed that Resident #31 had came and asked for her assistance in the dining room during the Thanksgiving meal.
CNA #83 reported as she entered the dining room, Resident #45 had the dirty brief on the table and was playing in the feces. CNA #83 reported two activity staff members (#49 and #92) were present and sitting at the first table when she entered the room. Additionally, CNA #83 reported that CNA #10 assisted in helping clean Resident #45 up in the bathroom once they were back on the 400 hall. It was at this time that they identified Resident #45 had a brief on and that they could not be sure whose dirty brief Resident #45 had been playing in while in the dining room.
During an interview on 12/09/24 at 3:18 PM, Resident #37 confirmed her presence in the dining room during the Thanksgiving meal when the incident occurred.
A subsequent record review found that Resident #31, Resident #24, Resident #71 and Resident #37 were all cognitively intact and would be able to accurately recall the events in the dining room and the fact that Resident #45 was permitted to play in the feces as though she was finger painting without staff intervention until residents intervened.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0921)
Could have caused harm · This affected multiple residents
Based on observation and staff interview, the facility failed to ensure a safe and homelike environment in regard to a black substance on packaged terminal air conditioner (PTAC) and ceiling vents. Th...
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Based on observation and staff interview, the facility failed to ensure a safe and homelike environment in regard to a black substance on packaged terminal air conditioner (PTAC) and ceiling vents. This had the potential to affect all residents living in the facility. Facility census: 107.
Findings include:
a) Dining Rooms
An observation, on 12/03/24 at 12:55 PM, revealed a black substance around the packaged terminal air conditioner (PTAC) units.
At an interview, on 12/03/24 at 12:58 PM, the Maintenance Director confirmed that the PTAC units had a black substance around them.
b) Ceiling vents.
An observation on 12/03/24 of the vents in the ceiling throughout the facility found a black substance and debris on and around the vents.
On 12/03/24 at around 1:15 PM, the Maintenance Director also confirmed the presence of debris in the heating and cooling unit. He stated that cover/vents would be clear of debris and black substance today.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Garbage Disposal
(Tag F0814)
Could have caused harm · This affected most or all residents
Based on observation and staff interview the facility failed to store garbage and refuse in a proper manner. The dumpster area was polluted with garbage and used medical supplies. This has the potenti...
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Based on observation and staff interview the facility failed to store garbage and refuse in a proper manner. The dumpster area was polluted with garbage and used medical supplies. This has the potential to affect all residents that reside in the facility. Facility census: 107.
Findings included:
a) Dumpster area
An observation on 12/09/24 2:57 PM found the dumpster area was polluted with garbage and used medical supplies.
On 12/09/24 at 3:16 PM during an Interview the Administrator verified the trash / medical supplies on the ground around the dumpster.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Administration
(Tag F0835)
Could have caused harm · This affected most or all residents
Based on record review and staff interview the facility failed to follow through with their plan of correction when a deficient practice was identified and investigated. This was true for ten (10) of ...
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Based on record review and staff interview the facility failed to follow through with their plan of correction when a deficient practice was identified and investigated. This was true for ten (10) of ten (10 records reviewed. Resident Identifiers: #19, #25, #30, #43, #64, #69, #77, #255, #256, and #258. Facility Census: 107
Findings Include:
a) Resident #19, #25, #30, #43, #64, #69, #77, #255, #256, and #258
On 12/04/24 at 11:23 AM a facility reported incident concerning a multi-resident medication error was reviewed.
The incident report alleged Registered Nurse (RN) #404 failed to pass Physician ordered medications to ten (10) residents. This occurred on each night shift from 04/06/24 through 04/09/24.
On 12/09/24 during an interview with the Director of Nursing (DON), she stated the error was identified when a random audit of the medication cart was performed by herself. It was found that the dated medication packets which come from the pharmacy were still in the medication cart, unopened. She then performed an audit of the Medication Administration Report (MAR) and found that the medication had been documented as given. The RN was suspended immediately pending the investigation of the alleged medication error. He resigned his position on 04/09/24 without proper notice.
During the investigation the facility reported the error to the Physician, the Nurse Practioner (NP), the Pharmacy, the residents or their Medical Power of Attorney (MPOA)/Health Care Surrogate (HCS). It was reported to Adult Protection Services (APS), the Ombudsman and the Office to Health Facility Licensure and Certification (OHFLAC).
The ten (10) residents identified were assessed for any adverse reactions to not receiving their scheduled medications, The remaining residents on the hall the RN was assigned to were assessed and interviewed and it was determined no other residents to have had missed medications.
Witness statements were obtained from four (4) nurses that routinely relieve RN #404 when they report to work for the day shift relating to a past history of finding medications in the medication cart that had not been administered. There were no prior incidents recalled from the witness statements.
On the five (5) day follow up report submitted to OHFLAC the facility plan of correction was as follows: Residents were assessed for adverse reactions to not receiving their scheduled medications by the NP on 04/10/24 and 04/12/24. The Physician, NP, Pharmacy were notified by interim Director of Nursing (IDON) on 04/10/24. MPOA's and Health Care Surrogates (HCS) were notified by Licensed Practical Nurses (LPN) on 04/10/24. The employee alleged to have failed to appropriately pass medication was suspended pending investigation. This incident was reported on 04/10/24 of OHFLAC, Ombudsman, and APS by the Executive Director (ED).
Nursing completed assessments on all residents on the hall the incident occurred, on 04/10/24 and 04/11/24 by floor nurses. No additional residents were determined to have missed medications.
All staff will be re-educated with a posttest to validate understanding on the policy related to Medication Administration by IDON/designee. All staff not available at this time will have education with posttest to validate understanding on the Medication Administration policy prior to next shift scheduled by ED/designee. All new staff will have education with posttest to validate understanding provided during orientation by SDC/designee.
Medication carts will be audited daily for two (2) weeks including weekends, then three (3) times a week for two (2) weeks, and then randomly thereafter with corrective action upon discovery. Findings will be reviewed at the facilities QAPI meeting each month.
The facility policy and procedure for NS-1197-05 Nursing Medication Administration stated on page seven of seven (7 of 7) as follows: IV. Documentation a. Documentation of medication will be current for medication administration. b. Documentation of medications will follow accepted standards of nursing practice.
Registered Nurse #404 was reported to the [NAME] Virginia Board of Registered Nurses.
A review of the Medication Administration Report (MAR) for the ten (10) residents identified as missing medications were reviewed. The following medications/dosages were identified as not being administered on each of the dates of alleged errors (04/06/24 - 04/09/24).
Resident #19
Mirtazapine 7.5 milligram (mg) for dementia
Singular 10 mg for allergies
Nifedipine 0.2% cream for hemorrhoids
Nutritional supplement for weight loss
Ocusoft lid scrub to both eyes for dry eyes
Systane Ultra Solution 0.4-0.3% 2 drops in both eyes for dry eyes
Sulfasalazine 500 mg for inflammation
Resident #25
Catapres-TTS-s transdermal patch weekly for hypertension
Lantus insulin 50 units for diabetes
Levothyroxine 25 micrograms (mcg) for hypothyroidism
Lipitor 20 mg for hyperlipedemia
Resident #30
Eliquis 5 mg for Atrial fibrillation
Entresto 49-51 mg for congestive heart failure
Med pass supplement for weight loss 90 ml for weight loss
Resident #43
Celexa 40 mg for depression
Senna-S 8.6-50 mg for constipation
Acetaminophen 1000 mg for pain
Eliquis 5 mg for anticoagulation
Fluticasone Proprionate Suspension 50 mcg 1 spray in each nostril for congestion
Quetiapine Fumarate 100 mg for schizophrenia
Seroquel 125 mg for schizophrenia
Symbicort Inhalation Aerosol 160-45 mcg for COPD
Tegretol 100 mg/5 ml for delusions
Resident #64
Lipitor 20 mg for hyperlipedemia
Refresh Ophthalmic Ointment 1 application in each eye for dry eyes
Spiriva inhalation 18 mcg for COPD
Trazodone 50 mg for depression
Tylenol Extra Strength 10000 mg for pain
Eliquis 5 mg for Atrial fibrillation
Norco 10-325 mg for pain
Requip 1 mg restless leg syndrome
Rewetting eyedrops 2 drops in both eyes for dry eyes
Resident #69
Med pass product 90 ml for weight loss
Rivaroxaban 2.5 mg for circulation
Tylenol 1000 mg for pain
Resident #77
Celexa 20 mg for anxiety and depression
Sennosides 8.6 mg for constipation
Med Pass product 90 ml for supplement
Metoprolol Tartrate 25 mg for hypertension
Pantoprazole 40 mg for GERD
Tegretol-XR 100 mg for anxiety
Tramadol 50 mg for pain
Ativan 0.5 mg for anxiety
Carafate 1 gram for digestive aid
Resident #255
Acetazolamine 250 mg for kidney disease
Budesonide inhalation solution 0.5 mg/2 ml for COPD
Guaifenesin ER 600 mg for mucus
Ipratropium Albuterol Solution 05.-2.5 mg/3 ml for COPD
Pantoprazole Sodium 40 mg for reflux
Spironolactine 25 mg for congestive heart disease
Torsemide 20 mg for congestive heart disease
Ipratropium Albuterol solution 0.5-2.5 mg/ml for COPD
Resident #256
Levothyroxine 125 mcg for hypothyroidism
Senna 8.6-50 mg for constipation
Famotidine 20 mg for acid indigestion
Lantus insulin 35 units for diabetes
Meclizine 12.5 mg for dizziness
Resident #258
Atrovastatin 10 mg for hyperlipedemia
Metformin 500 mg for diabetes
Pantoprazole 40 mg for acid indigestion
Tamsulosin 0.4 mg for urinary health
Trazadone 50 mg for depression
Carvedilol 25 mg for hypertension
Magnesium Oxide 400 mg for supplement
The above findings were confirmed on 12/10/24 at 9:10 AM with the DON and the Regional Director of Clinical Operations #400 who confirmed they do not have documentation of staff re-education or the medication cart audits. Administration failed to follow through with their plan of correction when a deficient practice was identified and investigated.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0925
(Tag F0925)
Could have caused harm · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident and staff interviews, the facility failed to incorporate an effective pest control program. This ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident and staff interviews, the facility failed to incorporate an effective pest control program. This had the potential to affect all residents residing in the facility. Facility census: 107.
Findings included:
a) Gnats
On 12/02/24 12:13 PM during the initial tour there were gnats all over the walls and ceiling in room [ROOM NUMBER]. The window was open, and a flying insect plug in was observed with multiple gnats trapped on the sticky pad.
On 12/03/24 at 11:40 AM an observation and interview with the Central Supply Coordinator verified the gnats in the dining room and on resident trays. She stated they also have an issue with gnats in rooms where residents wet themselves
On 12/03/24 at 12:11 PM during an interview with the exterminator, he stated he was never called to treat gnats in the facility prior to this date. He verified the gnats through the facility at this time.
During an interview on 12/03/24 at approximately 12:45 AM, the Administrator verified they tried to exterminate the gnats with the plug in and opened the window. He stated he moved Resident #108 out of room [ROOM NUMBER] on 11/29/24 due to the gnats.
During an interview, on 12/04/24 at 11:05 AM, Resident #29 reported she had resorted to killing the gnats in her room (on the 400 hall) with a fly swatter. Resident #29 also stated she had met with the Administrator to discuss the gnats as well as her dissatisfaction with the fact that the garbage in her room had not been taken out for three (3) days, and that she had resorted to bagging it up herself and placing it in the hallway. The resident stated she never received verbal or written follow-up from the Administrator regarding her concerns.
Dec 2023
24 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 provide a dignified dining experience for Resident's #106 and #61. These were random opportunities for discovery. Resident Identifiers:...
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Based on observation and staff interview, the facility failed to provide a dignified dining experience for Resident's #106 and #61. These were random opportunities for discovery. Resident Identifiers: #106 & #61. Facility Census: 106.
Findings Included:
a) Resident #106
On 12/10/23 at 12:30 PM, while observing the noon meal, Resident #106 was served his lunch on styrofoam dinnerware with plastic utensils. At this time, Licensed Practical Nurse (LPN) #87 was interviewed and asked why Resident #106 was served lunch on styrofoam? LPN #87 stated, I think it's because of his behaviors .he throws things.
On 12/11/23 at 10:20 AM, the Director of Nursing in Training (DON) was notified of the resident receiving meals on styrofoam. The DON stated, I think it's because he was throwing knives at the staff and behaviors.
On 12/11/23 at 10:45 AM, the DON confirmed there was no physician's order for meal service on styrofoam and the care plan had not been revised to reflect the behaviors and meal service on styrofoam. However, the dietary department had printed a meal ticket stating, styro box and utensils. (Typed as written.)
On 12/12/23 at 8:40 AM, the Administrator was notified and confirmed serving meals on styrofoam dinnerware with plastic utensils could be a dignity issue.
No further information was obtained during the survey process.
b) Resident #61
On 12/12/23 at 8:10 AM, Resident #61 was observed being fed by Registered Nurse (RN) #31. RN #31 was standing by the bed while assisting the resident.
On 12/12/23 at 8:35 AM, the Clinical Manager #125 was notified and confirmed the RN should not be standing while feeding the resident.
On 12/12/23 at 8:40 AM, the Administrator was notified and confirmed the staff should not be standing while feeding a resident.
No further information was obtained during the survey process.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Notification of Changes
(Tag F0580)
Could have caused harm · This affected 1 resident
Based on medical record review and staff interview, the facility failed to ensure the physician was notified of changes regarding the resident's physical status. This was true for one (1) of 28 sample...
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Based on medical record review and staff interview, the facility failed to ensure the physician was notified of changes regarding the resident's physical status. This was true for one (1) of 28 sample residents. The physician was not notified of a significant weight loss for Resident #40. Resident identifier: #40. Facility census: 106.
Findings included:
a) Resident #40
A medical record review on 12/11/23, revealed Resident #40 weighed 208 pounds on 10/06/23 and on 11/18/23 she weighed 183. There was no evidence the physician was notified of the significant weight loss of 25 pounds.
During an interview with the Director of Nursing (DON) on 12/11/23 at 2:05 PM, she could not provide any evidence the physician had been notified of the weight loss of 25 pounds between 10/06/23 and 11/18/23. The DON agreed the physician should have been notified of Resident #40's change in condition.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0582
(Tag F0582)
Could have caused harm · This affected 1 resident
Based on record review and staff interview, the facility failed to provide the required Skilled Nursing Facility Advanced Beneficiary Notice of Non-Coverage (SNF ABN) form to one (1) of three (3) resi...
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Based on record review and staff interview, the facility failed to provide the required Skilled Nursing Facility Advanced Beneficiary Notice of Non-Coverage (SNF ABN) form to one (1) of three (3) residents reviewed for the facility's beneficiary protection notification practice during an annual survey. This failure placed Resident #212 at risk of not being informed of her rights prior to the end of Medicare Part A covered services. Resident Identifier: #212. Facility census: 106.
Findings included:
a) Beneficiary Notice Review
The facility provided a list of residents who were discharged from a Medicare covered Part A stay with benefit days remaining in the past 6 months.
On 12/11/23 at 10:14 AM, a review was completed regarding the beneficiary protection notification liability notices given for Resident #212 who remained at the facility following her discharge from a Medicare covered Part A stay with benefit days remaining.
- Resident #212's last covered day of Part A service was 07/29/23. A Notice of Medicare Non-Coverage (NOMNC) was issued by the facility on 07/27/23. No Skilled Nursing Facility Advanced Beneficiary Notice of Non-Coverage (SNF ABN) form was provided.
Review of Form Instructions Skilled Nursing Facility Advanced Beneficiary Notice on Non-coverage (SNF ABN) Form CMS-10055 (2018) denoted Medicare requires Skilled Nursing Facilities to issue the SNF ABN to Medicare beneficiaries prior to providing care that Medicare usually covers, but may not pay for because the care is:
- not medically reasonable and necessary; or
- considered custodial.
In an interview on 12/11/23 at 10:30 AM, Business Office Manager #71 confirmed the facility had failed to issue a SNF ABN to Resident #212's legal representative.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** b) room [ROOM NUMBER]
Observation on 12/10/23 at 11:54 AM, found both curtains between the beds were heavily soiled with a brown...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** b) room [ROOM NUMBER]
Observation on 12/10/23 at 11:54 AM, found both curtains between the beds were heavily soiled with a brown, dried matter.
In the restroom, the baseboard around the toilet was missing, and a sharp edge of the baseboard was protruding from the wall at the corner of the alcove around the toilet.
There was a hole in the window blind at the top of the blind on the right side of the blind.
On 12/11/23 at 8:21 AM, the observations made the day before remained and were observed by housekeeping director #17 and director of plant maintenance #78.
On 12/12/23 at 8:45 AM, the above observations were discussed with the administrator. No further information was provided by the close of the survey.
c) room [ROOM NUMBER]
On 12/11/23 at 8:21 AM, observation found 5 holes in the bottom of the bathroom door. The bathroom door, as well as the closet door, was heavily scraped and marred. The drywall between the restroom and closet doors was scraped, with the outer finish of the sheetrock torn away in several places.
On 12/11/23 at 8:21 AM, the observations made the day before remained and were observed by housekeeping director #17 and director of plant maintenance #78.
On 12/12/23 at 8:45 AM, the above observations were discussed with the administrator. No further information was provided by the close of the survey.
Based on observation, resident interview and staff interview, the facility failed to provide a safe, clean and homelike environment for room [ROOM NUMBER] which had dirty, stained sheet rock, room [ROOM NUMBER] was noted with a heavily soiled bed curtain and holes in the blinds, and room [ROOM NUMBER] was noted with holes in the bathroom door and missing sheet rock in the bathroom . These were random opportunities of discovery. Facility Census: 106.
Findings Included:
a) room [ROOM NUMBER]
On 12/12/23 at 8:20 AM, upon observing medication administration in room [ROOM NUMBER], an observation was made of the sheet rock of the wall by the window. The sheet rock appeared to be dirty with brown, black and red stains. The top of the packaged terminal air conditioner (PTAC) was noted with a dry black substance.
On 12/12/23 at 8:30 AM, the Clinical Manager #125 was notified and stated, let me get Maintanence.
On 12/12/23 at 8:35 AM, the Director of Maintenance (DOM) #78 confirmed the sheet rock was dirty with multiple brown, black and red stains. The DOM #78, also, confirmed the PTAC was dirty as well. The DOM #78 stated, it looks like dried food .we will get this taken care of right away.
On 12/12/23 at 8:40 AM, the Administrator was notified and confirmed this issue was being taken care of by Maintanence.
No further information was obtained during the survey process.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Transfer Requirements
(Tag F0622)
Could have caused harm · This affected 1 resident
Based on record review and staff interview, the facility failed to ensure information was provided to the receiving provider to ensure continuity of care when the resident was transferred to the hospi...
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Based on record review and staff interview, the facility failed to ensure information was provided to the receiving provider to ensure continuity of care when the resident was transferred to the hospital. This was found for one (1) of three (3) discharged residents reviewed. Resident identifier: #108. Facility census: 106.
Findings included:
a) Resident #108
Record review found a nursing note dated 10/02/23 at 9:31 AM, which noted the resident was having increased congestion and mild edema to extremities. New orders were obtained for a chest x-ray and laboratory values to be obtained. When the medical power of attorney (MPOA) was contacted about the Resident's change in condition, the MPOA wanted the resident sent to the hospital. The facility complied with the MPOA wishes and sent the Resident to the hospital.
On 12/12/23 at 9:05 AM, the Director of Nursing (DON) in training Registered Nurse (RN) #118 reviewed the Hospital Transfer Form, dated 10/02/23. RN #118 confirmed this form accompanied the Resident to the hospital. RN #118 was unable to provide evidence the receiving facility was notified of the Resident's current medications, diet orders, treatment orders and code status which were not mentioned on the hospital transfer Form.
On 12/12/23 at 9:45 AM, the above discharge was discussed with the administrator. No further evidence was provided by the close of the survey.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Transfer Notice
(Tag F0623)
Could have caused harm · This affected 1 resident
Based on record review and staff interview, the facility failed to ensure the ombudsman was notified of the transfer to the hospital for one (1) of three (3) Resident's reviewed for transfer/discharge...
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Based on record review and staff interview, the facility failed to ensure the ombudsman was notified of the transfer to the hospital for one (1) of three (3) Resident's reviewed for transfer/discharge from the facility. Resident identifier: #108. Facility census: 106.
Findings included:
a) Resident #108
Record review found a nursing note dated 10/02/23 at 9:31 AM which noted the resident was having increased congestion and mild edema to extremities. New orders were obtained for a chest x-ray and laboratory values to be obtained. When the medical power of attorney (MPOA) was contacted about the Resident's change in condition, the MPOA wanted the resident sent to the hospital. The facility complied with the MPOA wishes and transferred the resident to the hospital. The Resident has not returned to the facility.
On 12/12/23 at 9:43 AM, Medical Records Coordinator (MRC) #18 and the Director of Nursing (DON) in training #118 were asked for verification to confirm the ombudsman was notified of Resident #108's transfer to the hospital. MRC #18 said she faxes a list of all the Residents discharged to the hospital monthly to the ombudsman. When asked for verification, MRC #18 said she had sent the discharges from November to the ombudsman but she didn't know about the discharges in October of 2023. She said another employee probably faxed it down. The surveyor asked if we could ask the other employee? MRC #118 said, that person doesn't work here anymore. MRC #118 said, I will call the ombudsman. She picked up the phone, dialed a number and said, that number doesn't work anymore. MRC #18 said, I can't find anything.
No further information was presented before the close of the survey.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0625
(Tag F0625)
Could have caused harm · This affected 1 resident
Based on record review and staff interview, the facility failed to ensure a copy of the bed hold notice was provided to the Resident/Medical Power of Attorney (MPOA) upon transfer to the hospital for ...
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Based on record review and staff interview, the facility failed to ensure a copy of the bed hold notice was provided to the Resident/Medical Power of Attorney (MPOA) upon transfer to the hospital for one (1) of two (2) residents reviewed for hospitalization. Resident identifier: #108. Facility census: 106.
Findings included:
a) Resident #108
Record review found a nursing note dated 10/02/23 at 9:31 AM, which noted the resident was having increased congestion and mild edema to extremities. New orders were obtained for a chest x-ray and laboratory values to be obtained. When the MPOA was contacted about the Resident's change in condition, the MPOA wanted the resident sent to the hospital. The facility complied with the MPOA wishes and sent the Resident to the hospital.
On 12/12/23 at 9:05 AM, the Director of Nursing (DON) in training Registered Nurse (RN) #118 reviewed the Hospital Transfer Form, dated 10/02/23. RN #118 confirmed this form accompanied the Resident to the hospital but no information regarding the bed hold was referenced. RN #118 was unable to provide evidence a copy of bed hold notice was provided to the Resident or MPOA. RN #118 said, I could just about guarantee you it wasn't sent with the Resident when she went to the hospital.
On 12/12/23 at 9:45 AM, the above information was discussed with the administrator. No further evidence was provided by the close of the survey.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
b) Resident #67
Record review found a physician's order for Hospice Services, dated 08/01/23 for a diagnosis of Malignant Neoplasm of Endometrium.
The facility's care plan noted the Resident was rece...
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b) Resident #67
Record review found a physician's order for Hospice Services, dated 08/01/23 for a diagnosis of Malignant Neoplasm of Endometrium.
The facility's care plan noted the Resident was receiving Hospice Services but did not include any documentation the Hospice Agency participated in developing a care plan. There was no guidance regarding when Hospice staff would visit or what services would be provided by the Hospice agency. For example when would nursing staff visit, when would Hospice aides visit, would the agency provide any counseling, including spiritual, dietary and bereavement services.
On 12/11/23 at 9:15 AM, the surveyor visited the nurses' station to ask DON #118 for the binder for resident #67 hospice visits. The DON scoured the area and could not initially find resident #67's binder with the other hospice binders.
An interview with the Director Of Nursing (DON) at 11:03 AM on 12/11/23, found the facility doesn't know when any of the Hospice Staff are coming to the facility. When asked for notes from the Hospice Staff the DON said we don't get notes from them. I will see if I can go into the Hospice portal to try to get their notes. The DON confirmed the Hospice staff have not attended the Resident's care planning process and the agency has not provided the facility with a care plan entailing what services would be provided by the Hospice staff.
Based on record reviews and staff interviews the facility failed to implement the comprehensive person-centered care plan for an altered nutritional status for Resident #40. For Resident #67 the care plan was not developed for coordination of hospice services. This deficient practice was true for two (2) of 28 sample resident care plans reviewed during the Long-Term Care Survey Process. Resident identifiers: #40 and #67. Facility census: 106
Findings included:
a) Resident #40
A medical record review on 12/11/23, revealed Resident #40 weighed 208 pounds on 10/06/23 and on 11/18/23 she weighed 183. There was no evidence the physician was notified of the significant weight loss of 25 pounds.
During a medical record review on 12/11/23 for Resident #40's care plan was not implemented for the nutritional intervention to notify the medical provider of any unplanned weight changes.
During an interview with the Director of Nursing (DON) on 12/11/23 at 2:05 PM, she could not provide any evidence the physician had been notified of the unplanned weight loss.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0657
(Tag F0657)
Could have caused harm · This affected 1 resident
Based on observation, record review and staff interview, the facility failed to revise the care plan regarding behaviors and the use of styrofoam dinnerware and plastic utensils. This was a random opp...
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Based on observation, record review and staff interview, the facility failed to revise the care plan regarding behaviors and the use of styrofoam dinnerware and plastic utensils. This was a random opportunity for discovery. Resident Identifier: Resident #106. Facility Census: 106.
Findings Included:
a) Resident #106
On 12/10/23 at 12:30 PM, while observing the noon meal, Resident #106 was served his lunch on styrofoam dinnerware with plastic utensils. At this time, Licensed Practical Nurse (LPN) #87 was interviewed why is Resident #106 being served lunch on styrofoam? LPN #87 stated, I think it's because of his behaviors .he throws things.
On 12/11/23 at 10:20 AM, the Director of Nursing in Training was notified of the resident receiving meals on styrofoam. The DON stated, I think it's because he was throwing knives at the staff and behaviors.
On 12/11/23 at 10:45 AM, the DON confirmed there was no physician's order for meal service on styrofoam and the care plan had not been revised to reflect the behaviors and meal service on styrofoam. However, the dietary department had printed a meal ticket stating, styro box and utensils. (Typed as written.)
On 12/12/23 at 8:40 AM, the Administrator was notified and confirmed the care plan was not revised regarding the resident's behaviors and meals being served on styrofoam and plasticware.
No further information was obtained during the survey process.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, the facility failed to maintain a safe and as free from accidents as possible. These w...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, the facility failed to maintain a safe and as free from accidents as possible. These were random opportunities for discovery. Facility Census: 106.
Findings Included:
a) room [ROOM NUMBER]
On 12/10/23 at 12:17 PM, upon initial observation of room [ROOM NUMBER], three (3) medication cups with a thick, white substance were noted sitting on the over the bed table which was pushed against the wall. Licensed Practical Nurse (LPN) #87 was notified and confirmed the thick, white substance in the medication cups was zinc oxide cream, which is used to prevent skin irritation during incontinence episodes.
On 12/10/23 at 12:19 PM, LPN #87 stated, that shouldn't be sitting there. LPN #87 removed the three (3) medication cups from the room.
On 12/10/23 at approximately 1:00 PM, the Director of Nursing (DON) was notified of the above issue. The DON stated, that shouldn't be at bedside.
No further information was obtained during the survey process.
b) Medication Cart
On 12/12/23 at 8:10 AM, LPN #121 was preparing medications to be administered. Upon completion of the preparation, LPN # 121 walked down the hallway and left the medication cart on [NAME] Court short hall unlocked. Upon surveyor intervention, LPN #121 returned to the medication cart and locked it.
On 12/12/23 at 8:35 AM, Unit Manager (UM) #125 was notified. UM #125 stated, thank you for letting me know.
On 12/12/23 at 8:40AM, the Administrator was notified and stated, the medication cart should never be left unlocked.
No further information was obtained during the survey process.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
Could have caused harm · This affected 1 resident
Based on observation, resident interview and staff interview, the facility failed to ensure respiratory care was provided according to professional standards of practice. These were random opportuniti...
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Based on observation, resident interview and staff interview, the facility failed to ensure respiratory care was provided according to professional standards of practice. These were random opportunities of discovery. Resident Identifier: #61 and #93. Facility Census: 106.
Findings Included:
a) Resident #61
On 12/12/23 at 8:32 AM, an observation was made during Resident #61's medication administration. The resident was ordered a breathing treatment of Albuterol Sulfate. Upon entering the room, the nebulizer was observed laying in the floor with the respiratory tubing wrapped around a chair arm near the resident's bed. The respiratory tubing was not stored in a respiratory bag.
On 12/12/23 at 8:33 AM, Licensed Practical Nurse (LPN) #121 confirmed the nebulizer was laying in the floor and the respiratory tubing was not stored correctly. LPN #121 stated, we will get you some new tubing.
On 12/12/23 at 8:35 AM, the Clinical Manager (CM) #125 was notified and confirmed the nebulizer and respiratory tubing were not stored correctly.
On 12/12/23 at 8:40 AM, the Administrator was also notified and confirmed the nebulizer and respiratory tubing were not stored correctly.
b) Resident #93
On 12/10/23 at 12:00 PM, an observation of a nebulizer machine with respiratory tubing was sitting on the bed beside of the resident. The mask was not stored in a respiratory bag. The resident was asked is this your breathing machine? Resident #93 stated that's not mine.
On 12/11/23 at 8:30 AM, the nebulizer machine with the respiratory tubing and mask was observed sitting in an wheelchair, and the mask was not stored in a respiratory bag.
On 12/11/23 at 9:33 AM, the nebulizer machine with the respiratory tubing and mask was observed still sitting in wheelchair with the mask not stored correctly.
On 12/11/23 at 9:35 AM, Licensed Practical Nurse (LPN) #101 confirmed the nebulizer machine, respiratory tubing and mask were not stored correctly. LPN #101 stated, No its not stored correctly .I think his nebulizer treatments were stopped a while ago. LPN #101 confirmed the physician's order for the nebulizer treatments was discontinued on 11/24/23. LPN#101 confirmed the used nebulize, respiratory tubing and mask should have been removed from the room.
On 12/11/23 at 9:45 AM, the Director of Nursing (DON) was notified and confirmed the nebulizer, respiratory tubing and mask were not stored correctly and should have been removed from the room.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0697
(Tag F0697)
Could have caused harm · This affected 1 resident
c) Resident #67
Review of the medical record found the Resident was receiving Hospice services for end of life care for a diagnosis of Malignant Neoplasm of Endometrium.
On 06/30/23 an order was wri...
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c) Resident #67
Review of the medical record found the Resident was receiving Hospice services for end of life care for a diagnosis of Malignant Neoplasm of Endometrium.
On 06/30/23 an order was written to monitor for pain, every shift.
Review of the Medication Administration record (MAR) for November and December 2023 found staff were monitoring for pain by placing a check mark on the MAR.
On 12/12/23 at 2:07 PM, the Director Of Nursing (DON) in training was asked how a check mark would indicate if the Resident was having pain. The DON said, well, I guess it wouldn't, checkmarks are ambiguous as to whether pain is present, or the amount of pain present.
No further information was presented by the close of the survey.
Based on record review and staff interview, the facility failed to assess and monitor pain every shift per the physician orders for Resident #106, #93 and #67. This was true for three (3) of three (3) residents reviewed under the care area of pain management. Resident Identifiers: #106, #93, and #67. Facility Census: 106.
Findings Included:
a) Resident #106
On 12/12/23 at 1:30 PM, a physician's order dated 04/03/23 for monitor pain every shift was noted. Upon reviewing the December, 2023, medication administration record (MAR), the notations for each shift were check marks. However, the notations did not include if the resident was having pain, a pain rating or the location of pain.
On 12/12/23 at 2:07 PM, the Director of Nursing in Training (DONIT) was notified of the finding and confirmed the notations did not include if the resident was having pain, a pain rating or the location of pain.
b) Resident #93
On 12/12/23 at 1:30 PM, a physician's order dated 10/18/23 for monitor pain every shift was noted. Upon reviewing the December, 2023, medication administration record (MAR), the notations for each shift were check marks. However, the notations did not include if the resident was having pain, a pain rating or the location of pain.
On 12/12/23 at 2:07 PM, the Director of Nursing in Training (DONIT) was notified of the finding and confirmed the notations did not include if the resident was having pain, a pain rating or the location of pain.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0730
(Tag F0730)
Could have caused harm · This affected 1 resident
Based on employee record reviews and staff interviews the facility failed to ensure nurse aides had annual performance evaluations completed. This was true for three (3) of five (5) employees reviewed...
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Based on employee record reviews and staff interviews the facility failed to ensure nurse aides had annual performance evaluations completed. This was true for three (3) of five (5) employees reviewed for the facility task of sufficient and competent nurse staffing. Employee identifiers: #1, #96, and #36. Facility census: 106.
Findings included:
a) Annual performance evaluations
During a review of the employee records on 12/12/23, it was discovered Nurse Aide (NA) #1 had an annual performance evaluation due on or before 08/15/23, NA #96 was due by 08/15/23, and NA #36 was due by 08/10/23. There was no evidence presented the three (3) employee annual performance evaluations had been completed.
An interview with the Human Resource Manager on 12/12/23 at 2:35 PM, reported he was unable to locate any annual performance evaluations completed for NA #1, #96, and #36.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview, the facility failed to monitor the medication refrigerator temperatures...
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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 monitor the medication refrigerator temperatures, store a schedule IV medication in a double lock system, remove personal food and drinks from the medication refrigerator and maintain a clean medication refrigerator on the [NAME] Court unit. These were random opportunities for discovery. Facility Census: 106.
a) Temperature Logs
On 12/12/23 at approximately 10:00 AM, a tour of the medication room on [NAME] Court was completed. The tour of the medication room found the medication refrigerator temperature logs had not been completed for the months of October, 2023, November, 2023 and December, 2023. The following is a list of the missing temperatures and dates for each month:
October, 2023
--10/01/23 PM
--10/02/23 PM
--10/09/23 PM
--10/10/23 PM
--10/12/23 PM
--10/13/23 PM
--10/14/23 PM
--10/15/23 PM
--10/20/23 PM
--10/22/23 AM & PM
--10/23/23 AM & PM
--10/24/23 AM & PM
--10/25/23 AM & PM
--10/26/23 AM & PM
--10/27/23 AM & PM
--10/28/23 AM & PM
--10/29/23 AM & PM
--10/30/23 AM & PM
November, 2023
--11/01/23 AM & PM
--11/02/23 AM & PM
--11/03/23 AM
--11/07/23 AM & PM
--11/08/23 AM & PM
--11/09/23 AM & PM
--11/10/23 AM & PM
--11/11/23 AM & PM
--11/12/23 AM & PM
--11/13/23 AM & PM
--11/16/23 PM
--11/17/23 PM
--11/21/23 PM
--11/22/23 AM & PM
--11/23/23 AM & PM
--11/24/23 AM & PM
--11/25/23 AM & PM
--11/26/23 AM & PM
--11/27/23 AM & PM
--11/30/23 AM & PM
December, 2023
--12/11/23 AM & PM
On 12/12/23 at 10:15 AM, the Clinical Manager (CM) #125 was notified and confirmed the temperature logs were incomplete.
On 12/12/23 at 2:10 PM, the policy entitled Refrigerator Maintenance and Temperature was reviewed. In Section III c. the policy states, Monitor refrigerators temps (temperatures) twice per 24 hour period and log. (Typed as written.)
b) Schedule IV Medication Storage
On 12/12/23 at 1:35 PM, a medication room tour was completed on [NAME] Court. The tour found a schedule IV medication (Ativan) was not stored in a double lock within the medication refrigerator. A box of liquid Ativan containing 30 milliliters (mls) was laying on a shelf in the refrigerator and was not placed in the additional lock box inside of the refrigerator.
On 12/12/23 at 1:35 PM, the CM #125 was notified and confirmed the schedule IV medication was not stored properly in a double lock within the medication refrigerator.
On 12/12/23 at 2:07 PM, the Director of Nursing In Training (DONIT) was notified and confirmed the medication should have been stored within the double lock system.
On 12/12/23 at 2:10 PM, the policy entitled Medication Controlled Drugs and Security was reviewed. In Section II b.the policy states, The compartment has a special lock and key and must be kept locked at all times when not being accessed by the nurse or qualified medication aide, where applicable . (Typed as written.)
c) Personal food and drinks
On 12/12/23 at 1:35 PM, while completing a medication room tour, multiple items of personal food and drinks were found in the [NAME] Court medication refrigerator. The items found are as follows:
--One (1)-12 oz cans of pop
--Four (4)-16oz cans of beer
--Two (2)-12oz protein drinks
--a plastic storage container with no name or date listed containing a pork chop, mashed potatoes, and baked beans
On 12/12/23 at 1:35 PM, CM #125 was notified and confirmed the personal food and drinks should not be stored in the medication refrigerator.
On 12/12/23 at 2:07 PM, the DON was notified and also confirmed the personal food and drinks should not be stored in the medication refrigerator.
On 12/12/23 at 2:10 PM, the policy entitled Refrigerator Maintenance and Temperature was reviewed. In Section II c i. the policy states, No food/liquids for consumption will be kept in the medication/vaccination refrigerator unless it is a liquid medication. (Typed as written.)
d) Dirty Medication Refrigerator
On 12/12/23 at 1:35 PM, while completing a medication room tour, the [NAME] Court medication refrigerator was observed with a dry, brown substance on the refrigerator floor.
On 12/12/23 at 1:45 PM, the CM #125 confirmed a dry, brown substance was in the medication refrigerator floor and was not clean.
On 12/12/23 at 2:07 PM, the DON was notified and verified the medication refrigerator should be kept clean at all times.
On 12/12/23 at 2:10 PM, the policy entitled Refrigerator Maintenance and Temperature was reviewed. In Section II d. the policy states, refrigerators must be maintained in a clean and sanitary state. (Typed as written.)
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0806
(Tag F0806)
Could have caused harm · This affected 1 resident
Based on resident interview, observation and staff interview the facility failed to accommodate a Residents' food allergy. This was true for one (1) of seven (7) residents reviewed for food during the...
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Based on resident interview, observation and staff interview the facility failed to accommodate a Residents' food allergy. This was true for one (1) of seven (7) residents reviewed for food during the long term survey process. Resident Identifiers: #103 Facility Census: 106
Findings Included:
a) Resident #103
On 12/10/23 at 12:19 PM it was observed that Resident #103 had baked apples on his lunch tray. He stated he is allergic to cinnamon as he smells the cinnamon on the apples. He also states he continues to get food with cinnamon on it even after he has told dietary staff that he is allergic to it.
On 12/11/23 at 08:23 AM record review shows his allergies are documented as cinnamon being one of his two allergies.
Review of his meal ticket for 12/10/23 shows as follows:
Rosemary Roast Beef Au Jus, Baked Potato, Margarine, Sour Cream, Sliced Parsley Carrots, Dinner roll, Margarine. It also has Allergies: Cinnamon.
The menu posted for 12/10/23 shows the following:
Rosemary Roast Beef Au Jus, Baked Potato, Margarine, Sour Cream, Sliced Parsley Carrots, Dinner roll, Margarine, Harvest Baked Apples
Upon review of the recipe for Apples, Harvest Blend (can) the following ingredients were listed:
Apples, sliced, canned
Margarine, solids
Syrup, Pancake Maple, Bulk
Spice, Cinnamon, Ground
Spice, Ginger, Ground
Juice, Lemon, Bulk
Extract, Vanilla, Imitation
On 12/11/23 at 2:10 PM the above information was confirmed with the Culinary Director #115 who agrees that Resident #103 should not have received the baked apples.
No further information was obtained during the long term survey process.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0813
(Tag F0813)
Could have caused harm · This affected 1 resident
Based on observation, policy review and staff interview the facility failed to obtain daily temperature checks on residents' personal refrigerators. This was true for three (3) of three (3) personal r...
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Based on observation, policy review and staff interview the facility failed to obtain daily temperature checks on residents' personal refrigerators. This was true for three (3) of three (3) personal refrigerators observed during the Long Term Care Process . Resident Identifiers: #34, #35, #23. Facility Census: 106
Findings Included:
a) Resident #34
On 12/10/23 at 12:45 PM it was observed that Resident #34 has a personal refrigerator in his room that had no temperature log located at the refrigerator.
According to the facility Policy #IC 1021-02 states Procedure: daily refrigerator temperature checks must be performed:
d. Record and Log temperatures daily on a log kept at the refrigerator.
On 12/10/23 at 1:58 PM, this was confirmed with the Director of Nursing #118 who stated they did not have any logs due to new maintenance personnel.
No further information was obtained during the long term survey process.
b) Resident #35
On 12/10/23 at 12:52 PM it was observed that Resident #35 has a personal refrigerator in her room.
Further observation found there was no temperature log located at the refrigerator.
According to the facility Policy #IC 1021-02 states Procedure: daily refrigerator temperature checks must be performed:
d. Record and Log temperatures daily on a log kept at the refrigerator.
On 12/10/23 at 1:58 PM, this was confirmed with the Director of Nursing #118 who stated they did not have any logs due to new maintenance personnel.
No further information was obtained during the long term survey process.
c) Resident #23
During an observational tour on 12/10/23 at 1:40 PM, it was noted that Resident #23 had a personal refrigerator in his room. There was no temperature log posted on or around fridge.
On 12/11/23 at 11:00 AM, the Business Officer Manager #71 accompanied Surveyor to Resident #23's room. There was now a December 2023 temperature log posted on Resident #23's personal refrigerator with a straight line drawn through December 1st - December 10th. Business Office Manager #71 confirmed no December temperatures were taken on those dates.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Garbage Disposal
(Tag F0814)
Could have caused harm · This affected 1 resident
Based on observation and staff interview the facility failed to maintain the garbage and refuse container in good condition. During a random opportunity for discovery, it was noticed one (1) of the tw...
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Based on observation and staff interview the facility failed to maintain the garbage and refuse container in good condition. During a random opportunity for discovery, it was noticed one (1) of the two (2) dumpsters had only a partial covering. This practice did not allow for garbage and refuse to be disposed of properly. Facility census: 106
Findings included:
a) Damaged dumpster
During a random opportunity for discovery on 12/12/23 at 3:00 PM, a dumpster was not covered properly due to a broken lid, there was only a partial covering over the container.
An interview with the Housekeeping Supervisor on 12/12/23 at 3:03 PM, verified half of the lid for the dumpster was missing and agreed the lid needed to be replaced.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0868
(Tag F0868)
Could have caused harm · This affected 1 resident
Based on record review and staff interview, the facility failed to provide evidence Quality Assessment and Assurance (QAA) meetings were held and required members were in attendance for the first and ...
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Based on record review and staff interview, the facility failed to provide evidence Quality Assessment and Assurance (QAA) meetings were held and required members were in attendance for the first and second quarter of 2023. This had the potential to affect all residents that resided at the facility. Facility census: 106.
Findings included:
a) QAA Meetings
During an interview on 12/12/23 at 9:12 AM, the Administrator reported the facility could not produce the QAA sign-in sheets for the first two quarters of 2023. The Administrator explained she started her position in June 2023. It was also noted the facility had reached out to the previous Administrator for help in locating the sign-in sheets for the first two quarters of 2023 and had received no response.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0947
(Tag F0947)
Could have caused harm · This affected 1 resident
Based on employee record review and staff interview, the facility failed to ensure nurse aides received the requied annual in-service training to include dementia management and abuse pervention train...
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Based on employee record review and staff interview, the facility failed to ensure nurse aides received the requied annual in-service training to include dementia management and abuse pervention training. This was true for one (1) of five (5) employees records reviewed for sufficient and competent nurse staffing. Resident identifier: #96. Facility census: 106.
Findings included:
a) Required in-service training
During a review of the employee record for Nurse Aide (NA) #96, there was no evidence he had completed the required 12 hour in-services to include dementia management and abuse prevention training.
During an intrview with the Human Resource Manager on 12/12/23 at 2:37 PM, he reported he was unable to locate any dementia management and abuse prevention training for NA #96.
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
b) Resident #23
At approximately 10:15 AM on 12/12/2023, during resident council, the resident stated that they had given $200 to Activities Leader (AL) #132 to do personal shopping, but the money has...
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b) Resident #23
At approximately 10:15 AM on 12/12/2023, during resident council, the resident stated that they had given $200 to Activities Leader (AL) #132 to do personal shopping, but the money has not been returned and the Resident has not received any of the items ordered. The Resident thought this was over two (2) weeks ago and was very upset stating, it's Christmas and I wanted to give my grandson something.
At approximately 11:00 AM on 12/12/23, the surveyor asked the social worker (SW) #114 if she was aware that residents #23 had given money to AL #132, who had not returned with the money or the items ordered. The social worker stated that she was not aware of the incident until 12/8/23, and returned with the official grievance form that she had initiated.
At 12:39 PM on 12/12/23, the administrator said the staff member who took the money, had a mental health crisis and the administrator did not think AL #132 willfully and intentionally took the funds, and that they handled the situation as they saw fit and did not report the incident to the State authorities. They normally request staff sign off on taking any funds from residents, but this is not specified under the facility policy. A timecard review for (AL) #132 indicates her last day of work was 11/29/23. The administrator said the facility is going to reimburse the Residents money.
c) Resident #82
At approximately 10:15 AM on 12/12/2023 during resident council, the resident stated that they had given $50 to Activities Leader (AL) #132 to do personal shopping. The resident said she told the staff she had not received the items requested. She said the facility had refunded her money.
At approximately 11:00 AM on 12/12/23, the surveyor asked the social worker (SW) #114 if she was aware that resident #82 had given money to AL #132, who had not returned items ordered. SW #114 confirmed that these funds had been returned to the resident. The social worker stated that she was not aware of the incident until 12/8/23, and returned with the official grievance form that she had initiated.
At 12:39 PM on 12/12/23, the administrator sid the staff member who took the money, had a mental health crisis and the administrator did not think AL #132 willfully and intentionally took the funds, and that they handled the situation as they saw fit and did not report the incident to the State authorities. They normally request that the staff sign off on taking any funds from residents, but this is not specified under the facility policy. A timecard review for (AL) #132 indicates her last day of work was 11/29/23.
d) Resident #67
On 12/11/23, a record review found the resident was receiving services from the hospice provider as of 08/01/23 for a diagnosis of Malignant Neoplasm of Endometrium.
On 12/11/23 at 9:15 AM, the surveyor visited the nurses' station to ask the Director Of Nursing (DON) #118 for the binder for resident #67's hospice visits. The DON scoured the area and could not initially find resident #67's binder with the other hospice binders.
At 11:03 AM on 12/11/23, a review of notes printed by the DON from the hospice provider portal found a note from a home health aide (typed as) written on 11/21/23:
Patient was in bed during arrival with facility aide, [name of aide] assisting her with a bed bath. Facility aide was putting on patient's dirty clothes back on her per patient request. Assisted aide with pulling up her pants and she told me I needed to wash her hair and when patient declined to have her hair wash. Facility aide went to get the nurse and the nurse also told the patient she had to have her hair washed due to it being matted to the back of her head. I got everything ready to wash patient's hair and wet it with conditioner to start combing it and patient started screaming for me to stop and that it was hurting her. I cleaned everything up and reported to the facility nurse that the patient does not want to have her hair bothered. She told me I needed to wash it or they were going to have to shave her head. I explained that the patient has capacity and it in the sound mind to make her own decisions and I will not be washing her hair today per patient request. Facility nurse said fine and she would document it. Will continue to offer regular visits as scheduled.
At 2:06 PM on 12/11/2023, an interview with social worker #114 reaffirmed that they did not know about the alleged abuse documented by the hospice aide but could have know if the facility was reading the notes from the Hospice provider. SW #114 stated that they would be getting statements and reporting it now.
On the morning of 12/12/23, the administrator provided the official allegation form dated 12/11/23, which was faxed to Adult Protective Services (APS), the Ombudsman, and Office of Health Facility Licensure and Certification (OHFLAC) opening an immediate investigation of the alleged abuse.
On 12/12/2023 at 2:00 PM, review of the policy entitled WV abuse neglect and misappropriation, section IV.2:
.Each occurrence of resident incident, bruise, abrasion, or injury of unknown source; or injury of unknown source; or report of alleged abuse, neglect, or misappropriation of funds will be identified and reported to the supervisor and investigated timely .
e) Resident #101 - Reporting of a Serious Bodily Injury
A record review, completed on 12/11/23 at 12:15 PM, revealed the following details:
-On 10/14/23 Resident #101 had a fall with a small abrasion to forehead. A subsequent CT Scan indicated overall findings were concerning for a chronic or old subdural hematoma/hygroma with a few small areas of acute hemorrhage.
-A reportable was faxed to the Office of Health Facility and Licensure (OHFLAC) office
-A reportable was faxed to the long-term care Ombudsman's office
-There was no evidence a reportable was faxed to Adult Protective Services (APS)
During an interview on 12/11/23 at 1:52 PM, Social Worker #114 confirmed the reportable was not sent to APS. Social Worker #114 stated this was in error.
Based on record review and staff interview, the facility failed to ensure a serious bodily injury was reported timely for Resident #109. Allegations of misappropriation of Resident funds for Residents #23 and #82 was not reported to State authorities. For Resident #67 an allegation of abuse was not reported. For Resident #101 an allegation of abuse was not reported to all the required State agencies. Resident identifiers: #109, #23, #82, #67 and #101. Facility census: 106.
Findings included:
a) Resident #109
Record review found the following progress notes:
08/09/23 at 9:00 PM:
Late Entry:
Note Text: Resident had fist fight with one of the confused resident. No apparent injury noted. resident's wife (Name of wife and facility physician) made aware. C/o (complained of) pain on left pinky, Tylenol given as ordered. Remained in bed.
08/10/23 at 09:07 AM IDT (interdisciplinary team) Follow Up
Late Entry:
Date of review:: 8/10/23
Type of incident:: Fall
What was happening at the time:: Resident attempting to redirect another resident out of his room and lost his balance.
Root cause of incident:: Lost balance assisting another resident out of his room
Intervention(s) put into place:: Check foot wear to insure proper fitting
8/10/2023 11:51 AM, Nurses Note
Note Text: NP (nurse practitioner) ordered x-ray of left hand due to swelling and bruising of the thumb and hand after altercation with another resident the previous shift. Order placed.
08/10/23 at 12:04 Nurses Note
Note Text: Skin sweep completed on resident r/t (related to) altercation with another resident on 8/9/23. Bruising and swelling noted to left hand and 5th finger. (Name of Nurse practitioner) NP aware. New order for X-ray of left hand noted.
08/10/23 at 6:47 PM Nurses Note
Note Text: Resident received x-ray to left hand. Waiting on results. Resident has c/o pain throughout this shift and has received scheduled Tylenol per Dr's orders. Will continue to monitor.
The results of the radiology report reads as follows:
Results: There is a fracture involving the proximal metaphysis of the fifth proximal phalanx with mild displacement. Decreased ossification is suggested, which may correspond clinically with osteopenia. Soft tissue swelling.
08/11/2023 12:06 PM Nurses Note
Note Text: X-ray result showed a fracture involving the proximal metaphysis of the fifth proximal phalanx with mild displacement. Decreased ossification is suggested, which may correspond clinically with osteopenia. Soft tissue swelling. Order for placement of an immobilizer and wrapped with an ace bandage. x-ray report.
On 08/11/23, at 12: 38 PM the Resident was seen by the nurse practitioner who noted:
.He is seen today for an acute visit following a fall on 08/09 and an altercation with another Resident on 08/09 .a finger splint was applied to his left fifth digit and his wrist and hand were wrapped with an Ace wrap. Consultation will be made to orthopedics secondary to fracture .
An immediate fax report of allegations found the date of incident was 08/10/23.
Brief description of the incident was described as:
During previously reported altercation from 08/10/23, Name of two (2) residents became involved in a physical altercation which resulted in Resident #109 receiving a fracture to pinky on left hand.
This report was completed and signed by the administrator on 08/14/23. The fax transmittal to State agencies was dated 08/14/23 at 1:20 PM.
At 3:56 PM on 12/12/23, the administrator said the incident occurred on 08/10/23. She said she was off from work and found the notes and reported the incident on 08/14/23. The administrator provided a sign in sheet from staff completed on 08/16/23 and said education was provided to staff for not reporting this incident. When asked if the incident was reported timely as required, the administrator said all I can say is the incident was reported by myself when I became aware of the situation.
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
c) Resident #67
Record review found a physician's order for Hospice Services, dated 08/01/23 for a diagnosis of Malignant Neoplasm of Endometrium.
The facility's care plan noted the Resident was rece...
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c) Resident #67
Record review found a physician's order for Hospice Services, dated 08/01/23 for a diagnosis of Malignant Neoplasm of Endometrium.
The facility's care plan noted the Resident was receiving Hospice Services but did not include any documentation the Hospice Agency participated in developing a care plan. There was no guidance regarding when Hospice staff would visit or what services would be provided by the agency. For example when would nursing staff visit, when would hospice aides visit, would the agency provide any counseling, including spiritual, dietary and bereavement services.
An interview with Director Of Nursing (DON) at 11:03 AM on 12/11/23, found the facility doesn't know when any of the Hospice Staff are coming to the facility. Then asked for notes from the Hospice Staff the DON said we don't get notes from them. I will see if I can go into the Hospice portal to try to get their notes. The DON confirmed the Hospice staff have not attended the Resident's care planning process.
Review of the hospice notes with DON #118 on 12/11/23 at 12:15 PM, found a note from a home health Aide (typed as) written on 11/21/23:
Patient was in bed during arrival with facility aide, [Name of aide] assisting her with a bed bath. Facility aide was putting on patient's dirty clothes back on her per patient request. Assisted aide with pulling up her pants and she told me I needed to wash her hair and when patient declined to have her hair wash. Facility aide went to get the nurse and the nurse also told the patient she had to have her hair washed due to it being matted to the back of her head. I got everything ready to wash patient's hair and wet it with conditioner to start combing it and patient started screaming for me to stop and that it was hurting her. I cleaned everything up and reported to the facility nurse that the patient does not want to have her hair bothered. She told me I needed to wash it or they were going to have to shave her head. I explained that the patient has capacity and it in the sound mind to make her own decisions and I will not be washing her hair today per patient request. Facility nurse said fine and she would document it. Will continue to offer regular visits as scheduled.
After reviewing the note, the DON stated, I did not know that note was there. She confirmed the situation was never investigated because the facility didn't read the Hospice notes prior to surveyor intervention. The surveyor and the DON review the medical record and confirmed no nurses notes were written on 11/21/23.
Review of the progress notes with the DON found a facility nurses not dated 11/13/23. RN (registered nurse) called hospice regarding resident pain medications. Hospice is going to send out a nurse to re-evaluate resident and see if she needs a stronger pain medication.
Review of a note from the Hospice agency found a RN did visit the resident on 11/13/23 and made the following note:
The resident denied pain when asked by RN. The resident told the RN that Tylenol doesn't help but Motrin and morphine help. The Hospice nurse noted that both pain medications were on the residents medication list.
A thorough review of the resident's medication list with the DON found there was No orders for morphine on 11/13/23. The DON said she didn't know what the note from the Hospice nurse was all about.
On 12/12/23 at 8:45 AM, the above situation was discussed with the administrator. No further information was provided by the close of the survey to confirm the Hospice agency was coordinating care with the facility.
d) Resident #63
A record review, completed on 12/11/23 at 11:35 AM, found the following times where the orders on the October 2023 Medication Administration Record (MAR) were left blank:
Lantus Solution 100 UNIT/ML (Insulin Glargine). Inject 35 unit subcutaneously at bedtime related to TYPE 2 DIABETES MELLITUS WITH DIABETIC NEUROPATHY, UNSPECIFIED
-10/16/23 at 9:00 PM
metFORMIN HCl Tablet 1000 MG. Give 1 tablet by mouth two times a day related to TYPE 2 DIABETES MELLITUS WITH DIABETIC NEUROPATHY, UNSPECIFIED
-10/16/23 at 9:00 PM
HumaLOG KwikPen Solution Pen injector 100 UNIT/ML (Insulin Lispro (1 Unit Dial). Inject 6 unit subcutaneously four times a day
-10/16/23 at 9:00 PM
-10/17/23 at 6:00 AM
Atorvastatin Calcium Tablet 10 MG. Give 1 tablet by mouth in the evening related to MIXED HYPERLIPIDEMIA
-10/16/23 at 8:30 PM
Omeprazole Capsule Delayed Release 20 MG. Give 2 capsule by mouth one time a day related to GASTROESOPHAGEAL REFLUX DISEASE WITHOUT ESOPHAGITIS give before breakfast.
-10/17/23 at 6:00 AM
Sennosides-Docusate Sodium Tablet 8.6-50 MG. Give 1 tablet by mouth in the evening for constipation.
-10/16/23 at 8:30 PM
Enhanced barrier precautions related to: History of MRSA. When dressing/bathing/showering/transferring/personal hygiene, changing linens, toileting and peri-care, providing care to resident with history of or colonized multi-drug resistant organism. Every shift.
-10/16/23 at 7:00 PM
Torsemide Tablet 20 MG. Give 1 tablet by mouth two times a day related to ESSENTIAL (PRIMARY) HYPERTENSION.
-10/16/23 at 9:00 PM
During an interview on 12/11/23 at 1:55 PM, the Director of Nursing (DON) in Training reviewed the October 2023 MAR and agreed the above-mentioned areas were left blank. The DON in Training reported when applying professional standards in the nursing world, Undocumented means not done.
b) Resident #106
On 12/10/23 at 12:30 PM, while observing the noon meal, Resident #106 was served his lunch on styrofoam dinnerware with plastic utensils. At this time, Licensed Practical Nurse (LPN) #87 was interviewed why is Resident #106 being served lunch on styrofoam? LPN #87 stated, I think it's because of his behaviors .he throws things.
On 12/11/23 at 10:20 AM, the Director of Nursing in Training was notified of the resident receiving meals on styrofoam. The DON stated, I think it's because he was throwing knives at the staff and behaviors.
On 12/11/23 at 10:45 AM, the DONIT confirmed there was no physician's order for meal service on styrofoam and plastic ware. However, the dietary department had a printed a meal ticket stating, styro box and utensils. (Typed as written.)
No further information was obtained during the survey process.
Based on record review, staff interview and policy review the facility failed to follow policy to re-weigh a resident when there was a five (5) pound difference in weight, to obtain a physician's order for the use of Styrofoam dinnerware, to coordinate with Hospice, to produce evidence physician orders were followed for enhanced barrier precautions and that medications were administered. Resident identifiers: #25, #106, #67, #63 Facility Census: 106
Findings Include:
a) Resident #25
On 12/12/23 at 11:11 AM record review shows there were no re-weights obtained when the current weight reflected a five (5) pound difference in weight.
Facility Policy #NS 1320-02 Resident Height and Weight states . 9) Re-weight Parameters: a) A plus/minus of 5 pounds of weight in one week will result in: i) Re-weigh within 24 hours
Record review shows the following weights with a +/- of five (5) pounds of weight difference that required to be re-weighed which was not performed as policy states.
05/19/23 weight 246.6 pounds
06/08/23 weight 239.4 pounds
reflecting a 7.2 pound weight difference
08/27/23 weight 265.5 pounds
08/31/23 weight 211.2 pounds
reflecting a 54.3 weight difference
09/16/23 weight 211.6 pounds
09/21/23 weight 202 pounds
reflecting a 9.6 weight difference
10/23/23 weight 212.2 pounds
10/26/23 weight 203.4 pounds
reflecting a 8.8 pound weight difference
During an interview on 12/12/23 at 01:15 PM with the Director of Nursing she agreed Resident #35 should have been re-weighed on the four (4) dates listed above.
No further information was obtained during the long term survey process.
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 observations and staff interview, the facility failed to maintain the kitchen in a safe and sanitary manner in accordance with professional standards of practice. During the kitchen tour it w...
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Based on observations and staff interview, the facility failed to maintain the kitchen in a safe and sanitary manner in accordance with professional standards of practice. During the kitchen tour it was discovered a heavily soiled floor in the storage room, several damaged floor tiles in the serving area and dish room, a trash can was parked directly in front of the hand washing sink, and dirty shelving units. This failed practice had the potential to affect all residents receiving nourishment from the kitchen. Facility census: 106
Findings included:
a) Kitchen tour
During the kitchen tour on 12/10/23 at 11:23 AM, it was discovered several damaged and missing floor tiles in the serving area and the dish room. The floor in the storage room was heavily soiled with a brown substance. The handwahing sink was blocked by a 30 gallon trash can used to collect debris from dirty dishes. There was an accumulation of dust on the shelving units used to house the mixing bowls and serving trays for the steam table.
An interview with the Dietary Manager on 12/10/23 at 12:35 PM, verified the floor tiles needed to be repaired, and the storage room floor needed to be cleaned. He also verified the trash can should not be located in front of the hand washing sink and the shelving units were in need of cleaning.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview the facility failed to provide hand hygiene in order to prevent the development and tra...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview the facility failed to provide hand hygiene in order to prevent the development and transmission of communicable diseases and infections. This was a random opportunity for discovery. Resident Identifiers: #8, #27, #38, #40, #68, #71, #97 and #101. Facility Census: 106
Findings Included:
a) On 12/10/23 at 12:11 PM it was observed that staff were passing the lunch meal trays on the [NAME] Fort Court hallway without providing hand hygiene for the residents. It was observed in Rooms 400, 401, 417 and 419 (each a semi-private room) received their meals without hand hygiene being offered or performed. The Residents affected were Resident numbers #8, #27, #38, #40, #68, #71, #97 and #101.
On 12/10/23 at 12:14 PM this was confirmed with Certified Nurse Aide #34 who stated they usually give the Residents sanitizer wipes to wipe their own hands. There were no wipes provided to the above Residents.
This was further confirmed with the Director of Nursing on 12/10/23 at 4:10 PM who agreed they should have been given hand sanitizer wipes.
No further information was obtained during the long term survey process.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0883
(Tag F0883)
Could have caused harm · This affected multiple residents
Based on record review and staff interview the facility failed to administer seasonal influenza vaccines in accordance to the Centers for Disease Control and Prevention (CDC) guidelines for the 2023-2...
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Based on record review and staff interview the facility failed to administer seasonal influenza vaccines in accordance to the Centers for Disease Control and Prevention (CDC) guidelines for the 2023-2024 influenza season. Facility: Facility Facility Census 106
Findings Included:
a) On 12/12/23 at 11:34 AM record review of facility influenza vaccines shows sixty six (66) of the 106 Residents residing in this facility have not been vaccinated for the 2023-2024 influenza season.
Facility Census: 106
Influenza vaccines administered as of 12/12/23 for the 2023-2024 influenza season: 40
Consents obtained in October and on 11/01/23 for the influenza vaccine but have not been administered as of 12/12/23: 16
Residents that have been entered in Point Click Care as vaccine requested but no consent obtained as of 12/12/23: 13
Residents that no action has been taken towards receiving the influenza vaccine consents or the vaccine itself this season: 17
Residents that have refused the vaccine: 10
According the the CDC vaccination should be offered during September or October
During an interview on 12/12/23 at 2:03 PM the above findings were confirmed with the Director of Nursing who confirmed the influenza vaccine serum vials are in house and the vaccines should have been administered prior to this date.
Sept 2023
4 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0583
(Tag F0583)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, the facility failed to ensure residents receiving a shower in the Long Hall Shower Roo...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, the facility failed to ensure residents receiving a shower in the Long Hall Shower Room on [NAME] Court were afforded full visual privacy. The shower curtain was torn in multiple areas and half of the shower curtain was hanging down from the ceiling track. This was a random opportunity for discovery. Facility census: 112.
Findings included:
a) Shower Curtain
Observation on 09/26/23 at 12:00 PM in the Long Hall Shower Room on [NAME] Court found the shower curtain to be torn in multiple areas and half of the shower curtain hanging down from the ceiling track. The Interim Director of Nursing (DON) acknowledged this did not allow a resident receiving a shower to have full visual privacy and stated she would have the issue addressed. The Interim DON stated to her knowledge the Maintenance Staff had not been notified of this issue prior to this observation.
During an interview on 09/26/23 at 1:50 PM, the Administrator reported the facility had no documentation that the ripped shower curtain in the Long Hall Shower Room on [NAME] Court had been addressed as an issue with the Maintenance Department prior to Surveyor intervention.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Medical Records
(Tag F0842)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based upon record review and staff interview, the facility failed to document accurately in the resident's medical record. Resid...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based upon record review and staff interview, the facility failed to document accurately in the resident's medical record. Resident #102. Facility census 113.
Findings include:
a) Resident #102
On 09/25/23 a review of Resident #102's skin assessment dated [DATE] at 11:18 a.m., revealed the resident did not have any skin areas noted. However, the resident had documented larva in a wound on 09/11/23.
Interview with the Interim Director of Nursing verified the finding and the finding was acknowledged by the Administrator upon exit on 09/26/23 at 5:00 p.m.
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
Safe Environment
(Tag F0921)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interviews, the facility failed to ensure a safe, functional, sanitary, and comfortable environme...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interviews, the facility failed to ensure a safe, functional, sanitary, and comfortable environment for the residents. Fecal matter was not cleaned from the shower room floor following resident showers. This had the potential to affect a limited number of residents. Facility census: 112.
Findings included:
a) Fecal Matter on the Floor in Shower Room
When entering the Short Hall Shower Room on [NAME] Fort Court on 09/26/23 at 12:10 PM, the Interim Director of Nursing (DON) stated, I am sorry. It seems to really smell in here today as she moved two (2) rolling bins with lids to the right to afford entry into the shower room itself. Surveyor and Interim DON then observed fecal matter which had been left on the floor following a resident's shower. The Interim DON stated, Well, that would be why it smells so bad. The Interim DON acknowledged the fecal matter as an infection prevention and immediately went to the Nurses Station to question the staff present if they knew had used the shower room last. Certified Nursing Assistant (CNA) #81 and CNA #5 reported it was not them. CNA #81 then questioned, Is there stuff on the floor? And then volunteered, I will go clean it up.
When questioned, both CNA #81 and CNA #5 reported they each had witnessed fecal matter on the shower room floor in the past that had been left after a resident had been showered. Both CNAs reported that they have found it necessary to clean it themselves prior to showering their assigned residents.
During an interview on 09/26/23 at 2:00 PM, the Administrator acknowledged the facility had previously been made aware of the concern (around 9/11/23) that CNAs were leaving fecal matter on the floor following resident showers and the facility had implemented a training program to address the concern. The Administrator agreed to provide the Surveyor with training records. At 4:11 PM, the Administrator reported she had spoken in error and that the training regarding the cleaning of fecal matter from shower floors had not yet been implemented. This had been an oversight and the Administrator stated it would immediately be addressed.
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
Infection Control
(Tag F0880)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** b) On 09/25/23 at approximately 12:!5 p.m., observation in the resident dining area revealed the facility had plastic up and had...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** b) On 09/25/23 at approximately 12:!5 p.m., observation in the resident dining area revealed the facility had plastic up and had been performing construction.
The plastic was not properly sealed which could cause dust and debris to enter the surrounding areas. It was also observed that the facility was not utilizing negative air flow and hepa filters in the construction area. The facility had not completed an Infection Control Risk Assessment (ICRA) regarding the construction needed.
b) Interview with the contractor and Director of Plant Maintenace verifed the findings and also the finding was acknowledged by the Administrator upon exit on 09/26/23 at 5:00 p.m.
Based on staff interview and resident interview, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Staff failed to don appropriate Personal Protection Equipment (PPE) when providing care for residents placed in Droplet Precautions. These failed practices had the potential to affect more than a limited number of residents who currently reside at the facility. Facility census: 112.
Findings included:
a) Donning Appropriate Personal Protection Equipment (PPE)
A brief general observation tour was conducted on 09/25/23 at 12:05 PM. The following resident rooms were under droplet precautions:
-room [ROOM NUMBER]
-room [ROOM NUMBER]
-room [ROOM NUMBER]
-room [ROOM NUMBER]
-room [ROOM NUMBER]
-room [ROOM NUMBER]
-room [ROOM NUMBER]
-room [ROOM NUMBER]
-room [ROOM NUMBER]
-room [ROOM NUMBER]
-room [ROOM NUMBER]
-room [ROOM NUMBER]
-room [ROOM NUMBER]
Review of the facility's Standard Precautions and Transmission Based Precautions - Infection Prevention / Infection Control policy, with a revision date of 06/25/21, revealed the following directive related to droplet precautions: Staff will utilize the proper PPE upon entering the room or cubical area including gloves, mask, and eye protection before contacting the resident or environment.
During Anonymous Interview on 09/25/23 it was reported the staff member had witnessed CNA #59 and CNA #82 enter Resident #14's room (room [ROOM NUMBER] which is a Droplet Precaution room) ungowned and ungloved to help transfer resident from her chair back to bed. The anonymous staff member also overhead resident's roommate, Resident #96, questioning why the two (2) staff were not wearing the appropriate PPE.
When interviewed on 09/26/23 at 4:00 PM, Resident #96 reported CNA #59 and CNA #82 had indeed entered the room ungowned and ungloved yesterday afternoon to help her roommate get back in bed. Resident #96 stated, They are not the only staff who do it. Many don't follow the rules.
Resident #14, who was the resident receiving the assistance back to bed the previous day, also confirmed CNA #59 and CNA #82 had not been wearing gowns or gloves. Resident #14 also stated it was not the first time staff had entered the room ungowned and ungloved.
A brief record review showed that both Resident #96 and Resident #14 were cognitively intact.
During an interview on 09/26/23 at 4:11 PM, the Administrator acknowledged that the facility had previously been made aware of the concern (around 9/11/23) that staff were not donning PPE prior to entering rooms under droplet precautions and the facility was in the process of implementing a training program to address the concern.
Sept 2023
2 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Medical Records
(Tag F0842)
Could have caused harm · This affected 1 resident
Based on record review and staff interview the facility failed to ensure medical records were complete. Resident #113's medical record did not contain information from psychiatric visits. This was a r...
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Based on record review and staff interview the facility failed to ensure medical records were complete. Resident #113's medical record did not contain information from psychiatric visits. This was a random opportunity for discovery. Facility census: 112.
Findings include:
a) Resident #113
At 10:54 AM on 09/13/23, the Director of Nursing confirmed the Resident had tele-med visits with a psychiatrist and the information from the visits were not in the Resident's medical record. The DON provided printed progress notes from visits to the psychiatrist occurring on 10/05/22, 03/27/23 and 06/27/23. There was no indication until today, 09/13/23 that the notes from the visits were obtained prior to surveyor intervention by the facility and provided to the physician for review.
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
Staffing Information
(Tag F0732)
Could have caused harm · This affected multiple residents
Based on observation and staff interview, the facility failed to ensure the daily posting of nursing staff working was completed and placed in an area accessible to residents and visitors. This had th...
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Based on observation and staff interview, the facility failed to ensure the daily posting of nursing staff working was completed and placed in an area accessible to residents and visitors. This had the potential to affect more than a limited number of residents. Facility census: 112.
Findings include:
a) Staff Posting
Observation of the staff posting with the Director of Nursing (DON) at 2:50 PM on 09/12/23 found the staff posting was dated 09/11/23. The DON said she would post current information.
Jun 2022
15 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0557
(Tag F0557)
Could have caused harm · This affected 1 resident
.
Based on observation, policy review and staff interviews the facility failed to ensure Resident #44 was provided dignity while participating in a group activity. A staff member was assisting Residen...
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Based on observation, policy review and staff interviews the facility failed to ensure Resident #44 was provided dignity while participating in a group activity. A staff member was assisting Resident #44 with a physician ordered snack while participating in bingo. This was a random opportunity for discovery. Resident Identifier: Resident #44. Facility Census: 111.
Finding Included:
a) Resident #44
During an observation on 06/13/22 at 2:13 PM, the scheduled 2:00 PM Bingo Game was held in the main dining room. Restorative Aide (RA) #26 was assisting Resident #44 with her snack during the group activities.
During an interview on 06/13/22 at 2:14 PM, RA #26 stated, If we don't assist her with her Ensure she will not eat it. I always feed them during the activities, if they are need help.
During an interview on 06/13/22 at 2:15 PM, the DON stated It is a dignity issue, you can't interrupted a activity.
.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0578
(Tag F0578)
Could have caused harm · This affected 1 resident
.
Based on record review and staff interview the Physicians Orders for Scope of Treatment (POST) form was not completed in its entirety in Section C for medical administered fluids and nutrition for R...
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Based on record review and staff interview the Physicians Orders for Scope of Treatment (POST) form was not completed in its entirety in Section C for medical administered fluids and nutrition for Resident #22. Resident identifiers: #22. Facility census: 111.
Findings included:
a) Resident #22
On 06/13/22 at 1:56 PM a record review found the POST form dated 11/19/20 instructing Do Not attempt resuscitation (DNR), comfort measures, no feeding tube and Intravenous Fluids (IVF) for a trial period of no longer than ____________ which was not completed in its entirety as no time period was stated.
On 06/14/22 at 11:49 AM an interview with the Director of Nursing confirmed the POST form was not completed correctly due to missing information relating to the trial period of IVF to be administered.
No further information was provided through the completion of the survey.
.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
.
b) Resident #71
An observation on 06/14/22 at 8:12 AM, revealed Resident #71's breakfast meal was served in a Styrofoam tray.
During a interview on 06/14/22 at 8:15 AM, the ADON #62 stated Resident ...
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b) Resident #71
An observation on 06/14/22 at 8:12 AM, revealed Resident #71's breakfast meal was served in a Styrofoam tray.
During a interview on 06/14/22 at 8:15 AM, the ADON #62 stated Resident #71 has had suicidal hallucinations, she has thrown silverware and plates, its to protect staff and herself.
Medical record review found a care plan with an initiation date of 12/10/19 and a revision date of 05/02/22 failed to address of use of Styrofoam plates, bowls and plastic cutlery with meals.
A medical record review on 06/14/22, found a physician order dated 04/06/22: regular diet, regular texture, Styrofoam plates, bowls and plastic cutlery with all meals.
During an interview on 06/14/22 at 10:34 AM, the Food Service Director #21 stated Resident #71 receives a Styrofoam tray due to stabbing people, throwing plates and cups at staff and other residents. I put some of the care plans in and the nursing puts some of them. It just depends on who sees it first that needs done. When I get a order I change it and check the care plan. I guess we all missed it. Food Service Director #21 acknowledged no care plan focus, goal or intervention was provided for the use of Styrofoam plates, bowls and plastic cutlery.
Based on resident interview, record review, and staff interview the facility failed to develop and or implement a care plan for two (2) of 28 residents reviewed during the long-term care survey. Resident #69's care plan was not implemented for pain management. Resident #71's care plan was not developed to include the use of Styrofoam plates during dining. Resident identifiers: #69 and #71. Facility census: 111.
Findings included:
a) Resident #69
During an interview with the Resident on 06/13/22 at 11:31 AM, she expressed she had pain due to neuropathy and Fibromyalgia.
Review of the current care plan found a focus:
Patient is at risk for pain/ RLS (restless leg syndrome)/neuropathy
The goal associated with the focus:
Patient's pain will be well managed as evidence by voiced satisfaction with pain management or no signs/symptoms of pain i.e.: grimacing, frowning, crying, moaning or guarding through next review period.
Interventions included:
Administer medications as prescribed by physician.
Assess characteristics of pain (location, duration, quality, aggravating/alleviating factors, radiation, intensity). If possible and document. Observe for signs and symptoms of pain such as grimacing, guarding, or moaning. Observe for effectiveness of pain relieving measures (non-pharmacological or medication).
Assess for effectiveness of medication, notify physician of unrelieved pain.
Assist patient with positioning frequently as patient will allow and tolerate.
Encourage patient to use relaxation techniques and/or diversional activity (music, television, conversation) as alternative methods of pain management.
Pain assessment per center protocol
Use positional devices such as pillows or wedges to reposition and sustain comfort for help with pain management.
Record review found the resident is receiving the following medications for pain management:
Neurontin Capsule 300 MG (Gabapentin), Give 2 capsule by mouth three times a day related to chronic pain. Start Date: 01/01/22.
Tylenol Extra Strength Tablet 500 MG. (Acetaminophen), Give 2 tablet by mouth at bedtime related
to other idiopathic peripheral autonomic neuropathy, do not exceed daily dose of 3 grams.
Start Date: 12/01/21.
Tylenol Extra Strength Tablet 500 MG., (Acetaminophen), Give 2 tablet by mouth every 12 hours as
needed for pain prior to administering attempt to redirect with non-pharm (non-pharmacological) interventions such as decreasing stimulation, repositioning, offering snacks, distraction techniques document 3 nonpharm attempts if no improvements administer med
Start Date: 06/12/22.
Prior to 06/12/22 the resident's order for PRN (as Needed) Tylenol read:
Tylenol Extra Strength Tablet 500 MG., (Acetaminophen), Give 2 tablet by mouth every 12 hours as
needed for pain: administer if pain is 1-5 on pain scale do not exceed daily dose of 3gm
Start Date: 03/02/22. Discontinued: 06/12/22.
Review of the medication administration record (MAR) for June 2022 found the facility rates pain daily by answering the question, Is Resident currently experiencing pain? (1) for yes and (2) for no for 2 shifts a day 7:00 AM - 7:00 PM and 7:00 PM to 7:00 AM.
On 06/11/22, 06/12/22, and 06/13/22 the resident was coded as having pain on 7:00 AM - 7:00 PM. shift. The resident did not receive the PRN (as needed) Tylenol. The new order for Tylenol, written on 06/12/22 which directed staff to provide non-pharmacological interventions prior to administering the Tylenol was not documented for the Residents complaints of pain on 06/12/22 and 06/13/22.
An interview with the Assistant Director of Nursing (ADON) at 10:11 AM on 06/14/22 confirmed nursing staff failed to provide Tylenol PRN on 06/11/22, 06/12/22 and 06/13/22 when the Resident complained of pain. In addition, the ADON confirmed nursing documentation for the non-pharmacological interventions on 06/12/22 and 06/13/22 should have been documented if the non-pharmacological interventions were offered, successful and relieved the Resident's pain. The ADON confirmed she could not find any indications non-pharmacological interventions were offered to try to relieve the Resident's pain.
On 06/14/22 at 12:46 PM, the care plan and the Resident's pain management was discussed with the Director of Nursing (DON.) No further information was provided.
.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected 1 resident
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Based on resident interview, record review, and staff interview, the facility failed to ensure a resident, totally dependent upon staff for bathing, received showers as preferred and scheduled.
This...
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Based on resident interview, record review, and staff interview, the facility failed to ensure a resident, totally dependent upon staff for bathing, received showers as preferred and scheduled.
This was true for one (1) of two (2) residents reviewed for the care area of activities of daily living (ADL) care. Resident identifier: #69. Facility census: 111.
Findings included:
a) Resident #69
On 06/13/22 at 10:51 AM, the resident expressed concern she was not always cleaned up very well after incontinence care and would like more showers.
Review of the most recent quarterly Minimum Data Set (MDS) with an assessment reference date (ARD) of 05/03/22, found the resident required total dependence with bathing.
Record of the Resident's medical record, found the resident receives showers on Monday and Thursdays from 7:00 AM to 7:00 PM. Further review of the shower schedule for the past 30 days found the following days when showers were scheduled and not received:
05/23/22
05/30/22
On 06/06/22 the Resident was coded as not being available for the shower
On 06/14/22 at 10:14 AM, the Assistant Director of Nursing (ADON) reviewed the documentation and was unable to explain why the Resident did not receive a shower on 05/23/22 and 05/30/22. In addition, the ADON said she did not have an answer as to why the Resident was coded as being unavailable for a shower on 06/06/22. The ADON said there was no evidence the resident was out of the facility on 06/06/22.
On 06/14/22 at 3:45 PM, the Director of Nursing (DON) reviewed the Resident's shower schedule and provided no further information.
.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0679
(Tag F0679)
Could have caused harm · This affected 1 resident
.
Based on resident interview, staff interview, and record review, the facility to ensure one (1) of one (1) resident reviewed for the care area of activities was offered an activity that reflected cu...
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Based on resident interview, staff interview, and record review, the facility to ensure one (1) of one (1) resident reviewed for the care area of activities was offered an activity that reflected current interests and former lifestyles. Resident identifier: #69. Facility census: 111.
Finding included:
a) Resident #69
On 06/13/22 at 10:54 AM, the resident said her activities mostly consistent of watching Netflicks on her tablet in her room. She said she would really like to go outside and expressed how she always loved the outdoors. She said they have activities outside because other residents go outside including her roommate. The resident said she could only set up for 45 minutes or so at a time due to the pain from her fibromyalgia and neuropathy. She said, they probably don't take me outside because they don't want to get me up and then put me back to bed after only 45 minutes.
Review of the resident's current care plan found the following focus:
Enjoys activities such as reading, music, group activities (bingo), outdoors, religious/spiritual and she likes crafts.
The goal associated with the problem:
Patient will participate in independent leisure activities of choice daily and out of room activities of choice as they become available through next review.
Interventions included:
Encourage participation in group activities of interest such music groups, special events, bingo and other action games.
Provide supplies/materials for leisure activities as needed/requested during 1:1 visits with activity cart.
Respect her choice of little or no activity involvement at times.
On 06/14/22 at 11:07 AM, the activity director acknowledged other residents do go outside as weather permits. The AD said residents like to set out front of the building on the patio and acknowledged residents were outside on this date. The surveyor observed several residents sitting on the front patio on all three (3) days of the survey. The AD provided the Resident's participation logs for May 2022 and June 2022. The daily participation record listed outdoor activities; however, the Resident had not attended any outdoor activities for May and June.
On 06/14/22 at 3:44 PM, the above observations and interviews were discussed with the Director of Nursing (DON.) No further information was provided.
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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
.
b) Resident #108
The facility's policy and procedure titled Neurological Assessment with implementation date 03/27/18 and review/revision date 05/03/21 stated neurological assessments were indicated...
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b) Resident #108
The facility's policy and procedure titled Neurological Assessment with implementation date 03/27/18 and review/revision date 05/03/21 stated neurological assessments were indicated following an unwitnessed fall.
Review of Resident #108's medical records revealed the resident had an unwitnessed fall on 05/28/22 at 12:30 PM. According to the incident report, This nurse looked up hallway and resident was crawling on hands and knees. The incident report also stated, Started neurochecks. Neurological checks following Resident #108's fall on 05/28/22 could not be located in the medical records.
During an interview on 06/15/22 at 7:49 AM, the Director of Nursing (DON) confirmed neurological checks following Resident #108's fall on 05/28/22 could not be located. The DON confirmed Resident #108's fall on 05/28/22 was unwitnessed and neurological checks were indicated.
Based on resident interview, record review, and staff interview, the facility failed to ensure residents received care and treatment in accordance with professional standards of practice. For Resident #15 non-pressure skin conditions were not investigated and the facility failed to ensure there was a joint collaborative effort, between the Hospice agency and the facility to provide Hospice care. For Resident #108 neurochecks were not completed after an unwitnessed fall. This was true for one (1) resident reviewed for non-pressure skin conditions, one (1) of one (1) resident reviewed for Hospice/end of life care, and one (1) of four (4) residents reviewed for accidents. Resident identifiers: #15 and #108. Facility census: 111.
Findings included:
a) Resident #15 - 1. Skin conditions
Observation of the resident on 06/13/22 11:22 AM, found two (2) horizontal abrasions to the right upper arm. Each abrasion was approximately 1 to 2 inches long and approximately 1/8 inches wide. The two (2) abrasions were separated by approximately 1/2 inch. When asked about the abrasions, the resident said, I was in the floor right there. The resident pointed to the floor beside his bed and said he fell earlier today.
Observation of the Resident with the Director of Nursing (DON) on 06/14/22 01:08 PM, found the areas on the right upper arm were still present and had began developing scabs. (The resident had a dressing to the left elbow which had been investigated and was currently being treated.) The DON said she would have to look to see how the resident received the injuries. When the Resident was asked today how the areas happened on the upper arm, the Resident stated, the nurses raked me across the bed and tore off the scabs.
On 06/14/22 at 2:08 PM, the DON said she was unable to find any information regarding how the two abrasions to the right arm occurred. The DON said she was investigating the incident and had reported the incident to the proper State authorities based on the Residents statement on 06/14/22 at 1:08 PM. On 06/14/22 after surveyor intervention, a physician's order was written to monitor scabbed areas to right arm for sign or symptoms of infection.
On 06/15/22 at 7:52 AM, the DON was again asked if she had found any information regarding the abrasions on the right arm.
At the close of the survey, no further information was provided.
a) Resident #15 - 2 Hospice Services
On 06/13/22 at 11:21 AM, the resident said he doesn't see the Hospice people and he doesn't know what Hospice does when they come to see him.
Record review found a physician order dated 03/23/22 for:
Hospice services provided by: (Name and address of Hospice agency.) Diagnosis: dementia with lewy bodies.
06/14/22 at 12:17 PM, Licensed Practical Nurse (LPN) #88 said she did not know where the communication between the facility and the Hospice agency is kept. She said, they (the Hospice nurse) just stops and talks to us when they are here. If they change anything we put it in the computer. They ask us if the resident has had any changes and then they go and assess the resident. If anything is new they stop and tell us. LPN #88 did not know when the Hospice staff makes visits to the facility.
On 06/14/22 at 12: 20 PM, LPN #123 said she was the resident's nurse for this day, and she did not know where Hospice staff notes are kept.
Review of the current care plan found a focus:
Resident had been admitted by name of Hospice agency. Terminal diagnosis dementia with Lewy Bodies.
The goal associated with the focus:
Resident will have physical, spiritual and emotional needs met through collaboration of Hospice/(Name of facility) as evidence by being clean, dry, well groomed, and will not show signs of unrelieved pain or distress such as crying, fearfulness, moaning, grimacing or guarding daily thorough next review.
Interventions included:
Admit to (Name of Hospice agency and telephone number.)
Avoid hospitalization if condition worsens. DO NOT CALL 911 - CALL HOSPICE (list number) and ask to speak to the Hospice nurse on call.
Call Hospice for changes in: medications, DME (durable medical equipment,) medical supplies, lab work/xrays, secondary physician consults, ambulance transfer, other areas relating to terminal disease.
Hospice aide to visit as ordered.
Hospice is responsible for clinical management of any care related to the resident's hospice diagnosis. PLEASE ALL HOSPICE FIRST regarding any clinical changes so they can discuss the POC (plan of care)and proposed changes for the following: pain control, SOB (shortness of breath), skin breakdown, N/V (nausea/vomiting), anorexia, constipation, appropriate activity level, general decline in condition and other area relating to terminal illness.
Hospice must approve of any changes in care of services related to palliative treatment of the Hospice diagnosis.
Hospice nurse to visit as ordered.
Hospice to provide (name of facility) with up to date copies of Hospice Care Plan and Care Plan review.
If a need for patient/family support or counseling between regular Hospice visits is identified, notify Hospice.
Keep the environment quiet and calm. Keep linens clean, dry and wrinkle free. Keep lighting low and familiar objects near.
May have compassionate care visits
Notify Hospice at time of death so that they may provide support to the family and to ensure that arrangements have been made.
Observe resident closely for signs of pain, administer pain medications as ordered, and notify physician and Hospice immediately if there is breakthrough pain.
Offer food and fluids as tolerated.
Spiritual Counselor to visit as ordered and prn (as needed.)
Work cooperatively with Hospice team to ensure the resident's spiritual, emotional, intellectual, physical and social needs are met.
On 06/14/22 at 12:24 PM, the Assistant Director of Nursing (ADON) said notes from the Hospice agency are kept in a note book which is kept by the medical records clerk (MRC.) The ADON was unable to provide any information the care plan was formulated with the Hospice agency. The ADON did not know when any staff from the Hospice agency visits.
On 06/14/22 12:31 PM, Employee #93, the MRC said she had a file folder in her office. She provided copies of the most recent notes from the Hospice agency. The last visit from the Hospice agency nurse was dated 05/09/22. MRC #93 said there are no more recent notes.
An interview on 06/14/22 at 12:46 PM, with the Director of Nursing (DON) found the facility was unable to provide evidence the Hospice agency had visited the resident since 05/09/22 and was unable to provide evidence the Hospice agency participated in the care planning process.
A second interview with the DON on 06/14/22 02:07 PM, found no further information was provided.
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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 resident interview, staff interview, and medical record review, the facility failed to provide evidence a fall was investigated timely to ensure the environment was free from accident hazar...
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Based on resident interview, staff interview, and medical record review, the facility failed to provide evidence a fall was investigated timely to ensure the environment was free from accident hazards over which the facility has control. The facility was unable to provide evidence at the time of discovery to ensure a complete investigation was conducted to determine if a resident fall was avoidable/unavoidable, evaluation of any possible risks/hazards surrounding the fall, and implementation of any individualized, resident-centered interventions for fall prevention. This was true for one (1) of four (4) residents reviewed for accidents. Resident identifier: #15. Facility census: 111.
Findings included:
a) Resident #15
On 06/13/22 at 12:05 PM , the Resident said he fell earlier. I was on the floor right there and pointed to the floor beside his bed. He stated, I don't know what happened, I just went down.
Further investigation into the alleged fall found a nursing note dated 6/13/22 at 4:30 AM. (Typed as written)
eINTERACT SBAR Summary for Providers Situation: The Change In Condition/s reported on this CIC Evaluation are/were: Falls
At the time of evaluation resident/patient vital signs, weight and blood sugar were:
- Blood Pressure: BP 144/72 - 6/13/2022 04:39 Position: Lying r/arm
- Pulse: P 63 - 6/13/2022 04:39 Pulse Type: UTD - Unable to Determine
- RR: R 16 - 6/13/2022 04:39
- Temp: T 97.9 - 6/13/2022 04:40 Route: Forehead (non-contact)
- Weight: W 184.8 lb - 6/8/2022 10:57 Scale:
- Pulse Oximetry: O2 96 % - 6/13/2022 04:39 Method: Room Air
- Blood Glucose: BS 146.0 - 6/12/2022 14:17
Resident/Patient is in the facility for: Long Term Care
Primary Diagnosis is: G31.83 Dementia with Lewy Bodies F02.81 Dementia in other diseases classified elsewhere with behavioral disturbance Z51.5 Encounter for palliative care
Relevant medical history is: CHF COPD Dementia Diabetes Chronic Renal Failure/ESRD
Code Status: DNR
Advance directives are:
Resident/Patient had the following medications changes in the past week:
Resident/Patient is on Coumadin/warfarin:No
The result of last INR: Date:
Resident/Patient is on anticoagulant other than warfarin: No
Resident/Patient is on:
Outcomes of Physical Assessment: Positive findings reported on the resident/patient evaluation for this change in condition were:
- Mental Status Evaluation: Other
- Functional Status Evaluation: Fall
- Behavioral Status Evaluation:
- Respiratory Status Evaluation:
- Cardiovascular Status Evaluation:
- Abdominal/GI Status Evaluation:
- GU/Urine Status Evaluation:
- Skin Status Evaluation:
- Pain Status Evaluation: Does the resident/patient have pain?
- Neurological Status Evaluation:
Nursing observations, evaluation, and recommendations are:Resident assisted back to bed; observed for injuries and neuro checks initiated
Primary Care Provider Feedback: Primary Care Provider responded with the following feedback:
A. Recommendations:
B. New Testing Orders:
- Other
- n/a
C. New Intervention Orders:
- Other
- n/a
Review of the current care plan found a focus:
Potential for injuries from falls. My most recent fall was 06/08/22.
The goal associated with the focus:
Resident will have no major injury from falls, such as fractures, head injury, or dislocations, through next review period.
Interventions included:
Assure that the lighting is adequate and keep room and hallways free of clutter.
Call light in reach and answered promptly
Check on resident frequently as he may not remember to use the call light
Dump wheelchair
Encourage/assist resident to keep frequently used items within reach
Ensure he is wearing gripper socks or shoes prior to transfers
Ensure non skid socks are easily accessible for resident in his room
Ensure resident has shoes on or nonskid socks while up in chair or transferring
Ensure resident is positioned in center of bed
Establish a toileting schedule
Evaluate current mattress
Evaluate current transfer status
Evaluate shoes for proper fitting
NP (nurse practioner) completed medication review and made adjustments
Observe for side effects from medications
Observe resident for steadiness, balance, proper positioning in bed and chair.
Offer to get unit charge nurse when restless at night
Offer use of hand held bell
Perimeter mattress
Provider to continue to observe due to continued decline in medical condition
Psych. consult
Remind resident to ring call light and wait for assistance
Staff education not to leave in bathroom
On 06/14/22 at 12:51 PM, the Director of Nursing (DON) provided the above progress note dated 06/13/22 at 4:30 AM, and said, this is all I can give you regarding the Resident's fall. The facility has completed a RMS (Risk Management System) report but this report is not a matter of public record it is an internal investigation that can't be shared. The DON said a note regarding the fall, what was going on at the time of the fall, the assessment of the resident, the interventions added if any, notification of a family member, etc. were supposed to be written in a progress note but that didn't happen for this fall for this resident. The surveyor asked if any information could be shared to determine if the fall was an accident, witnessed/non witnessed, were any interventions in place for fall prevention, were any interventions added, any information to determine if the facility provides proper supervision to prevent accidents etc?
The DON was able to provide a note the medical power of attorney (MPOA) was notified later in the morning regarding the Resident's fall.
On 06/15/22 at 8:15 AM, the DON said she wrote a note in the resident's medical record explaining the fall, this note was after surveyor intervention.
On 06/15/22 at 8:33 AM, the regional vice president of operations (employee #126) confirmed the RMS report can not be shared with surveyors as it is the facility's internal investigation. No further information was provided.
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CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Tube Feeding
(Tag F0693)
Could have caused harm · This affected 1 resident
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Based on record review and staff interview, the facility failed to ensure a resident who was fed by enteral means received treatment and services in accordance with professional standards of practic...
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Based on record review and staff interview, the facility failed to ensure a resident who was fed by enteral means received treatment and services in accordance with professional standards of practice. The physician's order for enteral water flushes was incorrectly recorded on the Medication Administration Record (MAR). This deficient practice had the potential to affect one (1) of one (1) residents reviewed for the care area of tube feeding. Resident identifier: #9. Facility census: 111.
Findings included:
a) Resident #9
Review of Resident #9's medical records showed a physician's order written on 04/22/22 for One time a day every shift flush PEG (percutaneous endoscopic gastrostomy) tube with 200 water Q4h (every four (4) hours) =1200 TDV (total diffusion volume).
Resident #9's MAR only indicated the water flush should be performed (1) time a day at 2:00 PM.
During an interview on 06/14/22 at 12:05 PM, Registered Nurse (RN) #79 stated Resident #9's PEG tube was to be flushed with 200 cc of water every four (4) hours or six (6) times a day to equal 1200 cc of water a day. RN #79 confirmed Resident #9's MAR indicated the PEG tube was to be flushed one (1) time a day.
No further information was provided through the completion of the survey.
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CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0698
(Tag F0698)
Could have caused harm · This affected 1 resident
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Based on policy review, record review and staff interview, the facility failed to complete pre and post dialysis assessments consistent with professional standards of practice. This is true for one ...
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Based on policy review, record review and staff interview, the facility failed to complete pre and post dialysis assessments consistent with professional standards of practice. This is true for one (1) of one (1) resident reviewed for dialysis. Resident (R) identifier: R #111. Facility census 111.
Findings include:
a) Resident #111
The facility policy titled Hemodialysis: Care and Maintenance with a revision date of 05/03/21, states staff will complete a pre-hemodialysis assessment before the resident leaves the facility for dialysis and a post-hemodialysis assessment upon return to the facility.
Review of the medical record found R #111 receives hemodialysis at an outside facility every Tuesday and Saturday. The Hemodialysis Communication Book notes the resident received dialysis treatments on the following days: 04/02/22, 04/06/22, 04/09/22, 04/12/22, 04/16/22, 04/19/22, 04/23/19, 04/26/22, 04/30/22, 05/03/22, 05/07/22, 05/10/22, 05/14/22, 05/17/22, 05/21/22, 05/24/22, 05/28/22, 05/31/22, 06/04/22, 06/07/22, and 06/11/22.
The facility records are silent for the following assessments:
Pre-dialysis assessments were not completed on: 04/02/22, 04/06/22, 04/09/22, 04/23/22, 04/26/22, 04/30/22, 05/03/22, 05/10/22, 05/17/22, 05/21/22, and 05/24/22. Post-dialysis assessments were not completed on 04/26/22, 05/17/22 and 05/21/22.
During a staff interview on 06/14/22 at 03:22 PM, Assistant Director of Nursing (ADON) #79 acknowledged R #111 receives Hemodialysis every Tuesday and Saturday. ADON #111 agreed pre and post dialysis assessments were not completed on the above listed dates.
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CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0813
(Tag F0813)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
b) room [ROOM NUMBER], room [ROOM NUMBER] (2) refrigerators and room [ROOM NUMBER]
A random observation on 06/13/22 found resi...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
b) room [ROOM NUMBER], room [ROOM NUMBER] (2) refrigerators and room [ROOM NUMBER]
A random observation on 06/13/22 found resident personal refrigerators in the following rooms 402, 413 and 415 containing food and drink with no temperature logs indicating the facility ensured safe storage of food.
On 06/14/22 at 3:05 PM, the Assistant Maintenance Director #70 acknowledge that the facility is not monitoring resident the temperatures of personal refrigerators.
Based on policy review, observation, and staff interview, the facility failed to ensure safe and sanitary use of resident owned refrigerators. This is true for five (5) refrigerators identified by random opportunity. Resident rooms: 207, 402, 413, and 415. Facility census: 111.
Findings include:
a) room [ROOM NUMBER]
The facility policy titled: Patient Refrigerators revised 05/03/21, states, It is the policy of this center to ensure safe and sanitary use of any patient owned refrigerator. Maintenance shall record refrigerator temperatures weekly on a temperature log attached to the refrigerator.
A random observation on 06/13/22 found a personal refrigerator in the corner of room [ROOM NUMBER]. A follow up review on 06/14/22 at 3:50 PM found the refrigerator contained multiple food and drink items and no thermometer or temperature log indicating the facility ensured safe storage of food items.
On 06/14/22 at 03:51 PM, the Assistant Director of Nursing (ADON) #79 reported she is unaware of a facility policy to check refrigerator temperatures. The ADON acknowledged the facility is not monitoring personal refrigerator temperatures and confirmed this practice puts the residents at risk for food bourne illnesses.
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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 medical record review and staff interview the facility failed to ensure a complete and accurate order for Seroquel for Resident #64 to include a mood disorder. This deficient practice was f...
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Based on medical record review and staff interview the facility failed to ensure a complete and accurate order for Seroquel for Resident #64 to include a mood disorder. This deficient practice was found for one (1) of five (5) residents reviewed for the care area of unnecessary medications, during the Long Term Care Survey Process. Resident identifier: #64. Facility census: 111
Findings included:
a) Resident #64
During a medical record review on 06/15/22, it was discovered an order for Seroquel 25 milligrams (mg) once daily in the evening for insomnia with a start date of 04/05/22 did not include the mood disorder. A review of the Neurology Consultation on 04/05/22 indicated the order was to include mood disorder and sleep disturbances.
An interview with the Director of Nursing (DON) on 06/15/22 at 11:30 AM, verified the order for Seroquel for Resident #64 was incomplete and did not include a mood disorder.
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CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0921)
Could have caused harm · This affected 1 resident
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Based on observation and staff interview the facility failed to provide a safe, clean and home like environment when a resident had an electrical extension cord in use. This was a random opportunity...
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Based on observation and staff interview the facility failed to provide a safe, clean and home like environment when a resident had an electrical extension cord in use. This was a random opportunity of discovery. Resident identifier: #100. Facility census: 111.
Findings included:
a) Resident #100
An observation on 6/13/22 at 11:36 AM, found an extension cord from the electrical outlet to an cell phone on the bed. Based on an interview on 6/13/22 at 11:38 AM with Restorative Nurse Aide (RNA) #30, no electrical extension cords are permitted for safety purposes. RNA #30 removed the extension cord from the residents room.
According to the Policy and Procedure dated 11/27/17, extension cords are to be used by maintenance personnel only. This was confirmed with the Director of Nursing on 6/14/22 at 3:05 PM.
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CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0697
(Tag F0697)
Could have caused harm · This affected multiple residents
.
c) Resident #65
Review of Resident #65's medical records showed an order written on 6/12/22 for acetaminophen (Tylenol) 500 mg, give one (1) tablet by mouth every six (6) hours as needed for pain. P...
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c) Resident #65
Review of Resident #65's medical records showed an order written on 6/12/22 for acetaminophen (Tylenol) 500 mg, give one (1) tablet by mouth every six (6) hours as needed for pain. Prior to administering, attempt to redirect with non-pharmacological interventions such as decreasing stimulation, repositioning, offering snacks, distraction techniques. Document three (3) non-pharmacological attempts. If no improvements administer medication.
Review of Resident #65's Medication Administration Record (MAR) showed the resident had received acetaminophen on 06/13/22 at 7:56 AM. The pain level was assessed as 9 on a scale from 1-10, with 10 being the worst pain. The MAR indicated the medication was ineffective at relieving the resident's pain.
A medication administration note
was written in the progress notes on 6/13/2022 at 7:56 AM, and stated Acetaminophen Tablet 500 MG Give 1 tablet by mouth every 6 hours as needed for pain prior to administering attempt to redirect with non-pharm interventions such as decreasing stimulation, repositioning, offering snacks, distraction techniques document 3 non-pharm attempts if no improvements administer med. (Note typed as written.) No pharmacological interventions were documented.
A medication administration follow-up note was written in the progress notes on 6/13/2022 at 3:25 PM. This was over seven (7) hours after the pain medication had been given. The note stated, Acetaminophen Tablet 500 MG Give 1 tablet by mouth every 6 hours as needed for pain prior to administering attempt to redirect with non-pharm interventions such as decreasing stimulation, repositioning, offering snacks, distraction techniques document 3 non-pharm attempts if no improvements administer med
PRN Administration was: Ineffective
Follow-up Pain Scale was: 9.
(Note typed as written.)
The medical records contained no further information regarding Resident #65's unrelieved pain on 06/13/22.
During an interview on 06/14/22 at 3:01 PM, the Director of Nursing confirmed non-pharmacological interventions were not documented before administration of the pain medication. The DON also confirmed follow-up regarding effectiveness of pain medication should be performed in one (1) hour after pain medication administration.
During a follow-up interview on 06/14/22 at 3:43 PM, the DON confirmed no additional actions had been taken when Resident #65's pain medication was ineffective in relieving her pain.
No further information was provided through the completion of the survey.
Based on medical record reviews, resident interviews, and staff interviews the facility failed to ensure pain management was provided to residents who require such services, consistent with professional standards of practice for Resident #66, #69 and #65. This was discovered for three (3) of four (4) residents reviewed for pain management. Resident identifiers: #66, #69 and #65. Facility census: 111.
Findings included:
a) Resident #66
In an interview with Resident #66 on 06/13/22 at 11:15 AM, reported his pain medications were given to him over an hour late.
A review of the medical record on 06/14/22 revealed Resident #66 receives Dexamethasone 2 milligrams (mg) once daily at 8:00 AM for low back pain. Baclofen 10 mg 3 times a day at 8:00 AM, 2:00 PM and 8:00 PM for low back pain and Gabapentin 300 mg 3 times a day at 8:00 AM, 2:00 PM, and 8:00 PM for back pain.
The Medication Audit Review for 06/01/22 to 06/14/22 indicated Resident #66 was administered pain medications late on the following days:
06/02/22 Gabapentin and Baclofen 8:00 PM dosages were 1 hour and 17 minutes late.
06/03/22 Gabapentin 8:00 PM dosage was 3 hours and 15 minutes late.
06/04/22 Gabapentin and Baclofen 8:00 PM dosages were 2 hours and 25 minutes late.
06/06/22 Dexamethasone, Gabapentin and Baclofen 8:00 AM dosages were 1 hour and 58 minutes late.
06/13/22 Gabapentin and Baclofen 8:00 AM dosages were 1 hour and 23 minutes late.
An interview with the Director of Nursing (DON) on 06/14/22 at 12:20 PM, verified Resident #66 did not get his pain medications timely on 06/02/22, 06/03/22, 06/04/22, 06/06/22 and 06/13/22. She also reported medications should not be administered outside the one (1) hour acceptable time frame.
b) Resident #69
During an interview with the Resident on 06/13/22 at 11:31 AM, she expressed she had pain due to neuropathy and Fibromyalgia.
Record review found the resident is receiving the following medications for pain management:
Neurontin Capsule 300 MG (Gabapentin), Give 2 capsule by mouth three times a day related to chronic pain. Start Date: 01/01/22.
Tylenol Extra Strength Tablet 500 MG. (Acetaminophen), Give 2 tablet by mouth at bedtime related
to other idiopathic peripheral autonomic neuropathy, do not exceed daily dose of 3 grams.
Start Date: 12/01/21.
Tylenol Extra Strength Tablet 500 MG., (Acetaminophen), Give 2 tablet by mouth every 12 hours as
needed for pain prior to administering attempt to redirect with non-pharm (non-pharmacological) interventions such as decreasing stimulation, repositioning, offering snacks, distraction techniques document 3 nonpharm attempts if no improvements administer med
Start Date: 06/12/22.
Prior to 06/12/22 the resident's order for PRN (as Needed) Tylenol read:
Tylenol Extra Strength Tablet 500 MG., (Acetaminophen), Give 2 tablet by mouth every 12 hours as
needed for pain: administer if pain is 1-5 on pain scale do not exceed daily dose of 3gm
Start Date: 03/02/22. Discontinued: 06/12/22.
Review of the medication administration record (MAR) for June 2022 found the facility rates pain daily by answering the question, Is Resident currently experiencing pain? (1) for yes and (2) for no for 2 shifts a day 7:00 AM - 7:00 PM and 7:00 PM to 7:00 AM.
On 06/11/22, 06/12/22, and 06/13/22 the resident was coded as having pain on 7:00 AM - 7:00 PM. shift. The resident did not receive the PRN (as needed) Tylenol. The new order for Tylenol, written on 06/12/22 which directed staff to provide non-pharmacological interventions prior to administering the Tylenol was not documented for the Residents complaints of pain on 06/12/22 and 06/13/22.
An interview with the Assistant Director of Nursing (ADON) at 10:11 AM on 06/14/22 confirmed nursing staff failed to provide Tylenol PRN on 06/11/22, 06/12/22 and 06/13/22 when the Resident complained of pain. In addition, the ADON confirmed nursing documentation for the non-pharmacological interventions on 06/12/22 and 06/13/22 should have been documented if the nonpharmacological interventions were offered, successful and relieved the Resident's pain. The ADON confirmed she could not find any indications non-pharmacological interventions were offered to try to relieve the Resident's pain.
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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 maintain the kitchen in a safe and sanitary manner in accordance with professional standards for food service safety. It was discovere...
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Based on observation and staff interview the facility failed to maintain the kitchen in a safe and sanitary manner in accordance with professional standards for food service safety. It was discovered during the kitchen tour coffee pots and a beverage dispenser were located directly beside a hand washing sink. This had the potential to affect any resident receiving coffee and fruit juices from the kitchen. Facility census: 111
Findings included:
a) Kitchen tour
During the kitchen tour on 06/13/22 at 10:50 AM, it was discovered the stainless steel table, which housed the two (2) commercial coffee pots and juice machine also had a reassessed sink. The sink was also used as a hand washing sink. The coffee pots were situated on the left side of the sink and the juice machine was located on the right side of the sink. Also water was obtained from the sink to fill the coffee pots and juice machine. At the time of observation there were six (6) pitchers filled with fruit juices situated under the hand soap dispenser. This would mean staff would have to reach over the pitchers to reach the soap dispenser on the wall.
An interview on 06/13/22 at 10:58 AM, with the Dietary Manager (DM), verified the coffee pots and the juice machine should not be located near a hand washing sick. He also reported getting water for the coffee and juice dispensers and reaching over the pitchers to reach the soap dispenser was not sanitary.
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CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
b) Resident #364
The facility policy titled: Isolation Precautions date implemented 11/27/17 with a reviewed/revised date 05/0...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
b) Resident #364
The facility policy titled: Isolation Precautions date implemented 11/27/17 with a reviewed/revised date 05/03/21,states
.8. a. Posting signs on the door or wall outside of the patient room that clearly describe the type of precautions needed and required Personal Protection Equipment (PPE).
During the initial tour on 06/13/22 at 11:30 AM, room [ROOM NUMBER] had contact isolation signage on the wall outside of the room and the PPE storage bin hanging on the door. Nurses Aide (NA) #54 entered room without donning PPE.
During an interview on 06/13/22 at 11:32 AM NA #54 stated I did not know she was in isolation, night shift never told me.
During an interview on 06/13/22 at 11:32 AM the Assistant Director Of Nursing #62 stated Resident #364 has ESBL (Extended Spectrum Beta-Lactamase) in urine, you have to gown up and put gloves on when you entered the room. She acknowledged that NA #54 did enter the room without donning PPE.
A medical record review revealed a physician order dated 06/13/22 maintain contact precautions every shift until 06/18/22 due to ESBL in urine.
c) Hand washing
During an observation on 06/14/22 at 7:56 AM, Licensed Practical Nurse (LPN) #65 administered Insulin to Resident #59. LPN #65 placed the used syringe on the sink in the resident's bathroom and washed her hands. LPN #65 then carried the syringe to the medication cart and disposed the syringe in the sharps box. Without washing or sanitizing her hands, LPN #65 gathered medications and administered them to Resident #39.
During an interview on 06/14/22 at 8:25 AM, LPN #65 confirmed her contaminated hands should have been cleaned/sanitized after she disposed of the syringe and before prepping the next residents medications.
Based on observation, record review, and staff interview, the facility failed to establish and maintain an infection prevention and control program designed to help prevent the development and transmission of communicable diseases and infections. The facility failed to process laundry properly. The facility also failed to don appropriate personal protective equipment (PPE) for a resident on transmission-based precautions (TBP). Additionally, the facility failed to ensure proper hand hygiene during medication administration. These were random opportunities for discovery that had the potential to affect more than a limited number of residents. Resident identifiers: #364, #59. Facility census: 111.
Findings included:
a) Laundry storage and processing
On 06/14/22 at 2:40 PM, a tour of the laundry facilities was done with the Housekeeping Supervisor.
In the dirty room of the laundry where dirty linen was kept before sorting and washing, mop heads were found to be hanging on the wall. Additionally, dustmop heads were found to be lying on a closed container. The Housekeeping Supervisor stated the mop heads and dustmop heads had been washed and were hanging to dry. The Housekeeping Supervisor stated she had not thought about clean items potentially becoming contaminated by drying in the dirty room of the laundry.
No further information was provided through the completion of the survey.
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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
- • 76 deficiencies on record. Higher than average. Multiple issues found across inspections.
- • Grade D (40/100). Below average facility with significant concerns.
Bottom line: Trust Score of 40/100 indicates significant concerns. Thoroughly evaluate alternatives.
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About This Facility
What is River Oaks Healthcare Center's CMS Rating?
CMS assigns RIVER OAKS HEALTHCARE CENTER an overall rating of 1 out of 5 stars, which is considered much below average nationally. Within West Virginia, this rating places the facility higher than 0% of the state's 100 nursing homes. A rating at this level reflects concerns identified through health inspections, staffing assessments, or quality measures that families should carefully consider.
How is River Oaks Healthcare Center Staffed?
CMS rates RIVER OAKS HEALTHCARE CENTER's staffing level at 2 out of 5 stars, which is below average compared to other nursing homes. Staff turnover is 55%, compared to the West Virginia average of 46%.
What Have Inspectors Found at River Oaks Healthcare Center?
State health inspectors documented 76 deficiencies at RIVER OAKS HEALTHCARE CENTER during 2022 to 2025. These included: 76 with potential for harm. While no single deficiency reached the most serious levels, the total volume warrants attention from prospective families.
Who Owns and Operates River Oaks Healthcare Center?
RIVER OAKS HEALTHCARE CENTER is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility is operated by COMMUNICARE HEALTH, a chain that manages multiple nursing homes. With 120 certified beds and approximately 116 residents (about 97% occupancy), it is a mid-sized facility located in CLARKSBURG, West Virginia.
How Does River Oaks Healthcare Center Compare to Other West Virginia Nursing Homes?
Compared to the 100 nursing homes in West Virginia, RIVER OAKS HEALTHCARE CENTER's overall rating (1 stars) is below the state average of 2.7, staff turnover (55%) is near the state average of 46%, and health inspection rating (1 stars) is much below the national benchmark.
What Should Families Ask When Visiting River Oaks Healthcare Center?
Based on this facility's data, families visiting should ask: "Can you walk me through typical staffing levels on day, evening, and night shifts?" "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" "Can I speak with family members of current residents about their experience?" These questions are particularly relevant given the below-average staffing rating.
Is River Oaks Healthcare Center Safe?
Based on CMS inspection data, RIVER OAKS HEALTHCARE CENTER has a clean safety record: no substantiated abuse findings (meaning no confirmed cases of resident harm), no Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death), and is not on the Special Focus Facility watch list (a federal program monitoring the lowest-performing 1% of nursing homes). The facility has a 1-star overall rating and ranks #100 of 100 nursing homes in West Virginia. While no facility is perfect, families should still ask about staff-to-resident ratios and recent inspection results during their visit.
Do Nurses at River Oaks Healthcare Center Stick Around?
RIVER OAKS HEALTHCARE CENTER has a staff turnover rate of 55%, which is 9 percentage points above the West Virginia average of 46%. Moderate turnover is common in nursing homes, but families should still ask about staff tenure and how the facility maintains care continuity when employees leave.
Was River Oaks Healthcare Center Ever Fined?
RIVER OAKS HEALTHCARE CENTER has no federal fines on record. CMS issues fines when nursing homes fail to meet care standards or don't correct problems found during inspections. The absence of fines suggests the facility has either maintained compliance or corrected any issues before penalties were assessed. This is a positive indicator, though families should still review recent inspection reports for the full picture.
Is River Oaks Healthcare Center on Any Federal Watch List?
RIVER OAKS HEALTHCARE CENTER is not on any federal watch list. The most significant is the Special Focus Facility (SFF) program, which identifies the bottom 1% of nursing homes nationally based on persistent, serious quality problems. Not being on this list means the facility has avoided the pattern of deficiencies that triggers enhanced federal oversight. This is a positive indicator, though families should still review the facility's inspection history directly.