Raleigh Center
For profit - Limited Liability company
68 Beds
GENESIS HEALTHCARE
Data: November 2025
Trust Grade
65/100
#57 of 122 in WV
Photo by Raleigh Center
Photo by Raleigh Center
Photo by Raleigh Center
1 / 5 photos
Last Inspection: August 2024
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
Raleigh Center in Daniels, West Virginia, has a Trust Grade of C+, which indicates it is slightly above average in terms of quality and care. It ranks #57 out of 122 facilities statewide, placing it in the top half, and is #1 out of 3 in Raleigh County, meaning it is the best option locally. The facility shows an improving trend, with issues decreasing from 17 in 2024 to only 2 in 2025, although it still reported 41 concerns in total. Staffing is a concern, rated at 2 out of 5 stars, but turnover is low at 20%, which is better than the state average, suggesting that staff tend to remain with the facility. Notably, there have been issues such as a medication cart being left unlocked and food being improperly stored and served, which could pose potential risks to residents.
- Trust Score
- C+
- In West Virginia
- #57/122
- Safety Record
- Low Risk
- Inspections
- Getting Better
- Staff Stability ✓ Good
- 20% annual turnover. Excellent stability, 28 points below West Virginia's 48% average. Staff who stay learn residents' needs.
- Penalties ✓ Good
- No fines on record. Clean compliance history, better than most West Virginia facilities.
- Skilled Nurses ○ Average
- Each resident gets 35 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
- 41 deficiencies on record. Higher than average. Multiple issues found across inspections.
65/100
Top 46%
No red flags
17 → 2 violations
★★★☆☆
3.0
Overall Rating
★★☆☆☆
2.0
Staff Levels
★★★☆☆
3.0
Care Quality
★★★☆☆
3.0
Inspection Score
↔
Stable
2024: 17 issues
2025: 2 issues
The Good
-
Low Staff Turnover (20%) · Staff stability means consistent care
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
-
Staff turnover is low (20%)
28 points below West Virginia average of 48%
Facility shows strength in staff retention, fire safety.
The Bad
3-Star Overall Rating
Near West Virginia average (2.7)
Meets federal standards, typical of most facilities
Chain: GENESIS HEALTHCARE
Part of a multi-facility chain
Ask about local staffing decisions and management
The Ugly 41 deficiencies on record
May 2025
2 deficiencies
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
Accident Prevention
(Tag F0689)
Could have caused harm · This affected multiple residents
Based on observation and staff interview the facility failed to maintain an accident and hazard free environment by leaving a medicine cart unlocked and unattended. This was a random opportunity for d...
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Based on observation and staff interview the facility failed to maintain an accident and hazard free environment by leaving a medicine cart unlocked and unattended. This was a random opportunity for discovery and had the potential to affect more than a limited number of residents residing in the Long-Term Care Facility. Facility census: 65.
Findings include:
a) During med pass observation, on 05/14/25 at 8:20 AM, LPN # 47 was observed preparing medicine on the cart, then turned and went into the resident's room leaving the medicine cart unlocked.
During an interview on 05/14/25, at 8:26 am with LPN # 47, the LPN stated, I realized when I came out of the room and saw the cart that I left it unlocked.
05/14/25 9:00 AM the administrator confirmed the medication cart should have been locked if not in direct line of cite from the Nurse.
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
Food Safety
(Tag F0812)
Could have caused harm · This affected multiple residents
Based on observation and staff interview, the facility failed to ensure food was stored/prepared and served in a sanitary manner, due to items sitting on the floor, an oven not being cleaned, and stac...
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Based on observation and staff interview, the facility failed to ensure food was stored/prepared and served in a sanitary manner, due to items sitting on the floor, an oven not being cleaned, and stacking serving pans and bowls while still wet. This was a random opportunity for discovery. This has the potential to affect more than a limited number of residents residing in the facility. Facility census: 65.
Findings include:
a) At approximately 9:30 AM on 5/13/2025 a case of oats and a case of grits were observed sitting on the floor in the dry stock room. Both items were dated for 05/06/25. This was confirmed by [NAME] #56.
On 05/13/25 at 9:48 AM the following observations were observed, five (5) trays with blue serving bowls were sitting near the area where food is plated. The bowls were still wet. Further observations revealed the large, medium, and small pans that go on the steam table and holds the food being served were stacked on a shelf near the steam table; after pulling two pans from each stack, all pans pulled for observations was wet. When holding the pans up a steady small stream of water ran off the pans into the floor.
During an interview, on 05/13/25 at 10:00 AM, Dietary Staff #56 stated, We just brought them out from the dish room. I will get it fixed.
On 05/13/25 at 10:05 AM an observation of the facilities cook range with double ovens underneath was completed. When the bottom right side oven door was opened there was evidence of crumbs and burnt substances in the bottom. Along the back of the oven there was evidence of a white/yellow dried substance appearing to be old grease drippings.
An interview completed on 05/13/25 at approximately 10:10 AM Dietary Staff #56 stated, We do not use those bottom ovens on the stove. When asked about the oven not being cleaned, Dietary Staff #56 stated, I don't use the bottom ovens. I'm not sure how it got like that, but will get it cleaned shortly.
Aug 2024
17 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Resident Rights
(Tag F0550)
Could have caused harm · This affected 1 resident
.
Based on resident interview, record review and staff interview, the facility failed to ensure each resident was treated with dignity. This was a random opportunity for discovery. Resident identifier...
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.
Based on resident interview, record review and staff interview, the facility failed to ensure each resident was treated with dignity. This was a random opportunity for discovery. Resident identifier: #12. Facility Census: 63.
Findings include:
a) Resident #12
On 08/25/24 at 11:40 AM, during an interview with Resident #12, she reported when she pressed her call light it often took staff up to 20 minutes to answer. Resident #12 had a privately paid care giver in the room with her who agreed with the statement of the resident. Resident #12 reported, if she asked to go to the bathroom, she required the use of a lift to put her in the bed to use the bedpan, and staff would make her go to bed for the remainder of the day and would not let her get back up until the following day.
On 08/27/24 at 2:00 PM, observed Nurse Aide (NA) #51 exit Resident #12's room with a lift. She reported she had just put the resident on the bedpan. She stated, Resident #12 has a private sitter due to blindness. She stated the resident gets up out of bed around 10:30 AM, will do her therapy and eat. She then calls to use the bedpan around approximately 1:30 PM- 2:00 PM. She stated Resident #12 had to be transferred to bed using a lift. After using the restroom, the resident normally likes to stay in bed the rest of the day.
On 08/27/24 at 3:08 PM, an additional interview was conducted with the resident and private care giver, different from the initial care giver interviewed. Resident #12 reported there were times she felt like she was being punished for needing to use the bathroom. She stated, when she asked to use the bedpan, she was told Once you go to bed you cannot get back up.
Resident #12 reported that sometimes she wanted to get back up but was told, That is against the rules. Resident's care giver reported she has heard a nurse aide suggest resident pee herself (use her brief so she does not have to go back to bed.)
On 08/27/24 at 3:38 PM, the information obtained from the interviews with the resident and the two (2) caregivers was reported to the Director of Nursing (DON) who stated, she was unaware of these issues and had never had a complaint from this resident but would report it to the proper channels and investigate.
On 08/27/24 at 4:22 PM, review of Resident #12's care plan revealed the following: Resident at risk for falls. intervention: transfer assistance assist of 2 (two) total lift full body sling medium with purple binding. maximum physical activity to enhance general muscle tone, functioning of lower G.I. tract, and ability to mobilize to bathroom in response to urge to defecate. Encourage resident to attend activities that maximize their full potential while meeting their need to socialize.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0558
(Tag F0558)
Could have caused harm · This affected 1 resident
.
Based on observation, staff interview and resident interview, the facility to ensure call light was placed in a position which would allow the resident to use it if she needed to call for help. This...
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.
Based on observation, staff interview and resident interview, the facility to ensure call light was placed in a position which would allow the resident to use it if she needed to call for help. This is true for one (1) of 22 sampled residents reviewed during the long term care survey process. Resident Identifier: Resident #35. Facility Census: 63.
Findings include:
a) On 08/26/24 at 10:55 AM, an observation found Resident #35 resting in her bed. Her call light button was clipped to the left side of her bed and was hanging down toward the floor. Resident #35 reported she was not able to use her left hand at all and was not able to use the call bell when it is clipped to the left side of her bed.
On 08/26/24 at 11:00 AM, when Licensed Practical Nurse (LPN) #17 came into the room, she acknowledged the light was clipped to the non dominant side of the resident and moved it to the right side of the bed and placed it in HER dominant hand. She stated, resident had been working with physical therapy to try to strengthen the left hand.
On 08/29/24 at 12:55 PM, The Director of Nursing (DON) #54 and Nurse Educator #34 acknowledged the resident's minimum data set (MDS) indicated the resident is dependent with upper extremities, physician believed maybe edema was causing the issue. No documentation on this from physician addressing Resident #35's use of her left hand could be found in the medical record. Both acknowledged the resident is not care planned nor does she have a diagnosis for inability to use her left hand but did acknowledge the resident was having difficulty using it. They reported therapy had been working with her with her use of the left hand. They stated they would change her call light to a flat device which could easily be used by the resident.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Abuse Prevention Policies
(Tag F0607)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on record review and staff interview the facility failed to implement the policy and procedure entitled, Abuse Prohibiti...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on record review and staff interview the facility failed to implement the policy and procedure entitled, Abuse Prohibition. This was a random opportunity for discovery. Resident identifiers: Resident #16, #6 and #24. Facility census 63.
Findings include:
c) Resident #16
On 08/27/24 at approximately 12:00 PM, a record review was conducted for Resident #16. During the record review, Resident #16 was noted to have the following diagnoses:
Anxiety disorder, unspecified, date 02/10/17
Insomnia, unspecified, date 03/25/17
Major depressive disorder, unspecified, date 02/10/17
Schizoaffective disorder, bipolar type, date 05/17/24
Psychotic disorder with hallucinations, date 12/15/23
Unspecified dementia, unspecified severity, date 02/10/27
Alzheimer's disease, unspecified, date 12/31.20
Vascular dementia with behavioral disturbance, date 12/31/20
Resident #16 was also noted to be receiving the following medications:
Clonazepam 0.5 milligram (MG) 1 (one) tablet by mouth three times a day
Cymbalta 60 MG 1 (one) capsule by mouth one time a day
Nuplaid 34 MG 1 (one) capsule by mouth one time a day
Remeron 15 MG 1 (one) tablet by mouth at bedtime
In addition the following care plans related to behavioral patterns:
Focus:
(First Name of Resident #16) has impaired/decline in cognitive function or impaired thought processes related to a condition other than delirium. Resident becomes agitated and aggressive at times. verbally cursing: Dementia (other than Alzheimer's disease), Parkinson's disease, Short/long term memory loss, Impaired decision making. Her spouse serves as MPOA assisting with decision making
Goal:
(First name of Resident #16) will make daily decisions/choices about activities of daily living when provided with appropriate level cues and supervision by the next review date.
Interventions:
Observe and evaluate types of changes in cognitive status, e.g., confusion, orientation, forgetfulness, decision making ability, ability to express self, ability to understand others, impulsivity, mental status and notify physician as needed.
Monitor for pain. Attempt non-pharmacological interventions to alleviate pain and document effectiveness.
Administer pain medication as ordered by physician and document effectiveness/side effects.
Evaluate responses from Brief Interview for Mental Status (BIMS) or Staff Assessment for Mental Status and address as indicated.
Redirect resident/patient using external cues (e.g., calendar, date book, radio, television etc.), as needed.
Provide consistent, trusted caregiver and structured daily routine, when possible.
Personalize the resident's/patient's room with familiar items to assist him/her in identifying the room
Explain all care, including procedures (one step at a time.), and the reason for performing the care before initiating.
Call resident/patient by his/her preferred name for self identity.
Focus:
Resident/patient exhibits or is at risk for distressed/fluctuating mood symptoms related to : Anxiety/fear caused by move into/within Center and/or inability to return home, coping with acute/chronic illnesses, dx of anxiety and depressive disorder as evidenced by (AEB) she will verbalize her anxiousness, crying/tearful and verbalizing sadness, agitation AEB cursing hitting staff.
Goal:
Resident/Patient will express anxieties/fears to staff regarding coping with acute/chronic illnesses, care at facility, therapy services by next review.
Interventions:
Resident frequently asks for a cigarette to calm her nerves as this was her coping mechanism at home. Facility to provide resident with an imitation cigarette that she can hold when she becomes agitated or anxious. Resident has a cigarette pouch that the imitation cigarettes are kept in to mimic her previous smoking habits. An ashtray has been provided for resident to dispose of her imitation cigarette.
Observe laboratory test results and report abnormal results to physician/advanced practice provider.
Observe for pain and effectiveness of current interventions. Attempt non-pharmacologic interventions.
Observe for signs of delirium, including delusions/hallucinations; notify physician/advanced practice practitioner as needed.
Observe for signs/symptoms of worsening sadness/depression/anxiety/fear/anger/agitation.
Determine the psychosocial cause for the residents/patients sadness/depression, anxiety/fear or persistent anger/agitation.
Encourage resident/patient to seek staff support for distressed mood.
Refocus resident/patient to something positive.
Allow time for expression of feelings, voice her concerns and talk through the problems; provide empathy, encouragement and reassurance.
Encourage resident/patient participation in activity preference.
Provide resident/patient with opportunities for choice during care/activities to provide a sense of control.
Social Service visits to provide support, as needed.
Furthermore, during the record review, Resident #16 had several progress notes documented related to aggressive behavior towards staff and other residents. The following documentation is typed as written:
eInteract Summary for providers 02/16/24 at 2:06 PM
Resident #6 reported that Resident #16 approached her from behind in the dining room and pulled Resident #6's hair to the extent that Resident #6's head went backwards. When Resident #16 was asked, Resident #16 stated, yes, I pulled her hair, she is stealing all my stuff.
Resident was cussing and try to hit another resident but was intervened and she missed. Resident trying exit doors. She was removed from situation and try to listen and offer food. Resident has delusions other residents are after husband. She threatened to hit staff because we removed her from other residents because she was verbally cussing along with staff. Was unsuccessful in interventions.
Nursing documentation note 02/22/24 at 12:03 AM:
Physical behaviors directed towards others occurs up to 5 (five) days a week. Verbal behaviors, directed towards others, occur up to 5 (five) days a week.
Assessment 03/18/24 at 10:52 PM:
Since the last evaluation there has been no change in behavior symptoms. Accusing others x5, cursing others x6, screaming at others x4, threaten 6, disruptive 1, enters others room [ROOM NUMBER], exit seeking 1, refusal 1, depression.
eMAR (electronic medication administration record) for 05/29/24 at 07:41 AM:
Was behavior observed? Yes
eMAR (electronic medication administration record) for 6/27/24 at 08:42 AM:
Was behavior observed? Yes
eMAR (electronic medication administration record) for 07/23/24 at 08:18 AM:
Was behavior observed? Yes
eMAR (electronic medication administration record) for 08/04/24 at 08:53 AM:
Was behavior observed? Yes
On 08/28/24 at approximately 12:00 PM, the policy and procedure entitled, Abuse Prohibition was reviewed. This policy states that if suspected abuse is patient-to-patient, the patient who has in any way threatened or attacked another will be removed from the setting or situation and an investigation will be completed. That the Center will provide adequate supervision when the risk of patient to patient altercation is suspected. The Center is responsible for identifying patients who have a history of disruptive or intrusive interactions or who exhibit other behaviors that make them more likely to be involved in an altercation. The patient representative and physician will be notified and any follow up recommended will be completed. Furthermore, the policy states that allegations involving abuse (physician, verbal, sexual or mental) shall be reported not later than 2 (two) hours after the allegation is made to the appropriate state authorities. In addition, the policy states the investigation shall focus on the causative factors and interventions to prevent further injury.
At approximately 12:30 PM on 08/27/24, while a fellow Surveyor was observing tray pass for lunch, Resident #16 was observed hitting her roommate, Resident #24, in the face during an altercation in their room. Two nurse aides were assisting Resident #16 out of her room at the time and were attempting to break up the altercation. Nurse Aide (NA) #13 was pushing Resident #16's chair out of the room and NA #36 ws trying to place a pillow between the two residents to keep Resident #16 from striking Resident #24 again.
At approximately 12:40 PM, an interview was conducted with NA #13 who stated Resident #16 pulled Resident #6's hair for an unknown reason and Resident #16 started swinging at her. NA #13 stated, I thought someone was going to get hurt bad this time.
At approximately 1:00 PM, an interview was conducted with NA #36 who stated, I did not see Resident #16 pull Resident #6's hair, but I did see Resident #16 slap Resident #24, causing me to grab a pillow and hold it up between them. I thought someone was going to get hurt. NA #36 then stated, This is not the first altercation Resident #16 has been in with other residents.
On 08/28/24 at approximately 1:05 PM, an interview was conducted with the Director of Nursing(DON). During the interview, the DON stated, Resident #16 and Resident #24 had in fact had multiple altercations, however no intervention had been put into place, such as a room move, because the family did not wish them to be separated. At that time, this Surveyor requested the documentation. The DON was unable to provide documentation related to this. The DON was able to provide the reporting documentation, investigation and intervention put into place for the occurrence from 02/16/24, however acknowledged there was none for the occurrence from 02/19/24. Also, the DON was unable to identify the other resident mentioned in the documentation from 02/19/24, with the DON stating, There was no investigation, there was no physician intervention required for the occurrence from 02/19/24, I didn't have to report it. At that time, this Surveyor supplied the DON with the document entitled, Office of Health Care Facilities Licensure and Certification Long Term Care Reporting Requirement dated 12/04/19 which states that an allegation of abuse must be reported within 2 (two) hours. After reviewing the DON acknowledged this had not been done. Furthermore, the DON acknowledged, she was unable to say what the behavior and non-pharmacological intervention was documented for the eMAR notes dated 05/29/24, 6/27/24, 07/23/24 and 08/04/24.
On 08/28/24 at approximately 2:20 PM, an interview was conducted with the facility Social Worker (SW) with the SW acknowledging she had not performed an investigation or reported the occurrence dated 02/19/24.
On 08/29/24 at approximately 12:30 PM, an additional interview was conducted with the DON who acknowledged the facility policy entitled, Abuse Prohibition had not been followed.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to report an allegation of abuse. This was a random opportunity f...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to report an allegation of abuse. This was a random opportunity for discovery. Resident identifiers: #16, #6, #24. Facility census: 63.
Findings included:
a) Resident #16
On 08/27/24 at approximately 12:00 PM, a record review was conducted for Resident #16. During the record review, Resident #16 was noted to have the following diagnoses:
Anxiety disorder, unspecified, date 02/10/17
Insomnia, unspecified, date 03/25/17
Major depressive disorder, unspecified, date 02/10/17
Schizoaffective disorder, bipolar type, date 05/17/24
Psychotic disorder with hallucinations, date 12/15/23
Unspecified dementia, unspecified severity, date 02/10/17
Alzheimer's disease, unspecified, date 12/31/20
Vascular dementia with behavioral disturbance, date 12/31/20
Resident #16 was also noted to be receiving the following medications:
Clonazepam 0.5 milligram (MG) 1 (one) tablet by mouth three times a day
Cymbalta 60 MG 1 (one) capsule by mouth one time a day
Nuplaid 34 MG 1 (one) capsule by mouth one time a day
Remeron 15 MG 1 (one) tablet by mouth at bedtime
In addition the following care plans related to behavioral patterns:
Focus:
(First Name of Resident #16) has impaired/decline in cognitive function or impaired thought processes related to a condition other than delirium. Resident becomes agitated and aggressive at times. verbally cursing: Dementia (other than Alzheimer's disease), Parkinson's disease, Short/long term memory loss, Impaired decision making. Her spouse serves as MPOA assisting with decision making
Goal:
(First name of Resident #16) will make daily decisions/choices about activities of daily living when provided with appropriate level cues and supervision by the next review date.
Interventions:
Observe and evaluate types of changes in cognitive status, e.g., confusion, orientation, forgetfulness, decision making ability, ability to express self, ability to understand others, impulsivity, mental status and notify physician as needed.
Monitor for pain. Attempt non-pharmacological interventions to alleviate pain and document effectiveness.
Administer pain medication as ordered by physician and document effectiveness/side effects.
Evaluate responses from Brief Interview for Mental Status (BIMS) or Staff Assessment for Mental Status and address as indicated.
Redirect resident/patient using external cues (e.g., calendar, date book, radio, television etc.), as needed.
Provide consistent, trusted caregiver and structured daily routine, when possible.
Personalize the resident's/patient's room with familiar items to assist him/her in identifying the room
Explain all care, including procedures (one step at a time.), and the reason for performing the care before initiating.
Call resident/patient by his/her preferred name for self identity.
Focus:
Resident/patient exhibits or is at risk for distressed/fluctuating mood symptoms related to : Anxiety/fear caused by move into/within Center and/or inability to return home, coping with acute/chronic illnesses, dx of anxiety and depressive disorder as evidenced by (AEB) she will verbalize her anxiousness, crying/tearful and verbalizing sadness, agitation AEB cursing hitting staff.
Goal:
Resident/Patient will express anxieties/fears to staff regarding coping with acute/chronic illnesses, care at facility, therapy services by next review.
Interventions:
Resident frequently asks for a cigarette to calm her nerves as this was her coping mechanism at home. Facility to provide resident with an imitation cigarette that she can hold when she becomes agitated or anxious. Resident has a cigarette pouch that the imitation cigarettes are kept in to mimic her previous smoking habits. An ashtray has been provided for resident to dispose of her imitation cigarette.
Observe laboratory test results and report abnormal results to physician/advanced practice provider.
Observe for pain and effectiveness of current interventions. Attempt non-pharmacologic interventions.
Observe for signs of delirium, including delusions/hallucinations; notify physician/advanced practice practitioner as needed.
Observe for signs/symptoms of worsening sadness/depression/anxiety/fear/anger/agitation.
Determine the psychosocial cause for the residents/patients sadness/depression, anxiety/fear or persistent anger/agitation.
Encourage resident/patient to seek staff support for distressed mood.
Refocus resident/patient to something positive.
Allow time for expression of feelings, voice her concerns and talk through the problems; provide empathy, encouragement and reassurance.
Encourage resident/patient participation in activity preference.
Provide resident/patient with opportunities for choice during care/activities to provide a sense of control.
Social Service visits to provide support, as needed.
Furthermore, during the record review, Resident #16 had several progress notes documented related to aggressive behavior towards staff and other residents. The following documentation is typed as written:
eInteract Summary for providers dated 02/16/24 at 2:16 PM
Resident #6 reported that Resident #16 approached her from behind in the dining room and pulled Resident #6's hair to the extent that Resident #16's head went backwards. When Resident #16 was asked, Resident #16 stated, yes, I pulled her hair, she is stealing all my stuff.
Nursing documentation note 02/19/24 at 11:40 PM:
Resident was cussing and try to hit another resident but was intervened and she missed. Resident trying exit doors. She was removed from situation and try to listen and offer food. Resident has delusions other residents are after husband. She threatened to hit staff because we removed her from other residents because she was verbally cussing along with staff. Was unsuccessful in interventions.
Nursing documentation note 02/22/24 at 12:03 AM:
Physical behaviors directed towards others occurs up to 5 (five) days a week. Verbal behaviors, directed towards others, occur up to 5 (five) days a week.
Assessment 03/18/24 at 10:52 PM:
Since the last evaluation there has been no change in behavior symptoms. Accusing others x5, cursing others x6, screaming at others x4, threaten 6, disruptive 1, enters others room [ROOM NUMBER], exit seeking 1, refusal 1, depression.
eMAR (electronic medication administration record) for 05/29/24 at 07:41 AM:
Was behavior observed? Yes
eMAR (electronic medication administration record) for 6/27/24 at 08:42 AM:
Was behavior observed? Yes
eMAR (electronic medication administration record) for 07/23/24 at 08:18 AM:
Was behavior observed? Yes
eMAR (electronic medication administration record) for 08/04/24 at 08:53 AM:
Was behavior observed? Yes
On 08/28/24 at approximately 12:00 PM, the policy and procedure entitled, Abuse Prohibition was reviewed. This policy stated that if suspected abuse is patient-to-patient, the patient who has in any way threatened or attacked another will be removed from the setting or situation and an investigation will be completed. That the Center will provide adequate supervision when the risk of patient to patient altercation is suspected. The Center is responsible for identifying patients who have a history of disruptive or intrusive interactions or who exhibit other behaviors that make them more likely to be involved in an altercation.
The patient representative and physician will be notified and any follow up recommended will be completed. Furthermore, the policy stated that allegations involving abuse (physician, verbal, sexual or mental) shall be reported not later than 2 (two) hours after the allegation is made to the appropriate state authorities. In addition, the policy states the investigation shall focus on the causative factors and interventions to prevent further injury.
At approximately 12:30 PM on 08/27/24, while a fellow Surveyor was observing tray pass for lunch, Resident #16 was observed hitting her roommate, Resident #24, in the face during an altercation in their room. Two nurse aides were assisting Resident #16 out of her room at the time and were attempting to break up the altercation. Nurse Aide (NA) #13 was pushing Resident #16's chair out of the room and NA #36 ws trying to place a pillow between the two residents to keep Resident #16 from striking Resident #24 again.
At approximately 12:40 PM, an interview was conducted with NA #13 who stated Resident #16 pulled Resident #6's hair for an unknown reason and Resident #16 started swinging at her. NA #13 stated, I thought someone was going to get hurt bad this time.
At approximately 1:00 PM, an interview was conducted with NA #36 who stated, I did not see Resident #16 pull Resident #6's hair, but I did see Resident #16 slap Resident #24, causing me to grab a pillow and hold it up between them. I thought someone was going to get hurt. NA #36 then stated, This is not the first altercation Resident #16 has been in with other residents.
On 08/28/24 at approximately 1:05 PM, an interview was conducted with the Director of Nursing(DON). During the interview, the DON stated, Resident #16 and Resident #24 had in fact had multiple altercations, however no intervention had been put into place, such as a room move, because the family did not wish them to be separated.
At that time, this Surveyor requested the documentation. The DON was unable to provide documentation related to this. The DON was able to provide the reporting documentation, investigation and intervention put into place for the occurrence from 02/16/24, however acknowledged there was none for the occurrence from 02/19/24.
Also, the DON was unable to identify the other resident mentioned in the documentation from 02/19/24, with the DON stating, There was no investigation, there was no physician intervention required for the occurrence from 02/19/24, I didn't have to report it.
At that time, this Surveyor supplied the DON with the document entitled, Office of Health Care Facilities Licensure and Certification Long Term Care Reporting Requirement dated 12/04/19 which stated that an allegation of abuse must be reported within 2 (two) hours. After reviewing the DON acknowledged this had not been done. Furthermore, the DON acknowledged, she was unable to say what the behavior and non-pharmacological intervention was documented for the eMAR notes dated 05/29/24, 6/27/24, 07/23/24 and 08/04/24.
On 08/28/24 at approximately 2:20 PM, an interview was conducted with the facility Social Worker (SW) with the SW acknowledging she had not performed an investigation or reported the occurrence dated 02/19/24.
On 08/29/24 at approximately 12:30 PM, an additional interview was conducted with the DON who acknowledged the facility policy entitled, Abuse Prohibition had not been followed.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Investigate Abuse
(Tag F0610)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on record review, staff interview and the facility policy and procedure review, the facility failed to provide evidence ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on record review, staff interview and the facility policy and procedure review, the facility failed to provide evidence that all alleged violations were thoroughly investigated, and that corrective action was taken. Residents level of care was not reviewed for possible discrepancies and statements were not obtain from all relevant staff members. This was true for one (1) of five (5) residents reviewed for abuse during the long terms survey process. Resident identifier: #4. Facility census: 63.
Findings Include:
a) Resident #4
On 08/29/24 at approximately 2:40 PM during the review of the facility investigation completed for the incident which occurred on 06/01/24 it was identified that statements from all staff who had cared for the resident during this time had not been obtained.
It was further identified Resident #4's radiology report results states Resident #4 had a moderately displaced impaction fracture of the distal femur metaphysis. The facility did follow up with the medical treatment for the resident. The facility was not able to identify the origin of the injury.
During a further review of the resident's medical record, the individual comprehensive care plan identified the level of care to be provided for bed mobility and toileting to be extensive assist of two persons assist.
A review of the facility Documentation Survey Report for the assisted daily living task performed revealed documentation for the bed mobility and or toileting was completed for the resident prior to and the day of the incident. This documentation identified the staff was using one person assistance and not two people as the individual care plan required.
This inaccurate level of care occurred on the following days and shifts;
* 05/14/24 Day, Evening and Night shift was one-person physical assist.
* 05/15/24 Evening was one-person physical assist.
* 05/16/24 Evening and Night (times two) shift was one-person physical assist.
* 05/18/24 Day, Evening and Night shift was one-person physical assist.
* 05/19/24 Day, Evening and Night shift was one-person physical assist.
* 05/20/24 Day, Evening and Night shift was one-person physical assist.
* 05/21/24 Day, Evening and Night shift was one-person physical assist.
* 05/22/24 Day, Evening and Night shift was one-person physical assist.
* 05/23/24 Day, Evening and Night shift was one-person physical assist.
* 05/24/24 Evening shift was one-person physical assist.
* 05/25/24 Night shift was one-person physical assist.
* 05/26/24 Night shift (two times) was one-person physical assist.
* 05/27/24 Day and Night shift (two times) was one-person physical assist.
* 05/29/24 Day, Evening and Night shift was one-person physical assist.
* 05/30/24 Day, Evening and Night shift was one-person physical assist.
* 05/31/24 Day, Evening and Night shift was one-person physical assist.
* 06/01/24 Night shift (two times) was one-person physical assist.
In reviewing the task list referenced above, Nursing Assistant (NA) #63 was identified to have assisted with an inaccurate level of care for Resident #4's toileting and bed mobility on 05/29/24 and 05/30/24.
A statement for NA #63 was not identified in the statements obtained by the facility during their investigation.
During an interview with Director of Nursing (DON), Nurse Practice Educator (NPE) #34 and Social Worker (SW) #61 on 08/29/24 at approximately 3:52 PM, SW #61 stated she had assisted NPE #34 with completing the Facility Reported Incident (FRI) for Resident #4 and she did not recall if the facility Documentation Survey Report for the assisted daily living task performed documentation was pulled. SW #61 stated she had reviewed the care plan, and it was extensive assist with the activities of daily living (ADL) care.
The DON further stated, the certified nursing assistants would identify their residents ADL care by the [NAME], and that information pulls from the care plan.
NPE #34 and SW #61 stated they had not considered reviewing facility Documentation Survey Report v2 for the assisted daily living task performed documentation to identify the risk for accidents. The DON, NPE #34 and SW #61 agreed this could have been helpful to have completed during their investigation.
In review of NA #63, was identified to have assisted with toileting and bed mobility on 05/29/24 and 05/30/24 prior to the injury being identified. NPE #34 stated that they do call staff for interviews if they are not on schedule but stated they did not obtain a statement from NA #63. The NPE further identified NA #63 had been in contact with the facility during this time regarding babysitting issues and she had informed them she would return as an as needed only employee at that time. NA #63 is noted to have not returned to the facility since.
The NPE acknowledged the interview with NA #63 who had assisted with toileting and bed mobility incorrectly on 05/29/24 and 05/30/24 should have been completed.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Assessment Accuracy
(Tag F0641)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on medical record review and staff interview the facility failed to accurately complete a Minimum Data Set (MDS) when Re...
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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 accurately complete a Minimum Data Set (MDS) when Resident #61 was discharged home. This was true for one (1) of 22 residents reviewed during the long term care survey process. Resident Identifier: Resident #61. Facility census: 63.
Findings include:
a) Resident #61
During a medical record review on 08/26/24 at 1:49 PM a review of a nursing note revealed the following [typed as written] Resident discharging home, discharge transition packet and medications discussed. Belongings packed up and sent with resident. All questions answered satisfactorily, medications called in to (Name of Local Pharmacy). Son at bedside to transport.
During a further review the facility discharge plan documentation's also identified the resident discharged to home.
During a medical record review of the MDS dated [DATE] it is identified in Section A. 2105 that the resident discharged to a short-term General Hospital.
During an interview with the Director of Nursing (DON) on 08/26/24, the DON agreed that MDS was not coded correctly as the resident had discharged home and not to the short-term General Hospital.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
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Based on medical record review and staff interview the facility failed to develop and implement the individualized comprehensive care plan for depression. This was true for one (1) of 22 residents r...
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Based on medical record review and staff interview the facility failed to develop and implement the individualized comprehensive care plan for depression. This was true for one (1) of 22 residents reviewed during the long term care survey process. Resident identifier: #26. Facility census: 63.
Findings include:
a) Resident #26
During a medical record review for Resident #26 on 08/27/24 at 12:40 PM it was identified the Resident had a physician order for Escitalopram Oxalate Tablet 20 MG to be given one (1) tablet by mouth for a diagnosis of depression.
A review of Resident #26's care plan found it did not include a individualized comprehensive care plan that addressed the diagnosis of depression.
During an interview with the Director of Nursing (DON), on 08/27/24 at 1:54 PM, the DON agreed the individual comprehensive care plan for the diagnosis of depression had not be developed for Resident #26.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
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Based on observation, record review and staff interview the facility failed to ensure residents receive treatment and care in accordance with professional standards of practice by failing to provide...
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Based on observation, record review and staff interview the facility failed to ensure residents receive treatment and care in accordance with professional standards of practice by failing to provide care according to physicians orders. This was a random opportunity for discovery during the Long Term Care Survey Process. Resident identifiers: Resident #15 and Resident #25. Facility census: 63.
Findings include:
a) Resident #15
On 08/26/24 at approximately 9:00 AM, a record review was conducted for Resident #15 revealing the following diagnoses:
Hemiplegia and heiparesis following unspecified cardiovascular disease affecting non-dominate side dated as admitting diagnosis.
Epilepsy, unspecified, date 05/18/18
Cerebral palsy, date 05/07/18
Nontraumatic subdural hemorrhage, unspecified, date 05/07/18
Personal history of traumatic brain injury, date 05/07/18
Unspecified convulsions, date 05/07/18
In addition, Resident #15 had a physicians order to wear a helmet when out of bed and an optifoam to head for breakdown prevention.
At that time, the following care plan was noted in reference to the above mentioned orders:
Focus:
Resident is at risk for falls: impaired mobility, cerebral palsy, cognitive loss, lack of safety awareness and traumatic brain injury.
Goal:
Resident will have no falls with injury throughout next review.
Intervention:
Protective helmet when restless or out of bed every shift.
On 08/26/24 at the following times, observations were made of Resident #15, at which times Resident #15 was noted to be up out of bed, in the geri-chair without the helmet in place:
11:12 AM
11:45 AM
12:15 AM
12:45 AM
1:35 PM
2:30 PM
On 08/27/24 at 9:40 AM, this Surveyor and LPN #17 went into make an observation of Resident #15, at which time Resident #15 did not have his helmet on and was out of bed in the geri-chair. At this time, LPN #17 acknowledged Resident #15 had an order for the helmet when out of bed and that the helmet and dressing to the head was due to where he had brain surgery, the screws have worked their way out and through his skin before. I thought the order for the helmet had been discontinued, but it hasn't. It is active, he should have it on.
b) Resident #25
During an interview on 08/25/24 at 3:00 PM, Resident #25 stated he does not get his medications on time. He stated, he has a diagnosis of bipolar and that if he does not get his evening medications by 9:00 PM, he cannot sleep. He reports sometimes his medications are up to three (3) hours late.
On 08/27/24 at 10:52 AM, a record review of Medication Admin Audit Report revealed the following
late medications:
-07/19/2024 Tamsulosin HCI Oral Capsule 0.4 MG, give one (1) capsule by mouth one time a day. Scheduled 8:00 PM and administered at 10:55 PM Licensed Practical #5 (five).
-08/25/2024 Depakote Tablet Delayed Release 250 MG. Give one (1) tablet by mouth two times a day for targeted behaviors: cursing staff, throwing items at staff, ensure environment safety and allow to decompress alone. Scheduled 9:00 PM and administered 11:04 PM by Registered Nurse #21.
On 08/28/24 at 2:25 PM an interview with Director of Nursing (DON) #54, DON acknowledged the Tamsulosin and Depakote were administered late on 7/19/24 and 08/25/24.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Drug Regimen Review
(Tag F0756)
Could have caused harm · This affected 1 resident
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Based on record review and staff interview the facility failed to timely act upon a Medication Regimen Review (MRR) of a high-risk medication. This was true for 1 (one) of 5 (five) residents reviewe...
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Based on record review and staff interview the facility failed to timely act upon a Medication Regimen Review (MRR) of a high-risk medication. This was true for 1 (one) of 5 (five) residents reviewed for the care area of unnecessary medications during the Long-Term Care Survey Process. Resident identifier: Resident #16. Facility census 63.
Findings include:
a) Resident #16
On 08/27/24 at approximately 12:00 PM, a record review was conducted for Resident #16. During the record review, Resident #16 was noted to have the following diagnoses:
Anxiety disorder, unspecified, date 02/10/17
Insomnia, unspecified, date 03/25/17
Major depressive disorder, unspecified, date 02/10/17
Schizoaffective disorder, bipolar type, date 05/17/24
Psychotic disorder with hallucinations, date 12/15/23
Unspecified dementia, unspecified severity, date 02/10/17
Alzheimer ' s disease, unspecified, date 12/31/20
Vascular dementia with behavioral disturbance, date 12/31/20
Resident #16 was also noted to be receiving the following medications:
Clonazepam 0.5 milligram (MG) 1 (one) tablet by mouth three times a day
Cymbalta 60 MG 1 (one) capsule by mouth one time a day
Nuplaid 34 MG 1 (one) capsule by mouth one time a day
Remeron 15 MG 1 (one) tablet by mouth at bedtime
On 08/28/24 at approximately 1:05 PM, a review of Resident #16's Psychiatrist progress note dated 05/17/24 and an MRR dated 01/17/24, for Resident #16 was conducted revealing the following recommendation:
Please review the current dose of Buspar as per CMS regulations due for a gradual dose reduction at this time.
At this time, it was noted Resident #16's Psychiatrist progress note addressed the recommendation from the MRR dated 01/17/24.
On 08/28/24 at approximately 1:05 PM, an interview was conducted with the Director of Nursing and facility Infection Preventionist (IP). The IP stated the facility had 90 days as per policy to review and act upon any recommendations made.
On 08/28/24 at 2:00 PM, a review of the policy and procedure entitled, Medication Regimen Review and Reporting was conducted which revealed the facility was to act upon pharmacy recommendations within 30 calendar days.
On 08/29/24 at 10:15 AM, an interview was conducted with the IP who acknowledged, the MRR dated 01/17/24 had not been acted upon until the Psychiatrist visit on 05/17/24 and the facility failed to address the recommendation in a timely manner.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0805
(Tag F0805)
Could have caused harm · This affected 1 resident
Based on observation, record review, and staff interview, the facility failed to ensure Resident #24 and #28 were served the correct diet to meet their needs. This was a random opportunity for discove...
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Based on observation, record review, and staff interview, the facility failed to ensure Resident #24 and #28 were served the correct diet to meet their needs. This was a random opportunity for discovery. Resident identifiers: #24, #28. Facility census: 63.
Findings included:
a) Nourishment Room
At approximately 10:15 AM on 08/25/24, during a tour of the nourishment room at the facility, two (2) bologna sandwiches, with labels for snacks from the previous night shift, were discovered with the names of Resident #24 and #28 on them. Upon further inspection, the labels for both sandwiches read Peanut Butter and Jelly and listed both residents' diets as advanced.
At approximately 10:45 AM, an interview was conducted with the Dietary District Manager (DDM) concerning the diets listed on the sandwiches, the type of sandwich indicated by the labels, and the actual sandwich that was served. The DDM confirmed the labels for both Residents #24 and #28 stated Peanut Butter and Jelly and listed both diets as advanced.
The DDM stated neither Resident #24 nor #28 should have received a bologna sandwich unless the meat was chopped. The DDM confirmed at this time both sandwiches were bologna sandwiches that did not contain chopped meat.
At approximately 11:00 AM, the DDM printed off meal tickets and confirmed the wrong diets were served to Resident #24 and #28. The meal ticket for Resident #24 reads Regular/Liberalized-Advanced and calls for ground meat. The meal ticket for Resident #28 reads Consistent Carbohydrate- Advanced and calls for ground meat.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Garbage Disposal
(Tag F0814)
Could have caused harm · This affected 1 resident
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Based on observation and staff interview, the facility failed to ensure garbage and refuse was disposed of properly. This was a random opportunity for discovery. This had the potential to affect mor...
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Based on observation and staff interview, the facility failed to ensure garbage and refuse was disposed of properly. This was a random opportunity for discovery. This had the potential to affect more than a limited number of residents residing in the facility. Facility census: 63.
Findings included:
a) At approximately 10:00 AM on 08/25/24, during a tour of the facility, the dumpster was observed with the lid and door open with debris (food particles and trash) laying all around it, on the ground.
Gloves and masks were observed laying on the ground around the dumpster as well. Housekeeper #88 acknowledged the state of the dumpster and the ground around it. The Director of Nursing (DON) arrived at the facility during this time and also acknowledged the dumpster.
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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According to record review and resident and staff interviews, the facility failed to accurately complete medical records pertaining to blood pressures for Resident #45 and a diagnosis of depression ...
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According to record review and resident and staff interviews, the facility failed to accurately complete medical records pertaining to blood pressures for Resident #45 and a diagnosis of depression for Resident #26. This was a random opportunity for discovery. Resident identifiers: #45, #26. Facility 63.
Findings include:
A) Resident #45
At approximately 10:30 AM on 08/29/24, during record review pertaining to Resident #45's dialysis, it was discovered the facility was documenting blood pressures in the resident's left arm, which she has orders not to, due to having a fistula in her left arm. The following dates were documented as times the resident's blood pressure was taken in her left arm:
10/07/2023- Three (3) times
10/10/2023
10/14/2023
10/28/2023
11/22/2023- Three (3) times
11/29/2023
11/30/2023
12/06/2023
12/09/2023
12/12/2023
12/20/2023
01/18/2024
01/25/2024
02/08/2024
02/18/2024
02/21/2024
03/13/2024
05/13/2024
05/14/2024
05/20/2024
05/22/2024
06/17/2024
06/27/2024
06/29/2024
At approximately 10:45 AM an interview was conducted with the Director of Nursing (DON) regarding the blood pressures. The DON stated it was documentation errors and the facility was already auditing the notes and documentation. The DON stated Resident #45 has capacity and will not let staff take blood pressure in her left arm.
At approximately 11:00 AM, an interview was conducted with Resident #45. Resident #45 stated, I absolutely will not let them take my blood pressure in my left arm. My doctor told me they couldn't do it or it would cause bad problems, and I won't allow them to touch it. Resident has capacity and a Brief Interview for Mental Status (BIMS) Score of 15, indicating the resident was cognitively intact.
b) Resident #26
During a medical record review 08/27/24 at 1:46 PM for Resident #26 it was noted the physician had an order for the resident to receive medication for a diagnosis of depression. Further review of the the physician diagnosis it was identified the resident does not have a depression diagnosis listed.
During an interview with the Director of Nursing (DON), on 08/27/24 at 1:53 PM, the DON agreed Resident #26 was receiving medication for a diagnosis of depression and also agreed that there was not a physician diagnosis for depression listed. The DON further stated she would make sure this was corrected.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected multiple residents
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Based on observation, staff interview and the facility policy, the facility failed to ensure the residents had a comfortable, homelike environment. Meal tray service without removal of tray, and sta...
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Based on observation, staff interview and the facility policy, the facility failed to ensure the residents had a comfortable, homelike environment. Meal tray service without removal of tray, and staff storing trash bags in residents room on residents hand towel rack.
This was a random opportunity for discovery and had the ability to affect a limited number of residents. Resident identifier: Meal tray service without removal of tray and staff storing trash bags in residents room on residents hand towel rack. Facility census: 63.
Findings include:
a) Meal tray service without removal of tray.
During an observation of the serving of the meal trays on 08/25/24 at approximately 11:50 AM the trays were being placed on the table for the residents and not being removed.
During an interview with the Assistant Director of Nursing (ADON) on 08/25/24 at approximately 11:53 AM the ADON acknowledged the trays were not being removed from the table and agreed that the trays should have been removed.
During an interview with the Administrator on 08/25/24 at approximately 12:00 PM, the administrator agreed that the trays should have been removed.
The Administrator then provided the facility policy titled NSG270 Meal Service This policy states that when serving meals in a dining room with tray service, they staff is to deliver the food to the patient, remove the plate cover and remove the tray.
b) B hall residential rooms
During a tour of entire Unit B hall way on 08/25/24 at 9:58 AM all the residents rooms on Unit B was observed to have numerous trash bags stored on the hand towel rack with clean towels and wash clothes above the residents sinks.
During an interview with Licensed Practical Nurse (LPN) #50 on 08/25/24 at approximately 10:00 AM LPN #50 stated the staff keep them stored there for the staff personal use and agreed it did not create a homelike environment for the residents.
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
Free from Abuse/Neglect
(Tag F0600)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on observation and resident and staff interview, the facility failed to ensure residents of the facility were free from ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on observation and resident and staff interview, the facility failed to ensure residents of the facility were free from abuse and neglect due to a Nurse Aide (NA) neglecting their duties, not serving Resident #2 lunch in a timely manner, and ensuring other residents were free from abuse by Resident #16. These were random opportunities for discovery. Resident identifiers: #2, #6, #24, #16. Facility census: 63.
Findings include:
a) Nurse Aide (NA) #39
At approximately 11:30 PM on 08/26/24, NA #39 was observed sitting in the area labeled Resident Sitting Area on her cell phone while a call light in her assigned area was ringing. NA #39 continued to look down at her phone and not answer the call light until approximately 11:38 PM. At approximately 11:42 PM, NA #39 returned from the room to the Resident Sitting Area, set back down in the chair, and resumed usage of her cell phone.
At approximately 11:58 PM, a call light was pressed in room [ROOM NUMBER], another assigned room for NA #39. The call light rang for approximately three (3) minutes and was answered by Registered Nurse (RN) #21, who had left the medication cart to answer the light. Upon exiting room [ROOM NUMBER], NA #39 was observed still sitting in the chair in the Resident Sitting Area, on her phone, while RN #21 answered the call light for her room. At approximately 12:05 AM on 08/27/24, NA #39 stood up from the seat in the Resident Sitting Area and went out the back door for a smoke break. NA #39 re-entered the facility at approximately 12:15 AM and immediately returned to the chair and resumed usage of her cell phone.
b) Resident #2
At approximately 1:55 PM on 08/27/24, Resident #2 asked Licensed Practical Nurse (LPN) #17 for some food due to her sleeping through lunch. Resident #2's lunch tray was observed sitting on her bedside table with the lid still on the plate, untouched. Resident #2 stated her food was cold and she would like to have a hot dog.
LPN #17 stated, I'm not sure if they can make a hot dog but we can probably do a grilled cheese. Resident #2 stated that would be fine and LPN #17 stated she would let the kitchen staff know to make a grilled cheese.
At approximately 2:35 PM an interview was conducted with Resident #2. At this time, Resident #2 states she was hungry due to her not getting her food from the kitchen. At this time, an interview was conducted with the Dietary Manager (DM) regarding food for Resident #2. The DM stated no one had come to the kitchen with a request for food for Resident #2.
At approximately 3:05 PM, Resident #2 still had not received her food. At this time, another interview was conducted with the DM regarding food for Resident #2. The DM stated there still had not been anyone to come request food for Resident #2, but the kitchen would go ahead and make it and deliver it. The DM delivered food to Resident #2 at approximately 3:15 PM, one (1) hour and twenty (20) minutes after the resident initially requested food.
c) Resident #16
On 08/27/24 at approximately 12:00 PM, a record review was conducted for Resident #16. During the record review, Resident #16 was noted to have the following diagnoses:
Anxiety disorder, unspecified, date 02/10/17
Insomnia, unspecified, date 03/25/17
Major depressive disorder, unspecified, date 02/10/17
Schizoaffective disorder, bipolar type, date 05/17/24
Psychotic disorder with hallucinations, date 12/15/23
Unspecified dementia, unspecified severity, date 02/10/27
Alzheimer's disease, unspecified, date 12/31.20
Vascular dementia with behavioral disturbance, date 12/31/20
Resident #16 was also noted to be receiving the following medications:
Clonazepam 0.5 milligram (MG) 1 (one) tablet by mouth three times a day
Cymbalta 60 MG 1 (one) capsule by mouth one time a day
Nuplaid 34 MG 1 (one) capsule by mouth one time a day
Remeron 15 MG 1 (one) tablet by mouth at bedtime
In addition the following care plans related to behavioral patterns:
Focus:
(First Name of Resident #16) has impaired/decline in cognitive function or impaired thought processes related to a condition other than delirium. Resident becomes agitated and aggressive at times. verbally cursing: Dementia (other than Alzheimer's disease), Parkinson's disease, Short/long term memory loss, Impaired decision making. Her spouse serves as MPOA assisting with decision making
Goal:
(First name of Resident #16) will make daily decisions/choices about activities of daily living when provided with appropriate level cues and supervision by the next review date.
Interventions:
Observe and evaluate types of changes in cognitive status, e.g., confusion, orientation, forgetfulness, decision making ability, ability to express self, ability to understand others, impulsivity, mental status and notify physician as needed.
Monitor for pain. Attempt non-pharmacological interventions to alleviate pain and document effectiveness.
Administer pain medication as ordered by physician and document effectiveness/side effects.
Evaluate responses from Brief Interview for Mental Status (BIMS) or Staff Assessment for Mental Status and address as indicated.
Redirect resident/patient using external cues (e.g., calendar, date book, radio, television etc.), as needed.
Provide consistent, trusted caregiver and structured daily routine, when possible.
Personalize the resident's/patient's room with familiar items to assist him/her in identifying the room
Explain all care, including procedures (one step at a time.), and the reason for performing the care before initiating.
Call resident/patient by his/her preferred name for self identity.
Focus:
Resident/patient exhibits or is at risk for distressed/fluctuating mood symptoms related to : Anxiety/fear caused by move into/within Center and/or inability to return home, coping with acute/chronic illnesses, dx of anxiety and depressive disorder as evidenced by (AEB) she will verbalize her anxiousness, crying/tearful and verbalizing sadness, agitation AEB cursing hitting staff.
Goal:
Resident/Patient will express anxieties/fears to staff regarding coping with acute/chronic illnesses, care at facility, therapy services by next review.
Interventions:
Resident frequently asks for a cigarette to calm her nerves as this was her coping mechanism at home. Facility to provide resident with an imitation cigarette that she can hold when she becomes agitated or anxious. Resident has a cigarette pouch that the imitation cigarettes are kept in to mimic her previous smoking habits. An ashtray has been provided for resident to dispose of her imitation cigarette.
Observe laboratory test results and report abnormal results to physician/advanced practice provider.
Observe for pain and effectiveness of current interventions. Attempt non-pharmacologic interventions.
Observe for signs of delirium, including delusions/hallucinations; notify physician/advanced practice practitioner as needed.
Observe for signs/symptoms of worsening sadness/depression/anxiety/fear/anger/agitation.
Determine the psychosocial cause for the residents/patients sadness/depression, anxiety/fear or persistent anger/agitation.
Encourage resident/patient to seek staff support for distressed mood.
Refocus resident/patient to something positive.
Allow time for expression of feelings, voice her concerns and talk through the problems; provide empathy, encouragement and reassurance.
Encourage resident/patient participation in activity preference.
Provide resident/patient with opportunities for choice during care/activities to provide a sense of control.
Social Service visits to provide support, as needed.
Furthermore, during the record review, Resident #16 had several progress notes documented related to aggressive behavior towards staff and other residents. The following documentation is typed as written:
eInteract Summary for providers 02/16/24 at 2:16 PM
Resident #6 reported that Resident #16 approached her from behind in the dining room and pulled Resident #6's hair to the extent that Resident #6's head went backwards. When Resident #16 was asked, Resident #16 stated, yes, I pulled her hair, she is stealing all my stuff.
Nursing documentation note 02/19/24 at 11:40 PM:
Resident was cussing and try to hit another resident but was intervened and she missed. Resident trying exit doors. She was removed from situation and try to listen and offer food. Resident has delusions other residents are after husband. She threatened to hit staff because we removed her from other residents because she was verbally cussing along with staff. Was unsuccessful in interventions.
Nursing documentation note 02/22/24 at 12:03 AM:
Physical behaviors directed towards others occurs up to 5 (five) days a week. Verbal behaviors, directed towards others, occur up to 5 (five) days a week.
Assessment 03/18/24 at 10:52 PM:
Since the last evaluation there has been no change in behavior symptoms. Accusing others x5, cursing others x6, screaming at others x4, threaten 6, disruptive 1, enters others room [ROOM NUMBER], exit seeking 1, refusal 1, depression.
eMAR (electronic medication administration record) for 05/29/24 at 07:41 AM:
Was behavior observed? Yes
eMAR (electronic medication administration record) for 6/27/24 at 08:42 AM:
Was behavior observed? Yes
eMAR (electronic medication administration record) for 07/23/24 at 08:18 AM:
Was behavior observed? Yes
eMAR (electronic medication administration record) for 08/04/24 at 08:53 AM:
Was behavior observed? Yes
On 08/28/24 at approximately 12:00 PM, the policy and procedure entitled, Abuse Prohibition was reviewed. This policy states that if suspected abuse is patient-to-patient, the patient who has in any way threatened or attacked another will be removed from the setting or situation and an investigation will be completed. That the Center will provide adequate supervision when the risk of patient to patient altercation is suspected. The Center is responsible for identifying patients who have a history of disruptive or intrusive interactions or who exhibit other behaviors that make them more likely to be involved in an altercation. The patient representative and physician will be notified and any follow up recommended will be completed. Furthermore, the policy states that allegations involving abuse (physician, verbal, sexual or mental) shall be reported not later than 2 (two) hours after the allegation is made to the appropriate state authorities. In addition, the policy states the investigation shall focus on the causative factors and interventions to prevent further injury.
At approximately 12:30 PM on 08/27/24, while a fellow Surveyor was observing tray pass for lunch, Resident #16 was observed hitting her roommate, Resident #24, in the face during an altercation in their room. Two nurse aides were assisting Resident #16 out of her room at the time and were attempting to break up the altercation. Nurse Aide (NA) #13 was pushing Resident #16's chair out of the room and NA #36 was trying to place a pillow between the two residents to keep Resident #16 from striking Resident #24 again.
At approximately 12:40 PM, an interview was conducted with NA #13 who stated Resident #16 pulled Resident #6's hair for an unknown reason and Resident #16 started swinging at her. NA #13 stated, I thought someone was going to get hurt bad this time.
At approximately 1:00 PM, an interview was conducted with NA #36 who stated, I did not see Resident #16 pull Resident #6's hair, but I did see Resident #16 slap Resident #24, causing me to grab a pillow and hold it up between them. I thought someone was going to get hurt. NA #36 then stated, This is not the first altercation Resident #16 has been in with other residents.
On 08/28/24 at approximately 1:05 PM, an interview was conducted with the Director of Nursing(DON). During the interview, the DON stated, Resident #16 and Resident #24 had in fact had multiple altercations, however no intervention had been put into place, such as a room move, because the family did not wish them to be separated. At that time, this Surveyor requested the documentation. The DON was unable to provide documentation related to this.
The DON was able to provide the reporting documentation, investigation and intervention put into place for the occurrence from 02/16/24, however acknowledged there was none for the occurrence from 02/19/24. Also, the DON was unable to identify the other resident mentioned in the documentation from 02/19/24, with the DON stating, There was no investigation, there was no physician intervention required for the occurrence from 02/19/24, I didn't have to report it. At that time, this Surveyor supplied the DON with the document entitled, Office of Health Care Facilities Licensure and Certification Long Term Care Reporting Requirement dated 12/04/19 which states that an allegation of abuse must be reported within 2 (two) hours. After reviewing the DON acknowledged this had not been done. Furthermore, the DON acknowledged, she was unable to say what the behavior and non-pharmacological intervention was documented for the eMAR notes dated 05/29/24, 6/27/24, 07/23/24 and 08/04/24.
On 08/28/24 at approximately 2:20 PM, an interview was conducted with the facility Social Worker (SW) with the SW acknowledging she had not performed an investigation or reported the occurrence dated 02/19/24.
On 08/29/24 at approximately 12:30 PM, an additional interview was conducted with the DON who acknowledged the facility policy entitled, Abuse Prohibition had not been followed.
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
Accident Prevention
(Tag F0689)
Could have caused harm · This affected multiple residents
.
Based on observation, resident interview and staff interview the facility failed to ensure the environment was free of accident hazards. Residents fall mats were preventing a resident to safely make...
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Based on observation, resident interview and staff interview the facility failed to ensure the environment was free of accident hazards. Residents fall mats were preventing a resident to safely make it to his bed in his wheelchair, oxygen was stored in resident sitting area with no signage, and medications were not stored in a safe manner. These were random opportunities for discovery during the long term care survey process and had the ability to affect a more than a limited number of residents currently resding in the facility. Identifier: Resident #26. Facility Census.: 63.
Findings include:
a) Resident #26 fall mats.
During a tour of the facility on 08/25/24 at approximately 2:15 PM, Resident #26 was observed attempting to wheel himself in his wheelchair to his side of the room by the window. The resident stated, he was unable to safely go to his side because he can't get over the fall mats with his wheelchair.
During this observation, fall mats were identified on the left and right side of the first bed entering the room and this resident was sitting in his wheel chair to the side of his bed on top of a fall mat. Resident #26 also had a fall mat to the front side of his bed with the left side of the bed placed against the wall.
On 08/25/24 at approximately 2:20 PM, Licensed Practical Nurse (LPN) #50 was asked about Resident #26 not being able to safely wheel himself in his room. LPN #50 stated, we normally remove the floor mats when the residents are up out of the bed. LPN #50 assisted Resident #26 and the fall mats were removed off the floor.
b) Oxygen stored in resident sitting area with no signage.
During a tour of the facility on 08/26/24 at 10:51 PM there were three (3) oxygen tanks identified to be sitting unattended on the back of wheel chairs in the residents sitting area. All residents were in bed and the oxygen was not in use. Upon further review it is identified this room is not marked with signage which identifies it to be an area the oxygen is located and or stored.
During an interview with the Registered Nurse (RN) #30 at 12:05 AM on 08/26/24, RN #30 stated they do not normally leave the oxygen stored in this room when the residents are not using them. She stated they are normally returned to the oxygen holder outside of the facility. RN #30 removed the oxygen tanks at this time. RN #30 agreed the room is not identified with signage for oxygen in use or oxygen stored.
c) Medication Storage
On 08/25/24 at 09:48 AM, a facility tour was conducted revealing the treatment cart unlocked with the key in the lock, with resident medications stored on top of it. At that time, RN #21 acknowledged the treatment cart should have been locked with the keys and medications securely stored out of resident reach.
On 08/26/24 at 11:35 PM, an additional tour of the facility was conducted revealing A Hall medication cart unlocked with key in lock with the top drawer open. No nurse was present at the time. At 11:40 PM, RN #30 came out of a resident room and walked to the cart. At that time, RN #30 acknowledged this was her cart for the shift and the cart should have been locked with the keys securely stored out of resident reach.
In addition, at 11:38 PM, B Hall medication cart was noted to have medications sitting on top of the cart with a white oblong pill in a pill cup, a bottle of Lactulose and a bottle of Melatonin. Again, no nurse was present at the time. LPN # 52 returned to the cart at 11: 43 PM stating the white oblong pill was a Norco, however LPN #52 was unable to tell me which resident this medication belonged too. In addition, LPN #52 stated, We just got a new admission to the facility I was working on. LPN #52 acknowledged the medications should not have been sitting on top of the cart unattended and should have been securely stored out of residents reach.
On 08/27/24 at approximately 12:00 PM, a review of the policy and procedure entitled, Medication Storage was conducted which revealed that in order to limit access to prescription medications, only licensed nurses, pharmacy staff and those lawfully authorized to administer medications are allowed access to medication carts. Medication rooms, cabinets and medication supplies should remain locked when not in use or attended to by persons with authorized access.
On 08/27/24 at approximately 02:30 PM, an interview was conducted with the Director of Nursing who acknowledged the medication carts should have been locked when unattended and the medications should not have been left unsecured on top of the medication carts.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0809
(Tag F0809)
Could have caused harm · This affected multiple residents
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Based on observation and resident and staff interviews, the facility failed to offer snacks to residents who wished to revieve a snack at night time, and failed to ensure all ordered snacks were del...
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Based on observation and resident and staff interviews, the facility failed to offer snacks to residents who wished to revieve a snack at night time, and failed to ensure all ordered snacks were delivered to residents at night time. This was a random opportunity for discovery. Resident identifiers: #24, #28, #33, #51, #52, #22, #58. Facility census: 63.
Findings included:
a) Resident #24
At approximately 10:15 AM on 08/25/24, during a tour of the nourishment room at the facility, a sandwich was found in the refrigerator with a label dated 08/24/24 S3 (third shift, night shift), with the resident's name on it. A review of the task sheet for snacks offered for Resident #24 indicated Not Applicable was selected under question 2, titled Snack Accepted.
At approximately 10:45 AM, an interview with the District Dietary Manager (DDM) confirmed the resident was ordered the snack, the S3 on the label meant third shift, or night shift, and they were not passed. At approximately 11:00 AM on 08/25/24, an interview was conducted with the Dietary Manager (DM) regarding snacks.
The DM stated the last dietary employee leaves the facility at approximately 7:00 PM each evening and the snacks are delivered to the nurses station at that time. The DM stated They never deliver the snacks. I have pictures on my phone of the snacks still sitting there the next day. It happens all the time.
At approximately 11:38 PM on 08/26/24, a sandwich labeled for third shift on 08/26/24 was found on the nurses station. At approximately 11:40 PM in interview was conducted with Nurse Aides (NA) #15 and #33. NA #15 and #33 confirmed they had not offered the snacks to residents during the shift. NA #15 stated, I haven't offered one to anyone and if they are still sitting there, no one from evening shift did either. NA #33 stated the employees were getting ready to throw the snacks in the trash because they have been sitting here all night.
b) Resident #28
At approximately 10:15 AM on 08/25/24, during a tour of the nourishment room at the facility, a sandwich was found in the refrigerator with a label dated 08/24/24 S3 (third shift, night shift), with the resident's name on it.
A review of the task sheet for snacks offered for Resident #28 indicated Not Applicable was selected under question 2, titled Snack Accepted. At approximately 10:45 AM, an interview with the District Dietary Manager (DDM) confirmed the resident was ordered the snack, the S3 on the label meant third shift, or night shift, and they were not passed.
At approximately 11:00 AM on 08/25/24, an interview was conducted with the Dietary Manager (DM) regarding snacks. The DM stated the last dietary employee left the facility at approximately 7:00 PM each evening and the snacks weree delivered to the nurses station at that time. The DM stated, They never deliver the snacks. I have pictures on my phone of the snacks still sitting there the next day. It happens all the time.
At approximately 11:38 PM on 08/26/24, a sandwich labeled for third shift on 08/26/24 was found on the nurses station. At approximately 11:40 PM an interview with Nurse Aides (NA) #15 and #33. NA #15 and #33 confirmed they had not offered the snacks to residents during the shift. NA #15 stated, I haven't offered one to anyone and if they are still sitting there, no one from evening shift did either. NA #33 stated the employees were getting ready to throw the snacks in the trash because they have been sitting here all night.
At approximately 11:45 PM, an interview was conducted with Resident #28. During the interview, Resident #28 stated no one had brought or offered her the snack that evening. Resident #28 stated, I would have liked to have had it. I didn't even know it was there.
c) Resident #33
At approximately 10:15 AM on 08/25/24, during a tour of the nourishment room at the facility, a house supplement shake was found in the refrigerator with a label dated 08/24/24 S3 (third shift, night shift), with the resident's name on it. A review of the task sheet for snacks offered for Resident #33 indicated Not Applicable was selected under question 2, titled Snack Accepted. At approximately 10:45 AM, an interview with the District Dietary Manager (DDM) confirmed the resident was ordered the snack, the S3 on the label meant third shift, or night shift, and they were not passed. At approximately 11:00 AM on 08/25/24, an interview was conducted with the Dietary Manager (DM) regarding snacks. The DM stated the last dietary employee leaves the facility at approximately 7:00 PM each evening and the snacks are delivered to the nurses station at that time. The DM stated They never deliver the snacks. I have pictures on my phone of the snacks still sitting there the next day. It happens all the time.
At approximately 11:38 PM on 08/26/24, a melted cup of ice cream labeled for third shift on 08/26/24 was found on the nurses station. At approximately 11:40 PM in interview was conducted with Nurse Aides (NA) #15 and #33. NA #15 and #33 confirmed they had not offered the snacks to residents during the shift. NA #15 stated I haven't offered one to anyone and if they are still sitting there, no one from evening shift did either. NA #33 stated the employees were getting ready to throw the snacks in the trash because they have been sitting here all night.
d) Resident #51
At approximately 10:15 AM on 08/25/24, during a tour of the nourishment room at the facility, a house supplement shake was found in the refrigerator with a label dated 08/24/24 S3 (third shift, night shift), with the resident's name on it.
A review of the task sheet for snacks offered for Resident #51 indicated Not Applicable was selected under question 2, titled Snack Accepted. At approximately 10:45 AM, an interview with the District Dietary Manager (DDM) confirmed the resident was ordered the snack, the S3 on the label meant third shift, or night shift, and they were not passed. At approximately 11:00 AM on 08/25/24, an interview was conducted with the Dietary Manager (DM) regarding snacks. The DM stated the last dietary employee leaves the facility at approximately 7:00 PM each evening and the snacks are delivered to the nurses station at that time. The DM stated They never deliver the snacks. I have pictures on my phone of the snacks still sitting there the next day. It happens all the time.
At approximately 11:38 PM on 08/26/24, a melted cup of ice cream labeled for third shift on 08/26/2028 was found on the nurses station.
At approximately 11:40 PM in interview was conducted with Nurse Aides (NA) #15 and #33. NA #15 and #33 confirmed they had not offered the snacks to residents during the shift. NA #15 stated I haven't offered one to anyone and if they are still sitting there, no one from evening shift did either. NA #33 stated the employees were getting ready to throw the snacks in the trash because they have been sitting here all night.
e) Resident #52
On 08/26/24 at 3:42 PM, an interview was conducted with Resident #52. At tist time, Resident #52 stated, I don't always get snacks before I go to bed. I would like them but they usually don't offer them. Its less than once every 2 (two) weeks I would say they even offer me something before bed.
On 08/27/24 at 10:45 AM, a record review was conducted for Resident #52's Nurse Aide (NA) task list documentation related to provision of snacks which revealed Resident #52 was not offered a snack on the following dates:
07/28/24
07/29/24
07/31/24
08/01/24
08/02/24
08/03/24
08/04/24
08/05/24
08/06/24
08/07/24
08/09/24
08/10/24
08/11/24
08/12/24
08/13/24
08/14/24
08/15/24
08/16/24
08/17/24
08/18/24
08/19/24
08/20/24
08/21/24
08/23/24
08/24/24
08/25/24
08/27/24
On 08/27/24 at 2:55 PM, an interview was conducted with the Director of Nursing (DON) who stated, we offer snacks every evening, if the resident is not on the list for an ordered snack they can ask for it.
On 08/28/24 at 10:22 AM, review of facility policy for meal/snacks revealed evening snack was planned as part of the menu.
Food and Nutrition Services delivers snacks to nursing stations at specified times. Nursing or designated staff offer an evening snack to every resident. Snacks are passed within 15 minutes of delivery to the unit or are properly stored at the nursing station and offered at a later time.
On 08/28/24 at approximately 1:30 PM, the DON acknowledged the facility had not been following the procedures as outlined in the policy and procedure for meal and snacks.
F) Resident Council, Residents #22 and #58
On 08/26/24 at 12:00 PM, review of six (6) month's of resident council meeting minutes with no addressed concerns.
On 08/26/24 at 1:10 PM, during resident council, Resident #22 and Resident #58 reported they were not offered snacks at bedtime. They reported staff lay the snacks down at the nurses station and do not pass them out in the evening. Maybe one day per week staff will go around from room to room and offer a snack was stated by Resident #58.
On 08/28/24 at 1:13 PM a review of records task form for Resident #22 revealed residents were not offered a bedtime snack on the following evenings between 07/30/24 and 08/27/24:
-7/31/24
-08/01/24
-08/2/24
-08/3/24
-08/4/24
-08/06/24
-08/08/24
-08/09/24
-08/10/24
-08/11/24
-08/12/24
-08/13/24
-08/15/24
-08/16/24
-08/17/24
-08/18/24
-08/19/24
-08/20/24
-08/21/24
-08/22/24
-08/23/24
-08/24/24
-08/25/24
-08/26/24
-08/27/24
On 08/27/24 review of recorded task form revealed, Resident #58 was not offered bedtime snacks on the following days between 07/30/24 and 08/27/24:
-07/30/24
-08/1/24
-08/2/24
-08/4/24
-08/5/24
-08/07/24
-08/08/24
-08/09/24
-08/10/24
-08/11/24
-08/12/24
-08/13/24
-08/17/24
-08/18/24
-08/19/24
-08/20/24
-08/21/24
-08/24/24
-08/25/24
-08/26/24
-08/27/24
On 08/28/24 at 10:22 AM, review of facility policy for meal/snacks revealed evening snack was planned as part of the menu. Food and Nutrition Services delivers snacks to nursing stations at specified times. Nursing or designated staff offer an evening snack to every resident. Snacks are passed within 15 minutes of delivery to the unit or are properly stored at the nursing station and offered at a later time.
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 ensure food was stored, prepared, and served in a sanitary manner. This was a random opportunity for discovery. This has the potentia...
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Based on observation and staff interview, the facility failed to ensure food was stored, prepared, and served in a sanitary manner. This was a random opportunity for discovery. This has the potential to affect more than a limited number of residents residing in the facility. Facility census: 63.
Findings include:
a) Kitchen Tour
At approximately 9:45 AM on 08/25/24, during the initial tour of the kitchen, a jar of apple sauce was discovered in the reach-in refrigerator. The apple sauce had a discard date of 7/19/24 on it and was still in use. [NAME] #82 acknowledged the apple sauce, discard date, and that it was still in use.
At approximately 11:00 AM, an interview was conducted with the Dietary Manager (DM) regarding the apple sauce. During the interview, the apple sauce was still in the refrigerator and acknowledged by the DM.
b) Dining Observation
On 08/25/24 at 12:00 PM, the Assistant Director of Nursing (ADON) #55 was observed assisting a resident with her fork, food and drink while the resident was eating. The ADON then turned and picked up a clean tray to serve another resident without sanitizing her hands.
On 08/25/24 at 12:01 PM, ADON #55 was made aware she was observed assisting a resident with her food and didn't sanitize before continuing to pass trays and putting others at risk for cross contamination. ADON #55 acknowledged and stated I'm messing up, I am not usually in here.
c) Placement of soiled tray.
During a dining room observation on 08/25/24 at approximately 11:47 AM the Assistant Director of Nursing (ADON) was observed to taking a resident meal tray from the enclosed food delivery cart and placed the tray on the table in front of the resident. The resident was observed to refuse the tray and the ADON was observed to take the tray and place it back into the enclosed food delivery cart with other residents trays which had not yet been served.
During an interview with the ADON on 08/25/24 at 11:50 AM the ADON agreed the tray being placed back in the food delivery cart after it was sat at the table does increase the potential of cross contamination and she knew she should not have done that but doesn't normally work in the dining room. She further stated the tray should have been taken to the kitchen.
During an interview with the Administrator on 08/25/24 at approximately 12:00 PM, the Administrator stated the ADON should not have placed the tray back into the food delivery cart.
May 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
Transfer Requirements
(Tag F0622)
Could have caused harm · This affected 1 resident
Based on record review and staff interview, the facility failed to convey the following information to the hospital when the resident was transferred: contact information of the practitioner who was r...
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Based on record review and staff interview, the facility failed to convey the following information to the hospital when the resident was transferred: contact information of the practitioner who was responsible for the care of the resident; Resident representative information, including contact information; advance directive information; all special instructions and/or precautions for ongoing care, as appropriate such as: treatments and devices (oxygen, implants, IVs, tubes/catheters);
special risks such as risk for falls, elopement, bleeding, or pressure injury and/or aspiration precautions; the resident's comprehensive care plan goals; and all other information necessary to meet the resident's needs, which includes, but may not be limited to: resident status, including baseline and current mental, behavioral, and functional status, reason for transfer, recent vital signs;
diagnoses and allergies; medications (including when last received); and most recent relevant labs, other diagnostic tests, and recent immunizations, etc. This was a random opportunity for discovery for one (1) eight (8) Residents reviewed during a complaint survey. Resident identifier: #64. Facility census: 63.
Findings included:
a) Resident #64
Review of the Resident census in the electronic medical record found the facility stopped billing for the Resident's stay on 04/14/23.
Review of the progress notes and the electronic medical record found no information as to why the Resident was no longer at the facility after 04/14/23. There was no change in condition form completed.
An interview with the Director of Nursing (DON) at 1:00 PM on 05/16/23 found the Resident was transferred to the hospital for abdominal pain per family request, or at least that was what the DON was told. There was no documentation in the medical record that the Resident had abdominal pain.
The DON was unable to find any documentation as to what the hospital received when the Resident was transferred. The DON said a change of condition form should have been completed. There was no documentation the family or the physician was notified of the transfer.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure an appointment was scheduled with a urologist as direc...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure an appointment was scheduled with a urologist as directed by the discharging in - patient hospital and the facility physician for a Resident with an indwelling Foley catheter. This was true for one (1) of two (2) residents reviewed for catheter care. Resident identifier: #64. Facility census: #63.
Findings included:
a) Resident #64.
Record review found the Resident was admitted to the facility on [DATE] after a hospital stay in a rehabilitation center for 39 days. The discharge summary follow up plan of care directed, .Needs to follow with urology in 2 weeks after discharge .
The Resident was admitted with a Foley catheter for urinary retention.
At 8:47 AM on 05/16/23, the Assistant Director of Nursing (ADON) provided a copy of a fax confirmation sheet sent to a local urologist for Resident #64, dated 03/28/23. The ADON was unable to provide any further documentation regarding the scheduling of an appointment. The ADON said the resident's stay is being paid for by the Veterans Administrator so authorization is required from the VA for all appointments. She was unable to provide documentation the VA was contacted for authorization to schedule an appointment with a urologist.
Further review of the medical record found the facility physician wrote an order for an urology consult for long term Foley catheter use on 04/02/23.
As of the day of discharge on [DATE] there was no evidence the Resident had an appointment scheduled with a urologist.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
Based on record review and staff interview, the facility failed to ensure the conditions surrounding a fall were correctly documented and identified to ensure the resident received adequate supervisio...
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Based on record review and staff interview, the facility failed to ensure the conditions surrounding a fall were correctly documented and identified to ensure the resident received adequate supervision to prevent accidents. This was true for one (1) of three (3) residents reviewed for the care area of falls. Resident identifier: #64. Facility census: 63.
Findings included:
a) Resident #64
Record review found the following progress note:
04/14/23 at 6:18 AM, General, Late Entry:
Note: this nurse was completing early morning pill pass outside the residents room when I heard resident fall on fall mat. This nurse entered resident room and observed resident lying on floor beside low bed on fall mat. This nurse proceeded to assess resident for injuries. Resident denied any pain that resulted from fall or hitting head or losing consciousness No redness or swelling found on head or anywhere on the body. VS (vital signs) were taken and were WNL (within normal limits.) Resident Pupils were equal, round and reactive to light and accommodation. Resident alert and oriented per baseline. Resident placed back in bed with assistance. Skin check was performed with no abnormal findings. Family called and notified of clinical situation. Family did not want resident sent out to ED (emergency department) for further evaluation. Provider notified.
Review of the fall incident report for 04/14/23 at 7:07 PM, found the following documentation:
CNA (certified nursing assistant) on shift was completing Q (every) 2 hr (hour) rounds when CNA calls out for this nurse. Upon entry into room resident observed laying floor face down on right side of bed in between the bed and heating/cooling unit in wall. Resident states I don't know what happened. I just rolled and fell and bumped my head. Notes: reddened area noted above ear on right side of head, small skin tear noted to back of right hand (approx. (aproximately) 2 cm X 2 cm), small skin tear noted to right arm near elbow (approx. 2 cm X 3 cm), and a hardened raised area can be palpated posterior top right cranium.
The immediate action taken was described as: Resident assessed, vital signs taken, resident assisted back to be via mechanical lift X 3 nursing staff, and neuro checks started. The Resident was sent to the hospital.
At 11:30 AM on 05/16/23, the Director of Nursing was asked to explain the different scenarios for a fall on 04/14/23. The DON said it was the same fall although a late entry for the progress note indicates it was made at 6:18 AM and the fall incident report was made at 7:07 PM. The DON was asked how a nurse would have known about the fall 11 hours before it supposedly happened. The DON said 2 separate nurses completed the documentation which the DON agreed did not match. The DON said the Resident was sent to the hospital for abdominal pain which was unrelated to the fall. The DON said the family wanted the Resident sent to the hospital although the first progress note said the family did not want the Resident sent to the emergency room. The first recording documents the resident had no skin issues yet the second documentation notes skin tears that occurred as a result of the fall. The DON could not explain the differences in the documentation of the fall on 04/14/23.
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 F0697
(Tag F0697)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure that pain management is provided to residents who requ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences. When as needed (PRN) Acetaminophen did not elevate the resident's pain, there was no documentation any further interventions were put into place to address the Resident's pain. In addition, pain medication was given when the resident indicated his pain rating was 0, which indicates the Resident had no pain. Resident identifier: #64. Facility census: 63.
Findings included:
a) Resident #64
Pain Management Policy, revised on 10/24/22.
9.3 Ineffectiveness of routine or PRN medications including interventions, follow-up, and physician/APP notification
Record review found the Resident was admitted to the facility on [DATE]. On 03/11/23, the physician wrote an order for Acetaminophen Tablet 325 milligrams MG. Give 2 tablets by mouth every 4 hours as needed for Mild pain. More than 3 doses in 48 hours, notify physician/advanced practice provider. Do not exceed 3 g (grams) a day.
On 04/01/23 at 8:02 PM, the Resident received Acetaminophen when his pain was rated 0.
On 04/05/23 at 12:39 AM, the Resident received Acetaminophen when his pain was rated 0.
On 04/11/23 at 6:23 PM, the Resident received Acetaminophen when his pain was rated 0.
On 04/08/23 at 8:00 PM, the Resident's pain was rated as a 7 - indicating severe pain, Acetaminophen was given and noted to be ineffective.
At 11:25 AM on 05/16/23, the Director of Nursing (DON) confirmed the nurse should have tried other interventions when the Resident rated his pain as a 7 on 04/08/23 and Acetaminophen was not effective. In addition, the DON did not know why Acetaminophen was provided if the Resident had no pain.
Mar 2023
8 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
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Based on record review, resident interview, and staff interview, the facility failed to develop and/or implement the comprehensive care plan. Resident #40's comprehensive care plan was not developed...
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Based on record review, resident interview, and staff interview, the facility failed to develop and/or implement the comprehensive care plan. Resident #40's comprehensive care plan was not developed in the area of shoulder pain. Resident #8's care plan was not implemented in the area of nutrition. This deficient practice had the potential to affect two (2) of 17 residents reviewed in the long-term care survey sample. Resident identifiers: #40, #8. Facility census: 63.
a) Resident #40
During an interview on 03/06/23 at 12:41 PM, Resident #40 reported bilateral shoulder pain. She stated she was receiving pain medication but still had shoulder pain, particularly in the morning when her clothing was changed.
Review of Resident #40's medical records revealed she had a diagnosis of osteoarthritis and a history of right humerus fracture. The resident had received bilateral shoulder steroid injections at an orthopedic office on 11/9/22, 12/14/22, and 2/15/23.
Review of Resident #40's comprehensive care plan showed the following focus related to pain, Resident exhibits or is at risk for alterations in comfort related to HX [history] of ruptured right tympanic membrane; debility, R [right] periprosthetic Fx [fracture] R [right] Femur. The resident's bilateral shoulder pain was not addressed in the care plan.
During an interview on 03/08/23 at 10:01 AM, the Director of Nursing confirmed Resident #40's comprehensive care plan did not address her bilateral shoulder pain.
No further information was provided through the completion of the survey process.
b) Resident #8
Review of Resident #8's comprehensive care plan showed a focus indicating the resident had a diagnosis of insulin dependant diabetes. An intervention was to monitor meal consumption every meal.
Review of Resident #8's task report for meals for the last 30 days showed meal consumption was not monitored for every meal on the following dates:
- On 02/06/23, only one (1) meal consumption was monitored.
- On 02/07/23, only two (2) meal consumption's were monitored.
- On 02/10/23, only one (1) meal consumption was monitored.
- On 02/11/23, only two (2) meal consumption's were monitored.
- On 02/12/23, only two (2) meal consumption's were monitored.
- On 02/15/23, only one (1) meal consumption was monitored.
- On 02/18/23, only two (2) meal consumption's were monitored.
- On 02/19/23, only two (2) meal consumption's were monitored.
- On 02/21/23, only one (1) meal consumption was monitored.
- On 02/22/23, only two (2) meal consumption's were monitored.
- On 02/23/23, only two (2) meal consumption's were monitored.
- On 02/24/23, only one (1) meal consumption was monitored.
- On 02/25/23, only one (1) meal consumption was monitored.
- On 02/26/23, only two (2) meal consumption's were monitored.
- On 02/27/23, only one (1) meal consumption was monitored.
- On 02/28/23, only two (2) meal consumption's were monitored.
- On 03/03/23, only two (2) meal consumption's were monitored.
During an interview on 03/07/23 at 12:31 PM, the Director of Nursing (DON) confirmed Resident #8's meal consumption was not monitored as specified in the comprehensive care plan.
No further information was provided through the completion of the survey process.
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CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on record review and staff interview and policy procedures the facility failed to provide treatment and care in accordan...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on record review and staff interview and policy procedures the facility failed to provide treatment and care in accordance with professional standards of practice. This was true for two (2) of three (3) records reviewed for accidents.
Findings Included:
Resident #28
a) On 3/6/23 at 1:04 PM record review shows that Resident #28 had a fall on 2/25/23. The fall was unwitnessed and he presented with a swollen right hand that required an x-ray (negative).
According to the facility Falls Management Policy dated 9/15/01, Revision date 6/15/22 Any patient who sustains an injury to the head from a fall and/or has an unwitnessed fall will be observed for neurological abnormalities by performing neuro check, per policy According to the Director of Nursing (DON) on 3/6/23 at 3:25 PM, the neurological checks are to be done in the following sequence. Every fifteen (15) minutes X's two (2) hours, Every thrifty (30) minutes X's two (2) hours. Every hour X's four (4) hours and every eight (8) hours X sixty-four (64) hours.
The neurological checks for this fall on 2/25/23 were not started until 2/27/23, two (2) days after the fall. This was confirmed with the DON on 3/8/23 at 10:36 AM.
b) Resident #7
1) Record review of Resident #7's chart shows she had an unwitnessed fall on 1/18/23 at 4:36 AM. There were no neurological checks performed for this unwitnessed fall.
According to the facility Falls Management Policy dated 9/15/01, Revision date 6/15/22 Any patient who sustains an injury to the head from a fall and/or has an unwitnessed fall will be observed for neurological abnormalities by performing neuro check, per policy According to the Director of Nursing (DON) on 3/6/23 at 3:25 PM, the neurological checks are to be done in the following sequence. Every fifteen (15) minutes X's two (2) hours, Every thrifty (30) minutes X's two (2) hours. Every hour X's four (4) hours and every eight (8) hours X sixty-four (64) hours.
This was confirmed with the DON on 3/8/23 at 10:01 AM.
2) Record review of Resident #7's chart shows she had an unwitnessed fall on 1/18/23 at 4:36 AM. There was a change of condition and a Risk Management Incident Report completed.
There was a Interact Transfer Form completed on 1/18/23 at 9:00 AM to transfer the resident to a local hospital for altered mental status change. There were no progress notes from the time she fell on 1/18/23 at 4:36 AM until 1/18/23 at 11:17 PM when a general note was entered that staff had Spoke to [NAME], stated she was admitted for possible stroke in (the local hospital).
According to the hospital discharge records the resident presented to the hospital with pupils were constricted.
There is no documentation of the residents status from the time of the fall on 1/18/23 at 4:36 AM until she was transferred to the hospital at 9:00 AM for altered mental status. The facility failed to provide medical attention in a timely manner. This was confirmed with the Director of Nursing on 3/8/23 at 10:01 AM.
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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 observation, record review, and staff interview, the facility failed to ensure the resident environment over which it had control was as free from accident hazards as possible. Resident #48...
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Based on observation, record review, and staff interview, the facility failed to ensure the resident environment over which it had control was as free from accident hazards as possible. Resident #48 did not have fall mats to her floor as ordered by the physician. This was a random opportunity for discovery. Resident identifier: #48. Facility census: 63.
Findings included:
a) Resident #48
On 03/06/23 at 12:35 PM, Resident #48 was observed lying in bed with fall mats on the floor on both sides of her bad.
On 03/08/23 at 8:45 AM, Resident #48 was observed lying in bed. The fall mats were propped up against the wall and not on the floor.
Review of Resident #48's physician's orders showed an order written on 06/11/21 for bilateral mats to bedside while the resident was in bed. Review of Resident #48's medical records showed the resident's most recent fall had occurred on 01/03/23.
On 03/08/23 at 9:10 AM, Nursing Assistant (NA) #35 confirmed Resident #48's floor mats were not properly placed on the floor.
No further information was provided through the completion of the survey process.
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CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Drug Regimen Review
(Tag F0756)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on record review and staff interview, the pharmacist failed to report a medication irregularity for one (1) of five (5) ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on record review and staff interview, the pharmacist failed to report a medication irregularity for one (1) of five (5) residents reviewed for the care area of unnecessary medications. Resident identifier: #8. Facility census: 63.
Findings included:
a) Resident #8
Review of Resident #8's medical records showed the resident was admitted from the hospital on [DATE]. The resident's hospital discharge instructions included an order for the medication Buspar (buspirone hydrochloride) 10 mg twice a day for anxiety. The resident had a diagnosis of end stage renal disease and was receiving dialysis treatments.
Further review of Resident #8's medical records showed a pharmacy medication review was performed on 08/08/23. The medication review stated, Clinically urgent recommendation: prompt response requested. [Resident's name] receives Buspar 10 mg twice daily for anxiety and requires dialysis. The use of buspirone hydrochloride is contraindicated in individuals receiving dialysis. Recommendation: Please evaluate the continued use of Buspar, consider discontinuing and if appropriate initiate alternative therapy, perhaps Lexapro 5 mg daily. Titrate to clinical effectiveness.
The physician discontinued the Buspar and ordered Lexapro [escitalopram oxalate] 10 mg daily.
According to the Buspar package insert available on the Food and Drug Administration (FDA) Website, administration of Buspar to patients with renal impairment cannot be recommended because Buspar is excreted by the kidneys.
On 12/12/22, Resident #8 was transferred to the hospital. When the resident returned to the facility on [DATE], the resident's hospital discharge instructions contained orders for both Buspar 10 mg twice a day and Lexapro 10 mg daily.
Pharmacy medication reviews were performed on 1/18/23 and 2/14/23 but the pharmacist did not address Buspar being prescribed for this resident despite a diagnosis of end stage renal disease.
During an interview on 03/07/23 at 1:59 PM, the Director of Nursing (DON) confirmed the pharmacist did not address Resident #8's Buspar prescription.
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CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected 1 resident
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Based on record review and staff interview, the facility failed to ensure the controlled substance count was completed and documented by two (2) licensed nurses during shift change. This was a rando...
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Based on record review and staff interview, the facility failed to ensure the controlled substance count was completed and documented by two (2) licensed nurses during shift change. This was a random opportunity for discovery. Facility Census: 63.
Findings Included:
a) Medication Administration
On 03/07/23 at 8:15 AM, a review of the controlled substances count was completed. The following dates were not signed by two (2) nurses during shift change and the narcotic count was not completed:
--02/07/23 off going nurse 7:00 AM
--02/08/23 off going nurse 7:00 AM
--02/09/23 on coming nurse 7:00 AM
--02/11/23 on coming nurse 7:00 AM
--02/11/23 off going nurse 7:00 PM
--02/17/23 on coming nurse 7:00 AM
--02/17/23 off going nurse 7:00 PM
--02/23/23 on coming nurse 7:00 PM
On 03/07/23 at 8:20 AM, licensed practical nurse (LPN) #60 confirmed the above dates were not signed by two (2) nurses at the end of each shift.
On 03/07/23 at 8:25 AM, Assistant Director of Nursing (ADON) #61 was notified and confirmed the dates were not signed by two (2) nurses and the pages were not complete.
b) Policy
On 03/07/23 at 10:00 AM, a review of the policy entitled Management of Controlled Drugs was reviewed. The section entitled Ongoing Inventory stated the following:
A complete count of all Schedule II (two) through IV (four) controlled substances is required at the change of shifts per state regulation or at any time in which narcotic keys are surrendered from one licensed nursing staff to another. The count must be performed by two licensed nurses and/or authorized nursing personnel, per state regulations. (Typed as written.)
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CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected 1 resident
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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 of practice. During the kitchen tour it ...
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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 of practice. During the kitchen tour it was discovered the freezer floor needed to be cleaned and the beverage dispenser was not draining properly. This had the potential to affect a limited number of residents receiving nourishment from the kitchen. Facility census: 63.
Findings included:
a) Kitchen tour
During the kitchen tour on 03/06/23 at 10:50 AM, it was discovered the walk-in freezer had six (6) individual cups of ice cream on the floor and also the floor needed to be cleaned. The tubing for the beverage dispenser wand was draining into the hand washing sink.
On 03/06/23 at 11:20 AM, the Dietary Manager on verified the floor to the walk-in freezer needed to be cleaned and the beverage dispenser machine should not have tubing draining into the hand washing sink.
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CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
c) Resident #27
On 03/06/23 at 11:33 AM, a nebulizer mask was observed laying on a [NAME] beside the bed. The nebulizer mask w...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
c) Resident #27
On 03/06/23 at 11:33 AM, a nebulizer mask was observed laying on a [NAME] beside the bed. The nebulizer mask was not stored in a respiratory bag. Nurse Aide (NA) #23 confirmed the nebulizer mask was not in a respiratory bag. NA #23 stated, I'll get one now.
On 03/08/23 at approximately 1:00 PM, the Director of Nursing (DON) was notified. The DON confirmed the nebulizer mask should have been stored in a respiratory bag.
No further information was obtained during the long-term survey.
Based on observation and staff interview the facility failed to store respiratory equipment at bedside in a sanitary manner according to professional standards of care. This was a random opportunities for discovery. Resident Identifier: #219, #3, #27 Facility Census: 63
Findings included:
a) Resident #219
During the initial interview process of the survey it was discovered that Resident #219 had a Bi-Pap at bed side that was not stored in a sanitary manner. The machine was on the bedside table with the tubing draped across the bedside table. There was nothing covering the Bi-Pap machine or tubing. The appropriate plastic storage bag was on the floor. This was confirmed with Licensed Practical Nurse # 9.
b) Resident #3
During the initial interview process of the survey it was discovered that Resident #3 had a nebulizer machine at bed side that was not stored in a sanitary manner. The machine was on the bedside table with the tubing draped across the machine. There was nothing covering them for protection. There was no appropriate plastic storage bag at bedside. This was confirmed with Licensed Practical Nurse # 9.
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CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Medical Records
(Tag F0842)
Could have caused harm · This affected multiple residents
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c) Resident #8
On 03/07/23 at 3:16 PM, the POST form was reviewed for Resident #8. The review found the resident's address and the date the Medical Power of Attorney (MPOA) signed the POST form were...
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c) Resident #8
On 03/07/23 at 3:16 PM, the POST form was reviewed for Resident #8. The review found the resident's address and the date the Medical Power of Attorney (MPOA) signed the POST form were blank. Also, the POST form was missing the date and signature of the preparer of the form.
On 03/08/23 at 8:20 AM, Social Worker (SW) #1 confirmed the POST form was incomplete.
No further information was obtained during the long-term survey process.
b) Resident #8
Review of Resident #8's medical records showed a Physician Orders for Scope of Treatment (POST) form completed by the resident on 08/05/22. The POST form indicated the resident's end-of-life wishes to not have cardiopulmonary resuscitation in the absence of pulse and breathing. The form also indicated the resident's wishes to have selective treatments for situations where pulse and breathing were present. However, the section of the POST form to indicate whether the resident wanted medically assisted nutrition was left blank.
Additionally, the back of the POST form was blank except for the signature of the health care provider who assisted with the form and the date the form was completed. The resident's name was not written in the specified area on the top of the back of the form. According to the guidance for the 2021 POST form, When completing the back of the POST form, the patient's name at minimum needs to be printed in the top box as it appears on the front of the POST form.
During an interview on 03/07/23 at 10:19 AM, the Social Worker confirmed Resident #8's POST form was not complete.
No further information was provided through the completion of the survey process.
Based on record reviews and staff interview the facility failed to ensure a complete and accurate medical record. The facility failed to ensure the Physician Orders for Scope of Treatment (POST) forms were completed per directions specified by the [NAME] Virginia Center for End-of-Life Care. This was true for three (3) of 17 residents reviewed for the Long-Term Care Survey Process. Resident Identifiers: #44, #66, and #8. Facility Census: 63.
Findings included:
a) Resident #44
A medical record review on 03/06/23 at 1:47 PM, revealed the POST form for Resident #44 noted no medically assisted nutritional status and no signature of the person participating or assisting the resident with the completion of the POST form.
An interview with the Licensed Social Worker on 03/07/23 at 10:19 AM, verified the resident's wishes for any medically assisted nutrition was not addressed and there was no signature for the person participating or assisting with the completion of the POST form.
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Dec 2021
10 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0558
(Tag F0558)
Could have caused harm · This affected 1 resident
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Based on observation and staff interview, the facility failed to ensure the call light was within reach for Resident #213. This was a random opportunity for discovery. Resident Identifier: #213. Fac...
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Based on observation and staff interview, the facility failed to ensure the call light was within reach for Resident #213. This was a random opportunity for discovery. Resident Identifier: #213. Facility Census: 64.
Findings included:
a) Resident #213
On 12/06/21 at 11:32 PM, Resident #213's call bell was found in the floor by the bed. Registered Nurse (RN) #53 verified the call bell was out of reach and placed the call bell on the bed within reach of Resident #213. On 12/08/21 at 8:50 AM, the Director of Nursing (DON) was notified.
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CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0685
(Tag F0685)
Could have caused harm · This affected 1 resident
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Based on resident interview, observation, record review, and staff interview the facility failed to provide services to maintain or improve Reisdent #41's ability to carry out his activities of dail...
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Based on resident interview, observation, record review, and staff interview the facility failed to provide services to maintain or improve Reisdent #41's ability to carry out his activities of daily living and maintain his quality of life. Resident #41 was observed with a large amount tape on his glasses which obstructed his view. This was found to have been on his glasses for at least multiple months. This was true for one (1) out of one (1) reviewed in the care area of vision. Identified: Resident # 41. Facility census 64.
Findings included:
a) Resident #41
During an interview on 12/06/21 at 11:25 AM, it was noted Resident #41 had a large amount of type in the middle of his glasses, and the right lens was obstructed with tape and gauze. When asked about his glasses, he said they are missing the nose pads and it digs into the bridge of his nose. He said it has been like that since his admission a year ago.
On 12/07/21 at 9:24 AM during an interview with the Social Worker when asked about the broken glasses for Resident #41 she said that the eye doctor came to the facility, and he was on the list to be seen. But on the day the eye doctor was there Resident #41 refused to wake up for his appointment. She was asked for the list of Residents that were scheduled to see the eye doctor and any notes stating he refused to go to his appointment.
On 12/07/21 at 12:15 PM, the Social Worker provided a list of names of Residents that were scheduled to be seen by a local optometrist dated: 04/14/2021 and it did not have Resident # 41 listed on it to be seen. She was asked about saying Resident #41 had refused to get up for his appointment when he was not on the list to be seen. She stated, I can't answer that. Social Worker was asked if anyone had made any attempts to have his glasses repaired. She replied, No I can't answer that. Social Worker went on to say maybe Resident #41 was on another list because he might have been back to see more residents in August. However Social Worker said she would not be able to provide that list because her email will not allow her to look at emails older than 180 days old. When it was stated, August would be within 180 days There was no response.
On 12/07/21 at 12:40 PM, the Director of Nursing (DON) was asked to speak to Resident #41 about his broken glasses. Upon entering the room, it was noted Resident #41 did not have his glasses on. When he was asked about them, he said the Social Worker came in and took his glasses about 10 minutes ago. The DON asked if his glasses had tape on them for just a little while and Resident #41 shook his head to indicate no. Resident #41 said it has been a long while. She said like a few weeks. Resident #41 said no like for several months or a year.
On 12/07/21 at 12:44 PM, Nurse Aide #20 came into the room while the DON was talking to Resident #41 and stated Resident #41 has had tape on his glasses forever. She went on to say that she has asked him many times how do you even see out of those glasses, because half of the lens was covered with tape.
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CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
Could have caused harm · This affected 1 resident
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Based on observation, medical record review and staff interview the facility failed to provide necessary respiratory care and services. This was true for three (3) of three (3) residents reviewed fo...
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Based on observation, medical record review and staff interview the facility failed to provide necessary respiratory care and services. This was true for three (3) of three (3) residents reviewed for respiratory services during the investigation phase of the survey process. It was observed Resident #16, Resident #4 and Resident #213, was not receiving oxygen therapy at the prescribed rate. Resident identifier: Resident #16, Resident #4 and Resident #213. Facility census: 64
Findings Included:
a) Resident #16
Observation made during tour at 10:27 AM on 12/06/21, found Resident # 16 was receiving oxygen (02) via nasal cannula. The oxygen flow rate was set at 4.5 liters/per minute (L/min) by an oxygen concentrator.
An interview with Licensed Practical Nurse (LPN) # 24 on 12/06/21 at 10:44 AM, verified the oxygen order for Resident #16's oxygen flow rate was for 2 L/min, LPN #24 checked the oxygen flow rate on the concentrator and verified it was at 4.5 L/min. She stated its suppose to be on 2 liters and adjusted to correct flow rate.
During an interview with the Director of Nursing (DON) on 12/06/21 at 10:47 AM, the DON stated she messes, with it all the time, she changes the tubing and puts it on her portable tank, it's all care planned. I have been in there twice this morning and fixed it, there are stickers on the concentrator to let staff know what it should be set on and they can let the nurse know.
A Care Plan date 09/04/20, Inventions stated Check at bedtime to make sure resident has oxygen on and connected to concentrator Resident frequently removes nasal cannula, attempts to switch tubing from portable tank to concentrator.
A Physician Order dated 04/16/19 was Oxygen at 2 L/min via nasal cannula continuously.
b) Resident #4
Observations made during tour at 11:06 AM on 12/06/21, found Resident # 9 was not receiving oxygen (02) via nasal cannula. The nasal cannula was laying on the oxygen concentrator without the a proper storage bag. The oxygen flow rate was set at 2 liters/per minute (L/min) by an oxygen concentrator that was turned on.
During an interview on 12/06/21 at 11:21 AM the DON verified that Resident # 4, was not receiving her 02 via nasal cannula she stated (Resident #4's name) does not wear it sometimes, its for 2 L/min PRN(as needed).
A physician order dated 06/07/16, was Oxygen at 2 L/min via nasal cannula continuously.
c) Resident #213
On 12/06/21 at 11:32 AM, the oxygen setting on the concentrator was 1.5 (one point five) Liters Per Minute (LPM). A physician's order dated 11/24/21 was for the oxygen setting of 2 (two) LPM. Registered Nurse (RN) # 53 verified the setting of the oxygen was incorrect for Resident #213 and corrected the setting.
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CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Medical Records
(Tag F0842)
Could have caused harm · This affected 1 resident
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Based on record review and staff interview the facility failed to ensure an accurate medical record for Resident # 47. This was a random opportunity for discovery and had the potential to affect a l...
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Based on record review and staff interview the facility failed to ensure an accurate medical record for Resident # 47. This was a random opportunity for discovery and had the potential to affect a limited number of residents. Facility census 64.
Findings included:
During a record review it was revealed that Resident #47 changed her Medical Power of Attorney MPOA from one daughter to a different daughter because the first daughter was allegedly taking her money. Resident #47 has capacity and asked that no information concerning her, and her health be released to the first daughter. However, when reviewing the electronic chart, the first daughter was still listed as the first contact and MPOA.
During an interview on12/08/21 at 12:25 PM, the Director of Nursing (DON) was asked about the two different sets of MPOA papers naming the daughters the first daughter that lives in the area MPOA dated 02/26/2021. The daughter that lives out of town was made MPOA by Resident #47 on 05/17/2021. It was shown in the electronic chart under the Profile tab that the first daughter was still listed as MPOA and first contact. The infection Control Nurse was also in the room and stated she just changed it.
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CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0883
(Tag F0883)
Could have caused harm · This affected 1 resident
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Based on record review and staff interview, the facility failed to administer an influenza vaccination to a resident after a consent was obtained. This was true for one (1) of five (5) residents rev...
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Based on record review and staff interview, the facility failed to administer an influenza vaccination to a resident after a consent was obtained. This was true for one (1) of five (5) residents reviewed under the care area of immunizations during the Long-Term Survey Process. Resident Identifier: #46. Facility Census: 64.
Findings Included:
a) Resident #46
On 12/08/21 at 8:00 AM, a record review of Resident #46's current influenza, pneumococcal and COVID-19 immunizations was completed. The review found Resident #46 did have documentation of the influenza immunization consent signed by the Medical Power of Attorney (MPOA) on 07/27/21 and 10/26/21. The influenza immunization was never given. After Surveyor intervention, the influenza immunization was scheduled to be given on 12/08/21.
On 12/08/21 at 8:50 AM, the Director of Nursing (DON) stated it got missed but he will get it today. They (Influenza Vaccinations) were given in October.
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CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0561
(Tag F0561)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on observation, resident interviews and staff interviews, the facility failed to promote and facilitate resident self-de...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on observation, resident interviews and staff interviews, the facility failed to promote and facilitate resident self-determination through support of resident choice in regards to having access to the dining room during meals and activities. This failed practice had the potential to affect more than an isolated number of residents currently residing in the facility. Facility Census: 64
Findings Included:
a) Meals
During an initial tour of facility on 12/06/21, a few residents were going to the dining room, this surveyor heard staff members tell Resident #5, they were eating in their rooms today.
The Administrator stated on 12/06/21 we are having 25 days of Christmas, things daily for everyone to do and today is our baked potato and salad bar.
The following is the list of the 25 days of Christmas posted:
[DATE] Christmas Sock Day
[DATE] Reindeer Dress and Pizza Time (Lunch Time)
[DATE] Hot Cocoa and Cupcakes
[DATE] Baked Potato and Salad Bar
[DATE] Brownies and Ice Cream 2:30 PM
[DATE] Ornament Making and Popcorn
[DATE] Christmas Pajama Day
[DATE] Mexican Buffet (Lunch Time)
[DATE] Ugly Sweater Day
[DATE] Grinch Dress Day
[DATE] Elf Dress Day, Jenga and Snacks 2:30 pm
[DATE] Italian Buffet ( Lunch Time)
[DATE] Santa Dress Day
[DATE] Christmas Wrap Game an Snacks 2:30 pm
[DATE] Christmas Pajama Day Nachos 2:30 pm
[DATE] Employee Christmas Dinner
[DATE] Snacks 2:30
The following residents ate their lunch meal in the Dining Room on 12/07/21:
Resident # 5
Resident #30
Resident # 62
Resident # 6
Resident # 14
Resident # 52
Resident # 19
Resident # 32
Resident # 24
Resident #58
The following Residents ate their lunch meal in the Dining Room on 12/8/21:
Resident # 57
Resident # 56
Resident # 16
Resident # 52
Resident # 24
Resident # 8
Resident # 12
Resident # 22
Resident # 14
Resident # 58
During an interview with the Director of Nursing (DON) on 12/08/21 at 8:17 AM, stated Everybody is involved in the 25 days of Christmas even the Residents.
This surveyor asked if the Residents received brownie sundaes yesterday, which was on the list. The DON stated The activity and front office girl are in charge of all that.
During an interview with Resident # 5 on 12/08/21 at 9:40 AM, he stated I like to go to the dining room when we get to go. They never tell me until I get down there and it is closed. I eat lunch with my girlfriend.
During an interview with Resident # 58 on 12/08/21 10:00 AM, she stated We like to eat in the Dining Room, I don't like to eat in my room, we are in our rooms enough.
During an interview with Resident # 24 on 12/08/21 10:02 AM, she stated I enjoy eating in the dining room, I get to talk to all these ladies. I don't like to eat in my room either.
During an Interview on 12/08/21 at 11:50 AM with Recreation Director #71 stated The 25 days of Christmas is for the staff, a few things are on the calendar that the resident participate in like Christmas sock day, pj day.
This surveyor asked if the residents participated in the brownie sundaes yesterday the RD stated No, the had a snack cart in the hallway.
This surveyor asked the RD if the Residents participated in the Baked Potato and salad bar, she stated No, they ate in their rooms.
This surveyor asked where they had the activity named fitness zone that was scheduled at 10:30 am on 12/06/21 take place, RD stated in their rooms, I changed it on the calendar in the hallway and the one I gave you. We canceled the lunch bunch and eating lunch in the dining room for the staff events like pizza on the 2nd and baked potato bar on the Monday and Friday we will be having a Mexican buffet.
This surveyor stated you also changed the group activities on this day to in room activities, the RD stated Yes.
b) Activities
During an interview on 12/06/21 at 10:58 AM, Resident #22 stated I go to bingo, the other stuff is dumb. I get bored easy, they don't give me anything in my room to do.
During an interview on 12/08/21 at 9:45 AM , Resident #22 stated I love the Bingo, we are old people we like that game. I am so bored and most of this stuff is dumb. They ask me to go to Bingo when they have it.
During an interview on 12/06/21 at 10:22 AM, Resident # 52 stated I go to activities, when they have them we don't have too many because of the virus.
During an interview on 12/08/21 at 9:50 AM, Resident stated I like to go to activities when they have them, nothing to do in the evenings, so I just go to bed.
During an interview on 12/08/21 at 9:42 AM, Resident #62, while sitting in the Dining Room stated I like to go to Bingo, I always try to go when I feel good. Not enough stuff to do especially in the evenings.
During an interview on 12/08/21 at 10:02 AM, Resident #24, while sitting in the Dining Room stated They bring me down here for something's, but some of them are boring. I like to come down here ( dining room) and sit drink my coffee and talk with the ladies.
During an interview on 12/08/21 at 10:00 AM, Resident #58, while sitting in the Dining Room stated we are having an activity in a little bit, we came down to get a drink and wait. Not sure what they are going to do. I like to get out my room, we are not out of rooms enough. We don't have enough activities out of our room.
While interviewing the residents in the Dining Room, the Dietary Manager # 1, stated this bunch of ladies come in everyday at 10:00 AM for coffee and drinks and at 2:00 PM they come back for ice cream. This gives them something to do instead of always sitting in their rooms.
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CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Grievances
(Tag F0585)
Could have caused harm · This affected multiple residents
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Based on record review, staff interview, Resident interview, and observation, the facility failed to promptly initiate and resolve grievances in regard to missing items for Resident #30, personal ca...
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Based on record review, staff interview, Resident interview, and observation, the facility failed to promptly initiate and resolve grievances in regard to missing items for Resident #30, personal care issues for Resident #47, and broken eyeglasses for Resident #41. This was true for three (3) out of three (3) residents reviewed for grievances and concerns. Resident identifiers: #30, #41, #47. Facility Census: 64.
Findings included:
a) Resident #30
Record review of the facility's policy titled Grievance/Concern, revised on 11/01/21, showed immediate action will be taken to prevent further potential violations of any resident right while the alleged violation is being investigated. Notify the person filing the grievance of resolution within 72 hours.
During an interview on 12/06/21 at 11:01 a.m., Resident #30, stated, A couple weeks ago 3 cakes of soap got stolen, I told [NA #69's first name] and Social Worker [Social Worker's first name] knows about it too. The Resident further stated that the missing soap was brought in by her family and had not been replaced by the facility, and several items had been reported as missing but they [ the facility] never do anything about it.
During an interview on 12/08/21 at 12:32 p.m., the Social Worker stated the Resident has had quite a few missing items in the past, but a grievance/concern has not been completed on the missing soap. The Social Worker stated that the family brings soap, and they are obsessive about it. The Social Worker stated, I think it was ivory soup, I'll work on it.
Record Review on 12/07/21 8:45 a.m., showed no grievance/concerns on file or in progress for Resident #30 within the past 2 months that pertains to missing items or missing soap.
During an interview on 12/08/21 at 12:53 p.m., Nurse Aid (NA) #69 stated, Yes about 2 weeks ago she [Resident #30] told me she had 3 bars of new dove soap missing, I looked through the Room and even in trash can to see if it had been dropped in there. NA #69 further stated she reported the missing soap to the Social Worker (SW) and the SW asked if the missing item was found and stated nothing further.
b) Resident #47
During a review of Grievance/Concern form date received: 11/18/21 the following was found.
Concern reported to: Name of Social Worker.
Documentation of Grievance/Concern:
- Resident #47 made a complaint staff does not answer call light timely, missing clothing, lost dentures top, peri care issues.
Designated to take action:
-Was not assigned to any department this was blank:
Date assigned: 11/18/2021
Date to be resolved:11/20/2021
Describe actions taken:
-search for clothing and dentures, complete body audit and tx (treatment) orders
Resolution of Grievance/Concern:
-Was grievance/concern resolved? (it was answered yes), describe resolution:
Found clothing and dentures, No changes noted to wounds nor new areas, tx (treatment) orders.
Written Notification Provided (required for civil Rights grievance/concerns)
Date provided: was blank.
Staff Member: The name of the Social Worker was typed in.
A review of the facility form titled; Skin Check dated: 11/19/2021 done after the complaint revealed the following:
A. Skin Check
1. Skin injury wound identified: Yes
2. New Skin injury/wounds: YES
3. Previously noted skin injury/wounds: yes
B. New skin injury/wound type
Discoloration new, new treatment order apply antifungal cream to buttock.
During an interview on 12/08/21 at 10:00 AM, Social Worker was asked about what was done when the new area on the buttock was discovered from the body audit. She stated there was no new skin problems found when the body audit was done. Social Worker was shown where the wound nurse wrote in the findings on the Skin Check form that there was a new area of redness on the buttock. She returned with a handwritten statement from the wound nurse read:
On 11/19/21 skin assessment completed with the finding of what appeared to be yeast to buttock. Obtained order for antifungal.
No other documentation was provided from the Social Worker about re-educating the staff about reporting new discoloration or any other skin issues.
c) Resident #41
1.) Concern Dated 11/08/21.
A review of Resident #41's medical record found the resident was admitted to the facility on on 10/26/20.
A review of the Grievance and Concern Forms found a Grievance/ Concern form dated 11/08/21.
A review of this form found the following:
-Concern reported to: Name of Social Worker.
Documentation of Grievance/Concern:
-Resident # 47 requested cap on PICC line stating it is open line and increase chances of infection, request calendar, clock, and white board.
Investigation designated to take action:
-Center Nurse Exec.
-Maintenance
-Recreation
-Director of Social Services
Date Assigned: 11/08/2021
Date to be Resolved: 11/10/201
Resolution of Grievance/Concern
-Was grievance/concern resolved? YES, describe resolution:
-Recreation department provided Monthly activities calendar to patient
-Maintenance department provided clock and white broad to room
Written Notification Provided, Date provided: was blank
Staff Member was blank
On 12/08/21 at 10:00 AM, the Social Worker was asked about what if any re-education was done concerning the caps on the picc line. Showed Social Worker this was not mentioned under the Resolutions. In addition, was not signed or dated.
2.) Resident #41's Glasses
During an interview on 12/06/21 at 11:25 AM, it was noted Resident #41 had a large amount of tape in the middle of his glasses, and the right lens was obstructed with tape and gauze. When asked about his glasses, he said they are missing the nose pads and it digs into the bridge of his nose. He said it has been like that ever since he first came here a year ago and was told they would get them repaired but it has been a year.
On 12/07/21 at 9:24 AM an interview with the Social Worker when asked about the broken glasses for Resident #41 she said that the eye doctor came to the facility, and he was on the list to be seen. But on the day the eye doctor was there Resident #41 refused to wake up for his appointment. She was asked for the list of Residents that were scheduled to see the eye doctor.
On 12/07/21 at 12:15 PM, the Social Worker provided a list of names of Residents that were scheduled to be seen by a local optometrist dated: 04/14/2021 and it did not have Resident # 41 listed on it to be seen. She was then asked about Resident #41 refusing to get up for his appointment when he was not on the list to be seen. She stated, I can't answer that. Social Worker was asked if anyone had made any attempts to have his glasses repaired. She replied, No I can't answer that.
The Social Worker went on to say maybe Resident #41 was on another list because he might have been back to see more residents in August. However; the Social Worker said she would not be able to provide that list because her email will not allow her to look at emails older than 180 days old. When it was stated, August would be within 180 days from now. There was no response.
On 12/07/21 at 12:40 PM, the DON was asked to speak to Resident #41 about his broken glasses. Upon entering the room, it was noted Resident #41 did not have his glasses on. When he was asked about them, he said the Social Worker came in and took his glasses. The DON asked if his glasses had tape on them for just a little while and Resident #41 shook his head to indicate no. Resident #41 said it has been a long while. She said like a few weeks. Resident #41 said no like for several months.
On 12/07/21 at 12:44 PM, Nurse Aide #20 came in room while the DON was talking to Resident #41 and stated Resident #41 has had tape on his glasses forever. She went on to say that she has asked him many times how do you even see out of those glasses, because half of the lens was covered with tape.
On 12/08/2021 at 2:45 PM, the Social Worker provided a Grievance/Concern form for Resident #41 dated:12/07/2021.
Individual presenting concern
Resident and Surveyor
Concern reported to: Name of Social Worker
Investigation designated name of Social Worker
Date assigned: 12/07/2021
Dated to be resolved by: 12/09/2021
Actions taken obtain eye glass kit and attempted to repair glasses
Resolution of Grievance/Concern
Was grievance/concern resolved? Yes
Describe
-Resident came into facility with broken glasses. He had been placing tape and gauze on glasses. Facility was closed at time and no eye appointment were being scheduled or any ancillary services in building. When building opened then facility scheduled Optometrist in building. Entire building needed seen. Optometrist seen residents on 04/16/2021. He was to return to facility although unable to due to his own illness. Attempted another visit and the facility was closed again for COVID-19. When reopened had not a scheduled visit in building social services placed sticky nose pads on 12/07/2021. On 12/08/2021 obtain new nose pieces and screws to place on glasses. Social Services left message for Optometrist to visit this month. Resident pleased with current glasses and pending optometry.
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CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0679
(Tag F0679)
Could have caused harm · This affected multiple residents
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Based on observation, record review and staff interview and resident interview, the facility failed to implement an ongoing resident centered activities program designed to meet the interest of and ...
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Based on observation, record review and staff interview and resident interview, the facility failed to implement an ongoing resident centered activities program designed to meet the interest of and support the physical, mental and psychosocial well-being of each resident. This practice was found true for five (5) of five (5) Residents reviewed for the Activity Care Area. Resident Identifiers: Resident #22, Resident #52, Resident #62, Resident #24 and Resident #58 Facility Census: 64
Findings Included:
a) Resident #22
During an interview on 12/06/21 at 10:58 AM, Resident #22 stated I go to bingo, the other activities are dumb stuff. I get bored easy, they don't give me anything in my room to do.
During an interview on 12/08/21 at 9:45 AM , Resident #22 stated I love the Bingo, we are old people we like that game. I am so bored and most of this stuff is dumb. They ask me to go to Bingo when they have it.
During a medical record review of the Activity Participation Record, it was found Resident #22 attended Bingo on 10/4/21.
According to the October 2021 Activity Calendar, Bingo was held on the following days:
10/18/21
10/22/21
10/25/21
10/29/21.
During a medical record review of the Activity Participation Record, it was found Resident #22 refused to attend Bingo on 11/5/21 and 11/27/21.
According to the November 2021 Activity Calendar, Bingo was held on the following days:
11/01/21
11/05/21
11/08/21
11/12/21
11/15/21
11/19/21
11/22/21
11/26/21
11/29/21
b) Resident #52
During an interview on 12/06/21 at 10:22 AM, Resident # 52 stated I go to activities, when they have them we don't have too many because of the virus.
During an interview on 12/08/21 at 9:50 AM, Resident #52 stated I like to go to activities when they have them, nothing to do in the evenings, so I just go to bed.
c) Resident # 62
During an interview on 12/08/21 at 9:42 AM, Resident #62, while sitting in the Dining Room stated I like to go to Bingo, I always try to go when I feel good. Not enough stuff to do especially in the evenings.
d) Resident # 24
During an interview on 12/08/21 at 10:02 AM, Resident #24, while sitting in the Dining Room stated They bring me down here for something's, but some of them are boring. I like to come down here ( dining room) and sit and drink my coffee and talk with the ladies.
e) Resident # 58
During an interview on 12/08/21 at 10:00 AM, Resident #58, while sitting in the Dining Room stated we are having an activity in a little bit, we came down to get a drink and wait. Not sure what they are going to do. I like to get out my room, we are not out of rooms enough. We don't have enough activities out of our room.
f) Staff Interviews
While interviewing the residents in the Dining Room, the Dietary Manager # 1, stated this bunch of ladies come in everyday at 10:00 AM for coffee and drinks and at 2:00 PM they come back for ice cream. This gives them something to do instead of always sitting in their rooms.
During an interview with the Recreation Director (RD) #71, stated We have been doing a lot of in room and hallway activities due to Covid and we are just in a habit and have not got back into group activities.
The evening activities are two times a week, there is just me and my assistance and just not enough time to provide them.
Christmas Day has no activities on the December 2021 Activity calendar, the RD stated the families come and visit that day, we might come in sometime to show a movie but not sure what time we will get here.
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CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected multiple residents
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Based on observation and staff interview the facility failed to store and handle food in a safe and sanitary manner. These failed practices were found during the tour of the kitchen and had the pote...
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Based on observation and staff interview the facility failed to store and handle food in a safe and sanitary manner. These failed practices were found during the tour of the kitchen and had the potential to affect more than a limited number of residents that currently reside in the facility. Facility census 64.
Findings included:
On 12/06/21 at 10:10 AM, a tour of the kitchen revealed there was an opened and half drank bottle of water in the walk-in freezer belonging to staff. The bottle was removed by the Kitchen Manager.
On 12/06/21 at 11:15 AM, observed Dietary Aide #3 preparing slices of bread to be served for lunch. She had one glove on her right hand, she picked up the loaf of bread from the bread rack with the gloved right hand. She laid the loaf of bread on the prep counter, using her one gloved hand and the ungloved hand she untwisted the bread tie, using the same gloved hand she pulled out two (2) slices of bread and began to put it in a white paper bags. DA #3 was asked about touching other items with the same gloved hand as the bread. Kitchen Manager took over the bread prep.
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CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected multiple residents
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Based on observation, resident interview and staff interview the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary environment to help prev...
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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 environment to help prevent the development and transmission of communicable diseases and infections, related to not providing hand hygiene for the residents during and/or before mealtime, storage of oxygen equipment, and during medication pass. This failed practice had the potential to affect all residents who reside on hallway B, and Resident #4. Identified Residents #62, #41, #13, #17, #14, #38, #27, and #4.
Findings included:
a) Hand hygiene during mealtime
On 12/06/21 at 11:15 AM Residents on the B hallway where being served lunch in their rooms due to the facility having a staff buffet (only for the staff) in the dining area. No hand hygiene was observed being provided for the residents.
Resident # 62 was in the bed and was asked if the staff assisted her with washing her hands, she said no I should have asked them too.
Resident's #41, #13, #17, #14, #38, and #27 were all asked if they received hand hygiene before they were served lunch and they all said no.
Interview with Nurse Aide #47 on 12/06/21 at 11:45 AM, was asked if any of the staff helped any of the residents with hand hygiene and she said no.
b) Resident #4 Oxygen Tubing
Observation made during tour at 11:06 AM on 12/06/21, Resident #4's nasal cannula and tubing was laying on the oxygen concentrator without the a proper storage bag.
During an interview on 12/06/21 at 11:21 AM the DON verified that Resident # 4, nasal cannula and tubing was not stored in a proper storage bag.
c) Resident #4 Medication Administration
On 12/07/21 at 8:15 AM, during medication administration to Resident #4, Registered Nurse (RN) #73 was wearing gloves while crushing the medications. RN# 73 continued wearing the gloves after touching the trash can on the medication cart. While wearing the contaminated gloves, RN #73 was touching the pills while crushing the medications. Hand hygiene was not performed. After entering Resident #4's room, RN# 73 placed the inhaler on the bedside table without a barrier. RN #73 stated I'm sorry I was nervous. On 12/07/21 at 9:05 AM, the Director of Nursing (DON) was notified.
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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.
- • 20% annual turnover. Excellent stability, 28 points below West Virginia's 48% average. Staff who stay learn residents' needs.
Concerns
- • 41 deficiencies on record. Higher than average. Multiple issues found across inspections.
Bottom line: Mixed indicators with Trust Score of 65/100. Visit in person and ask pointed questions.
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About This Facility
What is Raleigh Center's CMS Rating?
CMS assigns Raleigh Center an overall rating of 3 out of 5 stars, which is considered average nationally. Within West Virginia, this rating places the facility higher than 99% of the state's 100 nursing homes. This mid-range rating indicates the facility meets federal standards but may have areas for improvement.
How is Raleigh Center Staffed?
CMS rates Raleigh Center's staffing level at 2 out of 5 stars, which is below average compared to other nursing homes. Staff turnover is 20%, compared to the West Virginia average of 46%. This relatively stable workforce can support continuity of care.
What Have Inspectors Found at Raleigh Center?
State health inspectors documented 41 deficiencies at Raleigh Center during 2021 to 2025. These included: 41 with potential for harm.
Who Owns and Operates Raleigh Center?
Raleigh Center is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility is operated by GENESIS HEALTHCARE, a chain that manages multiple nursing homes. With 68 certified beds and approximately 64 residents (about 94% occupancy), it is a smaller facility located in DANIELS, West Virginia.
How Does Raleigh Center Compare to Other West Virginia Nursing Homes?
Compared to the 100 nursing homes in West Virginia, Raleigh Center's overall rating (3 stars) is above the state average of 2.7, staff turnover (20%) is significantly lower than the state average of 46%, and health inspection rating (3 stars) is at the national benchmark.
What Should Families Ask When Visiting Raleigh 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 Raleigh Center Safe?
Based on CMS inspection data, Raleigh 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 3-star overall rating and ranks #1 of 100 nursing homes in West Virginia. While no facility is perfect, families should still ask about staff-to-resident ratios and recent inspection results during their visit.
Do Nurses at Raleigh Center Stick Around?
Staff at Raleigh Center tend to stick around. With a turnover rate of 20%, the facility is 26 percentage points below the West Virginia average of 46%. Low turnover is a positive sign. It means caregivers have time to learn each resident's needs, medications, and personal preferences. Consistent staff also notice subtle changes in a resident's condition more quickly.
Was Raleigh Center Ever Fined?
Raleigh 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 Raleigh Center on Any Federal Watch List?
Raleigh 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.