ELKINS REHABILITATION & CARE CENTER
Non profit - Corporation
111 Beds
Independent
Data: November 2025
Trust Grade
45/100
#69 of 122 in WV
Last Inspection: October 2023
Over 2 years since last inspection. Current conditions may differ from available data.
Overview
Elkins Rehabilitation & Care Center has a Trust Grade of D, indicating below-average care with some significant concerns. It ranks #69 out of 122 facilities in West Virginia, placing it in the bottom half, but it is the best option among three local facilities in Randolph County. The facility is improving, with issues decreasing from 11 in 2023 to just 1 in 2025. Staffing is a relative strength, with a 4/5 star rating and a 39% turnover rate, which is better than the state average. However, RN coverage is concerning, as it is lower than 80% of state facilities, which raises potential care quality issues. Specific incidents noted include a serious issue where a nurse administered medication without a physician's order, resulting in a resident falling and sustaining a sprained hip. Additionally, there were failures to follow care plans for residents receiving hospice services, leading to inadequate coordination of care. While the facility has no recent fines, the overall quality of care still raises several red flags that families should consider.
- Trust Score
- D
- In West Virginia
- #69/122
- Safety Record
- Moderate
- Inspections
- Getting Better
- Staff Stability ○ Average
- 39% turnover. Near West Virginia's 48% average. Typical for the industry.
- Penalties ✓ Good
- No fines on record. Clean compliance history, better than most West Virginia facilities.
- Skilled Nurses ○ Average
- Each resident gets 39 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
- 33 deficiencies on record. Higher than average. Multiple issues found across inspections.
45/100
Bottom 44%
Needs review
11 → 1 violations
★★☆☆☆
2.0
Overall Rating
★★★★☆
4.0
Staff Levels
★☆☆☆☆
1.0
Care Quality
★★★☆☆
3.0
Inspection Score
↔
Stable
2023: 11 issues
2025: 1 issues
The Good
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4-Star Staffing Rating · Above-average nurse staffing levels
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Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
-
Staff turnover below average (39%)
9 points below West Virginia average of 48%
Facility shows strength in staffing levels, fire safety.
The Bad
2-Star Overall Rating
Below West Virginia average (2.7)
Below average - review inspection findings carefully
Staff Turnover: 39%
Near West Virginia avg (46%)
Typical for the industry
The Ugly 33 deficiencies on record
1 actual harm
Aug 2025
1 deficiency
1 Harm
SERIOUS
(G)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Actual Harm - a resident was hurt due to facility failures
Quality of Care
(Tag F0684)
A resident was harmed · This affected 1 resident
Based on record review and staff interview the facility failed to provide care and services in accordance with current standards of practice by administering Resident #115 a Benzodiazepines that she w...
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Based on record review and staff interview the facility failed to provide care and services in accordance with current standards of practice by administering Resident #115 a Benzodiazepines that she was not ordered. The State Agency (SA) confirmed that this failed practice caused harm to Resident #115. After Resident was given the Benzodiazepines she fell, resulting in a sprained hip. The incident occurred on 07/06/24 and was corrected on 07/08/24, therefore it is cited at past non-compliance.In a addition the facility failed to ensure it followed its policy and procedure for Resident #45 on weight management. This failed practice was found true for (2) of (27) residents investigated for quality of care during the Long-Term Care Survey Process. Resident identifiers #115 and #45. Facility Census #103.Findings Include: a) Resident #115A review 0N 08/27/25 at 1:40 PM of an Facility Reported Incident dated 07/08/25, revealed a description of an incident that is summarized as follows: On 07/06/25 at approximately 11:00 AM, Nurse administered narcotic without a physician's order to Resident #115. The medication belonged to another resident. Nurse reported that she was attempting to control the resident's behaviors. Resident #115 then fell and was sent to the local emergency room where it was determined that she had a sprained hip. The nurse was terminated on 07/08/24 after admitting to administering the medication. The facility substantiated the incident. A record review on 08/27/25 at 2:15 PM, revealed an incident report dated 07/06/24 that describes an incident as follows:Resident was standing in the doorway between hallway and common room when another resident attempted to come by in her wheelchair. Resident went to move and lost her balance and slid down the doorway onto the floor. Resident fall was witnessed by this nurse and (2) two Nursing Assistants (NA). Resident sent later in the day to emergency room for pain and a bruise to right elbow and hip. Further record review revealed a nurses note dated for 07/06/24 at 6:42 PM that reads as follows:Resident back to facility via stretcher with RCEMT from (local emergency room named). Resident skin warm pink dry and intact and shows no sign or symptoms of discomfort or distress. Residents D/C summary states that she has a right hip sprain and she should follow up with her doctor in 2 days. A review of Resident #115's orders for Ativan shows that at the time of the incident Resident #115 did not have an order for Ativan.During an interview on 08/27/25 at 2:49 PM, with the Director of Nursing (DON), The administrator, and the Licensed Social Worker (LSW), The DON stated, We did not put it all together that this had happened. A CNA came forward and we reviewed the cameras and found out that the resident was given this medication. On the video it shows the nurse getting the Ativan out of another resident's medications and then putting other medications out of the drawer in a strawberry ice cream and making a milkshake in which she had the resident drink. Not long after that (Resident #115 named) fell and had to go out. We immediately fired that nurse. b) Resident #45 A record review on 08/27/25 at 8:43 AM, revealed that Resident #45 weighed 166.6 pounds (lbs.) on 05/09/25 and on 08/17/25 weighed 143 lbs. A review on 08/27/25 at 9:15 AM of the policy titled {Weight Policy/Assessment/Interventions}, under procedure number, reads as follows: The resident's first weight will be obtained by CNA on admission and readmission. The next two weights will be obtained by the shower team. Resident will be weighed for a total of three days following admission/readmission. Then weekly for four weeks. Monthly after that by the shower team. If there is a weight difference of 5 lbs., shower team will weight the following day to verify if there has been a change in the weight.Further record review of Resident #45's weights, revealed that on 07/11/25 Resident #45 weighed 154.4 lbs. and on 07/24/25 weighed 150.5 lbs. Which is a (5) five pound weight loss. Resident #45 was not re-weighed until 07/27/25. During an interview on 08/27/25 at 9:42 AM, The Administrator confirmed that Resident #45 had not been re-weighed the next day for a (5) five pound weight loss like it says to do in the policy.
Oct 2023
11 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0557
(Tag F0557)
Could have caused harm · This affected 1 resident
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Based on observation and staff interview, the facility failed to provide care and treatment in a dignified manner. Staff signed and dated a dressing after it was affixed to Resident #69's body. This...
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Based on observation and staff interview, the facility failed to provide care and treatment in a dignified manner. Staff signed and dated a dressing after it was affixed to Resident #69's body. This is true for one (1) of one (1) reviewed for wound care. Resident identifier: # 69. Facility census: 103.
Findings included:
a) Resident #69
On 10/25/23 at 8:50 AM Nurse Practitioner (NP) #32 was observed performing wound care and a dressing change on Resident (R) #69's buttocks. After cleaning the wounds, NP #32 applied two clean dressings onto R #69's buttocks. NP #32 signed and dated both dressings after they were affixed to the resident's body.
An interview was conducted immediately after this observation with the wound care team: NP #32, Licensed Practical Nurse (LPN) #74 and LPN #124. All three nurses reported they were unaware they should not sign and date a dressing after it is applied to a resident's body.
During an interview on 10/25/23 at 9:00 AM the Director of Nursing (DON) agreed staff writing on a dressing after it is affixed to the resident's body is a dignity concern. The DON acknowledged the dressing should be signed and dated before it is applied to the resident's body.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Notification of Changes
(Tag F0580)
Could have caused harm · This affected 1 resident
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Based on medical record review and staff interview the facility failed to notify the physician and resident representative of a change in condition. This was discovered for one (1) of three (3) resi...
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Based on medical record review and staff interview the facility failed to notify the physician and resident representative of a change in condition. This was discovered for one (1) of three (3) residents reviewed for the care area of nutrition during the Long-Term Care Survey Process. Resident # 91 had a significant weight loss and the physician and resident representative was not notified. Resident identifier: #91 Facility census: 103
Finding included:
a) Resident #91
A medical record review on 10/25/23 for Resident #91 indicated there was a significant weight loss. On 07/04/23 the resident's weight was 137 pounds and on 08/13/23 her weight was 115 pounds. This was calculated at a 16 percent weight loss of 22 pounds. There was no evidence the physician or the resident representative was notified regarding the change in condition.
In an interview with the Nursing Home Administrator and the Director of Nursing on 10/25/23 at 9:40 AM, both verified the physician and the Resident Representative had not been notified of the significant weight loss for Resident #91.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
Based on record review and staff interview the facility failed to follow Physicians order for medication administration and failed to have an order for pressure ulcer care. Resident Identifiers: #17 a...
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Based on record review and staff interview the facility failed to follow Physicians order for medication administration and failed to have an order for pressure ulcer care. Resident Identifiers: #17 and #12. Facility Census: #103
Findings included:
a) Resident #17
On 10/24/23 at 10:22 AM record review of Resident #17's care plan found she had a stage IV pressure injury to her sacrum. Review of her current orders found no Physicians order for pressure ulcer treatment.
During an interview on 10/25/23 at 10:00 AM Licensed Practical Nurse Wound Nurse Assistant #124 confirmed Resident #17 did have an open, stage IV pressure injury to her sacrum. She stated the wound care team failed to reassess a treatment order that was limited to fifteen (15) days for the pressure injury treatment. Wound care was provided on 10/18/23 and then the order fell off the Treatment Administration Record (TAR) due to the fifteen (15) day restriction on the antibiotic order. Therefore the pressure injury wound has not been treated for the last six (6) days. This was confirmed by documentation on the TAR for October.
The pressure injury was being treated with an antibiotic. The original order stated: Flagyl Oral Tablet 500 milligrams. Apply to PI (pressure injury) topically every day shift for Stage IV. Crush med, place in wound bed, pack lightly with tegaderm alginate rope and cover with foam border dressing.
The above information was confirmed with the Director of Nursing on 10/25/23 at 1:05 PM.
b) Resident #12
On 10/23/23 at 3:13 PM, a brief record review completed on Resident #12's October 2023 Medication Administration Record (MAR) revealed the following physician orders and times the prescribed medications were not administered because Resident #12 was noted to be sleeping:
-9:00 PM, Atorvastatin Calcium Tablet 40 MG, Give 40 mg by mouth one time a day Related to HYPERLIPIDEMIA - Not given 10/12/23 because Resident #12 was sleeping
-9:00 PM, Mirtazapine Oral Tablet, Give 7.5 MG tablet by mouth at bedtime related to MAJOR DEPRESSIVE DISORDER RECURRENT, SEVERE WITH PSYCHOTIC SYMPTOMS - Not given on 10/12/23 because Resident #12 was sleeping
-9:00 PM, Nortriptyline HCL Oral Capsule, Give 50 MG Capsule by mouth at bedtime related to HEREDITARY AND IDIOPATHIC NEUROPATHY - Not given on 10/12/23 because Resident #12 was sleeping
-9:00 PM, Omeprazole Tablet Delayed Release, Give 20 MG by mouth one time a day related to GASTRO-ESOPHAGEAL REFLUX DISEASE WITHOUT ESOPHAGITIS - Not given on 10/12/23 because Resident #12 was sleeping
-600 AM, Synthroid Tablet, Give 100 MCG by mouth one time a day related to HYPOTHYROIDISM - Not given on 10/12/23 because Resident #12 was sleeping
-9:00 PM, [NAME] Petrolatum - Mineral Oil Ointment, Instill 1 application in both eyes one time a day for dry eyes - Not given 10/12/23 because Resident #12 was sleeping
-9:00 PM, Ticagrelor Tablet, Give 90 MG Tablet by mouth two times a day related to ATHEROSCLERTOIC HEART DISEASE OF NATIVE CORONARY ARTERY WITHOUT ANGINA PECOTORIS - Not given 10/12/23 because Resident #12 was sleeping
-9:00 PM. Vitamin E Oral Tablet, Give 400-unit oral tablet by mouth two times a day for supplement - Not given 10/12/23 because Resident #12 was sleeping
-9:00 PM, Atorvastatin Calcium Tablet 40 MG, Give 40 mg by mouth one time a day Related to HYPERLIPIDEMIA - Not given 10/17/23 because Resident #12 was sleeping
-9:00 PM, Mirtazapine Oral Tablet, Give 7.5 MG tablet by mouth at bedtime related to MAJOR DEPRESSIVE DISORDER RECURRENT, SEVERE WITH PSYCHOTIC SYMPTOMS - Not given on 10/17/23 because Resident #12 was sleeping
-9:00 PM, Nortriptyline HCL Oral Capsule, Give 50 MG Capsule by mouth at bedtime related to HEREDITARY AND IDIOPATHIC NEUROPATHY - Not given on 10/12/23 because Resident #12 was sleeping
-9:00 PM, Omeprazole Tablet Delayed Release, Give 20 MG by mouth one time a day related to GASTRO-ESOPHAGEAL REFLUX DISEASE WITHOUT ESOPHAGITIS - Not given on 10/17/23 because Resident #12 was sleeping
-600 AM, Synthroid Tablet, Give 100 MCG by mouth one time a day related to HYPOTHYROIDISM - Not given on 10/17/23 because Resident #12 was sleeping
-9:00 PM, [NAME] Petrolatum - Mineral Oil Ointment, Instill 1 application in both eyes one time a day for dry eyes - Not given 10/17/23 because Resident #12 was sleeping
-9:00 PM, Ticagrelor Tablet, Give 90 MG Tablet by mouth two times a day related to ATHEROSCLERTOIC HEART DISEASE OF NATIVE CORONARY ARTERY WITHOUT ANGINA PECOTORIS - Not given 10/17/23 because Resident #12 was sleeping
-9:00 PM. Vitamin E Oral Tablet, Give 400-unit oral tablet by mouth two times a day for supplement - Not given 10/17/23 because Resident #12 was sleeping
During an interview on 10/24/23 at 2:40 PM, the Director of Nursing (DON) reported the professional standard of practice would be for the nurse to attempt to wake a sleeping resident gently, if no response it would be appropriate to temporarily move on to other residents, circle back to the sleeping resident and try again to wake them up. The DON went on to report that especially for scheduled nighttime medications it would be necessary to wake them up to ensure the physician order was followed. The DON noted if it was a pattern the resident could not be roused, the attending physician should be contacted to determine if they would like to change the time of the mediation administration. The DON agreed there was no documentation in the medical record that Licensed Practical Nurse (LPN) #23 had attempted to wake Resident #12 up nor did LPN #23 document the physician was notified of the fact that resident was sleeping through medication administration times.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0685
(Tag F0685)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on resident interview, record review, and staff interview, the facility failed to assist a resident in locating his lost...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on resident interview, record review, and staff interview, the facility failed to assist a resident in locating his lost hearing aide This was true for one (1) out of ( 2) residents reviewed for communication. Resident identifier #90. Facility census: 103.
Findings included:
a) Resident #90
During an initial interview on 10/23/23 at 11:15 AM, Resident #90 stated, Can you speak up, I can't hear without my hearing aide. Surveyor observed a hearing aide in Resident #90's left ear. Resident #90 stated, I am supposed to have hearing aides in both of my ears, they lost one of them. I haven't had it for a long time. When asked if he had reported it to anyone? Resident #90 stated, I have told all kinds of people I am not sure who they was. Resident #90 has a BIMS of 14 indicating he is cognitively intact.
A record review on 10/24/23 at 9:00 AM, found on Resident #90's admission Nursing assessment dated [DATE] the resident was admitted with hearing aides in both ears.
During a record review on 10/24/23 at 9:15 AM Resident #90's admission MDS dated [DATE] section b300 was marked yes for hearing aides or other hearing devices.
A review of Resident #90's care plan on 10/24/23 at 9:15 AM, found Resident #90's care plan did not contain any mention of hearing aides.
During an interview on 10/24/23 at 10:00 AM with day shift Licensed Practical Nurse (LPN) #181 was asked how she know Resident #90 wears hearing aides and when to put them in and change the batteries? Employee #181 stated, It is listed on the TAR.
A record review on 10/24/23 at 11:45 AM, Resident #90's TAR for September and October found no mention of hearing devices.
During an interview with the Social Worker on 10/24/23 at 10:15 AM she stated, Resident #90 has never mentioned this to me, and I was not aware that he had 2 hearing aides.
During an interview with the Director of Nursing (DON) on 10/24/23 at 11:00 AM she stated, I believe his hearing aide got sent to the VA to get fixed, I will check up on that.
A record review on 10/24/23 at 2:00 PM, found a Nursing Progress note dated for 04/13/23 which read as follows, Mailed Hearing aides per residents request to {local VA} Attention: Audiology Services.
During an interview on 10/24/23 with the DON at 3:45 PM, she stated, Here is a letter about residents hearing aids Letter read as follows, (Name of Resident #90)'s hearing aides were repaired and sent to a PO BOX. (Name of Resident #90)'s friend will be checking his box by the end of the week and will be bringing them in.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Pressure Ulcer Prevention
(Tag F0686)
Could have caused harm · This affected 1 resident
Based on record review and staff interview the facility failed to provide care to a pressure ulcer injury in order to promote healing. Resident Identifiers: #17. Facility Census: #103
Findings include...
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Based on record review and staff interview the facility failed to provide care to a pressure ulcer injury in order to promote healing. Resident Identifiers: #17. Facility Census: #103
Findings included:
a) Resident #17
On 10/24/23 at 10:22 AM, a record review of Resident #17's care plan found she had a stage IV pressure injury to her sacrum. Review of her current orders found no Physicians order for pressure ulcer treatment.
During an interview on 10/25/23 at 10:00 AM Licensed Practical Nurse Wound Nurse Assistant #124 confirmed Resident #17 did have an open, stage IV pressure injury to her sacrum. She stated the wound care team failed to reassess a treatment order that was limited to fifteen (15) days for the pressure injury treatment. Wound care was provided on 10/18/23 and then the order fell off the Treatment Administration Record (TAR) due to the fifteen (15) day restriction on the antibiotic order. Therefore the pressure injury wound has not been treated for the last six (6) days. This was confirmed by documentation on the TAR for October.
The pressure injury was being treated with an antibiotic. The original order stated: Flagyl Oral Tablet 500 milligrams. Apply to PI (pressure injury) topically every day shift for Stage IV. Crush med, place in wound bed, pack lightly with tegaderm alginate rope and cover with foam border dressing.
The above information was confirmed with the Director of Nursing on 10/25/23 at 1:05 PM.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
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Based on medical record review, resident interview, observation and staff interview, the facility failed to ensure the residents' environment remains as free of accident hazards as is possible. Morn...
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Based on medical record review, resident interview, observation and staff interview, the facility failed to ensure the residents' environment remains as free of accident hazards as is possible. Morning medications were left in Resident #37's room unsupervised and not taken until hours later. Antifungal powder was left on R #90's dresser. These were random opportunities for discovery. Resident identifiers: R #37 and R #90. Facility census: 103.
Findings included:
a) Resident (R) #37
During an interview and observation on 10/23/23 at 12:22 PM, R #37 retrieved a medicine cup containing 12 pills/tablets from his desk. When questioned, R #37 reported they were his morning medications that the nurse left for him to take. R #37 stated he took one pill, the rest included psyche meds for his head so he didn't take them.
On 10/23/23 at 12:27 PM, Licensed Practical Nurse (LPN) #179 acknowledged she left the pills in there this morning and added the resident stated he would take them. LPN #179 said she would go get the pills.
Review of the medical record on 10/24/23 found LPN #179 signed out the following medications for R #37 at 9:00 AM: aspirin 81 milligrams (mg), Finasteride 5 mg, Metoprolol Succinate ER 25 mg (antihypertensive), Protonix 40 mg, two Venlafaxine Hydrochloride (HCL) (antidepressant) 150 mg each, vitamin D3 1000 international units (IU), Buspirone HCL 15 mg (antianxiety), Entresto 24-26 mg, mucinex 1200 mg, and one Super Beta Prostate tablet.
The preadmission screening (PAS) form dated 08/31/23, states under section #28, R#37 in not capable of administering his own medications.
The Director of Nursing confirmed the nurse should watch the resident take his medications and not leave them in the room, during an interview on 10/24/23 at 12:00 PM.
b) Resident #90
During an observation on 10/23/23 at 12:30 PM, a bottle of Phytoplex anitfungal poweder was observed setting in the room of Resident #90 on the dresser underneath the TV.
During an interview on 10/23/23 at 12:30 PM Resident #90 stated, I always have that in my room, they use it to put on my private area.
During an obervation on 10/24/2023 at 9:30 AM, the same bottle of Phytoplex antifungal powder was still sitting in the room of Resident #90 on the dresser underneath the TV.
During an observation on 10/24/23 at 10:00 AM the warning label on the back of the bottle of Phytoples anitfungal powder read under warnings { Keep out of reach of children. If swallowed get medical help or contact a Poision Control Center right away.
A record review on 10/24/2023 at 11:00 AM revealed two (2) residents on the same hall as Resident #90 has Alzheimer's and wander.
During an interview on 10/24/23 at 3:00 PM, the DON stated, Of course that bottle is in there. She then went in and removed the bottle.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Medical Records
(Tag F0842)
Could have caused harm · This affected 1 resident
Based on record review and staff interview, the facility failed to ensure complete and accurate medical records. Resident #204's capacity status was incorrect in PointClickCare (the facility's electro...
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Based on record review and staff interview, the facility failed to ensure complete and accurate medical records. Resident #204's capacity status was incorrect in PointClickCare (the facility's electronic medical record software.) Resident #37's code status order was incorrect and did not match resident's Care Plan or resident's preference. This is true for two (2) of four (4) residents reviewed for Advanced Directives. Resident identifiers: Resident #204 and Resident #37. Facility census: 103.
Findings included:
a) Resident #204
When first opening Resident #204's electronic medical record, on 10/23/23 at 4:09 PM, the viewer immediately saw resident's name, gender, date of birth , age, physician, allergies, and code status. The code status was listed as DNR (Do Not Resuscitate), HAS Capacity.
The Physician Determination of Capacity, dated 10/13/23, reflected Resident #204 LACKS capacity.
During an interview on 10/24/23 at 1:22 PM, Licensed Practical Nurse (LPN) Clinical Supervisor #16 confirmed the error in the medical record and stated she felt it must have happened because two (2) people had worked on the admission.
b) Resident #37
Review of the medical record on 10/24/23 revealed a social services note dated 09/01/23 stating R#37 requested to be a full code. The current physician orders include an order written on 09/09/23 stating Do Not Resuscitate.
The medical record was reviewed with Social Worker (SW) #122 on 10/24/23 at 12:00 PM. SW #122 reported the social workers review the code status with each resident and family on admission. The resident's choice is documented in the initial social worker's note in the chart. SW #122 reported R#37 requested to be a full code. SW #122 stated the physician orders were incorrect, she would notify the nurse to change the orders.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected multiple residents
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Based on observation, record review and staff interview the facility failed to implement a resident's comprehensive person-centered care plan. This was discovered for one (1) of 28 care plans review...
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Based on observation, record review and staff interview the facility failed to implement a resident's comprehensive person-centered care plan. This was discovered for one (1) of 28 care plans reviewed during the Long-Term Care Survey Process in the areas of hospice scheduling, application and removal of a hand splint and nutritional interventions for weight loss. Resident Identifiers: #17, #23, #89, #49 and #91. Facility Census: #103
Findings Included:
a) Resident #17
On 10/24/23 a record review found Resident #17 has hospice services through (name of Hospice organization) Hospice.
On 10/25/23 at 9:00 AM record review found the care plan for Hospice services states the Hospice nurse is to visit two (2) times weekly and as needed. There is no care plan in place for the number of Aide visits. The care plan is to state scheduled days the nurse and aide is to provide services.
Review of the aide visit notes from 09/19/23 through 10/17/23 shows the aide is coming randomly on various days of the week. Aide visit records show a visit on 09/19/23 and not again until 09/29/23. No Aide visit records were available since 10/17/23. A review of the shower schedule shows Resident #17 has showers scheduled for Friday and Tuesday. Since the Aide comes on various days of the week, the facility Certified Nurse Aide does not know if the hospice aide is coming to provide care or not.
Review of the Nursing Visit Records from 08/29/23 through 10/18/23 found there were no nurse visits for the week of 09/04/23 or 09/25/23.
An interview on 10/25/23 at 1:30 PM with the Director of Nursing, confirmed the above information.
b) Resident #23
On 10/24/23 a record review found Resident #23 had hospice services through (name of Hospice organization) Hospice.
On 10/25/23 at 9:00 AM a record review found the care plan for Hospice services states the Hospice nurse is to visit two (2) times weekly and as needed and the Hospice Aide is to provide care three (3) times per week. The care plan is to state scheduled days for the nurse and aide to provide services.
Review of the aide visit notes from 10/04/23 through 10/17/23 shows the aide is coming randomly on various days of the week. No Aide visit records were available since 10/17/23. A review of the shower schedule shows Resident #23 has showers scheduled for Wednesday and Saturday. Since the Aide comes on various days of the week, the facility Certified Nurse Aide does not know if the hospice aide is coming to provide care or not.
Review of the Nursing Visit Records from 09/12/23 through 10/18/23 show there were nurse visits on 09/12/23 and 09/19/23 and not again until 10/04/23.
On 10/25/23 at 10:05 AM during an interview with Licensed Practical Nurse #139 and Certified Nurse Aide #167 neither of them knew the scheduled nurse or aide visits from (Name of Hospice organization) staff, in addition, they did not know where to locate the schedule.
An interview on 10/25/23 at 1:30 PM with the Director of Nursing, confirmed the above information.
c) Resident #89
On 10/24/23 record review found Resident #89 has hospice services through (name of Hospice organization) Hospice.
On 10/25/23 at 9:00 AM record review shows the care plan for Hospice services states the Hospice Aide is to provide care three (3) times per week and the Hospice nurse is to visit two times weekly and as needed. The care plan is to state scheduled days for the nurse and aide to provide services.
Review of the aide visit notes from 08/16/23 through 08/30/23 and 10/02/23 through 10/11/23 shows the aide is only coming twice a week, on Mondays and Wednesdays. Furthermore, there were no Aide visit notes available for September 2023.
According to the (name of Hospice organization) Aide Schedule posted at the nurses station for the house Certified Nurse Aides reference, Resident #89's shower days are Monday ad Friday. Therefore, the Hospice aide is not present to provide care on Fridays.
During an interview on 10/25/23 at 1:30 PM with the Director of Nursing, she confirmed there is an issue with the hospice services provided with this company and she is aware of the missed visits.
d) Resident #49
During an observation on 10/25/23 at 10:50 AM Resident #49 who has contractures of left hand was observed without his hand splint in place.
A record review on 10/25/23 at 11:00 AM of Resident # 49's care plan found on 10/12/23 an intervention to Apply splints as ordered for his left hand contracture.
A record review on 10/25/23 at 11:05 AM of Resident #49's found an active order for a Palm Protector to Left hand, Applies by FMP staff and removed by nursing. To be worn 10AM-4PM.
During an observation on 10/25/23 at 1:00 PM Resident #49 was again observed asleep in his room, and his left hand splint not in place
During an interview on 10/25/23 at 1:00 PM, CNA #167 stated, Therapy usually gets him ready, But I don't guess they did today. I will take care of it.
e) Resident #91
A medical record review on 10/25/23 for Resident #91 indicated there was a significant weight loss. On 07/04/23 the resident's weight was 137 pounds and on 08/13/23 her weight was 115 pounds. This was calculated at a 16 percent weight loss of 22 pounds. There was no evidence the physician or the dietician was notified regarding the change in condition.
The comprehensive person-centered care plan for Resident #91 had a nutritional intervention to alert the dietician and the physician to any significant weight loss or gain, this was not implemented.
In an interview with the Nursing Home Administrator and the Director of Nursing on 10/25/23 at 9:40 AM, both verified the comprehensive care plan had not been implemented regarding notifying the dietician or the physician of the significant weight loss for Resident #91.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0849
(Tag F0849)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record reviews and staff interviews, the facility failed to collaborate with hospice services to develop coordi...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record reviews and staff interviews, the facility failed to collaborate with hospice services to develop coordinated care plans for four (4) of four (4) residents reviewed for the care area of hospice during the Long-Term Care Survey Process. The care plans for Resident #18, #17, #23, and #89 did not specify when and what services were to be provided by the hospice staff. Resident identifiers: #18, #17, #23, and #89. Facility census: 103.
Findings included:
a) Resident #18
A medical record review on 10/25/23 revealed the person-centered care plan for Resident #18 was not developed to collaborate hospice services with the facility.
In an interview with the Director of Nursing on 10/25/23 at 1:50 PM, she verified the care plan did not specify when and what hospice services were to be provided.
b) Resdient #17
On 10/25/23 at 9:00 AM, a record review found the care plan for Hospice services states the Hospice nurse is to visit two times weekly and as needed. There is no care plan in place for Aide visits. The facility is required to collaborate with hospice services to develop a coordinated care plan and specify when and what services were to be provided by the hospice staff.
An interview with the Director of Nursing on 10/25/23 at 1:50 PM, confirmed the above information.
c) Resident #23
On 10/25/23 at 9:00 AM record review found the care plan for Hospice services states the Hospice nurse is to visit two (2) [NAME] weekly and as needed and the Hospice Aide to provide care three (3) times per week. The facility is required to collaborate with hospice services to develop a coordinated care plan and specify when and what services were to be provided by the hospice staff.
An interview with the Director of Nursing on 10/25/23 at 1:50 PM, confirmed the above information.
d) Resident #89
On 10/25/23 at 9:00 AM record review foun the care plan for Hospice services states the Hospice Aide is to provide care three (3) times per week and the Hospice nurse is to visit two times weekly and as needed. The facility is required to collaborate with hospice services to develop a coordinated care plan and specify when and what services were to be provided by the hospice staff.
An interview with the Director of Nursing on 10/25/23 at 1:50 PM, confirmed the above information.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected multiple residents
Based on observation and staff interview, the facility failed to establish and maintain an effective infection prevention and control program. Staff failed to remove gloves after incontinence care con...
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Based on observation and staff interview, the facility failed to establish and maintain an effective infection prevention and control program. Staff failed to remove gloves after incontinence care contaminating the residents bed and surrounding areas. A bedpan and two triangle graduate cylinders were noted hanging on the commode with the toilet seat lifted. This is true for one of one reviewed for wound care and a random opportunity for discovery. Resident identifiers: #69, #94 and #39. Facility census: 103.
Findings included:
1. Resident (R) #69 Incontinence care
On 10/25/23 at 8:50 AM, Nurse Practitioner (NP) #32 and Licensed Practical Nurse (LPN) #74 were observed performing incontinence care after completing wound care on R #69. NP #32 wiped the stool off of R #69's behind and placed a new pad under the resident with the assistance of LPN #74. Without removing her soiled gloves, NP #32 assisted with repositioning the resident, pulled the sheet and blanket up to R #69's chin, and touched the upper bed rail. NP #32 removed one glove and carried the trash to the bathroom. NP #32 returned to the bedside table with one contaminated glove still on, cleaned off the bedside table and then removed the soiled glove.
The above findings were reviewed with NP #32 immediately after this observation. NP #32 acknowledged she should have removed her gloves after providing incontinence care and agreed she contaminated multiple areas around R #69's bed and room.
2. Medical equipment storage.
On 10/25/23 at 8:20 AM an observation in Resident (R) #94 and R#39's bathroom revealed two clear bags hanging on the back of the commode with the toilet seat up. Both bags were resting against the toilet bowel edge. One bag contained a triangle graduate cup for urine measurement and the other contained a bed pan and a triangle graduate cup. Licensed Practical Nurse (LPN) #164 confirmed the bedpan and urine measurement cups were improperly stored during an interview at 8:22 AM on 10/25/23.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Antibiotic Stewardship
(Tag F0881)
Could have caused harm · This affected multiple residents
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Based on policy review, record review and staff interview, the facility failed to develop, promote, and implement a facility-wide system to monitor the use of antibiotics. This was true for two (2) ...
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Based on policy review, record review and staff interview, the facility failed to develop, promote, and implement a facility-wide system to monitor the use of antibiotics. This was true for two (2) out of three (3) residents reviewed for antibiotic use during the Long-Term Care Survey Process. Resident identifiers: #47 and #204. Facility census: 103.
Findings included:
a) Antibiotic Stewardship Program Policy, revised on 02/25/22
Review of the facility's Antibiotic Stewardship Program policy, completed on 10/25/23 at 9:15 AM, revealed:
-The purpose of the program is to optimize the treatment of infections while reducing the adverse events associated with antibiotic use.
-The program includes antibiotic use protocols and a system to monitor antibiotic use.
-The facility uses the McGeer Criteria to define infections.
-Attending physicians prescribe appropriate antibiotics in accordance with standards of practice and facility protocols.
b) Resident #47
A record review, completed on 10/25/23 at 9:35 AM, revealed the following physician orders:
-Amoxicillin-Pot Clavulanate Oral Tablet 875-125 MG (Amoxicillin & Pot Clavulanate)
Give 875 mg by mouth two times a day for sinusitis for 10 Days.
Start Date: 10/16/2023
Further medical review did not find an Infection Screening Evaluation / McGeer Criteria Checklist on file.
-Amoxicillin-Pot Clavulanate Oral Tablet
875-125 MG (Amoxicillin & Pot Clavulanate)
Give 875 mg by mouth two times a day for sinus infection for 5 Days.
Start Date: 09/10/2023
Further medical review did not find an Infection Screening Evaluation / McGeer Criteria Checklist on file.
c) Resident #204
A record review, completed on 10/25/23 at 9:50 AM, revealed the following physician orders:
-Keflex Oral Capsule 500 MG (Cephalexin)
Give 500 mg by mouth three times a day for UTI (Urinary Tract Infection) for 7 Days.
Start Date:10/23/2023
Further medical review did not find an Infection Screening Evaluation / McGeer Criteria Checklist on file.
d) Infection Preventionist Interview
During an interview on 10/25/23 at 10:20 AM, the Infection Preventionist stated as part of the facility's Infection Prevention Control Program, the facility developed an antibiotic stewardship program that promotes the appropriate use of antibiotics and includes a system of monitoring to improve resident outcomes and reduce antibiotic resistance. The Infection Preventionist described the following protocol that should be followed (according to their antibiotic stewardship program) prior to a physician ordering an antibiotic for a resident:
-When a nurse has identified a resident is experiencing a change in condition, the nurse should complete a SBAR (Situation, Background, Assessment, Recommendation) Report,
-Then the nurse should complete an Infection Screening Evaluation to determine if the McGeer's Criteria is met,
-Then the nurse should contact the doctor.
The Infection Preventionist went on to confirm that having met the McGeer's Criteria is an indication it would be appropriate to prescribe antibiotics in accordance with standards of practice and with the facility protocols for antibiotic stewardship.
When asked about the 10/16/23 order for Amoxicillin for Resident #47, the Infection Preventionist reported there was no Infection Screening Evaluation / McGeer's Criteria Assessment tied to this order. The nurse did not do it.
When asked about the 09/10/23 order for Amoxicillin for Resident #47, the Infection Preventionist reported there was no Infection Screening Evaluation / McGeer's Criteria Assessment tied to this order. The nurse did not do it.
When asked about the 10/23/23 Keflex order for Resident #204, the Infection Preventionist reported there was no Infection Screening Evaluation / McGeer's Criteria Assessment tied to this order. The nurse did not do it.
When asked the Infection Preventionist confirmed that all facility doctors had been trained on the antibiotic stewardship program and that each physician should question if an Infection Screening Evaluation / McGeer's Criteria Assessment had indicated the need for an antibiotic prior to issuing an order. The Infection Preventionist agreed for a physician to not question if a McGeer's Criteria Assessment had been done was not in accordance with standards of practice and facility protocols.
The Infection Preventionist reported she had noticed an uptick on the Infection Screening Evaluations / McGeer's Criteria Assessment not being completed and antibiotics still being prescribed in September 2023. The Infection Preventionist stated she reported these details at the October Quality Assurance (QA) meeting. Every month at the QA meeting, the Infection Preventionist notifies the QA Team what antibiotics were ordered, who the ordering physician was, and what met criteria and what did not. She vividly recalled questioning the overuse of antibiotics. To her knowledge no action had been taken on her report.
Jul 2022
16 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Resident Rights
(Tag F0550)
Could have caused harm · This affected 1 resident
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Based on observation and staff interview, the facility failed to ensure two (2) of 28 sampled residents had a dignified dining experience. Staff stood over residents while assisting them to eat. Res...
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Based on observation and staff interview, the facility failed to ensure two (2) of 28 sampled residents had a dignified dining experience. Staff stood over residents while assisting them to eat. Resident identifiers: #70 and #57. Facility census: 86.
Findings included:
a) Resident #70
Observation at 11:42 AM on 07/26/22, found the resident received his noon meal. The resident was in his room, in bed when the meal was served. Nurse Aide (NA) #118 was standing beside the bed looking down on Resident #70 while feeding him. NA #118 was asked if she should sit down when feeding the Resident? NA #118 replied, he's a feeder and I stand up when I feed him.
b) Resident #57
On 07/26/22 at 11:45 AM, NA #17 was observed standing by Resident #57's bed looking down on the resident while feeding him the noon meal. Resident #57 was in bed. NA #17 said she usually doesn't sit down when feeding Resident #57.
On 07/26/22 at 1:25 PM, the administrator said a nursing assistant should sit down when feeding a resident. The administrator asked if the residents were eating in their rooms? The surveyor replied yes, and the administrator said, Well I don't know if they need to sit down if the residents are eating in their rooms. The surveyor asked if feeding residents in their rooms was different than feeding a resident in the dining room? The administrator replied, No, I didn't really mean what I said.
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CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0578
(Tag F0578)
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 recognize the resident's right to formulate an advance dire...
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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 recognize the resident's right to formulate an advance directive. This was true for one (1) of seven (7) residents reviewed for the care area of advance directives. Resident identifier: #136. Facility census: 86.
Findings included:
a) Resident #136
Review of the electronic medical record found the Resident was a full code. Review of the current care plan found the following focus:
Resident elects to be a Full Code, dated 07/13/22.
The Resident was admitted to the facility on [DATE]. The Resident's daughter, the Medical Power of Attorney (MPOA) completed the resident's admission paperwork on 07/13/22.
On 07/15/22, the Resident's physician completed a History and Physical (H&P) and hand wrote the following: Here for long term care. He is a full DNR (Do Not Resuscitate) per his request but cannot make other health decisions without help from MPOA. The physician also checked the following Code Status on the H&P, Do Not Resuscitate.
On 07/25/22 at 2:30 PM, the administrator said the resident lacks capacity so therefore his MPOA would have been asked about formulating an advance directive.
The copy of the Advance Directives Acknowledgement Form, signed by the MPOA was reviewed with the administrator.
The form contained a section:
I have been informed of my right to formulate an Advance Directive, and I:
-Would like to formulate an Advance Directive
-Do not wish to formulate an Advance Directive
-Am not sure at this time.
None of the above answers were checked by the MPOA.
On 07/26/22 at 10:39 AM, Social Worker (SW) #104 reviewed the physician's History and Physical and said, I don't know why the doctor wrote that. That contradicts what we have. He (indicating the resident) doesn't have the capacity to make decisions. The SW was asked when the physician determined the resident lacked capacity to make medical decisions?
On 07/26/22 at 11:21 AM, SW #104 provided a copy of a Physician's Determination of Capacity form indicating the resident lacks capacity to make medical decisions. The form was not signed by the physician until today - 07/26/22. The SW said she had called the MPOA and the MPOA wanted the Resident's code status to be a DNR.
On 07/27/22 at 12:34 PM, the above information was reviewed with the administrator. No further information was provided by the facility.
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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
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Based on observation, staff interview and record review the facility failed to implement their abuse policy by reporting all injuries of unknown origin and thoroughly investigating all injuries of u...
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Based on observation, staff interview and record review the facility failed to implement their abuse policy by reporting all injuries of unknown origin and thoroughly investigating all injuries of unknown origins to determine a possible cause and/or to rule out abuse and/or neglect. This was true for Resident #42 who had bruising to the left side of her head and to both sides of her neck. This was true for one (1) of one (1) resident reviewed for the care area of non pressure skin conditions. Resident Identifier: #42. Facility Census: 86.
Findings included:
a) Resident #42
Observation of Resident #42 on 07/25/22 at 1:19 PM during the first phase of the Long Term Care Survey Process (LTCSP) found a bruise to the left side of her head and on both sides of her neck. The bruises were deep purple in color.
A review of Resident #42's medical record on 07/26/22 found a Non Pressure Skin Report which indicated the resident had bruise to the left side of face which was 4.5 centimeters X 1.8 centimeters X 0 centimeters depth, a bruise to the right side of the neck which was 5.0 centimeters X 3.0 centimeters X 0 centimeters depth, and a bruise to the left side of her neck which measured 6.5 centimeters X 2.0 centimeters X 0 centimeters depth. This report was completed on 07/21/22.
An interview with the Social Worker (SW) # 104 on 07/26/22 at 1:31 PM confirmed these bruises were not reported as an injury of unknown origin. She stated the Nursing Home Administrator (NHA) may have more information as to why they were not reported.
On 07/26/22 at 3:45 PM observations of Resident #42 with the NHA confirmed the bruises to the Left side of her face and her bilateral neck. She stated they were the same bruises she saw on 07/21/22 when they were reported to her. When asked why the decision was made not to report these bruises as injuries of unknown origin she stated, We felt with her bruising easy because of her aspirin use and diagnosis of anemia they were not anything to be concerned with. When asked about the location of the bruises the NHA remained silent.
A review of Resident #42's medical record found she has had a diagnosis of anemia, but there were no lab values to indicate how severe her anemia was. Resident #42 does take an 81 milligram aspirin daily. Bruising even if you bruise easily is caused by some sort of trauma or injury. There was no evidence the facility investigated the cause of the bruises to try to determine why the bruises occurred and/or to rule out abuse or neglect.
b) Policy Review
Review of the facility's abuse policy which was titled, Elkins Rehabilitation and Care Center Abuse Policy , which does not have a date found the following,
. 1. Any staff member witnessing, receives a compliant of, or suspects mistreatment, neglect and/or abuse, including injuries of unknown source, involuntary seclusion, and misappropriation of resident property is to report immediately to the immediate supervisor, but not later than 2 hours after forming the suspicion do not result in serious bodily injury.
.a. Suspect injuries of unknown source - unexplained bruises skin tears.
. An assistant administrator or social worker will complete the investigation and notify the required agencies with five (5) days of the allegation. The investigation will consist of, but not limited to the following:
1. An assistant Administrator and/or Social Worker will coordinate the investigation and in their absence the Director of nursing and or a clinical supervisor. The individuals conducting the investigation will keep the Administrator and Director of Nursing updated on the investigation.
2. The individual conducting the investigation will as a minimum:
a. Identify who was affected.
b. Identify the alleged perpetrator or document description provided by the victim.
c. What was the relationship of the alleged perpetrator to the resident?
d. Identify all witnesses.
e. What was the nature of the occurrence?
f. What effect did the occurrence have on the resident?
g. When did the incident occur?
h. Document all information provided by the victim and/or witnesses.
i. If the identity of the alleged perpetrator is unknown, list all individuals known to have had contact with the resident at the time of the event or at the time that the incident probably occurred.
j. Interview all individuals who may have information concerning the incident, including the resident (even a confused resident may be able to provide valid information), all individuals who were working at the time of the incident, anyone the resident may have shared information with etc.
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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
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Based on observation, record review and staff interview the facility failed to immediately report an injury of unknown origin to appropriate State agencies within the appropriate time frames. Reside...
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Based on observation, record review and staff interview the facility failed to immediately report an injury of unknown origin to appropriate State agencies within the appropriate time frames. Resident #42 had a deep purple bruising to the left side of the head and to both sides of her neck. There was no indication the facility knew how this injury occurred and there was no evidence this injury was reported. This was true for one (1) of one (1) reviewed for the care area of skin conditions non -pressure related. Resident Identifier: #42. Facility Census: 86.
Findings Included:
a) Resident #42
Observation of Resident #42 on 07/25/22 at 1:19 PM during the first phase of the Long Term Care Survey Process (LTCSP) found a bruise to the left side of her head and on both sides of her neck. The bruises were deep purple in color.
A review of Resident #42's medical record on 07/26/22 found a Non Pressure Skin Report which indicated the resident had bruise to the left side of face which was 4.5 centimeters X 1.8 centimeters X 0 centimeters depth, a bruise to the right side of the neck which was 5.0 centimeters X 3.0 centimeters X 0 centimeters depth. and a bruise to the left side of her neck which measured 6.5 centimeters X 2.0 centimeters X 0 centimeters depth. This report was completed on 07/21/22.
An interview with the Social Worker (SW) # 104 on 07/26/22 at 1:31 PM confirmed these bruises were not reported as an injury of unknown origin. She stated the Nursing Home Administrator (NHA) may have more information as to why they did not report these bruises.
On 07/26/22 at 3:45 PM observations of Resident #42 with the NHA confirmed the bruises to the Left side of her face and her bilateral neck. She stated, they were the same bruises she saw on 07/21/22 when they were reported to her. When asked why the decision was made not to report these bruises as injuries of unknown origin she stated, We felt with her bruising easy because of her aspirin use and diagnosis of anemia they were not anything to be concerned with. When asked about the location of the bruises the NHA remained silent.
A review of Resident #42 medical record found she has had a diagnosis of anemia, but there were no lab values to indicate how severe her anemia is. Resident #42 does take on 81 milligram aspirin daily. Bruising even if you bruise easily is caused by some sort of trauma or injury. There was no evidence the facility investigated the cause of the bruises to try to determine why the bruises occurred.
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CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Investigate Abuse
(Tag F0610)
Could have caused harm · This affected 1 resident
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Based on observation, staff interview and record review the facility failed to ensure all injuries of unknown origin are thoroughly investigated to determine a possible cause and/or to rule out abus...
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Based on observation, staff interview and record review the facility failed to ensure all injuries of unknown origin are thoroughly investigated to determine a possible cause and/or to rule out abuse and/or neglect. This was true for Resident #42 who had bruising to the left side of her head and to both sides of her neck. This was true for one (1) of one (1) residents reviewed for the care area of non pressure skin conditions. Resident Identifier: #42. Facility Census: 86.
Findings included:
a) Resident #42
Observation of Resident #42 on 07/25/22 at 1:19 PM during the first phase of the Long Term Care Survey Process (LTCSP) found a bruise to the left side of her head and on both sides of her neck. The bruises were deep purple in color.
A review of Resident #42's medical record on 07/26/22 found a Non Pressure Skin Report which indicated the resident had bruise to the left side of face which was 4.5 centimeters X 1.8 centimeters X 0 centimeters depth, a bruise to the right side of the neck which was 5.0 centimeters X 3.0 centimeters X 0 centimeters depth. and a bruise to the left side of her neck which measured 6.5 centimeters X 2.0 centimeters X 0 centimeters depth. This report was completed on 07/21/22.
An interview with the Social Worker (SW) # 104 on 07/26/22 at 1:31 PM confirmed these bruises were not reported as an injury of unknown origin. She stated the Nursing Home Administrator (NHA) may have more information as to why they did not report these bruises.
On 07/26/22 at 3:45 PM observations of Resident #42 with the NHA confirmed the bruises to the Left Side of her face and her bilateral neck. She stated, they were the same bruises she saw on 07/21/22 when they were reported to her. When asked why the decision was made not to report these bruises as injuries of unknown origin she stated, We felt with her bruising easy because of her aspirin use and diagnosis of anemia they were not anything to be concerned with. When asked about the location of the bruises the NHA remained silent.
A review of Resident #42 medical record found she has had a diagnosis of anemia, but there were no lab values to indicate how severe her anemia was. Resident #42 does take on 81 milligram aspirin daily. Bruising even if you bruise easily is caused by some sort of trauma or injury. There was no evidence the facility investigated the cause of the bruises to try to determine why the bruises occurred and/or to rule out abuse or neglect.
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CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0657
(Tag F0657)
Could have caused harm · This affected 1 resident
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Based on record review and staff interview the facility failed to review and revise the care plan when Resident #73 chose not to continue Hospice Care. This was true for 1 (one) of 28 sampled reside...
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Based on record review and staff interview the facility failed to review and revise the care plan when Resident #73 chose not to continue Hospice Care. This was true for 1 (one) of 28 sampled residents. Resident identifier: 73. Facility Census: 86.
Findings Included:
a) Resident #73
On 7/25/22 at 11:15 AM while reviewing medical records for Resident #73, it was noted the Resident was receiving Hospice Care. After reviewing the current orders, there was no order for the Resident to receive Hospice Care. Review of the current care plan found the resident was receiving Hospice Services.
An interview on 7/26/22 at 1:14 PM, with the Administrator, confirmed Hospice Care was declined on 7/15/22 and the care plan was not revised.
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CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on record review and staff interview the facility failed to ensure Resident #75 only received medications when ordered b...
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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 Resident #75 only received medications when ordered by the attending physician. Resident #75 received Tramadol on an as needed basis (PRN) from 02/13/22 through 02/20/22. Resident #75's attending physician indicated he never gave the facility an order to administer Tramadol. This was true for one (1) of one (1) resident reviewed for the care area of pain management. Resident Identifier: #75. Facility Census: 86.
Findings Included:
a) Resident #75
A review of Resident #75's medical record found a nursing progress note dated 01/11/22 (Resident was admitted to the facility on [DATE]) which read as follows, Received Fax from (Name of Attending physician) New orders as follows: Change Isosorbide mononitrate 10 mg tid (three times a day) to isosorbide mononitrate ER 30 mg by mouth dialy in am. Also stop Tramadol PCC (point click care) orders updated.
Resident #75 was admitted from hospital with a prescription for Tramadol which was discontinued by the attending physician the day after her admission.
Further review of the medical record found two additional orders for as needed Tramadol which was for 50 mg every 8 hours as needed for pain the orders were dated for 02/13/22 and 02/17/22. The nurse indicated on the order that the attending physician gave the order verbally. Resident #75 received Tramadol on the following dates and times:
-- 02/14/22 at 6:34 am
-- 02/14/22 at 9:00 pm
-- 02/15/22 at 6:45 am
-- 02/15/22 at 9:16 pm
-- 02/16/22 at 10:12 am
-- 02/16/22 at 8:37 pm
-- 02/17/22 at 9:40 am
-- 02/17/22 at 7:36 pm
-- 02/18/22 at 8:30 pm
-- 02/19/22 at 9:00 am and
-- 02/20/22 at 9:00 am.
A review of the controlled substance log for the Tramadol indicated it was received from the pharmacy 01/19/22 and 15 pills were received. This medication was received eight (8) days after it was discontinued by the attending physician. At the top of the controlled substance log was a hand written note which read, Faxed DR. (name of attending physician) for script 2-20. the writer of this hand written note is unknown. On the bottom of the infection control log an x was drawn and the Director of Nursing signed and dated it for 02/20/22. This indicates the medication was removed from the medication cart and stored elsewhere pending destruction of the medication with the licensed pharmacist.
A telephone interview with the attending physician on 07/26/22 at 10:15 am revealed he had never gave an order to give the Resident tramadol. He indicated he ordered the medication to be discontinued on 01/11/22 when he realized the resident had and addiction problem previously. He stated, I never gave them an order to give the medication. When asked when he first became aware of the fact she was receiving the medication he indicated he was not aware until 02/20/22 when they requested a new prescription. It was at this time he called the facility and asked why they needed a prescription when the medication was discontinued on 01/11/22. He stated in his 20 years as the physician at this facility nothing like this has ever happened, but he could not just set back and let stuff like this go.
The Nursing Home Administrator (NHA) was asked to provide the signed prescription for Resident #75's Tramadol on 07/26/22 at 1:26 pm. She provided a prescription from the physician at a local hospital for Tramadol. She indicated this was the only signed prescription they had. She indicated it came with her on admission on [DATE]. When asked if she had a signed prescription from the residents attending physician at the facility she stated she did not. When asked why this medication was not removed from the medication cart when the attending physician discontinued it on 01/11/22, she indicated it should have been but was not and education has been performed to remove all medication when it is discontinued.
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CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Pressure Ulcer Prevention
(Tag F0686)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to ensure two (2) of eight (8) residents review for the care area...
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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 two (2) of eight (8) residents review for the care area of pressure ulcers received care consistent with professional standards of practice to heal or prevent pressure ulcer development. Resident Identifiers: #57 and #70. Facility Census: 86.
Findings included:
a) Resident #57
While reviewing medical records it was noted Resident #57 was admitted on [DATE]. He was assessed as having a Stage III pressure ulcer upon admission. It was noted by the admitting Licensed Practical Nurse (LPN) #124 on 5/20/22 that the resident was admitted to facility with an open area to the coccyx.
According to the wound evaluation completed by Facility Nurse Practioner (FNP)/Wound Nurse #176 on 05/24/22 with treatment orders included, the resident had a Stage III pressure ulcer, it was 4 (four) days old from admission and present on admission to the right buttock. The FNP wrote the following order for treatment:
Cleanse stage III PI (pressure injury) to coccyx and right buttock wound cleanser, rinse with NS (normal saline), pat dry, apply calcium Ag (Algiate) and cover with foam border dressing. Every day shift every Mon, Wed, Fri for 15 days.
This order was not implemented on 05/24/22 when written.
There was also a Skin/Wound Note by LPN Wound Nurse #14 on 05/24/22 also indicating open areas
noted to coccyx and right buttock.
According to the Treatment Administration Record (TAR) for May 2022, there were no treatments to the pressure ulcer until May 30, 2022.
The resident was not assessed for wound care treatments until he was in house for 4 (four) days.
Treatment orders, written on 05/24/22 were not implemented until 05/30/22.
No wound treatment for the Stage III pressure ulcer was started until the resident was in house for 10 (ten) days.
At approximately 5:15 PM on 07/27/22, the administrator reviewed the information and agreed they was a delay in the pressure ulcer treatment for Resident #57.
.b) Resident #70
Observation of wound care for Resident #70 on 07/27/22 at 1:42 PM, with Licensed Practical Nurse (LPN) #14 found the following:
LPN #14 began by placing the wound treatment supplies on the bedside table without cleaning the table first.
LPN #14 removed the dressing to the right hip, the dressing was dated 07/25/22.
It was noted the right hip had a healing bruise, greenish/yellow in color and approximately 10 centimeters (cm) by 10 cm in size.
Inside the bruise were three (3) opened wounds.
LPN #14 pointed to the smallest of the wounds and said, this is the one I am treating.
LPN #14 was asked about the other two wounds which measured approximately 4cm by 3 cm and 3 cm by 3 cm. Both wounds were missing the top layer of skin and appeared as a shallow, crater-like wound.
LPN #14 was asked if the two (2) larger wounds were present on 07/25/22? LPN #14 stated she did not think so.
Current orders, with a start date of 07/13/22, for the pressure ulcer to the right hip include:
DTI Left and Right hip: Cleanse with normal saline, pat dry, apply skin prep and cover with large
foam border dressings for protection
every day shift every Mon, Wed,
The medication administration record (MAR) contained a second order for:
Stage II right hip: Cleanse with wound cleanser, rinse with normal saline, pat dry, apply calcium alginate and cover with large foam border dressing every day shift every Mon, Wed,
(This order was never performed to the right hip during this observation.
Deep Tissue Injury (DTI) pressure ulcers are defined as 'purple or maroon localized area of discolored intact skin or blood, filled blister due to damage of underlying soft tissue from pressure and/or shearing)
(SKIN-PREP is a Protective Dressing is a fast-drying, sterile, liquid film-forming skin protectant that prepares damaged or intact skin for attachment sites, tapes, films, and adhesive dressings. It also protects skin from incontinence, wound drainage, ostomy effluent, adhesive trauma, tape stripping, and friction.)
LPN #14 poured normal saline on one 4x4 gauze. With one single wiping motion across the right hip LPN #14 wiped all three (3) opened wounds at once with the same gauze.
LPN #14 used 1 premedicated single use skin prep and wiped all three open wounds .
The new dressing was applied.
LPN #14 removed the dressing dated 07/25/22 from the left hip and revealed two opened wounds with discolored dark skin around the wounds.
Once again LPN #14 did not clean or treat each wound separately.
LPN #14 removed one glove from her right hand, put a very small amount of hand sanitizer on the tips of the fingers on the right hand. She rubbed her fingers and thumb together for about 3 seconds before putting on one new glove to the right hand.
Using her left hand, she held the Calcium Alginate (this was ordered for the right hip which was applied to the left hip) to the two open wounds while applying the foam dressing on the wounds.
On 07/27/22 at 2:30 PM, Administrator was informed of the observation. At this time the Administrator stated she was in the process of have a consulting group come into the facility to provide wound care.
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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
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
c) Medication on Medication Cart
On 07/27/22 at 8:53 am Licensed Practical Nurse (LPN) #82 was observed walking away from her...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
c) Medication on Medication Cart
On 07/27/22 at 8:53 am Licensed Practical Nurse (LPN) #82 was observed walking away from her medication cart. She entered room [ROOM NUMBER] with a medication cup in her hand. While she was down the hall and in the resident room the medication cart was unsupervised. On the top of the cart was a medication card which contained at least 15 doses of Lexapro.
When LPN #82 returned to her medication cart she confirmed the medication should not be left on top of the cart. She stated it is discontinued and I pulled it out and laid it on top of the cart. She stated, Your right, it should remained locked in the cart until it can be taken to the medication room.
Based on observation, record review, and staff interview the facility failed to ensure the residents environment over which it had control was as free from accident hazards as possible. This has the potential to effect more than an isolated number of residents. For Resident #70 the facility failed to investigate bruising on the Residents forearms to possibly identify any hazards/risks, implement interventions to reduce any hazards/risks and monitor for the effectiveness of any interventions. Resident #69 had medication in the room. In addition, medication was left unattended on top of the medication cart. Resident identifiers: #70 and #69. Facility census: 86.
Findings included:
a) Resident #70
Review of the Skin/Wound notes in the electronic medical record found the following:
-05/09/2022 at 11:21 AM Skin/Wound Note
Note Text: Bruising on back of left hand is resolving well. Faded red in color. Resident denies pain to area.
-05/16/2022 at 7:11
AM Skin/Wound Note
Note Text: Bruising back of left hand is faded red in color. Resident shows no s/s (signs/symptoms) pain/discomfort at this time.
-05/22/2022 at 8:21 AM Skin/Wound Note
Note Text: Scattered deep purple/red bruising noted to bilateral hands/arms. Resident states he does not know how he got them. Resident is noted to have several occurrences of combative behaviors recently. Resident denies pain at this time.
-05/27/2022 at 7:03 AM Skin/Wound Note
Note Text: Assessed skin tears on RFA (right forearm) at this time. 2 noted. One measuring 0.5 x 0.5 x 0.1 cm. The other measuring 1.0 x 0.2 x 0.1 cm. Skin flaps pushed back into place and secured with steri-strips. Applied thin layer of bacitracin and covered with foam border dressing. Resident denies pain to area.
-05/29/2022 at 11:06 AM Skin/Wound Note
Note Text: Upon assessment of residents forearms, it was noted that dressing on right forearm was missing. Cleansed with wound cleanser, rinsed w/ NS (with normal saline). Placed bacitracim and foam border dressing.
Resident resting in bed at this time, no signs of distress noted,call bell within reach. Will continue to monitor.
-06/04/2022 at 1:00 PM Skin/Wound Note
Note Text: Skin tear to RFA: Scant amounts of serosanguinous drainage preset on removed dressing. No odor, erythema, or edema present. Slight warmth to touch. Area was cleansed with normal saline, patted dry, applied bacitracin and covered with 3x3 foam border dressing. No c/o pain or discomfort voiced with area or during treatment.
-06/13/2022 at 8:19
AM Skin/Wound Note
Note Text: Skin tear RFA remains but is beginning to scab over. Cleansed area with normal saline, patted dry, applied skin prep and left open to air. Resident was noted to have a foam border dressing on right hand. Once dressing was removed, this nurse noted a 2.0 x 0.1 x 0.1cm skin tear. Resident stated he was unaware of how he obtained the skin tear but denies pain. Area cleansed with normal saline, patted dry, applied thin layer of bacitracin and covered with foam border dressing. Bruising bilat (bilateral) arms/hands remains, but varies in stages of healing and color. Color ranging from deep purple to faded red. Resident denies pain to all areas at this time.
-06/20/2022 at 9:40 AM Skin/Wound Note
Note Text: Skin tear RFA has resolved at this time. Skin tear right hand is scabbed over and dry. Scattered bruising to BUE (bilateral upper extremities) remains and is faded red in color. [linked]
At 2:50 PM on 07/27/22, the administrator confirmed there was no documentation the facility investigated the cause of the bruises. She said, the nurse only wrote a note. I have nothing else.
b) Resident #69
On 7/27/22 at 2:40 PM, upon entering the room to observe wound care on Resident #69, a yellow oblong pill with the coating dissolved was found laying on the bed side table.
Licensed Practical Nurse (LPN) #124 and LPN #14 confirmed the pill was on the table. LPN #124 stated she takes her pills crushed .I don't know where that pill came from . I just got on this hall at noon .another nurse passed medications this morning.
On 07/27/22 at 2:55PM, LPN #124 and LPN #14 came to the conference room. we found out what that pill was .it's a B Complex.
Upon reviewing the current physician's orders, an order was found for Vitamin B Complex tablet give one (1) tablet by mouth one time a day for supplement dated 06/28/22.
At approximately 3:00 PM, the Administrator was notified about the pill found laying on the bed side table.
No further information was obtained during the survey process.
.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0691
(Tag F0691)
Could have caused harm · This affected 1 resident
.
Based on record review and staff interview the facility failed to ensure a resident with an ileostomy had physician orders for ileostomy care. This was a random opportunity for discovery. Resident I...
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.
Based on record review and staff interview the facility failed to ensure a resident with an ileostomy had physician orders for ileostomy care. This was a random opportunity for discovery. Resident Identifier: #1. Facility Census: 86.
Findings included:
a) Resident #1
On 7/25/22 at 11:30 AM, during the initial survey interview process Resident #1 stated she didn't feel well because she recently returned from the hospital and her stomach was upset. She proceeded to inform the surveyor she had an ileostomy due to surgery last year.
While reviewing her current medical records and orders it was noted there are no orders for ileostomy care to be provided by staff.
This was confirmed with the Administrator on 7/27/22 at 9:34 AM.
.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Staffing Information
(Tag F0732)
Could have caused harm · This affected 1 resident
.
Based on record review and staff interview the facility failed to have an accurate and completed staff posting. This failed practice had the potential to affect a limited number of residents that re...
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.
Based on record review and staff interview the facility failed to have an accurate and completed staff posting. This failed practice had the potential to affect a limited number of residents that reside in the facility. Facility census 86.
Findings included:
a) Staff posting
The staff posting form for 07/13/22, found Only the day shift section was completed for 7a-3p.
The facility census, evening and night shifts were not completed.
During a review of the facility postings for the last four weeks the following postings were not corrected to reflect the actual hours worked:
*07/23/22 staff posting had 3.81, the typed report provided by Administrator had 3.77 Hours Per Patient Day (HPPD).
*07/21/22 staff posting had 4.8 HPPD, the typed report provided by Administrator had 4.5 HPPD.
*07/20/22 staff posting had 4.54 HPPD, the typed report provided by Administrator had 4.20 HPPD.
*07/19/22 staff posting was 3.93 HPPD, the typed report provided by Administrator had 3.83 HPPD.
On 07/27/22 at 2:37 PM, Administrator was shown the inaccurate staff posting. No further information was provided.
.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Pharmacy Services
(Tag F0755)
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 pharmaceutical services were provided to each residen...
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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 pharmaceutical services were provided to each resident to meet their needs and to ensure an accurate reconciliation of each controlled substance. Resident #75 was administered tramadol after the medication was discontinued in part because the medication was not removed from the medication cart in a timely manner after the discontinuance of the drug. In addition when the remaining tramadol were destroyed the licensed pharmacist was the only person to sign the Disposition of Drug section. This was a random opportunity for discovery and was true for Resident #75. Resident Identifier: #75. Facility Census: 86.
Findings Included:
a) Resident #75
A review of Resident #75's medical record found a nursing progress note dated 01/11/22 (Resident was admitted to the facility on [DATE]) which read as follows, Received Fax from (Name of Attending physician) New orders as follows: Change Isosorbide mononitrate 10 mg tid (three times a day) to isosorbide mononitrate ER 30 mg by mouth daily in am. Also stop Tramadol PCC orders updated.
Resident #75 was admitted from hospital with a prescription for Tramadol which was discontinued by the attending physician the day after her admission.
Further review of the medical record found two additional orders for as needed Tramadol which was for 50 mg every 8 hours as needed for pain the orders were dated for 02/13/22 and 02/17/22. The nurse indicated on the order that the attending physician gave the order verbally. Resident #75 received Tramadol on the following dates and times:
-- 02/14/22 at 6:34 am
-- 02/14/22 at 9:00 pm
-- 02/15/22 at 6:45 am
-- 02/15/22 at 9:16 pm
-- 02/16/22 at 10:12 am
-- 02/16/22 at 8:37 pm
-- 02/17/22 at 9:40 am
-- 02/17/22 at 7:36 pm
-- 02/18/22 at 8:30 pm
-- 02/19/22 at 9:00 am and
-- 02/20/22 at 9:00 am.
A review of the controlled substance log for the Tramadol indicated it was received from the pharmacy 01/19/22 and 15 pills were received. This medication was received eight (8) days after it was discontinued by the attending physician. At the top of the controlled substance log was a hand written note which read, Faxed DR. (name of attending physician) for script 2-20. the writer of this hand written note is unknown. On the bottom of the infection control log an x was drawn and the Director of Nursing signed and dated it for 02/20/22. This indicates the medication was removed from the medication cart and stored elsewhere pending destruction of the medication with the licensed pharmacist on 02/20/22.
On the top right corner under the heading of Disposition of Unused Drugs. The Pharmacist signed indicating he destroyed three (3) remaining tramdol on 03/11/22. The signature area for the Nurse, Director of Nursing (DON), and Administrator/Designee were all blank.
The Nursing Home Administrator (NHA) was asked to provide the signed prescription for Resident #75's tramadol on 07/26/22 at 1:26 pm. She provided a prescription from the physician at a local hospital. She indicated this was the only signed prescription they had. She indicated it came with her on admission on [DATE]. When asked if she had a signed prescription from the residents attending physician at the facility she stated she did not. When asked why this medication was not removed from the medication cart when the attending physician discontinued it on 01/11/22. She indicated it should have been but was not and education has been performed to remove all medication when it is discontinued.
The NHA further agreed there should have been at least one (1) more signature under the disposition of unused drugs for this medication. She indicated there should always be at least two (2) signatures there.
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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
.
Based on record review and staff interview the facility failed to ensure medication irregularities identified by the Pharmacist, and accepted by the physician were implemented. This was true for one...
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.
Based on record review and staff interview the facility failed to ensure medication irregularities identified by the Pharmacist, and accepted by the physician were implemented. This was true for one (1) of five (5) residents reviewed for the care area of unnecessary medications. Resident Identifier: #1 Facility Census: 86.
Findings Included:
a) Resident #1
On 7/27/22 at 9:00 AM while reviewing medical records it was noted on the October, 2021 Consultation Report from the pharmacist, the Physician accepted the recommendation to change the timing on a medication (Bumex) from 9:00 PM to earlier in the evening due to this being a diuretic. This was not completed.
On the 06/2022 Consultation Report from the pharmacist, the Physician accepted the recommendation to have the Residents Hemoglobin A1C laboratory level checked and monitored. This was not completed and there are no orders to monitor the A1C in the future.
These two findings were confirmed with the Administrator on 7/27/22 at 9:34 AM.
.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on observation and staff interview, the facility failed to ensure foods were stored in a safe and sanitary manner. This ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on observation and staff interview, the facility failed to ensure foods were stored in a safe and sanitary manner. This failed practice had the potential to affect a limited number of residents. Facility census: 86.
Findings included:
a) Initial tour of the kitchen
During the initial tour of the kitchen on 07/25/22 at 10:48 AM, with the dietary manager, observation found a large silver tray containing strips of uncooked bacon in the walk - in refrigerator. There was no date on the tray of bacon to determine when the bacon was removed from the original packaging or when the bacon would expire and need to be discarded.
In addition a plastic bag containing at least 10 hot dog [NAME], removed from the original packaging, was present on a storage cart in the walk- in refrigerator. There was no date to determine when the hot dog [NAME] were opened or would the [NAME] would need to be discarded.
The Dietary Manager provided no explanation for the above observations.
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CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Medical Records
(Tag F0842)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
b) Resident #42
Review of Resident #42's medical record on 07/27/22 found the following Non - Pressure assessments for Reside...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
b) Resident #42
Review of Resident #42's medical record on 07/27/22 found the following Non - Pressure assessments for Resident #42:
-- assessment dated [DATE] indicated Resident #42 had a blister to the right outer leg that was 11 centimeters X 4 centimeters. Under the section of the assessment titled Stage Licensed Practical Nurse (LPN) #103 selected Suspected deep tissue injury.
-- assessment dated [DATE] indicated Resident #42 had bruising to the left cheek and left side of neck. Each bruise was measured with a length of .5 centimeters only. Under the section of the assessment titled Stage LPN #103 selected Suspected deep tissue injury.
-- assessment dated [DATE] indicated Resident #42 had bruising to the left upper chest that was 2 centimeter X 1 centimeter. Under the section of the assessment titled Stage LPN #103 selected Suspected deep tissue injury.
-- assessment dated [DATE] indicated Resident #42 had bruising to the left lower leg that was 6 centimeter X 3 centimeters. Under the section of the assessment titled Stage LPN #103 selected Suspected deep tissue injury.
On 07/27/22 at 12:35 PM and interview with the Nursing Home Administrator confirmed the Non Pressure assessments listed above were inaccurate. She indicated those injuries were not Suspected Deep Tissue injuries and should not have been staged on this assessment.
Based on record review and staff interview, the facility failed to ensure the medical records for Resident's #136 and #42 were accurate and correct. This was true for three (3) of 28 resident records reviewed during the long term care survey. Resident identifiers: #136 and #42. Facility census: 86.
Findings included:
a) Resident #136
Medical record review found the resident was admitted to the facility on [DATE].
On 07/13/22 a nursing admission assessment was completed indicating the resident had no pressure ulcers. The only skin issue was healed scratches to the feet.
On 7/16/22 a pressure ulcer assessment, noted a Deep Tissue injury (DTI) to the left buttock.
On 07/26/22 at 1:00 PM, the wound treatment nurse, Licensed Practical Nurse (LPN) #14 said the resident never had a pressure ulcer. A weekend nurse wrote that but I came in and looked on Monday and there is no pressure ulcer. I guess I should have clarified that somewhere in the medical record.
The nurse surveyor observed the resident and found no pressure ulcer to the left buttock.
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CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
e) Resident #47
On 07/25/22 at approximately 1:20 PM, an observation was made during incontinence care for Resident #47. Nurse...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
e) Resident #47
On 07/25/22 at approximately 1:20 PM, an observation was made during incontinence care for Resident #47. Nurse Aide (NA) #72 and NA #78 were observed throwing dirty linen and a soiled brief on the floor without a barrier leaving a wet spot directly on the floor.
On 07/25/22 at 1:27 PM, NA #78 stated, I forgot, when asked about using a barrier during incontinence care. NA #72 made no statement. Licensed Practical Nurse (LPN) # 77 confirmed the dirty linen and the soiled brief should not be put directly on the floor and the items were not discarded into a designated container.
The facility policy entitled Perineal Care, step #11 states, Discard disposable items into designated containers .
On 07/25/22 on 1:44 PM, the Director of Nursing (DON) was notified. The DON stated I'm embarrassed .I'm sorry.
No further information was obtained during the survey process.
f) Resident #20
On 07/25/22 at 11:26 AM, Resident #20 was found to be in a transmission-based precaution room for droplet precautions for observation due to the resident being a new admission to the facility.
On 07/25/22 at 11:40 AM, NA #61 did not put any personal protective equipment (PPE) on prior to entering the droplet precaution room. NA #61 stated I don't have to if I'm just picking up a tray. LPN #34 confirmed PPE was not worn into the droplet precaution room.
The signage placed on the door of room [ROOM NUMBER]-P, has illustrations of what preferred PPE should be worn during droplet precautions. These include face shield or goggles, an N95 face mask or higher, one pair of clean, non-sterile gloves and an isolation gown.
On 07/25/22 at approximately 12:00 pm, the Administrator was notified of the breach of infection control in a transmission-based precaution room.
No further information was obtained during the survey process.
g) Resident #23
On 07/27/22 at 12:35 PM, wound care was observed for Resident #23. LPN #14 did not wear a gown upon entering the enhanced barrier precaution room. LPN #14 was asked why the isolation gown was not worn? LPN #14 said, It's a new policy .I forgot.
The signage on the door of Resident #23's room states, wear gloves and gown for the following high-contact resident care activities .wound care: any skin opening requiring a dressing.
On 07/27/22 at 12:48 PM, the Administrator notified.
No further information was obtained during the survey process.
h) Resident #80
On 07/27/22 at 2:12 PM, wound care to the sacrum was performed by LPN #124. The bedside table was not cleaned prior to placing the barrier on the bedside table. The resident's personal belongings were left on the table. These personal belongings could contaminate the surrounding field. The personal belongings left were a crumbled up napkin, water pitcher, open pop can, a water bottle and a box of tissues. The bed control was on the floor and LPN#124 picked it up with a gloved hand and did not remove the glove or complete hand hygiene after placing the bed control back on the bed. LPN #124 also moved the bedside table and opened the door with a gloved hand. LPN #124 did not remove the glove or complete hand hygiene after touching these items.
On 07/27/22 at 2:40 PM, wound care to the right heel was performed by LPN #14. While wound care was being completed to the sacrum by LPN #124, LPN #14 placed the wound care supplies on a chest of drawers without cleaning the chest of drawers. LPN #14 then moved the wound supplies to the bedside table without cleaning the table. The resident's personal belongings were left on the table. These personal belongings could contaminate the surrounding field. The personal belongings left were a crumbled up napkin, water pitcher, open pop can, water bottle, and a box of tissues.
Throughout the process of wound care to the right heel, LPN #14 touched her eye glasses multiple times with unclean and ungloved hands.
On 07/27/22 at 3:05 PM, LPN #14 and LPN #124 stated, do we have to move the personal belongings? LPN #124 stated, I didn't realize I picked up the bed control with the same gloves. LPN #14 stated, Did I touch my glasses?
On 07/27/22 at approximately 3:30 PM, the Administrator was notified of the findings during wound care for Resident #23 and #80.
No further information was obtained during the survey process.
Based on observation, record review and staff interview the facility failed to develop and implement an infection control program designed to prevent the spread of communicable diseases. The laundry room door would not stay closed, hand hygiene was not provided to residents before meals, infection control standards were not followed during wound care, soiled linen was placed on the floor and staff did not don PPE (personal protective equipment) before entering a droplet precaution room. This failed practice had the potential to effect more than an isolated number of residents. Resident identifiers: #136, #70, #47, #20, #23, and #80. Facility census 86.
Findings Included:
a) Laundry room
On 07/27/22 at 8:53 AM, this surveyor observed the door between the potentially contaminated linen and clean linen side of the laundry room to be open. Environmental Service Aide (ESA) #73 stated that the door between the dirty and clean laundry rooms will not stay closed. ESA #73 stated I feel the breeze today.
On 07/27/22 at 9:20 AM, the Administrator acknowledged the door between the dirty and clean side of the laundry room should stay closed.
A review of a facility provided policy labeled laundry process with no effective date found the following reference: Centers for Disease Control and Prevention (CDC), Guidelines for Environmental Infection Control in Health-Care Facilities, Recommendations of CDC and the Health care Infection Control Practices Advisory committee (HICPAC)https://www.cdc.gov/mmwr/preview/mmwrhtml/rr5210a1.htm revealed the following information:
II. Laundry Facilities and Equipment
.Maintain the receiving area for contaminated textiles at negative pressure compared with the clean areas of the laundry
b) Reflections dining room - no hand hygiene during mealtime
During an observation of lunch being served on the Reflections dining room on 07/26/22 at 12:00 PM, found there were 11 residents seated in the dining room. Staff passed out clothing protectors and meal trays. The staff failed to offer hand hygiene to any of the 11 residents.
On 07/26/22 at 12:10 PM, Registered Nurse #206 and Nurse Aide #49 both agreed they did not provide any hand hygiene prior to serving lunch.
On 07/26/22 at 12:42 PM, Administrator informed of the above findings.
c) Resident #136
Observation of wound care on 07/26/22 at 3:09 PM, with LPN #14 found LPN #14 obtained a bottle of hand sanitizer from the top of the treatment cart. LPN #14 entered the the room of Resident #136. LPN #14 placed the bottle of hand sanitizer on the table without placing it on a barrier or cleaning the table prior to placing the bottle on the table.
While applying the medication, which was in a paste form to the buttocks of Resident #136, LPN #14 moved her glasses on the top of her head and back on her nose three times while wearing the soiled gloves that were used to apply the paste.
LPN #14 was asked if she was aware she had handled her glasses throughout the procedure? LPN #14 said, No I didn't even think about it.
LPN#14 said she was planning on putting the hand sanitizer back on the treatment cart.
On 07/26/22 at 3:15 PM, Administrator was informed of the above observations.
d) Resident #70 - Wound Care
Observation of wound care for Resident #70 on 07/27/22 at 1:42 PM, with Licensed Practical Nurse (LPN) #14 found the following:
LPN #14 began by placing the wound treatment supplies on the bedside table without cleaning the table first.
LPN #14 removed the dressing to the right hip, dated 07/25/22.
It was noted the right hip had a healing bruise greenish/yellow in color and approximately 10 centimeters (cm) by 10 cm in size.
Inside of the bruise boarders were three (3) opened wounds.
LPN #14 pointed to the smallest wound and said this is the one she was treating.
LPN #14 poured normal saline on one 4x4 gauze. With one single wiping motion across the right hip, LPN #14 wiped all three (3) opened wounds at once.
LPN #14 again wiped all three (3) wounds with a single dry 4x4 gauze.
Then LPN #14 opened one premedicated single use skin prep and wiped it over all three open wounds before applying the dressing.
LPN #14 removed the dressing dated 07/25/22 from the left hip and revealed two opened wounds with discolored dark skin around the wounds.
Once again LPN #14 did not clean or treat each wound separately, wipping both wounds with the same gauze.
LPN #14 removed one glove from her right hand, put a very small amount of hand sanitizer on the tips of the fingers on the right hand and rubbed her fingers and thumb together for 3 seconds before putting on one new glove to the right hand.
Using her left hand, she held the Calcium Alginate (this was ordered for the right hip and was applied to the left hip) to the two open wounds while applying the foam dressing on the wounds.
On 07/27/22 at 2:30 PM, Administrator was informed of the observation. The Administrator stated she was in the process of have a group come into the facility to provide wound care.
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Apr 2021
5 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Resident Rights
(Tag F0550)
Could have caused harm · This affected 1 resident
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Based on observation and staff interview, the facility failed to ensure a dignified dining experience for Resident #44 who was not served her meal at the same time as her table mate. This was a rand...
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Based on observation and staff interview, the facility failed to ensure a dignified dining experience for Resident #44 who was not served her meal at the same time as her table mate. This was a random opportunity for discovery. Resident identifiers #44. Facility Census 90
a) Dining observation
On 04/27/21 at 11:05 AM, Resident #77 was observed being assisted with her meal. Resident #44 who was seated at the same table as Resident #77 did not have her meal. An interview with Nursing Assistant #134 at 11:12 AM confirmed Resident #44 did not need any assistance with her meal. Resident #44 did not receive her meal until 11:25 AM.
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CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Assessment Accuracy
(Tag F0641)
Could have caused harm · This affected 1 resident
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b) Resident #91
A review of Resident #91's medical records revealed Resident # 91 was discharge from the facility on 03/08/21. The MDS with an ARD date of 03/08/21 indicated Resident #91 was dischar...
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b) Resident #91
A review of Resident #91's medical records revealed Resident # 91 was discharge from the facility on 03/08/21. The MDS with an ARD date of 03/08/21 indicated Resident #91 was discharged to an Acute Hospital. Further review of the medical record found the nursing notes and physician notes indicated Resident # 91 discharged to home with family.
During an interview on 04/27/21 at 1:49 PM, Registered Nurse MDS Coordinator # 67 stated she made a mistake and will correct it now.
Based on medical record review and staff interview, the facility failed to ensure a complete and accurate Minimum Data Set (MDS) for two (2) of 14 residents who received MDS reviews. Resident identifiers: #15, and #91. Facility census: 90.
Findings included:
a) Resident #15
Resident #15's Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 02/02/2021 documented under medications received seven (7) days of antipsychotic medication during the look back period. However, the antipsychotic medication review documented the resident had not received antipsychotic medication. Based on this response, the date of attempted gradual dose reduction (GDR) was not documented.
Review of Resident #15's medical records revealed the resident was receiving the antipsychotic medication Seroquel during the look back period for the MDS with an ARD 02/02/21. A GDR of Seroquel had been attempted on 11/12/20.
During an interview on 04/27/21 at 10:49 AM Registered Nurse MDS Coordinator #67 stated the MDS with an ARD 02/02/21 was incorrect. She stated Resident #15 was receiving antipsychotic medications during the look back period. She stated she would correct the MDS.
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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 deliver respiratory care services consistent with professional standards of practice. A physician's order for...
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Based on observation, medical record review, and staff interview, the facility failed to deliver respiratory care services consistent with professional standards of practice. A physician's order for oxygen was not followed. This practice affected one (1) of three (3) Residents reviewed for respiratory care during the Long-Term Care Survey Process (LTCSP). Resident Identifier: #14. Facility Census: 90.
Findings included:
a) Resident #14
An observation of Resident #14 on 04/26/21 at 01:05 PM, revealed the Resident was sitting up in a chair receiving oxygen at three and a half (3.5) liters via nasal cannula (an oxygen delivery device) from an oxygen concentrator.
A review of the Resident's physician order revealed, an order Oxygen two (2) Liters Per Minute (LPM) continuously related to Dyspnea, with an order start date of 04/11/20.
A second observation of Resident #14, on 04/27/20 at 9:46 AM, revealed the Resident was receiving oxygen at three and a half (3.5) liters via nasal cannula from an oxygen concentrator.
An interview with the Licensed Practical Nurse (LPN) Clinical Supervisor #91 on 04/27/21 at 09:46 AM, verified the Resident was receiving oxygen at three and a half (3.5) Liter Per Minute (LPM). LPN #91 confirmed Resident #14 was ordered oxygen at two (2) Liters via nasal cannula continuously. LPN #91 verified the oxygen level was wrong. LPN #91 changed Resident #14's oxygen to two (2) LPM on the concentrator at this time.
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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, prepare, distribute and serve food in accordance with professional standards for food service safety. This failed practice had ...
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Based on observation and staff interview the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety. This failed practice had the potential to more than a limited number of residents who receive nutrients from pantry refrigerators. Facility Census 90.
a) Pantry Refrigerators
An observation on 04/27/21 at 11:49 AM of the pantry refrigerators on each unit with the assistant dietary manager, found on the Reflection unit and the Mountain unit several dates were missing on the temperature logs for April 2021.
The logs were not completed for 04/08/21, 04/09/21, 04/17/21, 04/18/21, 04/20/21, and 04/25/21.
Assistant Dietary Manager stated, kitchen staff needs to make sure they do temperatures and not miss days.
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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 observations and staff interview, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment ...
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Based on observations and staff interview, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections with regards to Personal Protective Equipment (PPE), Catheter Care and Respiratory Care. This practice had the potential to affect more than an isolated number of Resident's. Facility census: 90.
Findings Included:
a) 300 Hall
An observation on 04/26/21 at 02:53 PM found, Nurse Aide (NA) #68 entering a room on transmission-based precautions without using the proper PPE. NA #68 was only wearing a medical mask, no eye protection, gloves or gown.
An interview on 04/26/21 at 02:55 PM with NA #36 and #68 confirmed, they were supposed to wear PPE in any room on transmission-based precautions.
An observation on 04/26/21 at 03:03 PM found, Physical Therapy Assistant (PTA) #95 providing therapy in a room on transmission-based precautions without proper PPE. PTA #95 was only wearing a N95 mask and eye protection, no gloves or gown.
An interview on 04/26/21 at 03:42 PM with PTA #95 revealed, she checked on the PPE procedure. PTA #95 stated that anyone doing care in a room with transmission-based precautions, is to wear PPE, a gown, gloves, mask, and eye protection.
An Observation on 04/27/21 at 10:57 AM found NA #143 and Licensed Practical Nurse (LPN) Clinical Supervisor #91 in a room on transmission-based precautions providing care, without wearing appropriate PPE. NA #143 and LPN #91 was only wearing a medical mask and eye protection, no gloves or gown.
During an interview on 04/27/21 at 11:04 AM with Licensed Practical Nurse (LPN) #147 confirmed, any staff providing care to a Resident in transmission-based precautions should be wearing PPE, gowns, gloves, mask, and eye protection.
b) Resident #290
An observation on 04/27/21 at 10:59 AM found, Resident #290's catheter bag hanging on a trash can receptacle.
During an interview on 04/27/21 at 11:04 AM with Licensed Practical Nurse (LPN) #147 confirmed, urinary catheter bags should not be hung on a trash can. LPN #147 went in and removed the catheter bag from the trash can.
c) Resident # 65
Facility Policy titled, CPAP/BiPAP cleaning dated, revised 1/20/21
-Clean mask frame daily after use with CPAP cleaning wipe or soap and water. Dry well, Cover with plastic bag or completely enclosed in machine storage when not in use.
Bi-PaP stands for Bilevel Posistive Airway Pressure, this is used in a non-invasive form of therapy for patients suffering from sleep apnea.
During the interviewing process on 04/26/21 at 12:42 PM, Resident #65's Bi-PaP mask was laying on night stand uncovered and not stored in a bag. Occupational Therapy (OT) # 208 verified the Bi-PaP mask was not in a bag and was not in use at the time.
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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 fines on record. Clean compliance history, better than most West Virginia facilities.
- • 39% turnover. Below West Virginia's 48% average. Good staff retention means consistent care.
Concerns
- • 33 deficiencies on record, including 1 serious (caused harm) violation. Ask about corrective actions taken.
- • Grade D (45/100). Below average facility with significant concerns.
Bottom line: Trust Score of 45/100 indicates significant concerns. Thoroughly evaluate alternatives.
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About This Facility
What is Elkins Rehabilitation &'s CMS Rating?
CMS assigns ELKINS REHABILITATION & CARE CENTER an overall rating of 2 out of 5 stars, which is considered below average nationally. Within West Virginia, this rating places the facility higher than 0% of the state's 100 nursing homes. A rating at this level reflects concerns identified through health inspections, staffing assessments, or quality measures that families should carefully consider.
How is Elkins Rehabilitation & Staffed?
CMS rates ELKINS REHABILITATION & CARE CENTER's staffing level at 4 out of 5 stars, which is above average compared to other nursing homes. Staff turnover is 39%, compared to the West Virginia average of 46%. This relatively stable workforce can support continuity of care.
What Have Inspectors Found at Elkins Rehabilitation &?
State health inspectors documented 33 deficiencies at ELKINS REHABILITATION & CARE CENTER during 2021 to 2025. These included: 1 that caused actual resident harm and 32 with potential for harm. Deficiencies causing actual harm indicate documented cases where residents experienced negative health consequences.
Who Owns and Operates Elkins Rehabilitation &?
ELKINS REHABILITATION & CARE CENTER is owned by a non-profit organization. Non-profit facilities reinvest revenue into operations rather than distributing to shareholders. The facility operates independently rather than as part of a larger chain. With 111 certified beds and approximately 101 residents (about 91% occupancy), it is a mid-sized facility located in ELKINS, West Virginia.
How Does Elkins Rehabilitation & Compare to Other West Virginia Nursing Homes?
Compared to the 100 nursing homes in West Virginia, ELKINS REHABILITATION & CARE CENTER's overall rating (2 stars) is below the state average of 2.7, staff turnover (39%) is near the state average of 46%, and health inspection rating (3 stars) is at the national benchmark.
What Should Families Ask When Visiting Elkins Rehabilitation &?
Based on this facility's data, families visiting should ask: "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" "Can I speak with family members of current residents about their experience?"
Is Elkins Rehabilitation & Safe?
Based on CMS inspection data, ELKINS REHABILITATION & CARE 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 2-star overall rating and ranks #100 of 100 nursing homes in West Virginia. While no facility is perfect, families should still ask about staff-to-resident ratios and recent inspection results during their visit.
Do Nurses at Elkins Rehabilitation & Stick Around?
ELKINS REHABILITATION & CARE CENTER has a staff turnover rate of 39%, which is about average for West Virginia nursing homes (state average: 46%). Moderate turnover is common in nursing homes, but families should still ask about staff tenure and how the facility maintains care continuity when employees leave.
Was Elkins Rehabilitation & Ever Fined?
ELKINS REHABILITATION & CARE 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 Elkins Rehabilitation & on Any Federal Watch List?
ELKINS REHABILITATION & CARE 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.