PIERPONT CENTER AT FAIRMONT CAMPUS
For profit - Corporation
120 Beds
GENESIS HEALTHCARE
Data: November 2025
Trust Grade
51/100
#82 of 122 in WV
Photo by Pierpont Center at Fairmont Campus
Photo by Pierpont Center at Fairmont Campus
Photo by Pierpont Center at Fairmont Campus
1 / 5 photos
Last Inspection: March 2024
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
Families considering the Pierpont Center at Fairmont Campus should be aware that it holds a Trust Grade of C, which means it is average and situated in the middle of the pack. It ranks #82 out of 122 nursing homes in West Virginia, placing it in the bottom half, and #4 out of 6 in Marion County, indicating that only two local facilities are rated higher. Unfortunately, the facility's trend is worsening, with reported issues increasing from 2 in 2023 to 23 in 2024. Staffing is relatively stable, with a turnover rate of 29%, significantly better than the state average of 44%, and it has more RN coverage than 86% of facilities, ensuring that qualified staff are available. However, the facility has faced concerns, including inadequate access to residents' personal funds, unclean living areas, and a failure to properly assess staffing needs, which could impact the level of care provided.
- Trust Score
- C
- In West Virginia
- #82/122
- Safety Record
- Low Risk
- Inspections
- Getting Worse
- Staff Stability ✓ Good
- 29% annual turnover. Excellent stability, 19 points below West Virginia's 48% average. Staff who stay learn residents' needs.
- Penalties ○ Average
- $3,250 in fines. Higher than 63% of West Virginia facilities. Some compliance issues.
- Skilled Nurses ✓ Good
- Each resident gets 42 minutes of Registered Nurse (RN) attention daily — more than average for West Virginia. RNs are trained to catch health problems early.
- Violations ⚠ Watch
- 48 deficiencies on record. Higher than average. Multiple issues found across inspections.
51/100
Bottom 33%
No red flags
2 → 23 violations
★★☆☆☆
2.0
Overall Rating
★★☆☆☆
2.0
Staff Levels
★★☆☆☆
2.0
Care Quality
★★☆☆☆
2.0
Inspection Score
↔
Stable
2023: 2 issues
2024: 23 issues
The Good
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Low Staff Turnover (29%) · Staff stability means consistent care
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Full Sprinkler Coverage · Fire safety systems throughout facility
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No fines on record
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Staff turnover is low (29%)
19 points below West Virginia average of 48%
Facility shows strength in staff retention, fire safety.
The Bad
2-Star Overall Rating
Below West Virginia average (2.7)
Below average - review inspection findings carefully
Federal Fines: $3,250
Below median ($33,413)
Minor penalties assessed
Chain: GENESIS HEALTHCARE
Part of a multi-facility chain
Ask about local staffing decisions and management
The Ugly 48 deficiencies on record
Mar 2024
23 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0561
(Tag F0561)
Could have caused harm · This affected 1 resident
Based on observation, resident interview, record review and staff interview, the facility failed to ensure the residents choices were honored in regard to diet. This was true for one (1) of one (1) re...
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Based on observation, resident interview, record review and staff interview, the facility failed to ensure the residents choices were honored in regard to diet. This was true for one (1) of one (1) residents reviewed for choices. Resident identifier: #9. Facility census: 106.
Findings included:
a) Resident #9
On 03/11/24 at 1:39 PM Resident #9 said she is lactose intolerant and today they gave her cheese on her sandwich again. She stated that she picked the cheese off of the grilled ham and cheese sandwich and ate the ham and one slide of the bread. Resident #9 stated she did not want anything else to eat.
Care Plan Review Revealed:
The resident is at risk for dehydration as evidenced by medications (diuretic, laxatives). H
Encourage residents to consume fluids during & between meals.
Offer 1 cup Lactaid milk & 1 cup Cranberry juice at breakfast.
Monitor weight per protocol and report as indicated
Resident is at nutritional risk r/t (related to) dx (diagnosis) of Type 2 Diabetes Mellitus (T2DM), adult failure to thrive (FTT), hypothyroidism, major depressive disorder, Chronic Kidney Disease (CKD) Stage 3B, Congestive Heart Failure (CHF). Significant wt loss over the past 90 days. Is <UBW range of 175-185 lb. R BKA (below knee amputation) w/ AIBW (adjusted ideal body weight) of 122.3 lb. Is 133% AIBW.
Monitor intake at meals; offer alternate choices as needed
Provide Regular/liberalized w/ sugar substitute. Lactose intolerance: prefers Lactaid milk.
A review of the meal ticket on Resident #9's tray listed dislikes which included many dairy products. Ice cream, and cheese. However, it did not include cheese sandwiches.
On 03/12/24 at 2:40 PM, the Director of Nursing (DON) was informed of the information above. She stated she would ensure that all dairies including cheese would be on the meal ticket.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Notification of Changes
(Tag F0580)
Could have caused harm · This affected 1 resident
Based on record review and staff interview, the facility failed to notify the resident's representative in a timely fashion when care was altered. An antibiotic, Amoxicillin, was ordered for Resident ...
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Based on record review and staff interview, the facility failed to notify the resident's representative in a timely fashion when care was altered. An antibiotic, Amoxicillin, was ordered for Resident #54 on 03/08/24 but the Resident Representative was not informed of the new medication order. The facility's failure to notify the resident's representative of a change in condition was true for one (1) of 29 residents sampled in the Long-Term Care Survey Process. Resident Identifier: #54. Facility Census: 106.
Findings included:
a) Resident #54
A record review, completed on 03/11/24 at 9:11 PM, revealed:
-A 03/08/25 at 00:00 Encounter note which stated, Patient requested to be seen by staff for right sided facial swelling. The patient is unable to provide information, family is not available, and prior charts do not include family history. Diagnosis and Assessment: Sialectasia of parotid gland (a condition resulting from duct obstruction of the parotid or submandibular glands associated with pain and swelling) and Abscess (abscesses occur when an area of tissue becomes infected and the body's immune system tries to fight and contain it.)
-A physician order, dated 03/08/24, for Amoxicillin. Instructions directed to give one (1) tablet by mouth every 12 hours for dental infection for seven (7) Days.
-A 03/09/24 at 19:35 (7:35 PM) General note which stated, Resident has swelling to the left jaw area. Resident is being treated with antibiotics. The swelling appears to be decreasing but the resident has dark purple bruising to the left jaw area and neck. Will report findings to MD (doctor).
-There was no evidence in the medical record that Resident #54's representative was notified of the new medication or the dental abscess.
During a telephone interview, on 03/12/24 at 8:34 AM, resident's Medical Power of Attorney (MPOA) expressed she had visited the previous day and was concerned that her mother had bruising on her cheek and down her neck but had to leave before having the opportunity to speak to a nurse. The MPOA was unaware resident had a tooth infection and was on an antibiotic.
The Director of Nursing, on 03/12/24 at 9:51 AM, reported the facility had no evidence the MPOA had been notified of the new order for Amoxicillin to treat the identified dental abscess.
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CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0583
(Tag F0583)
Could have caused harm · This affected 1 resident
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Based on observation and staff interview, the facility failed to ensure a resident's right for privacy and confidentiality. Resident #95 had three (3) signs regarding personal care information poste...
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Based on observation and staff interview, the facility failed to ensure a resident's right for privacy and confidentiality. Resident #95 had three (3) signs regarding personal care information posted throughout her room. Resident identifier: #95. Facility census: 106.
Findings included:
a) Resident #95
During a visit on 03/11/24 at 1:15 PM, the following three (3) typed signs were on display in Resident #95's room:
-I do not get up alone.
-I get help for the bathroom.
-No straws.
A subsequent record review, on 03/11/24 at 3:02 PM, revealed Resident #95 lacked decision-making capacity and had a family member serving as her Medical Power of Attorney (MPOA).
During a telephone interview on 03/11/24 at 7:59 PM, Resident #95's MPOA stated, The nursing staff must've done that. It wasn't a request from the family.
On 03/12/24 at 10:55 AM, the Social Worker #145 confirmed the signs in the resident's room were visible to others and included clinical and/or personal information on how to provide appropriate care to the resident. The Social Worker also confirmed the need for the signage to be in the resident's room was not care planned.
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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 record review and staff interview, the facility failed to ensure a resident fall resulting in serious bodily injury was reported in a timely manner to the appropriate state agencies. This f...
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Based on record review and staff interview, the facility failed to ensure a resident fall resulting in serious bodily injury was reported in a timely manner to the appropriate state agencies. This failed practice was true for one (1) of two (2) residents reviewed for falls during the Long-Term Care Survey Process. Resident identifier: #29. Facility Census: 106.
Findings included:
a) Resident #29
A record review, completed on 03/11/24 at 8:36 PM, revealed the following:
A General Note, dated 11/22/2023 at 8:56 PM, indicated a resident had fallen in her bathroom. The resident was alert and verbal. The resident complained of right arm pain and left hip pain. Resident's physician was notified, and the resident was sent to the hospital for further evaluation.
Another General Note, dated 11/23/2023 at 2:19 AM, documented, Resident returned from ER (emergency room) with diagnosis of facial contusion, cervical sprain, contusion of left hip, skin tear of right top hand, and nasal bone fracture.
Review of the facility's reportable log, completed on 03/12/24 at 1:25 PM, revealed the fall with serious bodily injury was not reported within two (2) hours of the facility having knowledge of the nasal bone fracture. The reportable log indicated it was not reported until 11/27/23, four (4) days after the facility had knowledge of the serious bodily injury.
During an interview on 03/12/24 at 2:10 PM, Social Worker #145 communicated the facility had not reported the fall with major injury incident in a timely fashion because both social workers had been off over the Thanksgiving Holiday.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Transfer Notice
(Tag F0623)
Could have caused harm · This affected 1 resident
Based on medical record review and staff interview, the facility failed to provide the Notice of Transfer to the State Ombudsman. This was discovered for one (1) of one (1) residents reviewed for a tr...
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Based on medical record review and staff interview, the facility failed to provide the Notice of Transfer to the State Ombudsman. This was discovered for one (1) of one (1) residents reviewed for a transfer/discharge during the Long-term Care Survey Process. Resident #105 was transferred to another long-term care facility and no notice of transfer was sent to the State Ombudsman. Resident identifier #105. Facility census: 106.
Findings included:
a) Resident #105
A medical record review on 03/13/24 revealed the notice of transfer was not sent to the State Ombudsman for Resident #105 when transferred to another facility on 12/12/23.
In an interview with the Licensed Social Worker (LSW) on 03/13/24 at 9:45 AM, verified the Notice of Transfer was not sent to the State Ombudsman regarding the transfer for Resident #105, who was transferred to another long-term care facility.
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CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
PASARR Coordination
(Tag F0644)
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 update the PASARR for a resident that had a diagnosis of a ...
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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 update the PASARR for a resident that had a diagnosis of a serious mental disorder after admission to the facility. This was true for one (1) of ten (10) residents reviewed for Pre admission Screening and Resident Review (PASARRs) during the long-term care survey process. Resident Identifier: #6. Facility census: 106.
Findings included:
a) Resident #6
At approximately 9:00 AM on 03/12/24, a record review was conducted for Resident #6. It revealed that Resident #6 was admitted to the facility on [DATE] and was diagnosed with schizophrenia on 09/07/19 and the resident's PASARR was not updated to reflect the diagnosis.
According to the PASARR for Resident #6, seizure disorder is marked as a current diagnosis, however, schizophrenia is not.
At approximately 12:00 PM on 03/13/24, the Director of Nursing was notified and acknowledged the missing diagnosis from Resident #6's PASARR.
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CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
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Based on record review and staff interview, the failed to develop a comprehensive person-centered care plan for the area of discharge planning. This was true for one (1) of one (1) resident care pla...
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Based on record review and staff interview, the failed to develop a comprehensive person-centered care plan for the area of discharge planning. This was true for one (1) of one (1) resident care plans reviewed for discharge planning during the Long-Term Care Survey Process. The care plan for Resident #105 was not developed for discharge planning. Resident identifier: #105. Facility census: 106.
Findings included:
a) Resident #105
A medical record review on 03/13/24, revealed Resident #105 was discharged on 12/12/23. The comprehensive person-centered care plan had not been developed for any discharge planning for Resident #105.
In an interview with the Licensed Social Worker (LSW) on 03/13/24 at 9:20 AM, verified the care plan had not been developed for discharge planning for Resident #105.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0657
(Tag F0657)
Could have caused harm · This affected 1 resident
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Based on record review and staff interview, the facility failed to revise a person-centered comprehensive care plan. This was true for one (1) of four (4) resident care plans reviewed for urinary ca...
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Based on record review and staff interview, the facility failed to revise a person-centered comprehensive care plan. This was true for one (1) of four (4) resident care plans reviewed for urinary catheter care during the Long-Term Care Survey Process (LTCSP). The care plan for Resident #84 had not been revised when the urinary catheter was removed. Resident identifier: #84 Facility census: 106.
Findings included:
a) Resident #84
A medical record review on 03/13/24 indicated Resident #84 had an indwelling urinary catheter removed on 02/05/24. The care plan had not been revised to indicate the urinary catheter had been removed for Resident #84.
During an interview with the Director of Nursing (DON) on 03/13/24 at 11:54 AM, verified the care plan had not been revised when the urinary catheter had been removed on 02/05/24 for Resident #84.
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CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on record review and resident and staff interview, the facility failed to ensure a resident who is unable to carry out a...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on record review and resident and staff interview, the facility failed to ensure a resident who is unable to carry out activities of daily living (ADL) received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. This was true for one (1) of one (1) residents reviewed for ADL care during the long-term care survey process. Resident Identifier: #38. Facility census: 106.
Findings included:
a) Resident #38
At approximately 1:41 PM on 03/11/24, an interview was conducted with Resident #38. During the interview, the resident stated they had been at the facility for a couple of weeks and had only received bed baths. The resident said, I would really like to get in the shower to get my hair washed.
At approximately 1:30 PM on 03/12/24, records were obtained from the Director of Nursing (DON) pertaining to Resident #38's showers. The DON stated Resident #38 was to receive baths on Wednesdays and Saturdays.
Upon review of the records obtained from the DON, it was revealed Resident #38 was documented as receiving showers, since admission on [DATE], on 03/05/24 at 10:59 PM, 03/06/24 at 12:54 AM, 03/07/24 at 1:32 PM, and 03/11/24 at 10:59 PM.
At approximately 1:40 PM on 03/12/24, Resident #38 was interviewed, along with Licensed Practical Nurse (LPN) #140, in which the resident confirmed a preference for showers, and wanted their hair washed, but had only received bed baths up to this point.
At approximately 1:51 PM on 03/12/24, LPN #140 was interviewed concerning the documentation stating Resident #38 was given showers as opposed to the bed baths they received. LPN #140 confirmed Resident #38 had received bed baths instead of showers on the listed dates.
LPN #140 stated I usually just check to see if my aides have completed their documentation, I didn't know there was even a place on there for them to choose between showers and bed baths. LPN #140 stated, We have had a ton of problems with documentation from our aides. LPN asked who the Nurse Aides were that documented showers were given instead of bed baths. LPN #140 was notified that Nurse Aide (NA) #11 and NA #160 documented showers instead of bed baths, to which they replied That explains a lot then.
At approximately 12:00 PM on 03/13/24, the Director of Nursing (DON) was notified and acknowledged bed baths were given over the preferred showers, and that Resident #38 had not had their hair washed.
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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
Based on observation and staff interview, the facility failed to ensure the resident environment remained free of accident hazards over which it had control. A prescribed medication was found on the f...
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Based on observation and staff interview, the facility failed to ensure the resident environment remained free of accident hazards over which it had control. A prescribed medication was found on the floor in Resident #43's room. This was a random opportunity for discovery. Resident Identifier: #43. Facility census: 106.
Findings included:
a) Resident #43
During an in-room visit on 03/11/24 at 12:14 PM, an unidentified white, round, scored (having a line down the middle to make it easier to split) pill was found on the floor in front of Resident #43's bed. On 03/11/24 at 12:17 PM, Social Worker #145 confirmed the pill was on the floor
During an interview, on 03/11/24 at 12:20 PM, LPN #16 identified the pill as Amiodarone and stated resident received the medication for AFib (atrial fibrillation, which is a type of arrhythmia, or abnormal heartbeat.)
According to Healthline, (https://www.healthline.com/health/amiodarone-oral-tablet), the medication Amiodarone has boxed warnings. A boxed warning is the most serious warning from the Food and Drug Administration (FDA). It alerts doctors and patients about drug effects that may be dangerous.
-Amiodarone should only be used if the patient has a life threatening arrhythmia or irregular heart rate.
-If a patient needs to be treated with Amiodarone for an irregular heart rate, they need to be admitted into the hospital to get the first dose. This is to make sure that Amiodarone is given to the patient safely and it's effective.
The Director of Nursing (DON), on 03/12/24 at 10:50 AM, reported she had been made aware of the medication being found on the floor in Resident #43's room. The DON stated it is a professional standard of practice for nurses to be certain all medications have been swallowed before documenting successful administration on the MAR (medication administration record) and walking away.
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CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Medication Errors
(Tag F0758)
Could have caused harm · This affected 1 resident
.Based on staff interview and record review, the facility failed to ensure all residents were free from unnecessary psychotropic medications used for refusal of care, no rationale provided for continu...
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.Based on staff interview and record review, the facility failed to ensure all residents were free from unnecessary psychotropic medications used for refusal of care, no rationale provided for continuing to use a psychotropic PRN (take as needed) medication used longer than 14 days. This was true for two (2) out of five (5) reviewed for unnecessary medication. Resident identifiers: #5. and #91. Facility census 106.
Findings included:
a) Resident #5
While reviewing orders for an antipsychotic medication Abilify it was discovered that Abilify was ordered on 01/07/2024.
The order was written as typed below:
Abilify Oral Tablet 5 MG (Aripiprazole)
Give 5 mg by mouth one time a day for antipsychotic Target behavior: refusal of care, combative, aggression.
On 03/13/24 at 11:24 AM the Director of Nursing (DON) was shown the above order. DON stated, We do not give medications for refusal of care.
Medical records show Resident #5 was ordered Xanax 0.25 mg 1 tablet Q12 hours as needed for anxiety on 01/07/24.
On 03/13/24 at 11:24 AM, the DON could not provide a rationale for having an order for a PRN (as needed) for more than 14 days.
At the close of this survey no additional information was available.
b) Resident #91
During record review for Resident #91 on 03/11/24 at approximately 12:15 PM, it was discovered the resident had the following order beginning on 01/25/24: Abilify Oral Tablet 10 MG (Aripiprazole) Give one tablet by mouth at bedtime for mood target behavior: refusal of care.
At approximately 12:00 PM on 03/11/24, Resident #91 was observed sleeping in the bed.
At approximately 10:15 AM on 03/12/24, Resident #91 was observed sleeping in the bed.
At approximately 12:00 PM on 03/12/24, Resident #91 was observed sleeping in the bed.
At approximately 12:38 PM on 03/12/24, Resident #91 was observed sleeping in the wheelchair, with their lunch tray on the bedside table, with the lid still on the tray.
At approximately 10:10 AM on 03/13/24, Resident #91 was observed sleeping in the bed.
At approximately 12:20 PM on 03/12/24, the Medication Administration Record (MAR) for February and March of 2024 was obtained for Resident #91. The MAR revealed that Resident #91 received Abilify every day in February and, so far, every day in March.
On the MAR for Resident #91, for the question Is resident free from side effects of psychotherapeutic medications? Yes or No Yes was marked for every day from February through March 11, 2024, except for 03/02/24 and 03/03/24, which are marked NA for not applicable.
At approximately 12:00 PM on 03/13/24, the Director of Nursing (DON) was notified and acknowledged the order for Abilify for refusal of care, the times Resident #91 was witnessed sleeping, and the documentation of Not Applicable on days where they were given the medication and were to be monitored for side effects.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0810
(Tag F0810)
Could have caused harm · This affected 1 resident
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Based on observation and staff interview, the facility failed to provide appropriate assistive devices to residents who need them to maintain or improve their ability to eat independently. This was ...
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Based on observation and staff interview, the facility failed to provide appropriate assistive devices to residents who need them to maintain or improve their ability to eat independently. This was a random opportunity for discovery. Resident identifier: #37. Facility census: 106.
Findings Included:
a) Resident #37
An observation on 03/11/24 at 12:36 PM, noon meal, found Resident #37 having issues drinking her milk.
Review on 03/11/24 of Resident #37's tray card revealed regular water in a spout cup.
During an interview on 03/11/24 at 12:40 PM, Nurse Aide #67 stated that Resident #37 doesn't like the spout cup, so they don't provide it to her.
A record review on 03/12/24 at 9:12 AM revealed a care plan:
Focus:
- Resident was dependent for ADL care in bathing, grooming, personal hygiene, dressing, eating, bed mobility, transfer, locomotion, toileting related to: Paralysis affecting left extremities.
Goals:
Residents ADL care needs will be anticipated and met throughout the next review period.
Intervention:
The resident must use a proval cup (blue handles) for all liquids.
Continued review revealed a diet order:
- Dysphagia Advanced texture with start date 06/13/23
During an interview on 03/13/24 at 12:51 PM the Corporate Nurse confirmed that Resident #37 needed the blue handled cup.
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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** .
Based on record review and resident and staff interview, the facility failed to maintain accurate and complete medical records...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on record review and resident and staff interview, the facility failed to maintain accurate and complete medical records by failing to accurately record side effects of psychotropic medications, and not accurately documenting the type of ADL care provided to dependent residents. This was true for two (2) of two (2) residents reviewed for documentation during the long-term care survey process. Resident identifiers: #38, #91. Facility census: 106.
Findings included:
a) Resident #38
At approximately 1:41 PM on 03/11/24, an interview was conducted with Resident #38. During the interview, the resident stated they had been at the facility for a couple of weeks and only received bed baths. The resident said, I would really like to get in the shower to get my hair washed.
At approximately 1:30 PM on 03/12/24, records were obtained from the Director of Nursing (DON) pertaining to Resident #38's showers. The DON stated Resident #38 was to receive baths on Wednesdays and Saturdays.
Upon review of the records obtained from the DON, it was revealed Resident #38 was documented as receiving showers, since admission on [DATE], on 03/05/24 at 10:59 PM, 03/06/24 at 12:54 AM, 03/07/24 at 1:32 PM, and 03/11/24 at 10:59 PM.
At approximately 1:40 PM on 03/12/24, Resident #38 was interviewed, along with Licensed Practical Nurse (LPN) #140. At this time the resident confirmed a preference for showers, and wanted their hair washed. The resident commented only bed baths had been received up to this point.
At approximately 1:51 PM on 03/12/24, LPN #140 was interviewed concerning the documentation that revealed Resident #38 was given showers as opposed to the bed baths they received. LPN #140 confirmed Resident #38 had received bed baths instead of showers on the listed dates. LPN #140 stated I usually just check to see if my aides have completed their documentation, I didn't know there was even a place on there for them to choose between showers and bed baths. LPN #140 stated, We have had a ton of problems with documentation from our aides. LPN was asked who the Nurse Aides (NAs( ere that documented showers were given instead of bed baths. LPN #140 was notified that NA #11 and NA #160 documented showers instead of bed baths, to which LPN #140 replied, That explains a lot then.
At approximately 12:00 PM on 03/13/24, the Director of Nursing (DON) was notified and acknowledged bed baths were given over the preferred showers, and that Resident #38 had not had their hair washed.
B) Resident #91
During record review for Resident #91 on 03/11/24 at approximately 12:15 PM, it was discovered the resident had the following order beginning on 01/25/24: Abilify Oral Tablet 10 MG (Aripiprazole) Give one tablet by mouth at bedtime for mood target behavior: refusal of care.
At approximately 12:00 PM on 03/11/24, Resident #91 was observed sleeping in their bed.
At approximately 10:15 AM on 03/12/24, Resident #91 was observed sleeping in their bed.
At approximately 12:00 PM on 03/12/24, Resident #91 was observed sleeping in their bed.
At approximately 12:38 PM on 03/12/24, Resident #91 was observed sleeping in their wheelchair, with their lunch tray on the bedside table, with the lid still on the tray.
At approximately 10:10 AM on 03/13/24, Resident #91 was observed sleeping in their bed.
At approximately 12:20 PM on 03/12/24, the Medication Administration Record (MAR) for February and March of 2024 was obtained for Resident #91. The MAR review revealed that Resident #91 received Abilify every day in February and, so far, every day in March.
On the MAR for Resident #91, the question Is resident free from side effects of psychotherapeutic medications? Yes or No
Yes was marked for every day from February through March 11, 2024, except for 03/02/24 and 03/03/24, which are marked NA for not applicable.
At approximately 12:00 PM on 03/13/24, the DON was notified and acknowledged the order for Abilify for refusal of care, the times Resident #91 was witnessed sleeping, and the documentation of Not Applicable on days where they were given the medication and were to be monitored for side effects.
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CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0567
(Tag F0567)
Could have caused harm · This affected multiple residents
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Based on resident and staff interviews, the facility failed to ensure each resident had reasonable and ready access to their personal funds held by the facility. This was true for four (4) out of 11...
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Based on resident and staff interviews, the facility failed to ensure each resident had reasonable and ready access to their personal funds held by the facility. This was true for four (4) out of 11 residents that were interviewed during the resident council meeting. This had the potential to affect more than a limited number of residents. Facility census: 106.
Findings included:
a) Resident Council
At approximately 3:00 PM on 03/12/24, a resident council meeting was held at the facility. During that meeting, four (4) residents in attendance expressed concerns about personal funds held by the facility. Residents stated that obtaining money on the evenings and weekends was difficult, with one resident stating I'm not even sure we can get the money after they leave the offices for the day, so the weekend wouldn't be possible. Another resident stated outings had to be canceled the day of the event, on more than one occasion, because the facility did not have money for the residents to take.
At approximately 12:50 PM on 03/13/24, an interview was conducted with Receptionist #107 regarding personal funds for the residents. Receptionist #107 stated they handled disbursement of funds along with the business office. Receptionist #107 stated the facility kept an emergency fund in the amount of $50 in the assisted living portion of the facility for residents to access on nights and weekends. Receptionist #107 stated residents would be limited in what they could obtain on nights and weekends, and that staff would have to ration the money in case other residents wanted money out of the emergency fund. Receptionist #107 stated all staff were aware of the emergency fund and how to access it.
Regarding canceled outings due to the facility not being able to provide residents with their personal funds, Receptionist #107 stated, There was a time a while ago there wasn't enough money for residents to go on the outing, so it had to be canceled. I'm not sure why there wasn't enough. As far as I know, there have been a couple different times this has happened.
At approximately 12:57 PM on 03/13/24, an interview was conducted with Licensed Practical Nurse (LPN) #140 and Licensed Practical Nurse (LPN) #20 concerning resident funds. Both said they were there until at least 7:00 PM, and sometimes later if they were mandated. LPN #140 stated, I'm not going to lie, I have no idea how residents would get money in the evenings or weekends after the people leave the offices up front. I would guess they would have to wait until the next day, or if it is a weekend, they would have to wait until Monday. LPN #20 stated, I would tell them they would have to either wait until the next day, or Monday if it were a weekend, to get their money, if there wasn't anyone in the offices up front.
At approximately 1:00 PM on 03/13/24, an interview was conducted with Registered Nurse (RN) #28 and LPN #37 concerning resident funds. LPN #37 stated, I have no idea what to do if a resident wants money on evenings or weekends. RN #28 stated, We are not allowed to handle resident funds. They would probably have to wait until the next day or Monday when the staff were back in the offices. We have a nurse on call that we could always call during those times and find out what to do if they asked for money, but as far as I know they would have to wait because we can't handle their money.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview and staff interview, the facility failed to ensure the living areas for residents were ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview and staff interview, the facility failed to ensure the living areas for residents were clean, safe, and sanitary; failed to ensure furniture was in good repair; failed to clean and/or change the P-Tac (packaged terminal air conditioner) vents (filters on the heat and air conditioners that are in each room.); and leaving a large amount of transparent type on a resident wheelchair. Resident identifiers: #35, #90. The facility census 106.
Findings included:
a) P-Tac vents
During a tour on 03/12/24 at 2:34 PM of Rooms #301, #302, #303, #304, and #305 it was discovered the P-Tac vents were heavily soiled with a thick layer of debris.
The above findings were verified on 03/12/24 at 2:54 PM with Maintenance Helper (MH) #43. MH #43 said the P-Tacs should be cleaned or replaced monthly. He went on to say it should be documentation of when it was last done on a form, he referred to Direct Supplies Tell MH #43 did not provide this documentation at the close of the survey. According to the records provided it was last marked as done on 01/12/24.
b) Poor quality furniture
An interview with the Administrator (NHA) on 03/11/24 at 1:05 PM two nightstands in the hallway on top of a bed pointed out the furniture was peeling exposing particle boards and therefore could not be cleaned properly. The NHA stated the facility had more and would replace it with better quality furniture.
On 03/13/24 at 1:04 PM it was pointed out to the NHA the same two (2) nightstands that were previously in the hallway on top of a bed were now in room [ROOM NUMBER] being used along with two other nightstands. All four (4) had exposed particle board.
Upon further observations on 03/13/24 at 2:22 PM it was found the following rooms also had nightstands in poor condition in room [ROOM NUMBER], #205, #306, #305, and 321.
On 03/13/24 at 2:35 PM the above findings were verified by the Director of Nursing.
c) Damaged ceilings
On 03/11/24 11:18 AM it was discovered room [ROOM NUMBER] had a leaking ceiling. Resident #90 said it has been an ongoing problem for two (2) months. There was dark brown staining on the ceiling above the windows and that was the length of the wall. It was approximately two (2) feet wide.
There was a large plastic barrel trash can and two gray basins on a table to catch rainwater.
Resident #90 was saying she has looked at the stains so long she sees a duck swimming to a log and a big bird flying in the stain. Resident #90 said they (maintenance) have put tar on the roof several times, but it still leaks.
On 03/12/24 at 3:02 PM Housekeeping Aide (HA) stated that Resident #22 was just now moved to another room, but her clothes and other belongings were still in there.
On 03/12/24 at 3:04 PM it was discovered room [ROOM NUMBER] had a leaking ceiling and the plaster had fallen from the ceiling. The ceiling was over 70 percent discolored. The discolored ceiling had rings of brown staining and a black substance showing in many places. The missing plaster and bowed exposed sheet rock was in the middle of the room. There were tall black trash cans in the middle of the floor with bath blankets under them that also had brown rings, along with chunks of plaster that had fallen from the ceiling scattered around the room. The room had a very strong odor of musky mildew.
On 03/12/24 at 3:37 PM MH #43 and the District Maintenance Manager (DMM) #158 arrived at room [ROOM NUMBER]. They were asked when did the leak start? MH #43 state on Saturday 03/09/24. MH #43 was informed that Resident #90 that is in room [ROOM NUMBER] said her ceiling had been leaking for more than two (2) months.
On 03/13/24 at 8:20 AM MH #43 provided a work order that was entered on 01/28/24 by the NHA for room [ROOM NUMBER]. There was not any other evidence that any other staff had informed the maintenance department of 301 was leaking as well.
Resident #22 refused to be interviewed on 03/11/24 at 12:09 PM and began yelling. Therefore, not wanting to upset the resident any further, no statement was obtained.
On 03/12/24 at 4:10 PM the NHA was asked when he was made aware of the condition of room [ROOM NUMBER]. The NHA stated he was told there was a leak in the room on Saturday 03/09/24. He was asked if Resident #22 should have been moved to a safer room on Saturday? The Administrator agreed the room had a very pungent odor. The large trash cans and stained peeling ceiling was also pointed out.
On 03/12/24 at 4:15 PM the NHA was shown room [ROOM NUMBER] as well. Resident #90 was in her room and spoke to the NHA.
On 03/13/24 at 8:20 AM the NHA informed this surveyor that Resident #90 was also moved to another room and the Maintenance crew are currently removing the ceiling in room [ROOM NUMBER] and 301 will be started on after 303 was completed.
d) Wheelchair armrest
On 03/11/24 at 12:22 PM, Resident #35 was seen in the hallway in his wheelchair. It was noted on the right armrest there was a large amount of tape clear (Office tape) wrapped around the armrest holding a cup holder to the armrest. Resident #35 stated one of the aides helped him put the cup holder on his wheelchair. Licensed Practical Nurse (LPN) #16 stated she would put a work order in to have it properly attached.
On 03/12/24 at 2:06 PM, Cooperate Nurse #157 was shown the tape was still hanging off of the armrest.
On 03/13/24 at 10:20 AM Resident #35 was in his wheelchair and was very happy about the tape not being on his wheelchair and his cup hold was now attached very securely.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0605
(Tag F0605)
Could have caused harm · This affected multiple residents
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Based on staff interview and record review the facility failed to ensure all residents were free from unnecessary medication psychotropic medications used for refusal of care. This was true for two ...
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Based on staff interview and record review the facility failed to ensure all residents were free from unnecessary medication psychotropic medications used for refusal of care. This was true for two (2) out of five (5) reviewed for unnecessary medication. Resident identifiers: #5. and #91. Facility census 106.
Findings included:
a) Resident #5
While reviewing orders for an antipsychotic named Abilify. It was discovered that Abilify was ordered on 01/07/2024.
The order was written as typed below:
Abilify Oral Tablet 5 MG (Aripiprazole) Give 5 mg (milligram) by mouth one time a day for antipsychotic Target behavior: refusal of care, combative, aggression.
On 03/13/24 at 11:24 AM Director of Nursing (DON) was shown the above order. DON stated, We do not give medications for refusal of care.
b) Resident #91
During record review for Resident #91 on 03/11/24 at approximately 12:15 PM, it was discovered the resident had the following order beginning on 01/25/24.
Abilify Oral Tablet 10 MG (Aripiprazole) Give one tablet by mouth at bedtime for mood target behavior: refusal of care.
At approximately 12:00 PM on 03/11/24, Resident #91 was observed sleeping in the bed.
At approximately 10:15 AM on 03/12/24, Resident #91 was observed sleeping in the bed.
At approximately 12:00 PM on 03/12/24, Resident #91 was observed sleeping in the bed.
At approximately 12:38 PM on 03/12/24, Resident #91 was observed sleeping in the wheelchair, with their lunch tray on the bedside table, with the lid still on the tray.
At approximately 10:10 AM on 03/13/24, Resident #91 was observed sleeping in the bed.
At approximately 12:20 PM on 03/12/24, the Medication Administration Record (MAR) for February and March of 2024 was obtained for Resident #91. The MAR stated that Resident #91 received Abilify every day in February and, so far, every day in March.
On the MAR for Resident #91, for the question Is resident free from side effects of psychotherapeutic medications? Yes or No Yes is marked for every day from February through March 11, 2024, except for 03/02/24 and 03/03/24, which are marked NA for not applicable.
At approximately 12:00 PM on 03/13/24, the Director of Nursing (DON) was notified and acknowledged the order for Abilify for refusal of care, the times Resident #91 was witnessed sleeping, and the documentation of Not Applicable on days where they were given the medication and were to be monitored for side effects.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0645
(Tag F0645)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on record review and staff interview, the facility failed to update the Pre admission Screening and Resident Review (PAS...
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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 update the Pre admission Screening and Resident Review (PASRR) for a resident that was diagnosed with a serious mental disorder upon admission to the facility. This was true for nine (9) of ten (10) residents reviewed for Preadmission Screening and Resident Review (PASARRs) during the long-term care survey process. Resident Identifiers: #82, #38, #6, #32, #29, #37, #102, #77. Facility census:106.
Findings included:
a) Resident #82
At approximately 9:00 AM on 03/12/24, a record review was conducted for Resident #82. It was revealed that Resident #82 was admitted to the facility on [DATE] with a diagnosis of major depressive disorder.
According to the PASRR for Resident #82, major depressive disorder was not marked.
At approximately 12:00 PM on 03/13/24, the Director of Nursing (DON) was notified and acknowledged the missing diagnosis from Resident #82's PASRR.
b) Resident #38
At approximately 9:00 AM on 03/12/24, a record review was conducted for Resident #38. It revealed that Resident #38 was admitted to the facility on [DATE] with a diagnosis of major depressive disorder.
A review of the PASRR for Resident #38 revealed major depressive disorder was not marked.
At approximately 12:00 PM on 03/13/24, the DON was notified and acknowledged the missing diagnosis from Resident #38's PASRR.
c) Resident #6
At approximately 9:00 AM on 03/12/24, a record review was conducted for Resident #6. It revealed that Resident #6 was admitted to the facility on [DATE] with a diagnosis of major depressive disorder.
According to the PASRR for Resident #6, seizure disorder is marked as a current diagnosis, however, major depression is not.
At approximately 12:00 PM on 03/13/24, the Director of Nursing was notified and acknowledged the missing diagnosis from Resident #6's PASRR.
d) Resident #32
A record review, completed on 03/11/24 at 3:02 PM, revealed Resident #32 was admitted to the facility on [DATE] with a bipolar diagnosis.
Further record review, completed on 03/12/24 at 9:49 AM, revealed two (2) PASRRs on file:
-Resident's admitting PASRR, dated 02/28/23, did not identify Resident #32 had a bipolar diagnosis on Section III, Question 30 of the PASRR. This PASRR indicated no Level II was required.
-Resident's readmission PASRR, dated 04/24/23, also failed to identify Resident #32 had a bipolar diagnosis on Section III, Question 30 of the PASRR. This PASRR indicated no Level II was required.
During an interview on 03/12/24 at 10:30 AM, an interview with Social Worker #145 acknowledged neither PASARR identified the resident's bipolar diagnosis. The Social Worker added, We will complete a new one.
e) Resident #29
A record review, completed on 03/11/24 at 2:57 PM, revealed Resident #29 was admitted to the facility on [DATE] with a diagnosis of bipolar and a major depressive disorder.
Further record review, completed on 03/12/24 at 12:00 PM, revealed two (2) PASRR evaluations file:
Resident's admitting PASRR, dated 07/21/23, did not identify Resident #29 had bipolar diagnosis or a major depressive disorder on Section III, Question 30 of the PASRR. This PASRR indicated no Level II was required. This PASRR indicated there was a possibility the resident may be able to return home.
The facility completed another PASRR on 09/31/23 to indicate the physician did not feel the resident would be able to return home. Again, this PASRR did not identify Resident #29 had a bipolar diagnosis or a major depressive disorder diagnosis on Section III, Question 30 of the PASRR. This PASRR indicated no Level II was required.
During an interview on 03/12/24 at 12:25 PM, Social Worker #14 confirmed both PASRR evaluations on file failed to identify the resident's bipolar and major depression diagnoses. The Social Worker added, We will work on submitting a new one.
f) Resident #37
On 03/12/24, a record review of the resident's electronic medical record (EMR), the resident's most recent PAS, dated 02/22/18, indicated no level II not required. Section lll #30 MI/MR Assessment indicated no current diagnosis of Psychosis.
The record also revealed the resident received a diagnosis of Psychosis on 07/19/18 but did not receive a new PAS to address whether or not specialized services were needed.
On 03/13/24 at 12:55 PM the DON verified Resident #37's PAS did not reveal her diagnosis of Psychosis. The DON confirmed a new PASRR was not completed.
g) Resident #102
On 03/12/24, a record review of the resident's electronic medical record (EMR), the resident's most recent PASARR, dated 02/16/24, indicated no level II not required. Section lll #30 MI/MR Assessment indicated no current diagnosis.
The record also revealed the resident had a diagnosis of Bipolar on admission [DATE] but did not receive a new PASRR to address whether or not specialized services were needed.
On 03/13/24 at 12:55 PM the DON verified Resident #102's PASRR did not reveal the diagnosis of bipolar disorder. The DON confirmed a new PASRR was not completed.
h) Resident #77
A record review on 03/13/24, revealed Resident #77 had an admitting diagnosis of bipolar on 05/12/23. A PASRR, dated 11/01/23, did not identify Resident #77 had a bipolar diagnosis in Section III, Question 30. Further record review indicated a new PASRR had not been completed to identify the resident's bipolar diagnosis and to address whether any specialized services were required.
During an interview on 03/13/24 at 12:20 PM, the DON acknowledged the PASRR completed on 11/01/23 failed to identify the resident's bipolar diagnosis and no new PASRR had been completed to reflect the bipolar diagnosis.
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CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected multiple residents
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Based on record review and staff interview, the facility failed to provide information and/or offer the Respiratory Syncytial Virus (RSV) immunization per recommendation of the CDC in a timely manne...
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Based on record review and staff interview, the facility failed to provide information and/or offer the Respiratory Syncytial Virus (RSV) immunization per recommendation of the CDC in a timely manner and failed to follow a physician's order regarding Insulin. This failed practice had the potential to affect more than a limited number of residents who currently reside in the facility. Facility census 106.
Findings included:
a) RSV immunization
During a review of the facility documents regarding immunization it was determined that zero (0) out of 106 residents had been provided educational information about the risk and benefits of receiving the RSV vaccination.
On 03/13/24 at 1:25 PM, the Infection Preventionist (IP) stated she had not offered the RSV vaccine. She stated that the facility did not offer the RSV vaccine.
b) The Centers for Disease Control and Prevention (CDC)
Respiratory Syncytial virus, or RSV, is a common respiratory virus that usually causes mild, cold-like symptoms. Most people recover in a week or two, but RSV can be serious. Infants and older adults are more likely to develop severe RSV and need hospitalization. Vaccines are available to protect older adults from severe RSV. Monoclonal antibody products are available to protect infants and young children from severe RSV.
CDC recommends RSV vaccines to protect adults ages 60 and older from severe RSV, using shared clinical decision-making.
According to the CDC the RSV vaccine was made available in early August of 2023.
In general, simultaneous administration of vaccines remains a best practice. Providers should continue to simultaneously administer the vaccines for which a patient is eligible, including COVID-19, influenza, and pneumococcal vaccines. Simultaneous administration of the RSV vaccine with other vaccines for older adults is also acceptable. When deciding whether to simultaneously administer other vaccines with RSV vaccine on the same day, providers should consider whether the patient is up to date with recommendations for currently recommended vaccines, the feasibility of administering additional vaccine doses later, risk for acquiring vaccine-preventable disease, vaccine reactogenicity profiles, and patient preferences.
The Above information was taken from the website: Centers for Disease Control and Prevention (.gov)
b) Resident #95
On 03/11/24 at 8:05 PM, an electronic medical record review was completed. There was an order for Resident #95 to receive insulin on a sliding scale. The term sliding scare refers to the progressive increase in doses, based on predefined blood glucose ranges.
The physician order outlined the following:
NOVOLOG FLEXPEN 100/ML INSULIN PEN
Inject as per sliding scale, if
200 - 250 = 2 units;
251 - 300 = 4 units;
301 - 350 = 6 units;
351 - 400 = 8 units
Inject subcutaneously before meals and at bedtime for DM
If Blood Sugar above 400 notify MD
Start Date 10/07/2023 at 6:30 AM
Review of the October 2023, November 2023, and December 2023 Medication Administration Records (MARs) revealed the following dates and times where nursing failed to obtain blood glucose levels, leaving the MAR completely blank:
-10/21/23 at 6:30 AM
-10/28/23 at 6:30 AM
-11/04/23 at 6:30 AM
-11/05/23 at 6:30 AM
-11/11/23 at 6:30 AM
-11/18/23 at 6:30 AM
-11/25/23 at 6:30 AM
-12/10/23 at 6:30 AM
During an interview on 03/12/24 at 10:02 AM, the Director of Nursing (DON) reported the documentation on the above-mentioned dates failed to meet professional standards of practice. The DON stated nursing staff should have taken the resident's blood glucose level, documented it, and assessed if Novolog needed to be administered or not.
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CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected multiple residents
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Based on observation and staff interview, the facility failed to ensure all vials of multi-use insulin were labeled with the initial date it was opened. This was true for three (3) out of three (3) ...
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Based on observation and staff interview, the facility failed to ensure all vials of multi-use insulin were labeled with the initial date it was opened. This was true for three (3) out of three (3) vials found in the medication cart. Resident identifiers: #32, #72, and #71. Facility census 106.
Findings included:
a) Medication cart
On 03/13/24 at 9:06 AM Registered Nurse (RN) #28 verified the following insulin vials for the following residents did not have a date to indicate what day it was initially opened. The facility staff should date the label of any multi-use vial when the vial is first accessed and access the vial.
A multi-use vial of Lispro belonging to Resident # 32 did not have a date on the vial.
A multi-use vial of Lantus belonging to Resident # 71 did not have a date on the vial.
A multi-use vial of Levemir belonging to Resident # 72 did not have a date on the vial.
A multi-use vial once punctured is not to be used longer than 30 days per the CDC.
On 03/13/24 at 11:30 AM the Director of Nursing (DON) was informed of the issues above.
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 observations and staff interview, the facility failed to store food in accordance with professional standards for food service safety. It was discovered food was not stored properly in the ...
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Based on observations and staff interview, the facility failed to store food in accordance with professional standards for food service safety. It was discovered food was not stored properly in the freezer, a trash can was situated near the beverage dispensers, a broken floor tile and a dirty floor in the walk-in freezer. This had the potential to affect all residents receiving nutrition from the kitchen. Facility census: 106.
Findings included:
a) Kitchen tour
During a kitchen tour, on 03/11/24 at 11:30 AM, it was discovered that a box of breaded fish filets were not sealed properly exposing the filets to the elements in the walk-in freezer. A trash can was stored in front of the beverage dispensers, causing the staff to lean over the trash can in order to fill the beverage pitchers, beside the ice machine there was a large section of a floor tile missing. Also the floor of the walk-in freezer had debris and food particles under the shelving unit.
In an observation and interview with the Dietary Manager (DM), on 03/11/24 at 11:45 AM, the DM verified the breaded fish filets were not covered properly, which allowed the filets to be exposed to the elements. He agreed the trash can should not be situated in front of the beverage dispensers, making staff lean over the unsanitary trash can to fill the beverage pitchers. He verified the floor tile was missing and needed to be repaired. He also verified the floor of the walk-in freezer had food debris under the shelving unit and needed to be cleaned.
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CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
QAPI Program
(Tag F0867)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on observations and staff interviews, the facility failed to ensure the Quality Assessment and Assurance committee made ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on observations and staff interviews, the facility failed to ensure the Quality Assessment and Assurance committee made good faith attempts to correct quality deficiencies of which it did have or should have had knowledge. The discovery was made during the facility tasks area for a Safe/Clean/Comfortable and Homelike environment for leaks in the ceiling, damaged furniture, a resident's wheelchair had damage to the armrest and the heating, ventilation and air conditioning (HVAC) units had an excessive amount of dust buildup. These deficient practices did not allow for a safe, clean, comfortable and homelike environment for residents. Facility census: 106.
Findings included:
Based on observation, resident interview and staff interview, the facility failed to ensure the living areas for residents were clean, safe, and sanitary; failed to ensure furniture was in good repair; failed to clean and/or change the Packaged Terminal Air Conditioner (P-Tac) vents (filters on the heat and air conditioners that are in each room.); and leaving a large amount of transparent type on a resident wheelchair. Resident identifiers: #35, # 90. The facility census 106.
Findings included:
a) P-Tac vents
During a tour on 03/12/24 at 2:34 PM of rooms 301, 302, 303, 304, and 305 it was discovered the P-Tac vents were heavily soiled with a thick layer of debris.
The above findings were verified on 03/12/24 at 2:54 PM with Maintenance Helper (MH) #43. MH #43 said the P-Tacs should be cleaned or replaced monthly. He went on to say it should be documentation of when it was last done on a form, he referred to Direct Supplies Tell MH #43 did not provide this documentation at the close of the survey. According to the records provided it was last marked as done on 01/12/24.
b) Poor quality furniture
An interview with the Administrator (NHA) on 03/11/24 at 1:05 PM two nightstands in the hallway on top of a bed pointed out the furniture was peeling exposing particle boards and therefore could not be cleaned properly. The NHA stated the facility had more and would replace it with better quality furniture.
On 03/13/24 at 1:04 PM it was pointed out to the NHA the same two (2) nightstands that were previously in the hallway on top of a bed were now in room [ROOM NUMBER] being used along with two other nightstands. All four (4) had exposed particle broad.
Upon farther observations on 03/13/24 at 2:22 PM it was found the following rooms also had nightstands in poor condition in rooms 202, 205, 306,305, and 321.
On 03/13/24 at 2:35 PM the above findings were verified by the Director of Nursing.
c) Damaged ceilings
On 03/11/24 11:18 AM it was discovered room [ROOM NUMBER] had a leaking ceiling. Resident #90 said it has been an ongoing problem for two (2) months. There was dark brown staining on the ceiling above the windows that was the length of the wall. It was approximately two (2) feet wide.
There was a large plastic barrel trash can and two gray basins on a table to catch rainwater.
Resident # 90 was saying she has looked at the stains so long she sees a duck swimming to a log and a big bird flying in the stain. Resident #90 said they (maintenance) have put tar on the roof several times, but it still leaked.
On 03/12/24 at 3:02 PM Housekeeping Aide (HA) stated that Resident #22 was just now moved to another room, but her clothes and other belongings were still in there.
On 03/12/24 at 3:04 PM it was discovered that room [ROOM NUMBER] had a leaking ceiling and the plaster had fallen from the ceiling. The ceiling was over 70 percent discolored. The discolored ceiling had rings of brown staining and a black substance showing in many places. The missing plaster and bowed exposed sheet rock was in the middle of the room. There were tall black trash cans in the middle of the floor with bath blankets under them that also had brown rings, along with chunks of plaster that had fallen from the ceiling scattered around the room. The room had a very strong odor of musky mildew.
On 03/12/24 at 3:37 PM MH #43 and the District Maintenance Manager (DMM) #158 arrived at room [ROOM NUMBER]. They were asked when the leak started. MH #43 stated it started on Saturday 03/09/24. MH #43 was informed that Resident #90 in room [ROOM NUMBER] said her ceiling had been leaking for more than two (2) months.
On 03/13/24 at 8:20 AM MH #43 provided a work order that was entered on 01/28/24 by the NHA for room [ROOM NUMBER]. There was no other evidence that any other staff had informed the maintenance department that room [ROOM NUMBER] was leaking as well.
Resident #22 refused to be interviewed on 03/11/24 at 12:09 PM and began yelling. Therefore, not wanting to upset the resident any further, no statement was obtained.
On 03/12/24 at 4:10 PM the NHA was asked when he was made aware of the condition of room [ROOM NUMBER]. The NHA stated he was told there was a leak in the room on Saturday 03/09/24. He was asked if Resident #22 should have been moved to a safer room on Saturday. The Administrator agreed the room had a very pungent odor. The large trash cans and stained peeling ceiling was also pointed out.
On 03/12/24 at 4:15 PM the NHA was shown room [ROOM NUMBER] as well. Resident #90 was in her room and spoke to the NHA.
On 03/13/24 at 8:20 AM the NHA informed this surveyor that Resident #90 was also moved to another room and the Maintenance crew are currently removing the ceiling in room [ROOM NUMBER] and #301 would be started on room [ROOM NUMBER] was completed.
d) Wheelchair armrest
On 03/11/24 at 12:22 PM, Resident #35 was seen in the hallway in his wheelchair. It was noted on the right armrest there was a large amount of tape clear (Office tape) wrapped around the armrest holding a cup holder to the armrest. Resident #35 stated one of the aides helped him put the cup holder on his wheelchair. Licensed Practical Nurse (LPN) #16 stated she would put a work order in to have it properly attached.
On 03/12/24 at 2:06 PM, Cooperate Nurse #157 was shown the tape was still hanging off of the armrest.
On 03/13/24 at 10:20 AM Resident # 35 was in his wheelchair and was very happy about the tape not being on his wheelchair and that his cup hold was now attached very securely.
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 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 an...
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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 cross-contamination and the development and transmission of communicable diseases and infections with regards to laundry services, bed pan storage and the community ice machine. This practice had the potential to affect all resident's resident in the Facility. Resident Identifiers: #16, #256, #257, and #59. Facility census: 106.
Findings included:
a) Bedpan Storage
An observation of Resident's #16, #256, and #257's adjoining restroom found their used bed pans stored together without covers in the bathtub.
During an interview and observation on 03/11/24 at 2:05 PM Nurse Aide (NA) #92 stated they should be stored in bags. When asked how to tell them apart she stated that they should have names on them. She proceeded to put the used bed pans in bags and place them back in the bathtub.
b) Laundry Services
An observation during the laundry tour on 03/13/24 at 3:20 PM found, the laundry room did not have a sealed separation from the soiled laundry area to the clean laundry area. There was also no negative air flow pulling from the clean area to the soiled area, failing to maintain a functional and safe laundry area to avoid contamination. The laundry was in progress in both areas, with clean laundry being exposed on the table being folded.
Observation of 11 bags of soiled isolation gowns, 1 bag of soiled cleaning rags, 2 bags of resident's soiled clothing, and multiple loose soiled isolation gowns laying on the floor of the soiled laundry room.
Four washers with lint buildup on the filter. Signs on washers (clean filter daily.)
Return vent and exhaust vent were not working or cleaned, buildup of lint, dust and dirt were observed.
During an interview with the Laundry Supervisor, on 03/13/24 at 3:20 PM, confirmed there was no sealed separation from the soiled laundry area to the clean laundry area. She verified the Bags of soiled laundry should be placed in carts and not be on the floor. She also verified the filters on the washers had not been cleaned daily and the vents were not working and had a buildup of lint.
Further discussion revealed the facility was aware for this issue and she was working on correcting the issues in the laundry area.
c) Resident #59
At approximately 8:50 AM on 03/12/24, Resident #59 was observed retrieving ice out of the ice chest located in front of the kitchen door. Resident #59 had two cups and filled them both with ice.
Receptionist #107 witnessed Resident #59 retrieve ice from the ice chest.
At approximately 12:00 PM, on 03/13/24, the Director of Nursing (DON) was notified of Resident #59 retrieving ice from the ice chest. The DON stated We have told the resident multiple times they cannot get ice from the coolers themselves. I don't know what we are going to do.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0838
(Tag F0838)
Could have caused harm · This affected most or all residents
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Based on record review and staff interview, the facility failed to ensure the facility assessment identified the staffing levels and training requirements needed to provide the necessary care and se...
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Based on record review and staff interview, the facility failed to ensure the facility assessment identified the staffing levels and training requirements needed to provide the necessary care and services for their residents. This deficient practice had the potential to affect more than a limited number of residents. Facility census: 106.
Findings included:
a) Facility Assessment
A review of the Facility Assessment was completed on 03/11/24 at 9:27 PM.
On page 20, Section II. Staffing, Training, Services & Personnel A.1. Function - Sufficiency Analysis Summary had the following guidance:
Considerations:
Use and/or refer to:
1. Staffing and scheduling systems
2. Staff training and competency program
3. A review of individual staff assignments and systems for coordination and continuity of care for residents within and across staff assignments.
Please document the total #/average/range of staff required to ensure a sufficient number of qualified staff are available to meet each resident's needs. Refer to the Staffing and Personnel Worksheet spreadsheet above for documentation assistance.
Other than the guidance described above, there was nothing written under this section.
On page 26, Section II. Staffing, Training, Services & Personnel B.1. Acuity - Sufficiency Analysis Summary had the following guidance:
Considerations:
Use and/or refer to:
1. Staffing and scheduling systems
2. Staff training and competency program
3. A review of individual staff assignments and systems for coordination and continuity of care for residents within and across staff assignments.
Please document total #/average/range of staff required to ensure a sufficient number of qualified staff were available to meet each resident's needs. Refer to the Staffing and Personnel Worksheet spreadsheet above for documentation assistance.
Other than the guidance described above, there was nothing written under this section.
On page 28, Section II. Staffing, Training, Services & Personnel C.1. - Cognitive - Sufficiency Analysis Summary had the following guidance:
Considerations:
Use and/or refer to:
1. Staffing and scheduling systems
2. Staff training and competency program
3. A review of individual staff assignments and systems for coordination and continuity of care for residents within and across staff assignments.
Please document the total #/average/range of staff required to ensure a sufficient number of qualified staff are available to meet each resident's needs. Refer to the Staffing and Personnel Worksheet spreadsheet above for documentation assistance.
Other than the guidance described above, there was nothing written under this section.
There was no evidence the facility identified the type of staff members, other health care professionals, and medical practitioners that were needed to provide support and care for residents.
There was no evidence the facility described their staffing plan/general approach to staffing to ensure that they would have sufficient staff to meet the needs of the residents at any given time.
There was no evidence the facility described the staff training/education and competencies that would be necessary to provide the level and types of support and care needed for their resident population
b) Interview with Administrator
During an interview, on 03/12/24 at 2:00 PM, the Administrator agreed the facility reviewed their facility-wide assessment, which was meant to include both their resident population and the resources the facility needs to care for their residents.
When asked to identify the areas in the Facility Assessment where the facility had determined the staffing level needed to meet resident needs, how the facility determined the skills and competencies required by those providing care, and where the facility had addressed the facility's training program to ensure any training needs were met for all new and existing staff, the Administrator indicated he would review the Facility Assessment and report back.
On 03/12/24 at approximately 4:10 PM, the Administrator reported he felt the above-mentioned questions had been addressed in the B.1. Acuity - Sufficiency Analysis Summary and C.1. - Cognitive - Sufficiency Analysis Summary sections.
Sept 2023
2 deficiencies
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected multiple residents
Based on observations, family interview, and staff interviews the facility failed to provide a
homelike environment by not having adequate bed linens. This had the potential to affect all
residents re...
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Based on observations, family interview, and staff interviews the facility failed to provide a
homelike environment by not having adequate bed linens. This had the potential to affect all
residents residing on the A hallway. Resident identifier: Resident #3. Facility Census: 108.
Findings included:
a) Resident #3
09/05/23 at 11:00 AM, Resident #3 and #39's family was standing in hallway. They said that staff was
cleaning Resident #3. She had a bowel movement and was all over her and the bed. They were told
that they would clean her up but would not be able to change the sheets as none were available.
09/05/23 at 11:10 AM asked Employee #147 if Resident #3's bed had been changed. She said she
had cleaned the resident but there were no sheets available to make the bed.
9/05/23 at 11:17 AM, the surveyor asked the Administrator why there were no sheets for bed
changes. He said they were on the way. The Laundry had been notified. When asked if they
routinely ran out of linen, he said not usually but occasionally they were late coming from the
laundry.
On 09/05/23 at 11:19 AM, the surveyor along with Infection Preventionist Registered Nurse
(IPRN), went to inspect the clean storage closet on the hall. There were no fitted or bottom
sheets there. IPRN asked Employee #147 why there were no sheets. She said they had called for
them. Sometimes they run out.
On 09/05/23 at 11:20 AM, Resident #3 was sitting up in recliner she was clean. Her bed had the
sheets removed but bed still not made.
On 09/05/23 at 11:25 AM, Administrator said he had upped the number of sheets to be kept on
hand.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Staffing Information
(Tag F0732)
Could have caused harm · This affected multiple residents
Based on observation and staff interview the facility failed to post up-to-date data for nurse staffing. During the tour for a complaint investigation, it was discovered the Daily Nurse Staffing Form ...
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Based on observation and staff interview the facility failed to post up-to-date data for nurse staffing. During the tour for a complaint investigation, it was discovered the Daily Nurse Staffing Form had not been updated since 09/01/23. The deficient practice had the potential to affect more than a limited number residents and visitors. Facility census: 108.
Findings included:
a) During an observation on 09/05/23 at 4:45 AM, it was discovered the staff posting, for public view had not been updated over the holiday weekend. The Daily Nurse Staffing Form had a date of 09/01/23.
In an interview with the Nursing Home Administrator on 09/05/23 at 9:00 AM, verified the Daily Nurse Staff Posting had not been updated since 09/01/23.
Nov 2022
18 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0698
(Tag F0698)
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 one (1) of one (1) resident reviewed for the care ar...
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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 one (1) of one (1) resident reviewed for the care area of dialysis during the long-term care survey received hemodialysis care consistent with professional standards of practice including ongoing assessment and oversight of the resident before, during and after dialysis treatments, including monitoring the resident's condition during treatments, monitoring for complications, and implementing appropriate interventions. Resident identifier: #105. Facility census: 112.
Findings included:
a) Resident #105
Record review found the resident is receiving hemodialysis at an outpatient dialysis center.
An order, written at the time of admission on [DATE]: Dialysis center phone number is: (telephone number) Dialysis days: Tuesday, Thursday, and Saturday. Time for Pick up: 0630 Transport to: (name of facility) - order date 10/22/22.
The facility uses a communication form, Hemodialysis Communication Record, sent with the resident to each dialysis visit.
The facility's licensed nursing staff evaluate the resident prior to the treatment. The facility completes vital signs, general condition, and the time of the resident's last meal prior to leaving for dialysis.
The dialysis center assesses the resident and completes information regarding the access site, blood pressure, pulse, pre and post dialysis weight, and notifies the facility of any new medications, and new orders/changes in condition during hemodialysis.
When the resident returns to the facility the licensed nursing staff obtain vital signs, any post dialysis complications, and any new orders from the dialysis center.
The hemodialysis communication forms were reviewed for the month of November, 2022 with the Director of Nursing (DON) at 2:00 PM on 11/29/22. The DON confirmed the communication forms were missing for 11/19/22, 11/24/22, and 11/26/22. On 11/22/22, 11/10/22, and 11/03/22, the facility failed to complete the post dialysis assessment of the resident. On 11/08/22, the dialysis center failed to complete their assessment of the resident while at dialysis.
On 11/30/22 at 8:46 AM, the DON said she checked with the dialysis center and the resident did receive dialysis on 11/19/22, 11/24/22, and 11/26/22. Due to the Thanksgiving holiday the DON wanted to confirm dialysis treatments were provided on 11/24/22 and 11/26/22.
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CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0712
(Tag F0712)
Could have caused harm · This affected 1 resident
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Based on resident interview, record review and staff interview, the facility failed to ensure the facility physician made all required visits to meet the requirements in frequency/ timeliness. This ...
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Based on resident interview, record review and staff interview, the facility failed to ensure the facility physician made all required visits to meet the requirements in frequency/ timeliness. This was true for one (1) out of two (2) residents reviewed for choices. Resident identifier: Resident #23. Facility census 112.
Findings included:
a) Resident #23
During an interview on 11/28/22 at 2:57 PM, Resident # 23 said she has not seen a doctor in long time.
Review of medical records revealed there were no visits from 12/24/21 thru 04/06/22.
On 11/29/22 at 9:30 AM Director of Nursing (DON) was asked if there were any documentation of a physician and/or provider visit during the time frame of 12/24/21 to 04/06/22.
A year look back on Physician visits revealed
-11/30/21 APRN (Advanced Practice Registered Nurse)
-12/24/21 visit by DO (Doctor of Osteopathic Medicine)
-04/6/22 APRN
-05/1/22 MD (Doctor of Medicine)
-06/3/22 APRN
-08/9/22 MD
-09/12/22 APRN
-10/7/22 MD
-11/21/22 APRN
During an interview on 11/30/22 at 8:19 AM, DON was asked if any information was located regarding the three (3) months of no physician and/or provider visits. DON stated, not as far as she can tell, Resident #23 was not seen for those three (3) months.
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CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected 1 resident
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Based on record review and staff interview, the facility failed to ensure medications were kept in proper temperature controls in accordance with the accepted professional standards of practice. Thi...
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Based on record review and staff interview, the facility failed to ensure medications were kept in proper temperature controls in accordance with the accepted professional standards of practice. This was a random opportunity for discovery. Facility Census: 112.
Findings Included:
a) Medication Refrigerator
On 11/29/22 at 8:55 AM, a tour of the medication room on B wing was completed. There was one incomplete temperature log hanging on the medication refrigerator. The November temperature log was entitled Temperature Log For Medication/Vaccine Refrigerator. The Temperature Log for Medication/Vaccine Refrigerators states record temps (temperatures) twice daily. (Typed as written.)
On 11/29/22 at 9:03 AM, Registered Nurse (RN) #135 confirmed the log was incomplete in recording the temperatures for the days in the month of November, 2022. RN #135 stated Those days are missing.
The following dates are missing temperature checks for the medication refrigerator:
--11/01/22 evening
--11/03/22 day
--11/03/22 evening
--11/06/22 evening
--11/08/22 day
--11/10/22 evening
--11/11/22 evening
--11/12/22 evening
--11/13/22 evening
--11/15/22 day
--11/15/22 evening
--11/17/22 evening
--11/18/22 day
--11/18/22 evening
--11/19/22 evening
--11/20/22 evening
--11/24/22 evening
--11/25/22 day
--11/25/22 evening
--11/26/22 evening
--11/27/22 evening
--11/28/22 evening
On 11/30/22 at 8:15 AM, the Director of Nursing (DON) confirmed the temperature log temperatures were missing on the above dates.
No further information was obtained during the long-term survey process.
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CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0883
(Tag F0883)
Could have caused harm · This affected 1 resident
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Based on medical record review and staff interview, the facility failed to administer a pneumococcal vaccine after Resident #86 signed a consent on 07/06/21. This was true for one (1) of five (5) re...
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Based on medical record review and staff interview, the facility failed to administer a pneumococcal vaccine after Resident #86 signed a consent on 07/06/21. This was true for one (1) of five (5) residents reviewed for pneumococcal vaccines. Resident identifiers: 86. Facility census: 112.
Findings include:
a) Resident #86:
Review of Resident #86's medical records found on 07/06/21, the resident and/or representative signed a consent for the pneumococcal vaccine.
Review of the medical record found no documentation the resident received the pneumococcal vaccine.
On 11/39/22 at 9:30 AM the Director of Nursing (DON) reviewed Resident #86's immunization record. She confirmed Resident # 86 had not received the pneumococcal vaccine. No further information was provided.
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CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Resident Rights
(Tag F0550)
Could have caused harm · This affected multiple residents
,
Based on observation and staff interview, the facility failed to provide a dignified dining experience. This was true for six (6) out of 12 residents dining in the Vintage dining room. Facility cens...
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Based on observation and staff interview, the facility failed to provide a dignified dining experience. This was true for six (6) out of 12 residents dining in the Vintage dining room. Facility census 112.
Findings included:
a) Vintage Dining Room
During an observation on 11/28/22 at 12:35 PM, Nurse Aide (NA) #37 served a tray to one resident that was seated with a table mate. NA #37 continued to serve two other tables, doing the same leaving the other resident at the table without their meal, before moving on to other tables. It was approximately seven (7) to 10 minutes before serving the other table mate.
On 11/28/22 at 12:52 PM, NA #37 said he has never heard of having to serve both residents at the same table before moving on to serve other residents seated at other tables.
During a brief interview on 11/28/22 at 1:10 PM, the Director on Nursing (DON) stated she will have to address that issue and she knows she has work to do. The DON went on to say she has only been in the facility for six (6) weeks.
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CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0565
(Tag F0565)
Could have caused harm · This affected multiple residents
.
Based on observation, resident council minutes, resident interview, and staff interview the facility failed to consider the voiced concerns of residents in resident council as grievances. The facili...
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Based on observation, resident council minutes, resident interview, and staff interview the facility failed to consider the voiced concerns of residents in resident council as grievances. The facility failed to act promptly to investigate resident grievances concerning issues of resident care. This had the potential to affect more than a limited number of residents living in the facility. Facility census: 112.
Findings Included:
A review of the facility policy titled Grievance/Concern with a revision date of 06/01/22 found the following.
.Policy
.Center leadership will investigate, document and follow up on all concerns and grievances registered by any patient or patient representative
a) Resident Council Meeting held on 05/30/22
Record review on 11/29/22 revealed a Resident Council meeting held on 05/30/22. The following concerns were voiced:
-There are issues with the lack of variety of the food
-The food has been cold.
-Complaints on cleanliness of rooms
-Wait times regards to call lights.
b) Resident Council Meeting held on 06/27/22
Record review on 11/29/22, revealed a Resident Council meeting held on 06/27/22. The following concerns were voiced:
-Lack of variety of food
-Food being cold
-Call lights not being answered timely - (up to half hour)
c) Resident Council Meeting held on 07/28/22
Record review on 11/29/22, revealed a Resident Council meeting held on 07/28/22. The following concerns were voiced:
-Issues with not having washcloths
-Double doors closing hard and hard to open
-Issues with getting medication on time.
-Issue with halls being blocked
d) Resident Council Meeting held on 08/29/22
Record review on 11/29/22, revealed a Resident Council meeting held on 08/29/22. The following concerns were voiced:
-Menus being wrong
-Laundry being late or not getting it at all
-Double doors being hard to open
-Call lights not answered timely
-Appointments
e) Resident Council 09/29/22
Record review on 11/29/22, revealed a Resident Council meeting was held on 09/29/22. The following concerns were voiced:
-Food being cold
-Laundry taking too long
-Call lights not answered timely
f) Resident Council Meeting held on 10/27/22
Record review on 11/29/22, revealed a Resident Council meeting was held on 10/27/22. The following concerns were voiced:
-Food needs variety
-Food not being the same as the menu
-Laundry being late
-Foul language on B wing
-Inventory sheets
No grievance/concern forms were completed on any of the above concerns.
During an interview on 11/30/22 at 9:09 AM, the Recreation Manager stated, when I have a concern in a Resident Council meeting I tell the Department manager the issues and they tell me what they are going to do to fix. I don't file a grievance for complaints, for each concern, I was not told to do that.
By the close of the survey, the RM had provided no evidence grievances expressed at resident council meetings were addressed.
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CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Notification of Changes
(Tag F0580)
Could have caused harm · This affected multiple residents
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Based on record review, staff interview, and resident interviews, the facility failed to notify a resident and/or resident's responsible party of a significant change in the resident's condition. Re...
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Based on record review, staff interview, and resident interviews, the facility failed to notify a resident and/or resident's responsible party of a significant change in the resident's condition. Resident's #64 and #42 was not informed of physician appointments and Resident #105's representative was not notified when a change occurred in the medication regimen. This deficient practice was found for three (3) of 17 sampled residents. Resident identifiers: #64, #42 and #105. Facility census: 112.
Findings included:
a) Resident #64
During an interview, with Resident #64, on 11/28/22 at 4:15 am, he voiced the concern about not being notified of his appointments prior to the ambulance and/or facility van arriving at his door. It is hard to be ready for an appointment when I am not informed about them.
Review of Resident 64's medical records found the resident has capacity to make his own medical decisions.
The following appointments found no documentation the resident was notified, and no physician order's for:
--10/26/21- Cardiologist
--05/03/22- CT scan
--01/04/22- Heart stress test
On 11/30/22 at 10:30 AM, the Director of Nursing (DON) reviewed Resident #64's medical records and was unable to find documentation the resident was notified of the above mentioned appointments.
b) Resident #42
During an interview, with Resident #42, on 11/28/22 at 3:34 PM, voiced concerns about not being informed of appointments.
Review of Resident 42's medical records found the resident has capacity to make his own medical decisions.
The following appointments found no documentation the resident was notified, and no physician order found:
--10/27/21- Neurologist
--06/09/22- Two (2) appointments according to nurses note but does not list who.
--07/11/22- Heart catheterization
--08/26/22- Renal ultrasound
--10/14/22-Surgical procedure does not say what kind of procedure.
--11/10/22- Taken out to sign a consent for surgery.
During an interview with the Director of Nursing (DON) on 11/30/22 at 11:30 am, the DON reviewed Resident #42's medical records and she was unable to find documentation the resident was notified of the above- mentioned appointments.
c) Resident #105
On 08/09/22 the resident's wife was appointed to be the Resident's Health Care Surrogate, due to the residents inability to make medical decisions.
On 10/20/22 the facility physician determined the resident lacked capacity to make medical decisions.
On 11/28/22 at 12:37 PM, the Resident's wife said her husband was given a new medication. She was not told about the new medication, and her husband had a bad reaction.
Review of the medical record found the following progress note from the Resident's physician:
11/08/22, (Name of Resident) was seen today for his acute complaint of muscle spasms. He visually has contractures in his ankles, and they won't straighten out. He complains of bad muscle spasms throughout the day. He has lost so much muscle mass. He has a hard time moving his left
side, it is stiff from a previous stroke. His right side is much better. I am going to talk to physical therapist about exercises to relax the muscles and stretch them out, to prevent these spasms. I gave muscle relaxer baclofen 5mg PO (by mouth) TID (three times a day) to help immediately. His mentation continues to get a lot better, each time I see him its better than before .
On 11/11/2022 at 1:06 PM a nurse's note was written: Text: Baclofen Oral Tablet 5 MG
Give 1 tablet by mouth every 8 hours for contractures in foot.
Held d/t (due to) sedation, NP (nurse practioner) notified.
On 11/29/22 at 8:59 AM, the Director of Nursing (DON) said she was aware of the incident with the medication, Baclofen. The DON confirmed the resident's responsible party (Wife) was not notified when the medication was started. That's already been identified as an issue, I'm working on that. The DON said a nurse told her about the incident. The same nurse said when the Resident's wife was contacted about the over sedation incident, the Resident's wife knew her husband couldn't take that medication and would have told them had she been contacted before the medication was ordered.
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CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected multiple residents
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Based on observation, resident interview, and staff interview, the facility failed to have adequate clean bed and bath linens in good condition. This had the potential to affect more than a limited ...
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Based on observation, resident interview, and staff interview, the facility failed to have adequate clean bed and bath linens in good condition. This had the potential to affect more than a limited number of residents at the facility. Facility census: 112.
Findings include:
a) Confidential interviews:
Confidential interviews found residents do not have linen available at all times - especially the fitted sheets, wash clothes, and towels in late evening hours through the night shift.
b) Laundry Supervisor Interview and tour of laundry facilities:
On 11/30/22 at 11:45 am, a tour of the building found the laundry facilities are located in a separate facility. The facility's laundry aide takes the dirty linen to another facility and picks up clean linens at 8:00 am, 11:00 am, 1:30 PM and 3:00 PM. The facility has no new linen available at the present time.
c) Linen storage closet inventory:
Inventory of the linen closets with the Laundry Supervisor on 11/30/22 at 1:10 PM. found:
Unit A- Sixteen (16) flat sheets, twenty (20) fitted sheets, five (5) wash cloths, twenty (20) towels and twenty (20) blankets
Unit B- Ten (10) fitted sheets, four (4) blankets, ten (10) flat sheets, six (6) wash cloths, six (6) towels and two (2) blankets.
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CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on record review and staff interview, the facility failed to ensure a person-centered comprehensive care plan was develo...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on record review and staff interview, the facility failed to ensure a person-centered comprehensive care plan was developed for smoking, an indwelling urinary catheter and dialysis. This was true for three (3) of 27 residents reviewed for the care area of developing and implementing a comprehensive care plan during the long term care survey process. Resident Identifiers: Resident
#99, #102 and #105 . Facility Census: 112.
Findings Included:
a) Resident #99
On 11/28/22 at 2:53 PM, a list of smokers was provided by the facility. Resident #99's name was on the list.
On 11/29/22 at 1:25 PM, a record review was completed for Resident #99. Upon completion of the review, the care plan did not list the smoking status as a focus area.
On 11/30/22 at 8:15 AM, the Director of Nursing (DON) confirmed the smoking status was not listed on the care plan.
No further information was obtained during the long-term survey process.
b) Resident #102
On 11/28/22 a record review was completed for Resident #102. Upon completion of the review, the care plan did not have a focus area for an indwelling urinary catheter.
On 11/30/22 at 8:15 AM, the DON confirmed the indwelling urinary catheter was not listed on the care plan.
No further information was obtained during the long-term survey process.
c) Resident #105
Record review found the resident is receiving hemodialysis at an outpatient dialysis center.
An order, written at the time of admission on [DATE]: Dialysis center phone number is: (telephone number) Dialysis days: Tuesday, Thursday, and Saturday. Time for Pick up: 0630 Transport to: (name of facility) - order date 10/22/22.
Review of the current care plan found no care plan regarding hemodialysis.
On 11/30/22 at 11:30 AM, the Director of Nursing (DON) reviewed the current care plan and confirmed there was no current care plan addressing the resident's hemodialysis.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected multiple residents
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c) Resident #14
During an interview on 11/28/22 at 12:12 PM, Resident # 14 stated I very rarely receive a bed bath/no showers.They are scheduled at least three times, Monday, Thursday and Friday.
D...
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c) Resident #14
During an interview on 11/28/22 at 12:12 PM, Resident # 14 stated I very rarely receive a bed bath/no showers.They are scheduled at least three times, Monday, Thursday and Friday.
During an interview on 11/29/22 on 11:16 AM, Resident # 14 stated, they came in here yesterday and offered me a bed bath. I told them yes if that is all you can give me. They never came back for my bed bath.
During an interview on 11/29/22 01:45 PM Nurses Aide #109 stated Resident #14 receives a shower, two (2) times a week, its supposed to be three (3) but she refuses at least one (1) time a week. She usually refuses the showers but a bed bath is offered. Monday she refused a shower and a bed bath.
A medical record review of the most recent Minimum Data Set (MDS) with a Assessment Reference Date of 11/04/22 found the resident was coded as requiring one (1) person extensive assistance for bathing.
A further review of Resident #14 medical record revealed a facility form titled, Documentation Survey Report
Bathing/showers for the month of November were as follows:
-11/01/22 refused
-11/02/22 shower
-11/03/22 blank
-11/04/22 shower
-11/05/22 blank
-11/06/22 blank
-11/07/22 shower
-11/08/22 refused
-11/09/22 blank
-11/10/22 blank
-11/11/22 refused
-11/12/22 blank
-11/13/22 blank
-11/14/22 refused
-11/15/22 showered
-11/16/22 blank
-11/17/22 blank
-11/18/22 not applicable
-11/19/22 blank
-11/20/22 blank
-11/21/22 showered
-11/22/22 refused
-11/23/22 not applicable
-11/24/22 blank
-11/25/22 refused
-11/26/22 blank
-11/27/22 blank
-11/28/22 refused
-11/29/22 refused
During an interview on 11/30/22 at 8:27 AM the DON stated I spoke to Resident # 14 she did refuse her shower yesterday and stated the CNA knows why the Resident does want to go to shower. I educated the CNA if the Resident refuses her shower or bed bath to get another CNA to ask her. If Resident #14 still refuses to tell the LPN and she has will make a note about the refusal.
b) Resident #19
During an interview on 11/28/22 at 2:19 PM, Resident #19 said she has not had a shower in two (2) weeks. Resident #19 skin appeared very dry with white scaly dry skin in ears, face and neck. Resident #19 said the Nurse Aides (NA) told her they are short staffed.
A review of the medical records revealed Nurse Aide #104 (the NA assigned to Resident #19) on 11/28/22. NA #104 documented Resident #19 refused her shower.
During an interview on 11/29/22 at 1:48 PM, Resident #19 was asked if she refused a shower yesterday. Resident # 19 said, Honey you can bet your sweet bippy I have never refused a shower here. The show opportunities are too few and far between to pass up on one. Resident #19 said if someone said she refused then that would be falsifying records.
A review of the facility form titled, Documentation Survey Report
Bathing for the month of November:
-11/01/22 blank
-11/02/22 blank
-11/03/22 coded as refused.
-11/04/22 blank
-11/05/22 blank
-11/06/22 blank
-11/07/22 coded as refused
-11/08/22 blank
-11/09/22 blank
-11/10/22 Showered
-11/12/22 blank
-11/13/22 blank
-11/14/22 blank
-11/15/22 blank
-11/16/22 blank
-11/17/22 showered
-11/18/22 blank
-11/19/22 blank
-11/20/22 blank
-11/21/22 blank
-11/22/22 blank
-11/23/22 blank
-11/24/22 blank
-11/25/22 blank
-11/26/22 blank
-11/27/22 blank
-11/28/22 coded refused
-11/29/22 blank
-11/30/22 blank
During a brief interview on 11/30/22 at 8:28 AM, DON informed about the above. The DON stated, she believes Resident #19 knows what she is talking about because she has capacity and is not confused.
During an interview on 11/30/22 at 10:15 AM, NA #104 was asked if Resident #19 had refused her shower on 11/28/22. NA #104 said she did not want to get in trouble, but Resident #19 said a trainee asked her if she wanted a shower and she told the trainee, no. NA #104 did not remember the name of a trainee. NA #104 said she personally asked Resident #19 and she said, no. NA #104 was asked if the refusal was reported to the nurse that was caring for Resident #19. NA #40 stated, she did but did not remember who she reported to. There was no nursing note to reflex a refusal on this day. NA #104 said she promised Resident #19 she would shower her on 11/30/22 before the end of her shift.
Based on resident interview, record review, and staff interview, the facility failed to ensure three (3) of four (4) resident's dependent upon staff for bathing activities, received the necessary care and services to maintain good grooming, and personal hygiene. Resident identifiers: #24, #19, and #14. Facility census: 112.
Findings included:
a) Resident #24
On 11/28/22 at 2:14 PM, the resident was observed to be disheveled. His hair was unclean, with the roots of the hair stuck to his head, and his hair was not combed. When asked if he was allowed to choose his bathing activity, the resident said he didn't think he had a bath for a while. He said he would like to have a shower every now and again.
Review of the most recent Minimum Data Set (MDS), a quarterly with an assessment reference date (ARD) of 11/11/22, found the resident was coded as requiring the extensive assistance of 1 staff person for bathing activities.
Review of the medical record on 11/29/22 found the resident's shower days are Monday and Thursday.
During the month of November 2022, the resident should have received a shower on 11/3/22, 11/7/22, 11/10/22, 11/14/22, 11/17/22, 11/21/22, 11/24/22, and 11/28/22.
Review of the documentation in the electronic medical record found the resident received a shower on 11/25/22.
At 10:58 AM on 11/29/22, the clinical nurse reimbursement coordinator Registered Nurse (RN) #150 reviewed the documentation and confirmed the resident received only 1 shower during the month of November- 11/25/22. RN #150 said the resident is known to refuse care. When asked if this was documented anywhere, RN #150 confirmed she could not find any documentation the resident refused showers when offered.
At 11:45 AM on 11/29/22, the Director of Nursing (DON) reviewed the documentation. No further information was provided.
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CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
c) Resident 69
A review of the Facility Policy, titled, Neurological Evaluation with a revision date of 06/01/21 found the fol...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
c) Resident 69
A review of the Facility Policy, titled, Neurological Evaluation with a revision date of 06/01/21 found the following.
Policy .
Neurological evaluation will be performed as indicated or ordered
A review of Resident #69's medical record revealed a diagnosis of Alzheimers.
A further review of Resident # 69 medical record revealed a unwitnessed fall occurred on 09/06/22. The immediate action was neuros were started.
A further review of Resident #69 medical record revealed a facility form titled, Neurological Evaluation Flow Sheet
-All Every (Q) 15 minutes Neuro checks were completed
-All Q 30 minutes Neuro checks were completed
-All Q one (1) hour Neuro checks were completed
-Q eight (8) hour 09/08/22 at 9:45 AM completed
-Q eight (8) hour 09/08/22 at 5:45 PM competed
-Q eight (8) hour 09/09/22 at 1:45 AM completed
-Q eight (8) hour 09/09/22 at 9:45 AM not completed
-Q eight (8) hour 09/09/22 at 5:45 PM not completed
-Q eight (8) hour 09/10/22 at 1:45 AM not completed
-Q eight (8) hour 09/09/22 at 9:45 AM not completed
-Q eight (8) hour 09/09/22 at 5:45 AM not completed
During an interview on 11/29/22 at 12:31 PM the DON acknowledge the Neurological Evaluation Flow Sheet was not completed for Resident #69's unwitnessed fall that occurred on 09/06/22.
d) Resident #115
During an interview on 11/30/22 at 11:41 AM, Resident's daughter stated that her father had cracked the discs in his back, and once they were repaired the two (2) more disc cracked requiring another surgery. The kyphoplasty surgery was scheduled for 11/02/22 at 6:30 AM at a hospital located about an hour away from the nursing home. On day of surgery Resident #115 was supposed to be there around 6:15 AM for the specialized surgery and did not show up until something after 3:00 PM. Once the Resident finally arrived at the hospital, he was car sick from being rushed there in the minivan used for transport and began to vomit. The surgical procedure was canceled due the Resident's condition and the Resident arriving too late. The Resident's daughter stated, My dad was dehydrated, and was so sick he after arriving late to the hospital we thought he wasn't going to make it so he had to go to the emergency department. Of course, the surgery was canceled, and he was admitted to the hospital.
The Resident's daughter further stated she had to call the facility several times the morning of 11/02/21 to get them [the facility] to send her father to the hospital for the procedure. The Resident's daughter stated, The department scheduler at the hospital was livid because so many special arrangements had been made for him [Resident #115] to have this surgery, and they kept moving the time of the surgery up waiting on the Resident to arrive. But by the time he got there it was too late. The surgery had to rescheduled five days later.
Record review revealed a progress note dated 11/02/21 at 2:15 PM that stated: Resident out of facility at this time for kyphoplasty procedure, resident transported via facility van with x1 attendant, resident dressed appropriately in day attire and well groomed. Papers sent with resident and O2 (oxygen) in use via nasal cannula.
Record review showed Resident #115 had an appointment scheduled in Interventional Radiology on 11/02/21 at 6:30 AM for kyphoplasty surgery. The Resident was to arrive 15 minutes prior to the appointment and check in at the Registration desk in the main lobby of the hospital.
During an interview on 11/30/22 at 1:27 PM, Licensed practical Nurse (LPN) #22, the facility's current appointment scheduler, stated she remembered speaking with the Resident's daughter on 11/02/21 and she was very upset that her father was not at the surgical appointment on time. LPN #22 stated, Yea after [Resident #115 name] daughter called here, I started working on trying to get someone to take him to [hospital name]. I know the appointment time was supposed to be sometime early that morning, but [Resident #115's name] didn't leave here until after 2:00 PM. LPN #22 further stated The previous Administrator and Social Worker were all involved, it was a mess.
On 11/30/22 at 2:24 PM, The Director of Nursing, LPN #22, and the facility's Corporate Nurse all agreed the facility did not provide the necessary transportation arrangements needed to ensure Resident #115 was at the hospital to receive his kyphoplasty surgery.
Based on record review and interview, the facility failed to ensure residents receive treatment and care in accordance with professional standards of practice. This failed practice had the potential to affect four (4) of seventeen (17) residents sampled. Resident identifiers: #79, #69 and 115. Facility census: 112.
Findings include:
a) Resident #79
Review of Resident #79's medical records, found he was admitted to the facility on [DATE] from an acute care facility. Admitting diagnosis included myelofibrosis, candidemia, bacteremia, urinary tract infection, diabetes mellitus, hypertension, and coronary heart disease. Resident had capacity to make medical decisions.
On 10/23/22 the Nurse Practitioner (NP) saw the resident and he was asked about his advance directives. The resident stated he has been on mechanical ventilation twice and does not ever want that again. He stated he would like selective treatments including hospitalization if needed and is willing to have artificial feeding (which he currently does have).
On 10/25/22 the Nurse Practitioner (NP) saw the resident coughing up blood and noted he is requesting a hospice consult. He was diagnosed with an active gastrointestinal bleed. The resident refused to be transferred to hospital and refused further lab testing. A new advance directive was completed on this date, but the resident failed to sign the advance directives.
Review of physician order on 11/29/22 found an order written for a hospice consult dated 10/25/22. Further review found a hospice consult completed on 10/25/22. Hospice services started on 10/25/22 with the primary diagnosis for upper gastrointestinal bleed. The medical record contained no order for hospice services and the hospice company providing the services could be found in the medical records.
Further review of Resident #79's medical records found he had a central line in the left arm 10 centimeters above the antecubital. On 10/24/22, an order which read, Change catheter site dressing. Indicate external catheter length and arm circumference. Notify the practitioner if the external length has changed since last changed. Change dressing and measurements weekly on Mondays. Central line discontinued on 11/28/22 late evening.
Review of Resident #79's Medication Administration Records (MAR) for October and November 2022 found the resident's central line dressing had been completed although no measurement of the external catheter length and arm circumference were recorded on 10/24/22, 11/07/22, 11/14/22, 11/21/22 and 11/28/22.
The Director of Nursing (DON) was interviewed on 11/30/22 at 10:38 am. During this interview the DON reviewed Resident #79's medical records and confirmed there was no order for hospice, and there was no documentation on the MAR of the arm circumference or the measurement for the external catheter length.
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CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Menu Adequacy
(Tag F0803)
Could have caused harm · This affected multiple residents
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Based on observation, resident council, staff interview, resident interview, record review and sampling of test tray, the facility failed to follow the dietary recipe to meet nutritional value and p...
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Based on observation, resident council, staff interview, resident interview, record review and sampling of test tray, the facility failed to follow the dietary recipe to meet nutritional value and palatability. This was a random opportunity for discovery and had a potential to affect more than a limited amount of residents receiving nutrition from the facility kitchen. Facility census: 112
Findings Included:
a) Chicken Vegetable Soup
During the interview process of the Long Term Care Survey Process on 11/28/22 several residents had food concerns about taste and temperature.
On 11/29/22 four (4) state surveyors tasted the noon time meal for palatability. The chicken vegetable soup was tasteless and not palatable.
On 11/30/22 the Certified Dietary Manager(CDM) #148 provided the recipe for the Chicken Vegetable Soup,
-Carrots: eight (8) pounds (lb)
-Celery: four (4) lbs
-Garlic Cloves: two (2) two/three (2/3) ounces (oz)
-Yellow Onions: four (4) three/four 3/4 lbs
-Squash, Zucchini: five (5) three/eight (3/8) lbs
-Margarine: 21 five/eight 5/8 oz
-Chicken: four (4) lbs
-Water: five (5) three/eight 3/8 gallons
-Chicken soup base: 16 one/four (1/4) oz
-Black Pepper: two (2) two/three 2/3 Tablespoon
-Sage: one (1) three/four 3/4 Tablespoon
-Green Peas: five (5) three/eight 3/8 lbs
During an interview 11/30/22 at 12:06 PM the CDM stated the chicken vegetable soup lacked seasoning and flavoring. I did not get the zucchini and another vegetable so I substituted it.
On 11/30/22 the CDM provided this surveyor with a recipe that was used for the chicken vegetable soup on 11/29/22 lunch meal.
-Carrots: eight (8) pounds (lb)
-Celery: three (3) lbs
-Onions: three (3) lbs
-Green Beans: six (6) lbs
-Margarine: 16 oz
-Chicken: five (5) lbs
-Chicken soup base: 18 oz
-Black Pepper: two (2) one/two 1/2 Tablespoon
-Garlic Powder: two (2) Tablespoon
-Green Peas: six (6) lbs
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CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0804
(Tag F0804)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on observations, resident interviews, staff interviews, Resident Council meeting interviews, tray temperatures at time o...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on observations, resident interviews, staff interviews, Resident Council meeting interviews, tray temperatures at time of service and a sampled meal, the facility failed to provide food that is palatable, attractive, and at a safe and appetizing temperature. This had the potential to [NAME] than a limited number of residents at the facility. Facility census:112.
Findings include:
a) Confidential Interviews
--Food is always cold
--Food is cold when we get it.
-- They run out of the alternative food cold I lost weight because I can't eat this food.
-- I just got beans and they know I don't eat that. I have ordered a chief salad.
-- Food is bad. I only eat breakfast the food does not have any seasoning at all.
-- Food is horrible.
-- Food is cold, bad, and given food I should not have. No salad on weekend due to no lettuce, the menus posted are not followed.
-- The food is awful
-- The food is horrible, the substitution meal is worse
b) Temperature checks
-- Food temperatures of lunch meal on 11/29/22 at 1:30 PM with the Certified Dietary Manager (CDM):
chicken vegetable soup- 130.8 F, Hamburger- 107 F, French Fries- 94 F.
Per CDM temperature at time of service should be 135 F or higher.
c) Resident Council Meeting:
A Resident Council Meeting held on 11/30/22 at 10:09 AM, the following concerns were presented:
-The food is cold
-The food is bad
-The food tastes horrible
-I like salads but they never have lettuce
-Never follow the menu
-Do not get what is posted on the menu
-Do not get what is on our meal ticket
d) Test tray
-- On 11/29/22, a test tray was provided by the facility's CDM at 12:20 PM. The chicken soup was clear containing carrots, peas, celery, and very small pieces of white chicken. The soup was tasted by two (2) surveyors, and it was very bland and not palatable. The appearance was not attractive.
e) CDM interview
During an interview CDM 11/30/22 12:30 PM the lunch tray lacked seasoning and flavoring. He said I did not get all the ingredients, so I substituted other vegetables. He was informed of all the above-mentioned food complaints.
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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 meal temperature of each meal prior to serving and staff interview, the facility failed to ensure monitoring records, of temperature logs from the tray line, were completed with each meal. ...
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Based on meal temperature of each meal prior to serving and staff interview, the facility failed to ensure monitoring records, of temperature logs from the tray line, were completed with each meal. This had the potential to affect more than a limited number of residents. Facility census: 112.
Findings include:
a) Temperature logs from the tray line:
Review of the last week of temperatures from the tray line taken for each meal found no temperatures documented for breakfast on 11/25/22 and 11/27/22.
On 11/28/22 at 5:00 PM, the Certified Dietary Manager (CDM) confirmed he could not find the temperatures for 11/25/22 and 11/27/22. No further information was provided.
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CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0868
(Tag F0868)
Could have caused harm · This affected multiple residents
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Based on staff interview and record review the facility failed to ensure the required Quality Assurance Performance Improvement Committee members attended the meetings. This failed practice had the ...
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Based on staff interview and record review the facility failed to ensure the required Quality Assurance Performance Improvement Committee members attended the meetings. This failed practice had the potential to affect more than a limited number of Residents residing at the facility. Facility census: 112.
Findings included:
Record review of the facility's sign in sheets for the Quality Assurance Performance Improvement (QAPI) meetings showed the Infection Preventionist had only attended one meeting (on 11/30/21) since September of 2021.
On 11/30/22 at 1:00 PM, the Administrator verified the Infection Preventionist was not attending the QAPI meetings. The Administrator stated, We [the facility] did not have one [Infection Preventionist] for a while, that position was vacant. [Current IP name] just started here on July 11th, 2022.
During an interview on 11/30/22 at 1:20 PM, the facility's Infection Preventionist (Registered Nurse #117) was asked if she had attended any QAPI meetings? The IP stated, No I have not. I was part of the newest group that just came here in July and needed to be on the medication cart, so it was either resident care or attend a meeting. I chose Resident care. Since the IP has been employed the QA committee has met on 07/29/22, 08/31/22, in October 2022 (exact date not specified) and 11/28/22.
Record review of the facility's policy titled Quality Assessment and Performance Improvement Plan, updated on 01/03/22, showed the Quality Assurance Performance Improvement Committee is to be composed of the following members: Center Executive Director, Center Nurse Executive, Medical Director, the Infection Preventionist, and a representative from each department.
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CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
c) Resident #83
On 11/28/22 at 12:35 PM, a nebulizer mask was observed laying on the night stand without being stored in a res...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
c) Resident #83
On 11/28/22 at 12:35 PM, a nebulizer mask was observed laying on the night stand without being stored in a respiratory bag in Resident #83's room.
On 11/28/22 at 12:38 PM, Registered Nurse (RN) #25 confirmed the nebulizer mask was not stored in a respiratory bag. RN #25 stated I'll get one right now.
On 11/30/22 at 8:15 AM, the Director of Nursing (DON) confirmed nebulizer masks should be stored in respiratory bags.
No further information was obtained during the long-term survey.
Based on observation, 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. PPE (Personal Protection Equipment) was not readily available for resident care. Hand hygiene for residents was not provided prior to being served a meal. Staff failed to use hand hygiene between residents being served meals and used unsanitized hands to pick up and butter slices of bread. Respiratory equipment was not stored in a sanitary manner. Resident Identifiers: Resident #5, and #83. Facility census 112.
Findings included:
a) Resident #5
Resident #5 is a totally dependent upon staff for care and has MDROs (Multidrug-Resistant Organisms) which can be easy spread from one resident to another without proper use of PPE. The current MDROs:
--Methicillin Resistant Staphylococcus Aureus (MRSA), Carbapenem-Resistant Enterobacter [NAME] (CRE), in wounds and Vancomycin-Resistant Enterococci (VRE) in urine.
During an observation on 11/28/22 at 1:40 PM, it was noted a sign on the door of the room belonging to Resident #5 instructing staff to wear PPE when providing care. Nurse Aide (NA)#40 was asked where is the PPE? NA#40 said it is in the clean utility room. NA #40 said we did have a cart by the door, but after COVID was over they stopped using the carts. NA #40 left to get a gown at 1:41 PM. At 1:47 PM, NA #40 rushed by said she has to look in another storage room for a gown. On 11/28/22 at 1:59 PM, Nursing Administration Registered Nurse (NARN)#25, provided a gown.
On 11/28/22 at 2:02 PM, the Director of Nursing (DON) was asked about the PPE. The DON said the gowns are in the storage room. The DON was informed NA #40 looked in two storage rooms and had to ask NARN #25 to find a gown. The DON stated the facility does have gowns. The DON was asked if she would agree the gowns are not readily available? The DON agreed the PPE was not readily available for staff to use to provide care.
b) Dining
During an observation on 11/28/22 at 12:30 PM, it was noted that NA #37 and NA#104 did not provide hand hygiene for each of the residents seated in the Vintage Dining room before serving lunch to the 12 residents in the Vintage Dining room.
Both NAs were asked if hand hygiene was provided. NA #37 said he gives hand hygiene when he gets the Residents up for the day. NA #104 shook her head to indicate, no.
Again NA #37 and NA #104 were asked if they used hand hygiene themselves between serving the trays to the Residents. NA #37 stated he did not have time for this while waving his hands around. He was assured there was only one question, did he use any hand hygiene before handling all the sliced bread he was observed removing from a clear bag and spreading butter on the bread with his bare hands? NA #37 walked away. NA #104 stated she just forgot to use the hand hygiene between serving trays.
During an interview on 11/28/22 at 2:02 PM, the DON was informed of the above observations. The DON stated the staff were just in serviced on the importance of hand hygiene on 11/22/22.
On 11/30/22 at 8:25 AM, the DON provided the sign in page for the inservice dated 11/22/22 for hand hygiene. The inservice sheet was signed by 22 nurses and nurse aides; however, the signatures of NA #37 and NA #104 were not present on the inservice sign in sheet.
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CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0882
(Tag F0882)
Could have caused harm · This affected multiple residents
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Based on record review and staff interview, the facility failed to designate a qualified individual(s) as the infection preventionist(s) (IP)(s) responsible for the facility's IPCP. This had the pot...
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Based on record review and staff interview, the facility failed to designate a qualified individual(s) as the infection preventionist(s) (IP)(s) responsible for the facility's IPCP. This had the potential to affect more than a limited number of residents at the facility. Facility census: 112.
Findings include:
Review of Employee #117, Registered Nurse (RN), Infection Preventionist (IP) records found her hire date was 07/11/22. She stated she is enrolled in a program to be certified but has not completed the program. Per the IP, I have been pulled to give medications frequently.
Employee #27, an RN, Market Resource Nurse, provided a certificate of training. E #27 said she was at the facility at least part time and she assisted with infection control program.
Review of Employee #27's timecard for November 2022, found she was at other facilities from 11/01/22 through 11/29/22.
No further information was provided.
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CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0887
(Tag F0887)
Could have caused harm · This affected multiple residents
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Based on medical record review and staff interview, the facility failed to ensure residents were offered the COVID-19 vaccine unless the immunization is medically contraindicated, or the residents h...
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Based on medical record review and staff interview, the facility failed to ensure residents were offered the COVID-19 vaccine unless the immunization is medically contraindicated, or the residents have already been immunized. This was true for 43 of 112 residents residing in the facility.
Resident identifiers: #38, #26, #105, #108, #107, #46, #89, #54, #365, #17, #104, #10, #8, #33, #48,
#84, #5, #110, #27, #100, #39, #11, #4, #32, #36, #69, #47, #82, #86, #13, #109, #1, #19, #44, #95,
#63, #103, #52, #90, #61, #58, #74, and 29. Facility Census: 112.
Findings include:
a. Covid-19 vaccinations:
Review of the Center for Disease Control and Prevention (CDC) indications for Covid-19 vaccinations as follows: 1st dose, 2nd dose 3 weeks after 1st dose, 3rd- booster- 4 weeks after the 2nd dose and
4th- booster- 2 months after 3rd dose.
The following residents were not offered Covid-19 boosters as follows:
1. Resident 38- Received three (3) vaccines- last given 11/10/21. Was eligible for 4th dose on 01/10/22.
2. Resident #26- Received three (3) vaccines- last given 11/08/21. Was eligible for 4th dose on 01/08/22.
3. Resident #105- Received two (2) vaccines- last given 09/10/21. Was eligible for 3rd dose on 10/10/21.
4. Resident #108- Received two (2) vaccines- last given 02/15/22. Was eligible for 3rd dose on 03/31/22.
5. Resident #107-Received three (3) vaccines- last given 11/06/21. Was eligible for 4th dose on 01/06/22.
6. Resident #46- Received three (3) vaccines- last given 03/07/22. Was eligible for 4th dose on 05/07/22.
7. Resident #89- Received three (3) vaccines- last given 04/13/22. Was eligible for 4th dose on 06/13/22.
8. Resident #54- Received two (2) vaccines- last given 12/10/21. Was eligible for 3rd dose on 01/08/22.
9. Resident #365- Received three (3) vaccines- last given 03/15/22. Was eligible for 4th dose on 05/15/22.
10. Resident #17- Received two (2) vaccines- last given 01/25/21. Was eligible for 3rd dose on 02/28/22.
11. Resident #104- Received three (3) vaccines- last given 09/29/21. Was eligible for 4th dose on 11/29/21.
12. Resident #10- Received three (3) vaccines- last given 03/07/22. Was eligible for 4th dose on 05/07/22.
13. Resident #8- Received three (3) vaccines- last given 11/08/21. Was eligible for 4th dose on 01/08/22.
14. Resident #33- Received three (3) vaccines- last given 11/08/21. Was eligible for 4th dose on 01/08/22.
15. Resident #48- Received three (3) vaccines- last given 11/08/21. Was eligible for 4th dose on 01/08/22.
16. Resident #84- - Received two (2) vaccines- last given 03/07/22. Was eligible for 3rd dose on 04/07/22.
17. Resident #5- Received three (3) vaccines- last given 08/31/21. Was eligible for 4th dose on 10/21/21.
18. Resident #110- Received two (2) vaccines- last given 12/30/21. Was eligible for 3rd dose on 01/31/22.
19.Resident #27- Received two (2) vaccines- last given 03/23/21. Was eligible for 3rd dose on 04/24/21.
20. Resident #100- Received two (2) vaccines- last given 07/13/21. Was eligible for 3rd dose on 08/15/21.
21. Resident #39- Received one (1) single dose and 1st booster on 11/08/21. Was eligible for 2nd booster on 01/09/22.
22. Resident #11-- Received three (3) vaccines- last given 11/08/21. Was eligible for 4th dose on 01/08/22.
23. Resident #4- - Received three (3) vaccines- last given 12/01/21. Was eligible for 4th dose on 02/04/22.
24. Resident #32- Received two (2) vaccines- last given 06/24/21. Was eligible for 3rd dose on 07/25/21.
25. Resident #36- Received two (2) vaccines- last given 02/20/21. Was eligible for 3rd dose on 03/28/21.
26. Resident #69- Received three (3) vaccines- last given 11/08/21. Was eligible for 4th dose on 01/08/22.
27. Resident #47- Received three (3) vaccines- last given 11/08/21. Was eligible for 4th dose on 01/08/22.
28. Resident #82- Received three (3) vaccines- last given 10/20/21. Was eligible for 4th dose on 12/20/21.
29. Resident #86- Received three (3) vaccines- last given 11/08/21. Was eligible for 4th dose on 01/08/22.
30. Resident #13-Received three (3) vaccines- last given 11/08/21. Was eligible for 4th dose on 01/08/22.
31. Resident #109-Received two (2) vaccines- last given 07/13/21. Was eligible for 3rd dose on 09/13/21.
32. Resident #1- Received two (2) vaccines- last given 10/20/21. Was eligible for 3rd dose on 12/20/21.
33. Resident #19- Received three (3) vaccines- last given 11/08/21. Was eligible for 4th dose on 01/08/22.
34. Resident #44- Received three (3) vaccines- last given 03/31/21. Was eligible for 4th dose on 06/01/21.
35. Resident #95- Received three (3) vaccines- last given 04/13/22. Was eligible for 4th dose on 06/13/22.
36. Resident #63- Received two (2) vaccines- last given 12/06/21. Was eligible for 3rd dose on 01/10/21.
37. Resident #103- Received three (3) vaccines- last given 10/06/21. Was eligible for 4th dose on 12/06/21.
38. Resident #52- Received three (3) vaccines- last given 07/21/22. Was eligible for 4th dose on 09/21/22.
39. Resident #90-Received three (3) vaccines- last given 06/29/22. Was eligible for 4th dose on 08/29/22.
40. Resident #61- Received three (3) vaccines- last given 06/29/22. Was eligible for 4th dose on 08/29/22.
41. Resident #58- Received three (3) vaccines- last given 07/21/22. Was eligible for 4th dose on 09/21/22.
42. Resident #74- Received three (3) vaccines- last given 07/21/22. Was eligible for 4th dose on 09/21/22.
43. Resident #29- Received three (3) vaccines- last given 06/01/22. Was eligible for 4th dose on 08/01/22.
On 11/30/22 at 8:30 AM, the Director of Nursing (DON) reviewed the list of Covid- 19 vaccinations log and individual immunization records. She confirmed the above-mentioned residents had not been offered the 3rd and 4th doses of Covid-19 boosters. No further information was provided.
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Sept 2021
5 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
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Based on observation, interviews, and record review the facility improperly stored Skin Protective Wipes in Resident #86's room. This failed practice was a random opportunity for discovery and had t...
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Based on observation, interviews, and record review the facility improperly stored Skin Protective Wipes in Resident #86's room. This failed practice was a random opportunity for discovery and had the potential to affect a limited number of Residents. Resident Identifiers: #86, #58, #17, #73, and #29. Facility census: 97.
Findings included:
a) Resident #86
Observation on 09/27/21 at 12:29 p.m., found four (4) Sure Prep Skin Protective Wipes and one (1) 4X4 gauze pad stored on Resident #86's over bed table in the Residents room. Resident #86 asked the Surveyor to put the items over on the sink and stated that they were in the way. Resident #86 stated They've been laying here [wheeled over the bed side table] since [Wound Care Nurse, Licensed Practical Nurse (LPN) #40's first name] left them there this morning.
Unit Manager, Registered Nurse (RN) #60, was brought into Resident #86's room and asked to verify if the supplies [Skin protective wipes] should have been stored on the over bed table, unattended by staff. Unit Manager, RN #60 stated the supplies should not have been left in room. RN #60 removed the supplies. Unit Manager, RN #60 asked Resident #86 if the nurse had already completed the treatment, or was about to use the supplies? The Resident stated, Yea, she already done it [skin treatment], those [supplies] are for tomorrow.
Review of Resident #86's medical record found an order to cleanse bilateral heels, pat dry, and apply sure prep [skin protectant wipes] twice a day for prophylaxis. Resident #86 has capacity with a Brief Interview for Mental Status score (BIMS) of 14 according to Quarterly Minimum Data Set (MDS) reported on 09/04/21. A score of 14 indicates the resident is cognitively intact.
b) Residents #58, #17, #73 and #29
Review of Safety Data Sheet provided by the facility for the Sure Prep Skin Protectant, manufacturer (Name of Manufacturer), verified to avoid contact of skin protectant wipes with eyes, do not ingest, and store in a segregated area. If ingested or eye exposure occurs, seek medical advice immediately. Wear protective gloves when handling.
Review of wandering residents for the B-Wing unit where Resident #86's room was located found the following Residents could have potentially accessed the Skin Protective wipes: Residents #58, #17, #73, and #29.
During an interview on 09/27/21 at 2:43 p.m., Wound Care Nurse, Licensed Practical Nurse (LPN) #40 stated, I guess I did leave them [skin barrier wipes and gauze] laying there when I done his treatment this morning, sorry about that. Wound Care Nurse, LPN #40 agreed the skin protective wipes could be hazardous if a Resident accidentally accessed and used the skin barrier wipe in an incorrect way. Wound Care Nurse, LPN #40 stated that the skin protective wipes should only been stored in the wound supply cart.
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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, record review, and staff interview, the facility failed to deliver respiratory care services consistent with professional standards of practice. The resident was receiving oxyg...
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Based on observation, record review, and staff interview, the facility failed to deliver respiratory care services consistent with professional standards of practice. The resident was receiving oxygen without a physician's order. This was a random opportunity for discovery. Resident identifier #246. Facility census: #97.
Findings included:
a) Resident #246
An observation of Resident #246, on 09/27/19 at 01:10 PM, revealed the Resident was receiving oxygen at three and half (3.5) Liters via nasal cannula (an oxygen delivery device) from an oxygen concentrator.
A review of the Resident #246's medical record on 09/28/21 at 9:12 AM, found no physician's order for use of oxygen.
A second observation on 09/28/21 09:40 AM, revealed Resident #246 was lying in bed receiving oxygen at three and half (3.5) Liters via nasal cannula.
An interview with Licensed Practical Nurse (LPN) #77, on 09/28/21 at 10:05 AM, verified Resident #246 was receiving oxygen at three and half (3.5) Liter Per Minute. LPN #77 confirmed Resident #246 was receiving oxygen without an active physicians order. LPN #77 stated that she would notify the physician at this time to obtain an oxygen order.
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CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0578
(Tag F0578)
Could have caused harm · This affected multiple residents
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d) Resident #10
On 09/27/21 at 12:45 PM, a review of the Physician's Order for Scope of Treatment (POST) form found the form was incomplete. The section containing the address, date of birth , last ...
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d) Resident #10
On 09/27/21 at 12:45 PM, a review of the Physician's Order for Scope of Treatment (POST) form found the form was incomplete. The section containing the address, date of birth , last four digits of the social security number and sex were left blank. Section E of the POST form with the Patient/Resident preferences as a guide for this POST form and the Medical Power of Attorney's (MPOA) address and telephone number were also blank.
On 09/27/21 at 12:46 PM, the Director of Nursing (DON) was notified.
On 09/28/21 at 10:57 AM, a review of the chart was completed. The corrected copy of the POST form had not been placed on the chart or uploaded to the Electronic Medical Record (EMR). No further information was obtained by the end of the survey process.
b) Resident #48
Record review on 09/28/21, revealed the section for Patient Information, Section D - (Medically Assisted Nutrition) and Section F (Health care provider)- on Resident #48's active Physician Order for Scope of Treatment Form (POST Form) was not completed.
During an interview on 09/28/21 at 11:12 AM, Social Worker (SW) #51 confirmed Resident #48's sections on patient Information, section D and section F on the POST form was incomplete.
A second interview on 09/28/21 at 12:05 PM, with staff #51 (SW) revealed, Resident #48's POST Form was corrected to reflect the Residents Advanced Directive wishes.
c ) Resident # 247
Record review on 09/28/21, revealed section for Patient Information, Section E - (Patient or Patient Representative Signature) and Section F (Health care provider)- on Resident #247's active Physician Order for Scope of Treatment Form (POST Form) was not completed.
During an interview on 09/28/21 at 11:12 AM, Social Worker (SW) #51 confirmed Resident #247's sections patient Information, section E and section F on the POST form was incomplete.
A second interview on 09/28/21 at 11:22 AM, with (SW) #51 revealed, Resident #247's POST Form was corrected to reflect the Residents Advanced Directive wishes.
Based on record review and staff interview, the facility failed to ensure residents Physician Order for Scope of Treatment (POST) form conveying end of life wishes was completed correctly. This is true for four (4) of six (6) residents reviewed. Resident identifiers: #88, #48, #247 and #10. Facility census: 97.
Findings include:
a) Resident # 88
Review of the POST form for Resident #88 found a physician signature dated 08/31/21. The resident signature and the unit manager #60 both signed the form but there is no evidence of the date this occurred.
Social worker #51 was made aware of this error on 09/28/21 at 11:10 AM.
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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, staff interview, and record review, the facility failed to store food in accordance with professional standards for food safety. This was a random opportunity for discovery dur...
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Based on observation, staff interview, and record review, the facility failed to store food in accordance with professional standards for food safety. This was a random opportunity for discovery during the long-term care annual survey. This has the potential to affect more than a limited number of residents. Facility Census: 97.
Findings included:
a) Tour of the kitchen
A tour of the kitchen began on 9/27/21 at 10:35 AM with the Dietary Manager (DM) #120.
b) Walk-in freezer
Observation revealed bags of mixed vegetables located in the walk-in freezer, that were open to air and not in a sealed bag. There was a box of lettuce that was open to air and not sealed. DM #120 explained that the food was shipped like that. DM #120 was asked ``How is it stored once you open the bag of vegetables? DM, We keep it in the blue bag, roll and tuck it.
c) Refrigerator
There was a personal bottle of soda stored in the same refrigerator as the resident snacks. A jar of expired apple sauce labeled June 2021. In addition, three pitchers of orange juice were not labeled to indicate when they were poured.
d) Milk Cooler
Observation of the milk cooler found staff cigarettes and drinks stored on top of the cooler.
DM #120 when asked, Is storing personal items on top of the cooler a standard of practice? The Dietary Manager stated, We allow staff to store their stuff here because they have no other place to put their belongings.
e) Dry food pantry
Observation found a bag of powdered sugar that was opened and not labeled. The powdered sugar was secured with saran wrap, but no date noted as when it was opened. The DM confirmed that the sugar should be labeled.
f) Nutrition rooms
A tour of the facility nutrition rooms began at 12:40 PM on 09/27/21 with Employee #27.
Observation of the 200 hall nutrition room found the following:
Two (2) two bottles of chocolate boost had expired dates. The first bottle expired on 06/12/21. The second bottle had a use by date of 06/20/21. Staff #27 confirmed that the boost should be discarded after the expiration date.
Observation of the 300-hall nourishment room with staff #27 found:
The microwave had brown and yellow discolored substances on the walls of the microwave. There were sticky substances inside. The top of the refrigerator was dusty. Staff #27 confirmed the microwaves needed to be cleaned.
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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** .
c) Resident #246
On 09/28/21 at 8:47 AM during medication administration, Resident #246's nasal cannula tubing was found lying...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
c) Resident #246
On 09/28/21 at 8:47 AM during medication administration, Resident #246's nasal cannula tubing was found lying on the nightstand. The nasal cannula tubing was not dated or placed in a respiratory bag. Licensed Practical Nurse (LPN) #77 was notified and stated I don't know why it's there .he probably went out to an appointment. LPN #77 proceeded to dispose of the nasal cannula tubing in the trash can.
On 09/28/21 at 8:57 AM, the Director of Nursing (DON ) was interviewed. No further information was received by the end of the survey.
b) Coronavirus Screening
On 09/27/21 at 01:51 PM, observation revealed a restaurant delivery man entering the facility and proceeding to the receptionist desk located in the lobby without wearing a mask. He continued to stand at receptionist service desk without wearing a mask or being screened for signs of Covid-19, while the Receptionist #36 tried to locate the staff who ordered the food.
During an interview on 09/27/21 at 01:59 PM, the Administrator stated the receptionist should have ask him to put a mask and eye protection on. The Administrator asked the delivery man to put a mask on at this time.
An Observation on 09/27/21 at 03:44 PM, revealed two (2) County rescue squad ambulance employees bringing a resident back to the facility. The two rescue squad employees continued through the building to the 300 hall, to the Residents room, without being screened for covid-19.
On 09/27/21 at 04:01 PM, the two (2) County rescue squad employees confirmed they were not screened when they entered the facility. They also stated no one from the facility stopped them or ask them to be screened.
During an interview on 09/28/21 at 01:55 PM, the Infection Control Nurse #41 stated she agrees the screening process does not follow the facility policy. Staff #41 stated the facility moved the receptionist/screener back to the desk in the lobby when they were not in outbreak, and they haven't moved the screener back to the entrance since they have a Covid -19 positive resident.
Based on observation, medical record review and staff interviews, it was determined that the facility failed to effectively screen and educate individuals who were permitted to enter the facility on appropriate Covid-19 precautions. In addition, the facility failed to maintain appropriate infection control standards for oxygen therapy for Resident #246. These failed practices had the potential to affect more than a limited number of\ residents residing at the facility. Resident identifier: #246. Facility census: 97.
Findings included:
a) Covid-19 Visitor Education and Hand Hygiene
Record review of the facility's policy titled IC405 Covid-19 revised on 06/07/21, showed direction for facility screening staff to provide Covid-19 education to all visitors, employees, and patients who were permitted entry to the facility.
Record review of the facility's IC405 Covid-19 policy's subsection titled Screening of Visitors and Employees, Return to Work Guidance for Employees, and Employees Workers Comp Procedures revised 07/26/21, showed the Visitor Instructions were to explain the infection control measures in place at the facility, including room confinement, wearing masks throughout the center, frequent hand washing or use of hand sanitizer, and social distancing. The policy's subsection also stated that visitors who are permitted need to be reminded to frequently perform hand hygiene.
During entry to the facility for the long-term care survey process on 09/27/21, 09/28/21, and 09/29/21, six (6) of six (6) Surveyors were not provided with any Covid-19 education or visitor instructions handouts; and none of the six (6) Surveyors were prompted to immediately or routinely perform hand hygiene upon entry.
During an interview on 09/29/21 at 9:44 a.m., Employee #36 (facility entry screener) was asked if any Covid-19 education was available to provide to visitors that were allowed entry. Employee #36 stated that two handouts were available if visitors asked about vaccines. Employee #36 provided the Surveyor with two separate fact sheets, both pertaining to Covid-19 vaccines.
The fact sheets were titled:
Fact Sheet for Recipients and Caregivers Emergency Use Authorization (EUA) of the Moderna Covid-19 Vaccine to Prevent Coronavirus Disease 2019 (Covid-19) In Individuals [AGE] years of age and Older revised 08/27/21.
Vaccine Information Sheet for Recipients and Caregivers About Comirnaty (Covid-19) Vaccine, mRNA) and Pfizer BioNTech Covid-19 Vaccine to Prevent Coronavirus Disease 2019 (Covid-19), revised 09/22/21.
During an interview on 9/29/21 at 10:38, the Infection Preventionist (IP) nurse stated, We just got too relaxed, we were without any Covid-19 cases for a short period of time and let things go. The IP nurse agreed the Covid-19 screening process does not meet the expectations of the facility's policy, the CDC (Center for Disease Control) recommendations, and visitor education. The IP nurse stated, Everyone should be stopped upon entry to the facility and asked to perform hand hygiene, even the employees. The IP nurse stated that the facility has a specific visitor instructions handout that should have been provided during the screening process. The IP nurse said corrective action would be taken to ensure proper procedures are carried out in the future.
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Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated
K - Pattern
L - Widespread
Actual Harm
G - Isolated
H - Pattern
I - Widespread
Potential for Harm
D - Isolated
E - Pattern
F - Widespread
No Harm (Minor)
A - Isolated
B - Pattern
C - Widespread
Questions to Ask on Your Visit
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • No major safety red flags. No abuse findings, life-threatening violations, or SFF status.
- • $3,250 in fines. Lower than most West Virginia facilities. Relatively clean record.
- • 29% annual turnover. Excellent stability, 19 points below West Virginia's 48% average. Staff who stay learn residents' needs.
Concerns
- • 48 deficiencies on record. Higher than average. Multiple issues found across inspections.
- • Grade C (51/100). Below average facility with significant concerns.
Bottom line: Mixed indicators with Trust Score of 51/100. Visit in person and ask pointed questions.
✓ Report will be sent to your email
About This Facility
What is Pierpont Center At Fairmont Campus's CMS Rating?
CMS assigns PIERPONT CENTER AT FAIRMONT CAMPUS 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 Pierpont Center At Fairmont Campus Staffed?
CMS rates PIERPONT CENTER AT FAIRMONT CAMPUS's staffing level at 2 out of 5 stars, which is below average compared to other nursing homes. Staff turnover is 29%, compared to the West Virginia average of 46%. This relatively stable workforce can support continuity of care.
What Have Inspectors Found at Pierpont Center At Fairmont Campus?
State health inspectors documented 48 deficiencies at PIERPONT CENTER AT FAIRMONT CAMPUS during 2021 to 2024. These included: 48 with potential for harm.
Who Owns and Operates Pierpont Center At Fairmont Campus?
PIERPONT CENTER AT FAIRMONT CAMPUS is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility is operated by GENESIS HEALTHCARE, a chain that manages multiple nursing homes. With 120 certified beds and approximately 111 residents (about 92% occupancy), it is a mid-sized facility located in FAIRMONT, West Virginia.
How Does Pierpont Center At Fairmont Campus Compare to Other West Virginia Nursing Homes?
Compared to the 100 nursing homes in West Virginia, PIERPONT CENTER AT FAIRMONT CAMPUS's overall rating (2 stars) is below the state average of 2.7, staff turnover (29%) is significantly lower than the state average of 46%, and health inspection rating (2 stars) is below the national benchmark.
What Should Families Ask When Visiting Pierpont Center At Fairmont Campus?
Based on this facility's data, families visiting should ask: "Can you walk me through typical staffing levels on day, evening, and night shifts?" "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" "Can I speak with family members of current residents about their experience?" These questions are particularly relevant given the below-average staffing rating.
Is Pierpont Center At Fairmont Campus Safe?
Based on CMS inspection data, PIERPONT CENTER AT FAIRMONT CAMPUS 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 Pierpont Center At Fairmont Campus Stick Around?
Staff at PIERPONT CENTER AT FAIRMONT CAMPUS tend to stick around. With a turnover rate of 29%, the facility is 17 percentage points below the West Virginia average of 46%. Low turnover is a positive sign. It means caregivers have time to learn each resident's needs, medications, and personal preferences. Consistent staff also notice subtle changes in a resident's condition more quickly. Registered Nurse turnover is also low at 24%, meaning experienced RNs are available to handle complex medical needs.
Was Pierpont Center At Fairmont Campus Ever Fined?
PIERPONT CENTER AT FAIRMONT CAMPUS has been fined $3,250 across 1 penalty action. This is below the West Virginia average of $33,111. While any fine indicates a compliance issue, fines under $50,000 are relatively common and typically reflect isolated problems that were subsequently corrected. Families should ask what specific issues led to these fines and confirm they've been resolved.
Is Pierpont Center At Fairmont Campus on Any Federal Watch List?
PIERPONT CENTER AT FAIRMONT CAMPUS 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.