How many inspection deficiencies does TYGART CENTER AT FAIRMONT CAMPUS have?

TYGART CENTER AT FAIRMONT CAMPUS has 61 deficiencies from recent inspections. None are at the Immediate Jeopardy level.

What are the staffing levels at TYGART CENTER AT FAIRMONT CAMPUS?

TYGART CENTER AT FAIRMONT CAMPUS has a two-star staffing rating from CMS with 0.67 RN hours per resident per day. This rating is based on registered nurse (RN), licensed practical nurse (LPN), and nurse aide staffing hours.

Where is TYGART CENTER AT FAIRMONT CAMPUS located?

TYGART CENTER AT FAIRMONT CAMPUS is located in FAIRMONT, WV. It is a Medicare and Medicaid certified skilled nursing facility.

How many beds does TYGART CENTER AT FAIRMONT CAMPUS have?

TYGART CENTER AT FAIRMONT CAMPUS has 119 certified beds.

Who owns TYGART CENTER AT FAIRMONT CAMPUS?

TYGART CENTER AT FAIRMONT CAMPUS is a for profit - corporation facility and is part of the GENESIS HEALTHCARE chain.

How does TYGART CENTER AT FAIRMONT CAMPUS compare to other nursing homes?

TYGART CENTER AT FAIRMONT CAMPUS has a 2-star overall rating, which is below average compared to other nursing homes in WV. Families should carefully review inspection findings and consider alternatives.

TYGART CENTER AT FAIRMONT CAMPUS

Name: TYGART CENTER AT FAIRMONT CAMPUS
Address: 1539 COUNTRY CLUB ROAD, FAIRMONT, WV, 26554, US
Telephone: (304) 366-9100
Rating: 2.0

1539 COUNTRY CLUB ROAD, FAIRMONT, WV 26554 · (304) 366-9100

For profit - Corporation 119 Beds GENESIS HEALTHCARE Data: November 2025

Trust Grade

43/100

#88 of 122 in WV

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Photo by Tygart Center at Fairmont Campus

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Last Inspection: May 2025

Inspected within the last 6 months. Data reflects current conditions.

Overview

Tygart Center at Fairmont Campus has received a Trust Grade of D, indicating below-average performance with some concerns about care quality. They rank #88 out of 122 nursing homes in West Virginia, placing them in the bottom half of facilities in the state, and #5 out of 6 in Marion County, meaning only one local option is better. The facility is experiencing a worsening trend, with issues increasing from 20 in 2023 to 24 in 2025. Staffing is a relative strength, with a turnover rate of 36%, which is below the West Virginia average of 44%, and they have good RN coverage, exceeding 79% of state facilities. However, they have faced some significant compliance issues, including a serious incident where a resident sustained a laceration requiring 16 stitches due to improper transfer, and concerns about inaccurate staffing records and pest control, indicating ongoing operational challenges.

Trust Score: D
In West Virginia: #88/122
Safety Record: Moderate
Inspections: Getting Worse
Staff Stability: 36% turnover. Near West Virginia's 48% average. Typical for the industry.
Penalties: $8,278 in fines. Lower than most West Virginia facilities. Relatively clean record.
Skilled Nurses: Each resident gets 39 minutes of Registered Nurse (RN) attention daily — about average for West Virginia. RNs are the most trained staff who monitor for health changes.
Violations: 61 deficiencies on record. Higher than average. Multiple issues found across inspections.

★★☆☆☆

2.0

Overall Rating

★★☆☆☆

2.0

Staff Levels

★★☆☆☆

2.0

Care Quality

★★☆☆☆

2.0

Inspection Score

↔

Stable

2023: 20 issues

2025: 24 issues

The Good

Full Sprinkler Coverage · Fire safety systems throughout facility
No fines on record
Staff turnover below average (36%)
12 points below West Virginia average of 48%

Facility shows strength in fire safety.

The Bad

2-Star Overall Rating

Below West Virginia average (2.7)

Below average - review inspection findings carefully

Staff Turnover: 36%

10pts below West Virginia avg (46%)

Typical for the industry

Federal Fines: $8,278

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 61 deficiencies on record

1 actual harm

May 2025 19 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

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Based on record review, resident interview and staff interviews, the facility failed to ensure food choices were obtained and honored. This was true for one (1) of six (6) residents reviewed during the annual survey process. Resident identifier: #309. Facility census: 106 Findings included: a) Resident #309 On 04/29/25 at 10:32 AM, during an interview with Resident #309, the resident stated they had not been asked about food choices. The Resident said, They just bring me whatever they want, if I like it, I eat it. If I don't like it, I just go without. When asked if anyone had told them about the Always Available menu, they were not aware of it. When asked if anyone had asked what they liked and disliked food-wise, they stated, no. On 05/06/25 at 10:53 AM, a phone interview was completed with the dietician. When asked to describe the process of obtaining newly admitted resident's food choices, the dietician stated that within 24 hours of admission [NAME] #124, was supposed to obtain the food preferences from the resident. The dietician further stated she did the nutritional assessment within 14 days of admission. During an interview with [NAME] #124 at 10:59 AM on 05/06/25, when asked about Resident #309's food choices, the [NAME] stated, I will be honest, I am supposed to get the food preferences within 24 hours of admission, but I am doing two people's jobs right now, and I have not gotten around to interviewing the resident about their food choices. [NAME] #124 said the resident could ask her Nurse Aid to obtain what the menu was for the day, and if they did not like it, then the staff could get them something else from the Always Available Menu. When asked how the resident would know to ask the Nurse Aid about obtaining the menu for the day, [NAME] #124 did not have an answer. The resident's care plan was a 24-hour baseline care plan, and no food preferences were listed on the care plan. A review of the facility's Person Center Choice, Food and Nutrition Services revealed Director of Dining Services/Director of Culinary Services or designee visits resident within 48 hours of admission to introduce Food and Nutrition Services, the meal offerings, and gather any food preferences. Residents may pre-select their meals by Personal Choice Menus. The conclusion is that the resident was not visited by the Dietary Department to obtain food preferences, nor was this resident given a Personal Choice Menu.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Abuse Prevention Policies (Tag F0607)

Could have caused harm · This affected 1 resident

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Based on observation, record review and staff interview the facility failed to implement their abuse prohibition policy by ensuring allegations of mental/emotional abuse were reported to the required state agencies within the required time frames. This was a random opportunity for discovery for Resident #93. Resident identifier: #93. Facility Census: 106. Findings Include: a) Resident #93 On 05/01/25 at approximately 1:20 PM while passing through the dining room this surveyor overheard a nurse (later Identified at LPN #133) say to Resident #93, You can't have your pain medicine until you eat at least half of your food. The nurse then left the dining room. This was reported to facility staff immediately after the observation. Facility staff intervened and had the nurse give Resident #93 her Tylenol. An interview with the resident in the dining room prior to the nurse returning found she did not feel like eating because her arm was hurting. She then stated, They told me I had to eat to get my medicine. A review of the medical record found Resident #93's order for the as needed Tylenol did not contain any special directions to indicate the resident had to eat prior to getting the medication. On 05/05/25 at 4:53 the Person in Charge (PIC), the Director of Nursing (DON), Corporate Registered Nurse (CRN) #131 was asked if this allegation was reported to the required state agencies. They all agreed it had not been reported. The DON stated, The nurse did give her the medication. However, this did not occur until after surveyor and management intervention. The PIC stated to the surveyor, If you felt like it was abuse why didn't you say that. According to the facility's abuse prohibition policy with an effective date of 07/01/13 and a revision date of 10/24/22 the facility will, Immediately upon receiving information concerning a report oof suspected or alleged abuse, mistreatment or neglect, the Administrator or designee will perform the following. 7.2 Report allegations involving abuse (physical, verbal, sexual, mental) not later than 2 hours after the allegation is made 7.4 Report allegations to the appropriate state and local authority (S) involving neglect, exploitation or mistreatment (including injuries of unknown source), suspected criminal activity, and misappropriation of patient property within 24 hours after the allegation is made if the event does not result in serious bodily injury.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Report Alleged Abuse (Tag F0609)

Could have caused harm · This affected 1 resident

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Based on observation, record review and staff interview the facility failed to ensure all allegations of mental abuse were reported to the required state agencies with in the required time frames. This was a random opportunity for discovery and as true for Resident #93. Resident Identifier: #93. Facility Census: 106. Findings Include: a) Resident #93 On 05/01/25 at approximately 1:20 PM while passing through the dining room this surveyor overheard a nurse (later Identified at LPN #133) say to Resident #93, You can't have your pain medicine until you eat at least half of your food. The nurse then left the dining room. This was reported to facility staff immediately after the observation. Facility staff intervened and had the nurse give Resident #93 her Tylenol. An interview with the resident in the dining room prior to the nurse returning found she did not feel like eating because her arm was hurting. She then stated,They told me I had to eat to get my medicine. A review of the medical record found Resident #93's order for the as needed Tylenol did not contain any special directions to indicate the resident had to eat prior to getting the medication. On 05/05/25 at 4:53 the Person in Charge (PIC), the Director of Nursing (DON), and the Corporate Registered Nurse (CRN) #131 was asked if this allegation was reported to the required state agencies. They all agreed it had not been reported. The DON stated, The nurse did give her the medication. However, this did not occur until after surveyor and management intervention. The PIC stated to the surveyor, If you felt like it was abuse why didn't you say that.

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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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident interview and staff interview, the facility failed to develop and/or implement the care plans for three (3) of 42 sample residents. Resident identifiers: #48, #9, and #309. Facility Census: 106. Findings Include: a) Resident #48 An interview with Resident #48 on 04/2925 at 12:46 PM found she was a hemodialysis patient. She stated, They use the port in my groin for now, but I have one in my upper arm that needs to mature. A review of Resident #48's medical record found she returned from the hospital on [DATE] after the placement of an Arteriovenous Fistula (AVF) in her left upper arm. A review of Resident #48's care plan found it was void or any mention of the residents AVF in her left upper arm. An interview with the Director of Nursing (DON) on the afternoon 05/06/25 confirmed a care plan was not developed for Resident #48's AVF. The facility failed to develop and or implement the care plan. PS RL a) #48 AVF b #9 contractures ASC c) #309 incomplete blanks KW Resident #48 Dialysis 698 Based on record review, resident interview and staff interview the facility failed to ensure Resident #48 who require dialysis received such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences. This was true for one (1) of one (1) resident reviewed for the care area of dialysis. 656 Based on record review and staff interview the facility failed to ensure Resident #48's care plan was updated after the surgical placement of an AV fistula to her left upper arm. This was true for one (1) of care plans reviewed during the long term care survey process. 04/29/25 12:46 PM Resident recieves dialysis. She has port i her groin she said it is uncomfortable she stated she had one in her chest but she pulled it out some how. She stated that she has a graft in her left arm she states she listens too it and if she dont here it she will tell them Inter view with [NAME] Rn she stated that they really dont do any thing with the istuala becuase they are not using it. She said dialysis told them they did not need to do the buit and thril b) Resident #9 On 04/29/25 at 10:00 AM, a record review was completed for Resident #9. The review found the resident had contractures of the left and right knee. Further review found the bilateral contractures of the knees were not listed in the care plan. On 04/30/25 at 1:13 PM, the Director of Nursing (DON) confirmed the bilateral contractures were not on the care plan. c) Resident #309 Resident #309 was admitted on [DATE]. A review of Resident #309's care plan on 05/06/25 showed the care plan had not been personalized in terms of the assistance needed for toileting, transfers, bathing, etc. There were incomplete blanks where someone who was completing the care plan should fill in the blanks.

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 care plan for a change in code status for Resident #99. This is true for one (1) of four (4) residents reviewed under the care area of advanced directives. Resident Identifier: #99. Facility Census: 106. Findings Include: a) Resident #99 On 05/05/25 at 2:15 PM, a record review was completed for Resident #99. The review noted the [NAME] Virginia Physician's Order for Scope of Treatment (POST) form was Do Not Resuscitate, Comfort Measures and no artificial means of nutrition, which was dated 03/03/25. However, the care plan indicated the resident was a full code. On 05/05/25 at 3:10 PM, the Director of Nursing (DON) confirmed the care plan had not been revised to indicate the change in code status.

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

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to provide activities of daily living for dependent Resident #259 and #35. This was true for two (2) of four (4) residents reviewed under the care area of activities of daily living. Resident identifiers: #259 and #35. Facility Census: 106. Findings Include: a) Resident #259 On 05/06/25 at 8:15 AM, a record review was completed for Resident #259. The review found the resident did not receive showers or bed baths for the timeframe of 03/21/25 through 03/28/25; which is seven (7) days. The resident was listed as dependent for showers and bed baths on the discharge Minimum Data Set (MDS) dated [DATE]. On 05/06/25 at 9:00 AM, the Director of Nursing (DON) confirmed there was no documentation to indicate the resident received showers and/or bed baths for the seven (7) days between 03/21/25 and 03/28/25. b) Resident #35 During an interview with resident on 04/29/25 at 01:38 PM she reported that she would like a shower at least once per week and that she does not currently get one that often. On 04/30/25 at 4:31 PM a review of the Minimum Data Set Assessment (MDS) section F dated 03/05/25. Question C. How important is it to you to choose between a tub bath, shower, bed bath or sponge bath. The resident's recorded response was entered 1.Very important. On 05/05/25 at 11:06 a review of care plan for resident revealed the following: Focus: Resident/Patient requires assistance/is dependent for ADL care in bathing, grooming, personal hygiene, dressing, eating, bed mobility, transfer, locomotion, toileting related to: limited mobility. Interventions: Provide resident/patient with Substantial/ maximal assist of one for personal hygiene (grooming). On 05/05/25 a review of shower tasks shows that resident had a shower on 04/10/25 and did not receive another shower until 04/28/25. On 05/06/25 at 11:00 AM. Interview with Director of Nursing DON who acknowledge that Resident did not have showers between 04/10/25 and 04/28/25 and that resident would prefer at least one shower per week and not just bed baths.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0698 (Tag F0698)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident interview and staff interview the facility failed to ensure Resident #48 who required dialysis received such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences. This was true for one (1) of one (1) residents reviewed for the care area of dialysis during the long-term care survey process. Resident identifier: #48. Facility Census: 106. Findings Include: a) Resident #48 A review of Resident #48's medical record on 05/05/25 found the resident received dialysis on Monday, Wednesday and Friday at a local dialysis center. Each day the facility completed and sent with the resident a Hemodialysis communication sheet. The sheet consisted of three (3) Sections. The first and third were to be completed pre and post dialysis by the facility's nurse. The middle section is to be completed by the dialysis center. A review of the electronic medical record found the following missing dialysis communication sheets: 03/03/25 03/14/25 03/17/25 04/02/25 04/25/25 The facility had the following sheets however they were not completed in their entirety: 03/24/25 03/31/25 04/04/25 04/28/25 and 05/02/25. The post dialysis section was blank and not completed by the nurse upon the residents return to the facility. This was confined with the Director of nursing on the afternoon of 05/06/25. An interview with Resident #48 on 04/2925 at 12:46 PM found she was a hemodialysis patient. She stated, They use the port in my groin for now, but I have one in my upper arm that needs to mature. A review of Resident #48's medical record found she returned from the hospital on [DATE] after the placement of an Arteriovenous Fistula (AVF) in her left upper arm. A nursing note in the medical record indicated the resident had asked nursing staff to write it down so they would remember to monitor her AVF because she forgot her stethoscope at the hospital and was having anxiety over this. Further review of the record found no physician order and/or care plan to monitor the AVF for the Bruit and thrill as requested by the hospital. This was confirmed with the DON on the afternoon of 05/06/25. A review of Resident #48 medical record on 05/06/25 found a diet order which indicated the resident should not have tomatoes and oranges. The care plan did indicate the resident would at time request tomato soup or a food item with tomatoes in it. A review of the menu for the noon time meal on 05/06/25 found the two (2) choices were option 1 tomato soup and a grilled cheese or option 2 Taco with Mexican Rice. Both options came with oranges as the fruit. Both options also contained tomato products. An observation of Resident #48's lunch meal found she was served the taco with tomatoes and lettuce on the side along with the Mexican rice. Also on her tray was a cup of oranges. She was also served a bowl of chicken noodle soup. Resident #48 looked at her meal and stated, I did not ask for the taco and rice. I just wanted this soup and some pudding. She then opened the lid to the oranges and stated, I can't have this. I wanted pudding. Nurse Aide #26 confirmed what was on the residents tray and indicated she would go get her a pudding. The previous Nursing Home Administrator #92 later in the afternoon of 05/06/25 brought in a meal selection sheet and indicated the resident had chosen option 2 this morning with the activities department. The form she provided also had written on it chicken noodle soup and pudding. NHA #92 indicated that was what she told them she wanted for dinner. When it was pointed out that both meal options contained tomatoes NHA #92 remained silent.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Drug Regimen Review (Tag F0756)

Could have caused harm · This affected 1 resident

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Based upon record review and staff interview, the facility failed to ensure they maintained the requirements of their policy for the time allotted for the physician to respond to gradual dose reduction recommendations from the pharmacist. The facility also failed to ensure the pharmacist identified the need for possible gradual dose reduction for a resident receiving an antidepressant. This was found to be true for 1 (one) of 42 (forty-two) residents reviewed during the annual survey process. Resident identifier: #50. Facility census: 106. Findings included: a) Resident #50 Record review revealed the resident had a physician's order for: Mirtazapine Tablet 7.5 MG (Remeron) Give 2 tablets by mouth at bedtime for depression The Medication Regimen Review reports for 02/27/25 and 12/28/24, had a notation which revealed there was a more detailed report. On the detailed report for 12/28/24, the pharmacist recommended a Gradual Dose Reduction (GDR) review for Mirtazapine. The attending physician failed to provide the response within the facility's 30 calendar day time-frame per their Medication Regimen Review and Reporting Policy. When the physician failed to provide feedback on the recommendation, the pharmacist followed up with the attending physician on 02/27/25. The physician provided a response on 03/05/25 to maintain current dosage, with note See physician progress notes for clinical rationale. The last gradual dose reduction was 05/2024. On 04/30/25 at 1:47 PM, the surveyor requested to see if there were any more GDR reviews after 05/2024. DON responded around 3:30 pm on the same day, There were no GDR reviews after 12/28/24, and provided a printed GDR Summary Report. This report documented the next intended GDR review was due in 02/25. DON stated she would need to follow-up with the Pharmacist to see what happened that this was not completed. No further information was provided prior to the survey exit.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0947 (Tag F0947)

Could have caused harm · This affected 1 resident

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Based upon record review and staff interview, the facility failed to ensure nurse aides completed 12 hours of required education annually. This was found to be true for one (1) of five (5) nurse aide personnel files reviewed during the annual survey process. Staff identifier: #46. Facility census: 106. Findings included: a) Nurse Aide (NA) #46 Nurse Aide #46 completed 9 hours and 34 minutes of education during the calendar year 2024. She completed 24 minutes of education on dementia. This was reviewed with the DON on the morning of 05/06/25, and asked if she had any additional education for this Nurse Aide to support the 12 hours required training, to please provide it No additional education was supplied prior to the survey exit.

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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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, the facility failed to ensure resident's rooms were a clean and homelike environment (residents' privacy curtains were stained). This is true for Resident #94 and Resident #133. Findings included: a) On 04/29/25 at 9:45 AM an observation of Resident #94's room revealed that her privacy curtain was dirty with stains. On 04/29/25 at 9:50 AM an interview was conducted with Licensed Practical Nurse #133 who acknowledged that the curtain in Resident #94's room needed cleaned. She stated that generally when they see them dirty they will contact house keeping to be cleaned, b)On 04/29/25 at 12:53 PM during an interview with Resident #103, stains on his privacy curtain were observed and he stated it was vomit. Based on observations and staff interviews, the facility failed to ensure a safe, clean, comfortable and homelike environment for three (3) residents. Resident identifiers: #82, #65, and #3. Room identifiers: #404, #400, #412. Facility census: 106. Findings include: a) room [ROOM NUMBER] 04/29/25 at 1:17 PM, the following issues were observed in room [ROOM NUMBER]. In the bathroom areas there were screws sticking out of the drywall on the left side wall. There was an unfinished dry wall patch on the right-side wall. Resident #82 resided in this room. b) room [ROOM NUMBER] On 04/29/25 at 11:53 AM the following issues were observed in room [ROOM NUMBER]'s room. In the bathroom screws sticking out of the bathroom dry wall in the paint on right side wall. Resident #65 resided in this room. c) room [ROOM NUMBER] On 4/29/25 at 1:355 PM the following issues were observed in room [ROOM NUMBER]. In the bathroom there were unfinished dry wall patches to the left of the sink above the towel rack. Resident #3 resided in this room. During a walk through and interview with the DON on 04/30/25 at 10:55 AM, she acknowledged the bathroom areas were not in good repair for room [ROOM NUMBER], #404, #412 and stated she would report to maintenance for repairs.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0628 (Tag F0628)

Could have caused harm · This affected multiple residents

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c) Resident #85 A review of Resident #85's medical record found the following transfers to the hospital 08/09/24, 08/31/24, 09/06/24,and 10/22/24. Resident #85 went on therapeutic leave of absence on 11/27/24. On the afternoon of 05/06/25 the facility was asked to provide the notice of the transfer, the bed hold agreement, and the ombudsman notification for each of the aforementioned discharges. Later in the afternoon on 05/06/25 the Person In Charge provided two incomplete Bed Hold Notices dated 08/31/24 and 09/06/24. The only information completed on the form was the residents name and medical record number along with the nursing signature. On the form date 08/31/24 the nurse signed both the resident and the center representative space. On the form dated 09/06/24 the nurse signed the center representative space and documented a verbal notification of the resident representative. Neither form contained the number of bed hold days remaining. No other information was provided for the discharges. The PIC stated, This is all we have. He confirmed he could not find any of the notifications to the Office of the State Long Term Care Ombudsman. He had no other information to provide. d) Resident #17 On 04/29/25 at 12:42 PM, a record review was completed for Resident #17. The review found the resident had been hospitalized on two (2) occasions for complaints of chest pain, (10/23/24 and 12/20/24). Upon further review, the Office of the State Long Term Care Ombudsman had not been notified of either hospitalization. On 05/01/25 at 1:20 PM, the Director of Nursing (DON) was notified and confirmed the Office of the State Long Term Care Ombudsman was not notified for either hospitalization. d) Resident #20 The facility failed to notify the resident and the resident's representative(s) of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand. The facility must send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman. 05/06/25 12:35 review of Hospitalizations for Resident on 04/22/25 and 04/02/25. Bed Holds and Notice of Transfer was completed for both dates. 3/3/25 bed hold policy was completed with no transfer notice or ombudsman notification. No record of Ombudsman notification. 05/06/25 1:50 PM interview with Person in Charge who reported that they did not have any documentation that the transfer notice had been copied to the Ombudsman that they had changed offices and lost the book the notices were kept in. Based upon record review and staff interview, the facility failed to notify the resident and the resident's representative(s) of the transfer or discharge, including the reasons for the move in writing, in a language and manner they understood. The facility also did not send a copy of the notices to the Office of the State Long-Term Care Ombudsman. This was found to be true for 5 (five) of 6 (six) resident records reviewed during the annual survey process. Resident identifiers: #40, #66, #85, #17. Facility Census: 106. Findings included: a) Resident #40 On 02/11/25, Resident #40 was transferred to an acute care hospital. A Notice of Transfer was completed on 02/11/25, but no reason for the transfer was marked on the form. The form stated the facility representative notified someone verbally, but did not provide the name of person notified. The form was not counter signed by a second person as a witness. A copy of the notice was not sent to the Office of the State Long-Term Care Ombudsman. The Bed Hold Notice and Authorization form was also initiated on 02/11/25, and stated, Verbal consent obtained. However, the form does not specify who verbal consent from obtained from. b) Resident #66 Resident #66 was transferred to an acute care facility on 12/16/24. A Notice of Transfer or Discharge Form was completed on 12/16/24 by a facility representative. The form stated a verbal notification was done on 12/16/24, but did not provide the name of the person who gave the consent. The form was not counter signed by a second person as a witness. A copy of the Notice of Transfer or Discharge form was not sent to the Office of the State Long-Term Care Ombudsman. During an interview with the DON on 05/01/25, the DON stated they did not have anything to show that the Notice of Transfers for Resident #40 or #66 were sent to the Office of the State Long Term Care Ombudsman.

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

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b) Resident #20 A review of the Resident #20's medical record on the after noon of 04/30/25 found Resident #20 sustained a fall on 03/12/25 at 5:30 PM. The incident report indicated neurological assessments were done per policy. The facility was asked to provide the completed neurological assessments related to this fall. On 05/01/25 at 9:08 AM the Director of Nursing (DON) stated they could not locate the neurological assessments for this fall. Based on record review and staff interview, the facility failed to discontinue wound treatment for Resident #21, when the wound was healed and failed to complete neurological (neuro) checks for Resident #20. This was true for two (2) of 42 residents reviewed during the survey process. Resident Identifiers: #21 and #20. Facility Census: 106. Findings Include: a) Resident #21 On 05/06/25 at 2:55 PM, a record review was completed for Resident #21. The review found an active physician's order for wound care to the resident's left gluteus. The wound treatment was cleanse left gluteus with IHWC (in-house wound cleanser), pat dry. Apply hydrogel and an Opti foam dressing every 3 (three) days and PRN (as needed). (Typed as written.) However, the wound was resolved on 04/07/25. The facility continued to treat the abrasion 10 more times before the physician's order was discontinued. On 05/06/25 at 3:30 PM, an interview was held with Registered Nurse (RN) #32. RN #32 stated, The wound was resolved on 04/07/25 .I should've discontinued the order .it was my fault. On 05/06/25 at 3:50 PM, the Director of Nursing (DON) was notified and confirmed the wound treatment should have been discontinued on 04/07/25.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0697 (Tag F0697)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation record review staff interview and resident interview the facility failed to ensure Resident #21, and Resident #22 received the treatment and care in accordance with professional standards of practice, the comprehensive care plan, and the resident's choices, related to pain management. This was true for two (2) of 10 residents reviewed for the care area of pain during the long-term care survey process. Resident identifiers: #21, and #22. Facility Census: 106. Findings Include: a) Resident #21 On 04/29/25 at 1:36 PM Resident #21 stated, she had been asking them for pain medication, and they had not given her any yet. The resident was asked to rate her pain on a scale from zero (0) to ten (10) with zero (0) being no pain and ten (10) being the worst pain ever. Resident #21 stated that her pain was an eight (8). The surveyor immediately reported Resident #21's pain level to Registered Nurse (RN) #10. RN #10 stated, I told her she could not have any just yet because it had not been 12 hours since her last dose. RN #10 then stated, Well I guess I could call the Doctor to see if I can give her a dose now. Less than five (5) minutes later RN #10 returned to Resident #21's room and stated, The doctor changed your pain meds to one (1) every eight (8) as needed instead of every 12 hours. The resident stated I'm glad they changed it, but I wish they would have done it sooner. A review of Resident #21's medical record on 05/05/25 found it included the following physician orders pertaining to pain management: -- OXY Codone 5 milligrams every 12 hours as needed for pain. This order began on 01/29/25 and ended on 04/29/25. -- OXY codone 5 milligrams every eight (8) hours as needed for pain. This order began on 04/28/25 and ended on 05/01/25. -- OXY Codone 5 milligrams every eight (8) hours as needed for pain. This order began on 05/01/25 and was the current order at the time of this review. Further review of the medical record found when the resident receives a pain medication which is documented on the Medication Administration Record (MAR) the facility will document the pain level at the time of administration and a half to one (1) hour later will evaluate the effectiveness of the pain medication. Upon further review of Resident #21's medical record, a comparison of the MAR and the controlled substance log was completed. This comparison revealed the following days and times Resident #21's oxycodone was signed out on the controlled substance log but the nurse failed to document it as administered on the MAR therefore the effectiveness of the medication was not evaluated. The dates and times are as follows: -- 02/14/25 - 3:30 pm -- 02/18/25 - 8:00 am -- 03/01/25 - 2:25 PM -- 03/07/25 - 9:00 AM -- 03/11/25 - 8:00 PM -- 03/14/25 - 4:30 PM -- 03/23/25 - 8:00 am -- 04/06/25 - 12:00 am. An interview with the Director of Nursing (DON) on 05/6/25 at 1:00 PM confirmed the above findings. She stated, I'll look to see if I can find anything where we evaluated the effectiveness of the PRN pain medication on these dates. No further information was provided prior to the time of exit on 05/06/25. 04/29/25 01:36 PM Resident stated at 1 pm that she had been asking them for Pain medicine and they have not gave it to her yet she rated her pain at an 8. Told the RN on duty that the resident was asking for her pain medication. She stated that it had not been a full 12 hours since she had her last dose she said it was almost time. She then stated that she would call the Dr. She came in within minutes. And told the resident that she called the dr and it was now going to be every 8 hours . The resident was pleased but did not understand why they did not do it sooner. Interview with the DON 05/06/25 09:41 AM she stated that it was a cycle with her they tried therapy, and she said that hurt. Then they set up an ortho appointment and then she refused to get out of bed to go to the ortho she stated that she had refused so much that the ortho will not see her anymore. She confirmed the meds are signed out on the controlled substance log and the MAR stated that the pain was assessed when it puts it in the e-mar. b) Resident #22 During an interview with Resident #22 on 04/29/25 at 2:28 PM she stated she had been having a lot of trouble with pain. She stated she had a pill this morning, but it had worn off and her leg was still hurting badly. She indicated she still had to do therapy, and she was worried she would not be able to. A review of Resident #22's medical record found the resident sustained a fall at home and fractured her hip. During her hospital stay they indicated the resident was not a candidate for surgical repair and left the hip unrepaired. She was sent to the facility for therapy with the goal of returning home. During the review of the medical record on 05/05/25 the following orders were found pertaining to pain management: -- Oxycodone 5-325 every four hours as needed for pain. This was the effective order from 04/03/25 to 04/05/25. (Resident was admitted to the facility on [DATE]). -- Oxycodone 10-325 milligrams (MG) every six (6) hours as needed for pain. This was the effective order from 04/05/25 to 04/09/25. -- Oxycodone 10-325 milligrams (MG) every six (6) hours as needed for pain for five (5) days. This was the effective order from 04/09/25 to 04/13/25. -- Oxycodone 7.5 mg every 6 hours as needed for pain. This was the effective order from 04/14/25 to 04/21/25 -- Oxycodone 5 mg every 12 hours as needed for pain. This was the effective order from 04/24/25 to 04/29/25. -- Oxycodone 5 mg every 6 hours beginning on 04/29/25 and was the current order at the time of this review. Upon further review of Resident #22's medical record a comparison of the MAR and the controlled substance log was completed. This comparison found on the following days and times Resident #22's oxycodone was signed out on the controlled substance log, but the nurse failed to document it as administered on the MAR therefore the effectiveness of the medication was not evaluated. The dates and times are as follows: -- 04/13/25 at 8:00 PM -- 04/18/25 at 2:00 PM During an interview with the Director of Nursing (DON) on 05/06/25 at 9:41 AM, the DON indicated Resident #22 really liked her pain pills. When asked about the fractured hip which had not been repaired the DON stated, She waited three weeks to go to the hospital so her tolerance for pain must be high. The DON indicated the resident had refused to take Ultram. When asked to provide documentation to indicate the resident had refused Ultram, she was unable to do so.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0804 (Tag F0804)

Could have caused harm · This affected multiple residents

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Based on observation, resident interview and staff interview the facility failed to ensure Resident Meals were served, which were palatable and at an appetizing temperature. This failed practice has the potential to affect more than an isolated number of Residents. Facility Census: 106 a) Resident #6 During an interview with Resident #6 on 04/29/25 at 10:27 AM, Resident stated food was terrible here. When I asked her if it was not the proper temperature, did not taste b) Resident #11 On 04/29/25 at 1:43 PM during an interview, Resident #11 reported the food has no taste, sometimes it is too cool, and she was concerned about the nutritional status. She went on to report on the facility does not serve fresh fruits or veggies and the food has no seasoning and is not appealing. c) Resident #35 On 04/29/25 at 1:38 PM during an interview, Resident #35 reported the food does not taste good. She also reported that she has never been told about an always available menu. d) Resident #21 During an interview with Resident #21 on 04/29/25 at 1:30 PM the resident indicated the food here is terrible. She stated, sometimes its cold when we get it and she was supposed to have yogurt with every meal but most of the time she does not get it. The surveyors tasted the lunch meal on 05/05/25. The meal consisted of fried potatoes, pinto beans, macaroni and cheese and broccoli. The meal was tasted by four (4) surveyors. All four agreed the Macaroni and Cheese was overcooked and not seasoned, and the broccoli also was overcooked and not seasoned. On 05/05/25 at 12:53 PM the corporate dietary manager obtained the temperatures of a test tray. The temperatures were taken immediately after the last resident received their meal. All items were at the proper temperature except for fried potatoes. The temperature of the potatoes was 113 degrees Fahrenheit.

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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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** e) Reheated food during the noon time meal service o 05/05/25. An observation of the noon time meal on 05/05/25 at 12:35 PM, found [NAME] #124 reheated broccoli which was previously held for service but fell below the acceptable temperature of 135 degrees Fahrenheit (F). She reheated the broccoli to a degree of 160 degrees f. Dietary Account Manager #96 told her 160 degrees F was an acceptable temperature and it was okay to serve the broccoli. [NAME] #124 then served the reheated broccoli. An interview with the corporate account manager at 2:04 PM on 05/05/25 confirmed the broccoli should have been reheated to 165 degrees F. He stated, They told me that but there was not much to do about it after the fact. Based on observation, resident interview, and staff interviews, the facility failed to distribute and serve food in accordance with professional standards for food service safety, to ensure meals were served at a palatable, appetizing and temperature, safe and sanitary manner, preventing the spread of food-borne illnesses, and also failed to reheat food to the required temperature prior to serving. These were random oppotunities of discovery with the potential to effect a great number of residents. Facility Census 106 Findings include: Dining Room: Based on observations and staff interviews, the facility failed to distribute and serve food in accordance with professional standards for food service safety regarding to: Dining room observation of drinks being served without proper hand hygiene: 04/20/25 During the dining room observation at 12:35PM, Employee #82 walked from the counter where the food was being served over to resident # 81 and touched her on the shoulder then over to resident #54 picked up a cup and went back to the counter poured a drink into the cup and served it to resident #54 without washing or sanitizing her hands. Staff interview: 04/29/25 at 12:43PM in an interview with The Person in charge, he acknowledged the employee should have sanitized her hands before serving the resident. Kitchen a) Hairnets and beard nets not worn in the kitchen: 04/29/25 10:12 AM During the initial visit to the kitchen,The Dietary Account Manager was working in the kitchen, wearing a ballcap but not wearing a hairnet nor a beard net. The hair on the back of his head was visible and not covered completely. Intital Kitchen Visit Staff Interview: In an interview with the Dietary Account Manager, at approximately 10:30 Am on 4/29/25, He stated he was not aware that he had to have a hairnet on if he wore a hat. He also stated that his beard was very short and thought it had to be longer to have to wear a beard net. 2nd Kitchen Visit: 4/30/25 11:45 During the follow up kitchen visit, the cook was working in the kitchen wearing a ball cap exposing hair around the back of the neck, not completely covered. He also had a beard that was not covered. 2nd Visit Staff Interview: In an interview with the District manager on 4/30 25 at 1150 PM, He stated he was not aware the ball cap was not a sufficient covering but, he stated, the cook should have been wearing his beard net. b) 400 Hall Nourishment Room Obervations: Staff personal belongings, drink cups, and open containers: On 4/30/25 1:45PM, during a check in the Nourishment room on the 400 hall, it was observed there were drinks in [NAME] cups, a restaurant drink cup with a straw, an opened can drink on the counter, also a purse on the counter, and under the counter in the lower cabinet, bottles of Coke and a Fairmont State University shirt and other articles of clothing were found. It was observed a sign on the door of the refrigerator stating no staff items to be in the nourishment rooms or refrigerators. In an interview with the DON, on 4/30/25 at 1:53 PM, she acknowledged the staff items located in the the 400 hall Nourishment Room and stated staff personal items should have been in the staff break room instead.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Medical Records (Tag F0842)

Could have caused harm · This affected multiple residents

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b) Resident #102 An observation on the afternoon of 05/05/25 found Resident #102's10:00 AM mighty shake still sitting at the nurses' station unopened. A review of the Medication Administration Record (MAR) found Registered Nurse (RN) #10 had documented Resident #102 had consumed 100 percent of his 10:00 am mighty shake. An interview with RN #10 immediately following the record review found she should have documented refused on the mighty shake. c) Resident #78 An observation on the afternoon of 05/05/25 found Resident #78's 10:00 am mighty shake still sitting at the nurses' station unopened. A review of the Medication Administration Record (MAR) found Registered Nurse (RN) #10 had documented Resident #78 had consumed 100 percent of his 10:00 am mighty shake. An interview with RN #10 immediately following the record review found she should have documented refused on the mighty shake. Based on record review and staff interview, the facility failed to ensure an accurate and complete record for Resident #37's skilled nursing evaluation, documentation of supplements for Resident #102 and #78, and a Physician's Order for Scope of Treatment (POST) form for Resident #86. This was true for four (4) of 42 residents reviewed during the survey process. Resident Identifiers: #37, #102, and #78. Facility Census: 106. Findings include: a) Resident #37 On 04/30/25 at 10:15 AM, a record review was completed for Resident #37. The review found a physician's order dated 11/15/24, Enteral feed order: Jevity 1.5 cal. Administer via pump at 65ml(milliliter) per hour x 20 hours QD (every day) or until total nutrient delivered to provide 1300ml/1950 kcal (kilocalorie), 82.9gm (gram) PO (protein) QD, downtime 5am-7am and 5pm and 7pm. (Typed as written.) Upon further review, a skilled nursing evaluation dated 04/15/25, indicated the resident was taking nutrition and hydration orally. No complaints of thirst. No signs/symptoms of a swallowing disorder. Mucous membranes moist. The resident was noted as NPO (nothing by mouth) and received all nourishment through a gastrostomy (G-tube) tube. On 05/01/25 at 8:15 AM, Corporate Registered Nurse #132 and #133 confirmed the resident received nutrition from his G-tube and not orally.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Infection Control (Tag F0880)

Could have caused harm · This affected multiple residents

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Based on observation, record review and staff interview, the facility failed to maintain infection control standards during wound care for Resident #61, storage of a nebulizer and mask for Resident #60 and maintaining a wheelchair for Resident #19. These were random opportunities for discovery. Resident identifiers: #61, #60 and #19. Facility Census: 106. Findings include: a) Resident #61 On 05/01/25 at 10:08 AM, an observation of the wound care provided by Registered Nurse (RN) #32 was completed. As RN #32 provided the wound care to the right gluteal fold, RN #32 touched her glasses multiple times. On 05/01/25 at 10:30 AM, Nurse Aide (NA) #25 set a bath basin of water and wash cloths on the over-the-bed table which was the sterile field for the wound care. On 05/01/25 at 10:42 AM, an interview was held with RN #32. RN #32 was asked, Did you realize you touched your glasses multiple times during the wound care? RN #32 stated, No, I didn't realize. RN #32 was asked, Do you think the bath basin of water placed on the over-the-bed table disturbed your sterile field? RN #32 stated, I appreciated NA #25 assisting me, but I don't think it should have been placed there. On 05/01/25 at 11:00 AM, Corporate Registered Nurse (CRN) #132 was notified. CRN #132 did confirm these events during wound care was a breach of infection control. b) Resident #60 On 04/29/25 at 9:12 AM, an observation revealed a nebulizer machine and mask sitting on the floor by Resident #60's bed. On 04/29/25 at 9:17 AM, Registered Nurse (RN) Supervisor #56 was notified of the observation of the nebulizer machine and mask sitting on the floor. On 04/29/25 at 9:19 AM, RN Supervisor #56 immediately removed the machine and mask from the room. RN Supervisor #56 stated, Let me get this out of the floor. c) Resident #19 During facility entry on 04/29/25 at 12:10 AM, Resident #19's wheelchair was found to have a tear/crack in the covering on the top of the back rest, exposing the inner padding. 04/29/25 at approximately 12:20 PM , during an interview with Nurse Aide (NA) #127, she acknowledged the crack in seat of the wheelchair. On 04/29/25 at 12:40 PM, during an interview with the Infection Control Manager (ICM), she acknowledged the crack in the seat, and stated she would remove and replace the wheelchair. She further stated, and stated, I did not know it was in this condition.

CONCERN (F)

Potential for Harm - no one hurt, but risky conditions existed

Staffing Information (Tag F0732)

Could have caused harm · This affected most or all residents

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Based upon record review and staff interview, the facility failed to provide accurate daily staffing posting for actual hours worked. This was found to be true for 14 (fourteen) of 15 (fifteen) days of staffing data reviewed during the annual survey process. Facility census: 106 Findings included: Nursing staffing data and time and attendance reports were reviewed for the following dates: 04/25/25, 04/26/25, 03/21/25, 03/22/25, 03/23/25,02/20/25, 02/21/25, 02/22/25, 02/23/25 01/01/25, 01/02/25, 01/03/25, 12/31/24, 11/25/24, 11/27/24 Examples of staffing data not aligning with time and attendance reports: On 11/27/24, posted nurse staffing data showed 258 total hours worked for RNs, LPNS, and Certified Nurse Aides. A review of the time and attendance report for the same date, showed 227.78 hours worked. On 12/31/24, posted nurse staffing data showed 264 total hours worked for RNs, LPNs, and Certified Nurse Aides. A review of time and attendance reports for the same date shows 231.40 total hours worked. On 04/26/25, posted nurse staffing data showed 243 total hours worked for RNs, LPNs, and Certified Nurse Aides. A review of time and attendance reports for the same date shows 197.21 total hours worked. This data was reviewed with the Director of Nurses (DON) on 05/06/25. When asked about the differences, the DON did not have a response.

CONCERN (F)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0925 (Tag F0925)

Could have caused harm · This affected most or all residents

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Based on observations and staff interviews, the facility failed to maintain an effective pest control program so the facility is free of pests and rodents. This was a random opportunity for discovery with the possibility of affecting multiple residents. Facility census: 106. Findings include: a) During a walk-through of the dish room side of the kitchen, on 04/30/25, at 12:00 PM, many mature gnats were observed swarming around the drain area under the dishwasher table. In an interview with the district manager on 04/30/25 at 12:15 PM, he acknowledged the gnats and stated the facility had contacted the extermination for advice a week ago, but the facility had not yet been treated for the gnats.

Jan 2025 5 deficiencies 1 Harm

SERIOUS (G) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Actual Harm - a resident was hurt due to facility failures

Accident Prevention (Tag F0689)

A resident was harmed · This affected 1 resident

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Based on record review, and resident and staff interviews, the facility failed to ensure Resident # 90 was transferred in a safe manner to prevent physical injury. This resulted in actual harm for Resident #90 who sustained a laceration to her lower extremity requiring16 stitches. After the incident with Resident #90 the facility identified the failures and took appropriate action to correct the failures prior to the state agency entering the facility to conduct this complaint investigation. Therefore this will be cited as past non compliance. This was true for one (1) of three (3) sampled residents. Resident Identifier: #90. Facility Census: 110. Findings Include: A) Resident #90 On 04/09/24 Nurse Aide (NA) # 136 was transferring Resident #90 from the wheelchair to the bed when the resident sustained a laceration to her right lower extremity. Resident #90 was taken to the emergency room requiring 16 stitches. The facility reported the incident as required to all state agencies and began an investigation into what happened. A review of the facility's investigation found a statement written by NA #136, in this statement she confirmed she did not use the appropriate procedure when lifting Resident #90. Based on the Care Plan, Resident #90 was a lift sit to stand transfer. NA #136 used a gait belt to transfer resident # 90 from the wheelchair to her bed and discovered the resident's laceration to her right lower extremity. The facility substantiated neglect and reported NA #136 to the state registry and terminated her employment on 04/10/24. During the course of the investigation the facility discovered other NA's caring for Resident #90 may not have been transferring her appropriately. The facility then completed a whole house audit finding incorrect transfer procedures to be isolated to Resident #90. Staff inservices and education on resident transfers and lifts using the kardex started 04/10/24 and was completed 04/17/24 with scheduled future staff monitoring. During an interview with Resident #90, on 1/29/25 at 9:18 AM, she was up and sitting in her wheelchair down the hall from her room. She stated staff used a lift to transfer her to her wheel chair. She stated she did not have to wait for long periods of time for transfers when she requested to be up. She stated she hasn't missed meals or activities due to waiting to be transferred to the chair. She stated her call lights were answered timely. She did not remember being hurt during her transfer from the bed to the chair. She stated she hasn't had any falls lately. Resident room observation: at 9:24 Am 01/29/24 found Resident #90's bed is at wheelchair level and against the wall and bedside table at bed level with a longreach appliance tool. Grip strips fall prevention on the floor and call light clipped to bed within resident's reach while in the room. During an interview with the DON, Nurse Administrator, and Corporate Resource Nurse, on 01/29/24 at approx 2:30 PM, the facility provided verification of employment termination of NA #136, staff transfers/lift education and inservices/monitoring(pre and post incident), and whole house transfer/lifts audits. No further incidents related to improper transferring were identified during course of the survey.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Investigate Abuse (Tag F0610)

Could have caused harm · This affected 1 resident

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Based on record review, interview, and investigation, the facility failed to conduct the required training and education for staff on issues which impacted resident care. Resident Identifier: #74. Facility Census: 110. Findings include: a) Resident #74 A Facility Reported Incident (FRI) report submitted on 05/01/24, indicated Resident #74 had complained of abuse by staff. The complaint stated, staff were rough when providing care. During an interview, with Resident #74 on 01/29/25 at approximately 11:55 AM, she stated, she had pain in her left leg, was be bound, and incontinent. She stated, she wears briefs, but her bed linen frequently becomes soiled. Upon being questioned about the staff being rough, she stated some staff members pulled on her leg a little too hard when changing her diaper and removing bed linen. She further stated, the staff members who were 'rough' were no longer employed at the facility. Record review of resident's care plan revealed the following notes: FOCUS: [Resident] requires assistance/is dependent for ADL care in bathing, grooming, personal hygiene, dressing, bed mobility, transfer, locomotion, toileting related to: Limited mobility. [Resident] refuses lift transfers 2/2 acute pain, prompting resident to refuse weights and showers, only permits bed baths. [Resident] prefers her husband to move her legs while receiving care at times. Date Initiated: 07/27/2022 Created on: 07/27/2022 Created by: RN #93 Revision on: 01/28/2025 INTERVENTIONS: Provide resident/patient with extensive assist of one for personal hygiene (grooming). Date Initiated: 07/27/2022 Created on: 07/27/2022 Revision on: 07/27/2022 During interviews with Nursing Aides (NA) # 50 and #134, on 01/29/25 at approximately 2:25 PM, they stated the resident's husband was not always present when the resident needed care. They further stated incontinence care frequently involved completely changing the bed linen too. A review of the investigative documents revealed the facility had interviewed and obtained statements from Residents #28, #32, #78, #89, and #108. Residents had stated the staff were not impatient or rough when providing care. The facility indicated in the FRI they would follow up with education for staff on issues which impacted resident care. A record review on 01/29/25 at 9:45 AM revealed no follow-up for staff education. The Director of Nursing (DON) on 01/29/25 at approximately 3:15 PM, confirmed she did not have any staff education records.

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 F0624 (Tag F0624)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, investigation, and interview, the facility failed to provide sufficient preparation and orientation and take steps under its control to ensure one of one resident discharge was safe and orderly. Resident #111 was taken to a local homeless shelter who was not equpieed to meet her needs to her physical limitations. Resident identifier: #111. Facility Census: 110. Findings included: a) Resident #111 A record review revealed, the facility notified the resident of a pending discharge on [DATE] at 9:12 AM. The resident was discharged from the facility on 03/13/24 at 9:39 AM. In addition the facility made the referral to a homeless shelter without adequate planning to ensure the shelter could meet the needs of the resident. When the homeless shelter declined to accept the resident, the facility kept the resident in the transport vehicle, while searching for other shelters that would be able to accept the resident. A record review revealed the following notes in resident's medical record: A nursing note dated 3/13/24 at 7:21 AM by RN #141 stated: This nurse and another nurse asked [Resident] if she was okay if we were able to search her room. [Resident] stated Yeah, that's fine. [Resident] was present sitting in her chair and her bed while said nurses searched her belongings/room. When checking the nightstand, [Resident] voluntarily unlocked her lock box to allow this nurse to see inside. While checking the nightstand there was a single credit card laying on night stand, white residue noted to one side of the card. This nurse obtained white particles of a pill off the floor. There were smaller white particles on the floor by the night stand. While searching [Resident's] bed, her Teddy bear that was sitting on the bed was searched as well. This nurse noted a hole in the neck of the teddy bear, upon further investigation there was a white oblong tablet scored with the letters M365 wrapped up in tissues stuffed inside a ziplocked baggy. This nurse asked [Resident] what the contents of the baggy were she stated Oh, those are just Tylenol 'resident 102644' gave me. Educated [Resident] that she is prescribed Tylenol and is able to ask the nurse for medicine as the needs arise, that we are unable to keep medications at bedside. [Resident] verbalized understanding. Items searched were placed back in the way they were prior to search. Ziplocked baggy and white pill particle confiscated. Pill was identified as Hydrocodone-Acetaminophen 5-325 mg Tablet. This resident is not currently prescribed this medication. 9:12 am - This nurse, another nurse, and sheriff spoke with [Resident] regarding her need to discharge due to finding the narcotic in her room, per facility Administrator. [Resident] stated, That's fine, I will go, I just need to gather a couple of things. Resident gathered the belongings she wanted to take with her, presented to the 500 hall, discharge paperwork reviewed. [Resident] verbalized understanding of her discharge instructions. A note by SW #142 on 3/13/24 at 9:05 AM which stated: Late Entry: 3/13/2024 10:56 Informed this resident is agreeable to discharge today following situation regarding narcotics found in room. She did allow staff to search her room and found some narcotics hidden in some of her belongings. Called (Name of local Homeless shelter) to make referral. A note on 03/13/24 at 9:07 AM by RN #93 stated: Discharge Plan Documentation was completed, The Resident Discharge Summary and Transition Plan can be found in the Document tab of the resident's chart. A nursing note on 3/13/24 at 9:39 AM by RN #93 stated: All discharge paperwork reviewed with resident, education provided for all medications with verbal understanding voiced, resident taking all medications and was notified that MD discontinued oxycodone, resident took 25 Lyrica 50mg, resident chooses to not allow staff to make appt with MD for follow up at this time and will do on her own. Resident took all belongings that she wanted and left several boxes. Resident is being transferred by facility van to (name of local homeless shelter), resident left with facility wheelchair that facility allowed her to keep. A note by SW # 142 on 3/13/24 at 10:00 AM which stated: Called by staff transporting resident to (Name of local homeless shelter). They are unable to accommodate [Resident] at this time as she is unable to complete the stairs to the sleeping quarters and dining area. No other available accommodations in the area at this time. Message left for (Name of neighboring county shelter). Another note by SW #142 on 03/13/24 at 10:35 AM which stated: [Resident] requested to be taken to the area of McDonald's/[NAME] on Fairmont Avenue. APS referral made. Intake number 3976939 A Note by SW #144 on 03/14/24 at 10:45 AM which stated: Received a call from yesterday morning. CED (center executive director) was attempting to assist the facility social services department on creating & facilitating the most successful/safe discharge available. [Resident] was agreeable to be transferred to a homeless shelter and was accepted by one arranged by #142, facility social worker. However, it was determined upon arrival to the shelter, [Resident] was unable to climb stairs, which was necessary to safely ambulate throughout that facility. MSW #145 contacted many additional homeless shelters throughout the state and the (Name of shelter in a town 1 an 1/2 hours away fromwere resident was) accepted [Resident] for placement. Resident was informed and stated that she would rather be transported to McDonalds where there is Wi-Fi and she would figure it out. Facility explained this was her decision and they would be more than willing to transport her to (Name of town where accepting shelter was locate) - resident declined. On 01/29/25 at approximately 10:30 AM during an interview with the Interim Administrator #29, The Director of Nursing (DON) #111, and the Corporate Resource Nurse #137, it was confirmed that the facility did not ensure that resident was discharged safely and appropriately.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Comprehensive Care Plan (Tag F0656)

Could have caused harm · This affected 1 resident

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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 develop and implement a comprehensive person-centered care plan for a venous access device. This was true for one (1) of one (1) residents reviewed. Resident identifier: #113. Facility Census: 110. Findings Include: a) Resident #113 On 01/29/25 at 11:30 AM a record review found Resident #113 had a central line while a resident at the facility from 10/20/23 through 01/10/24. He was transferred to the facility from a local hospital with a central ([NAME]) Intravenous line in his right chest. On 01/29/25 at 3:30 PM a record review of the comprehensive care plan for Resident #133 found there was no care plan implemented for care of the central line. According to documentation and an interview provided by the Director of Nursing (DON) on 01/29/25 at 1:10 PM, they follow their pharmacy (PharMerica) recommendations for venous access devices which is also stated in their policy. The document provided from the pharmacy, Catheter Care and Flush Protocols states tunneled venous access device will have a transparent dressing changed every seven (7) days and as needed (PRN). The facility Infection Control Infection Prevention Measures for IV Catheter Dressings policy states: A sterile dressing is utilized as an infection control measures. Transparent, semi-permeable membrane (TSM) dressings are changed a minimum of every seven (7) days and PRN whenever the dressing integrity becomes disrupted, becomes wet, loose, or soiled or if skin integrity is compromised under the dressing On 01/29/25 at 3:30 PM it was confirmed with the Administrator that the central line was not addressed on the care plan.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Quality of Care (Tag F0684)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review and staff interview the facility failed to provide proper care for a venous access device according to their Infection Prevention Measures Policy and standard practice of care. This was true for one (1) of one (1) resident reviewed. Resident identifier: #113 Facility Census: 110. Findings Include: a) Resident #113 On 01/29/25 at 11:30 AM a record review found Resident #113 had a central line while a resident at the facility from 10/20/23 through 01/10/24. He was transferred to the facility from a local hospital with a central ([NAME]) Intravenous line in his right chest. According to documentation and an interview provided by the Director of Nursing (DON) on 01/29/25 at 1:10 PM, they follow their pharmacy (PharMerica) recommendations for venous access devices which is also stated in their policy. The document provided, Catheter Care and Flush Protocols stated that tunneled venous access device will have a transparent dressing changed every seven (7) days and as needed (PRN). The facility Infection Control Infection Prevention Measures for IV Catheter Dressings policy states: A sterile dressing is utilized as an infection control measures. Transparent, semi-permeable membrane (TSM) dressings are changed a minimum of every seven (7) days and PRN whenever the dressing integrity becomes disrupted, becomes wet, loose, or soiled or if skin integrity is compromised under the dressing Review of the Medication Administration Record (MAR) for October 2023 through January 2024, at which time he was discharged , the intravenous central line dressing in his right chest was never changed. Review of progress notes and the Treatment Administration Record (TAR) found no evidence that the dressing had been changed. According to the Director of Nursing the central line was never used. The resident had IV antibiotics, but the facility placed a peripheral IV and then later a midline IV for administration of these antibiotics. This was confirmed by review of the progress notes. This was confirmed with the Director of Nursing and the Administrator on 01/29/25 at 3:30 PM. No additional documentation was received prior to exiting the facility on 01/30/25.

Mar 2023 20 deficiencies

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0582 (Tag F0582)

Could have caused harm · This affected 1 resident

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. Based on record review and staff interview, the facility failed to provide the required Skilled Nursing Facility Advanced Beneficiary Notice of Non-Coverage (SNF ABN) form to two (2) of three (3) residents reviewed for the facility's beneficiary protection notification practice. This failed practice placed residents at risk of not being informed of their rights prior to the end of Medicare Part A covered services. Resident identifiers: #102, and #80. Facility census: 107. Findings included: a) Resident (R) #102 A facility record review of the SNF ABN for the Long-Term Survey Process revealed, no notice was given to R #102 prior to the end of skilled service(s). During an interview on 03/14/23 at 12:42 PM, the Coordinator-Clinical Reimbursement (CRC) #2 verified the SNF ABN was not given to R#102 or the representative. The CRC #2 stated that she was just starting to be trained on the SNF ABN. b) Resident #80 A facility record review of SNF ABN for the Long-Term Survey Process revealed, no notice was given to R# 80 prior to the end of skilled service(s). During an interview on 03/14/23 at 12:42 PM, the CRC #2 verified the SNF ABN was not given to R #80 or the representative. The CRC #2 stated that she was just starting to be trained on the SNF ABN. .

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Abuse Prevention Policies (Tag F0607)

Could have caused harm · This affected 1 resident

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. Based on policy review titled Abuse Prohibition, resident interview, record review, and staff interview, the facility failed to ensure implemention of the facility written abuse prohibition policy in regard to investigating and reporting to proper agencies an alleged allegations of abuse. This has to potential to affect a limited number of residents that reside at the facility. Resident identifiers: R #83 and R #92. Facility census: 107. Findings included: a) Policy review Record review of the facility's policy titled, Abuse Prohibition, showed: --The Administrator, or designee, is responsible for operationalizing policies and procedures that prohibit abuse, neglect, involuntary seclusion, injury of unknown source, exploitation, and misappropriation of property. The center must ensure that all staff are aware of reporting requirements and must support an environment in which covered individuals report a reasonable suspicion of a crime. --Immediately upon receiving information concerning a report of suspected or alleged abuse, mistreatment, or neglect the administrator of designee will perform the following. --Report allegations involving abuse (physical, verbal, sexual, mental) not later than 2 hours after the allegation is made. --Report allegations to the appropriate state and local authority. --Initiate an investigation within 24 hours of an allegation of abuse that focuses on weather abuse or neglect occurred and to what extent. b) Resident #83 During an interview on 03/13/23 at 10:57 AM, Resident #83 stated that a male nurse aide was rude, disrespectful and rough with his care. He stated that it happened two (2) months ago, and he reported the issues to the weekend Nurse Manager. He stated that the Nurse Aide (NA) is not allowed to work with him anymore. He also provided a name of the accused. A record review or grievances, concerns and reportables found no documented issues from Resident #83. Resident #83's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/01/23 noted the resident had a score for Brief Interview for Mental Status (BIMS) of 15. A BIMS score of 15 indicates that the resident is cognitively intact and has capacity. On 03/14/23 at 10:33 AM during an interview with the Social Worker #64 (SW) stated she was unaware of any issue of any allegations of abuse from Resident #83. On 03/14/23 at 10:42 AM during an interview with the Administrator (NHA) she stated that she was unaware of any reported allegation from Resident #83 or any allegation on NA #1. She stated that she would look into the issue. 03/14/23 at 12:35 PM during an interview with the NHA and Director of Nursing (DON) both verified that no grievance was completed, the allegation was not investigated or reported. The DON stated that the weekend Nurse Supervisor (NS) felt like it was a personality conflict, so she didn't fill out a grievance form. The DON stated that the NS removed NA #1 from that assignment and re-assigned NA #1 to a different group. During an interview on 03/15/23 at 11:47 AM, the DON stated that they did not followed up on the abuse allegations that was brought to their attention on 03/14/23, she did state that the Nurse Manager took care of the situation, at the time. On 03/15/23 at 12:39 PM the DON stated that the facility would do a reportable now. She stated that they thought the SW #64 would report the abuse allegation yesterday when it was report to her, but she did not. c) Resident #92 During an interview on 03/13/23 at 10:55 AM Resident #92 stated that a male Nurse Aide is rough and says rude comments when he provides care for him. He also provided a name of the accused. A record review or grievances, concerns and reportables found no documented issues from Resident #92. Resident #92's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/28/23 noted the resident had a score for Brief Interview for Mental Status (BIMS) of 15. A BIMS score of 15 indicates that the resident is cognitively intact and has capacity. On 03/14/23 at 10:33 AM during an interview the with Social Worker #64 (SW) stated that she was unaware of any issue of any allegations of abuse from Resident #92. On 03/14/23 at 10:42 AM during an interview with the NHA stated that she was unaware of any reported allegation from Resident #92 or any allegation on NA #1. She stated that she would look into the issue. 03/14/23 at 12:35 PM during an interview with the NHA and Director of Nursing (DON) both verified that no grievance was filled out, the allegation was not investigated or reported. The DON stated that the weekend Nurse Supervisor felt like it was a personality conflict, so she didn't fill out a grievance form. The DON stated that the Nurse Supervisor removed NA #1 from that assignment and re-assigned him to a different group. During an interview on 03/15/23 at 11:47 AM the DON stated that they did not follow up on the abuse allegations that was brought to their attention on 03/14/23 for Resident #92. She did state that the Nurse Manager took care of the situation, at the time. On 03/15/23 at 12:39 PM the DON stated that the facility would do a reportable now for Resident #92. She stated that they thought the SW #64 would report the abuse allegation yesterday when it was report to her, but she did not. .

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

Report Alleged Abuse (Tag F0609)

Could have caused harm · This affected 1 resident

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. Based on Abuse Policy review, Resident interview, record review, and staff interview, the facility failed to identify and report all allegations of abuse and neglect to appropriate state agencies within regulation time frames. This had the potential to affect a limited number of residents that reside in the facility. Resident identifiers: R#83 and R#92. Facility census: 107. Findings included: a) Policy review Record review of the facility's policy titled, Abuse Prohibition, showed: --The Administrator, or designee, is responsible for operationalizing policies and procedures that prohibit abuse, neglect, involuntary seclusion, injury of unknown source, exploitation, and misappropriation of property. The center must ensure that all staff are aware of reporting requirements and must support an environment in which covered individuals report a reasonable suspicion of a crime. --Immediately upon receiving information concerning a report of suspected or alleged abuse, mistreatment, or neglect the administrator of designee will perform the following. --Report allegations involving abuse (physical, verbal, sexual, mental) not later than 2 hours after the allegation is made. --Report allegations to the appropriate state and local authority. --Initiate an investigation within 24 hours of an allegation of abuse that focuses on weather abuse or neglect occurred and to what extent. b) Resident #83 During an interview on 03/13/23 at 10:57 AM Resident #83 stated that a male Nurse Aide (NA) was rude, disrespectful and rough with care. He stated that this happened two (2) months ago, and he reported the issues to the weekend Nurse Manager. He stated that the NA is not allowed to work with him anymore. He also provided a name of the accused. A record review or grievances, concerns and reportables found no evidence of issues from Resident #83. Resident #83's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/01/23 noted the resident had a score for the Brief Interview for Mental Status (BIMS) of 15. A BIMS score of 15 indicates that the resident is cognitively intact and has capacity. On 03/14/23 at 10:33 AM during an interview with the Social Worker #64 (SW) stated she was unaware of any issue of any allegations of abuse from Resident #83. On 03/14/23 at 10:42 AM during an interview with the Administrator (NHA) stated that she was unaware of any reported allegation from Resident #83 or any allegation on NA #1. She stated that she would look into the issue. On 03/14/23 at 12:35 PM during an interview with the NHA and the Director of Nursing (DON) both verified that no grievance was completed. The allegation was not reported timely to the appropriate agencies. The DON stated that the weekend Nurse Supervisor felt like it was a personality conflict, so she didn't fill out a grievance form. The DON stated that the Nurse Supervisor removed NA #1 from that assignment and re-assigned him to a different group. During an interview on 03/15/23 at 11:47 AM, the DON stated that they did not followed up on the abuse allegations that was brought to their attention on 03/14/23. She did state that the Nurse Manager took care of the situation, at the time. On 03/15/23 at 12:39 PM the DON stated that the facility would do a reportable now. She stated that they thought the SW would report the abuse allegation yesterday when it was report to her, but she did not. b) Resident #92. During an interview on 03/13/23 at 10:55 PM Resident #92 stated that a male Nurse Aide (NA) was rough and says rude comments when he providing care for him. He also provided a name of the accused. A record review or grievances, concerns and reportables found no evidence of issues from Resident #92. Resident #92's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/28/23 noted the resident had a score for Brief Interview for Mental Status (BIMS) of 15. A BIMS score of 15 indicates that the resident is cognitively intact and has capacity. On 03/14/23 at 10:33 AM during an interview the Social Worker #64 (SW) stated she was unaware of any issue of any allegations of abuse from Resident #92. On 03/14/23 at 10:42 AM during an interview with the NHA stated that she was unaware of any reported allegation from Resident #92 or any allegation on NA #1. She stated that she would look into the issue. On 03/14/23 at 12:35 PM during an interview with the NHA and the Director of Nursing (DON) both verified that no grievance was filled out. In addition, the allegation was not reported to the appropriated state agencies in timely manner. The DON stated that the weekend Nurse Supervisor felt like it was a personality conflict, so she didn't fill out a grievance form. The DON stated that the Nurse Supervisor removed NA #1 from that assignment and re-assigned him to a different group. During an interview on 03/15/23 at 11:47 AM the DON stated that no follow up on the abuse allegations that was brought to their attention on 03/14/23 for Resident #92. She did state that the Nurse Manager took care of the situation, at the time. On 03/15/23 at 12:39 PM the DON stated that the facility would do a reportable now for Resident #92. She stated that they thought the SW would report the abuse allegation yesterday when it was report to her, but she did not. .

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Assessment Accuracy (Tag F0641)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review, resident interview and staff interview, the facility failed to complete an accurate Minimum Data Set (MDS) with a new diagnosis of cataracts. This was true for one (1) of 28 residents reviewed under the vision/hearing care area. Resident Identifier: #85. Facility census: 107. Findings Included: a) Resident #85 On 03/13/23 at 11:25 AM, an interview was held with Resident #28. The resident stated, I'm not doing to good .I have cataracts. On 03/14/23 at 10:18 AM, a record review was completed. The record review found the resident had an eye examination on 10/20/22 stating #3 (number three) as cataracts with a follow up examination with pictures in four (4) months. (Typed as written.) The resident was noted with a vision consult on 12/15/22 for decreased vision in both eyes. The impression/plan stated, #1 (number one) Assessment Age-related nuclear cataract, bilateral; and, plan cataracts are mild; we will monitor for progression. (Typed as written.) A review of the quarterly MDS dated [DATE] noted the resident had adequate vision and wore corrective lens. However, the new diagnosis of cataracts was not listed. On 03/15/23 at 10:10 AM, the Clinical Reimbursement Coordinator (CRC) #2 confirmed the diagnosis of cataracts had not been added to the quarterly MDS dated [DATE]. .

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

PASARR Coordination (Tag F0644)

Could have caused harm · This affected 1 resident

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. Based on facility policy, record review, and staff interview, the facility failed to ensure a Level II of the [NAME] Virginia Department of Health and Human Resources Pre-admission Screening and Resident Review (PASARR) was complete as directed on the initial PASARR. This was true for one (1) of one (1) PASARR's reviewed during the long term survey process. Resident identifier: #69 Facility census: #107. Findings included: a) Policy review According to the facility Pre-admission Screening for Mental Disorder and/or Intellectual Disability Patients Policy with revision date of 01/15/21, the facility purpose was .to ensure that individuals identified with Mental Disorders (MD) or intellectual Disability (ID) are evaluated and received care and services in the most integrated setting appropriate to their needs. Practice Standards on the policy states Social Services will coordinate and/or inform the appropriate agency to conduct the evaluation and obtain results if: 1.1 It is learned after admission that the Pre-admission Screening and Resident Review (PASARR) was not completed or is incorrect b) Resident #69 On 03/13/23 at 1:24 PM during the initial review of the PASARR dated 05/03/22, it was noted that Resident #69 was required to have a Level II review. During an interview with the Administrator (NHA)on 03/15/23 at 10:33 AM, she stated that the Level II PASARR was not available. Resident #69 had medical diagnoses of anxiety, depression, insomnia, suicidal ideation's, Cerebrovascular Accident (CVA), brain aneurysm with coiling and a partial craniotomy. The above information was confirmed with the NHA on 03/15/23 at 10:33 AM. .

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0645 (Tag F0645)

Could have caused harm · This affected 1 resident

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. Based on facility policy review, record review, and staff interview, the facility failed to ensure a Level II of the [NAME] Virginia Department of Health and Human Resources Pre-admission Screening and Resident Review (PASARR) was completed as directed on the initial PASARR. This was true for one (1) of one (1) PASSR's reviewed during the long term survey process. Resident identifier: #69 Facility census: #107 Findings included: a) Policy review According to the facility Pre-admission Screening for Mental Disorder and/or Intellectual Disability Patients Policy with revision date of 01/15/21, the facility purpose was .to ensure that individuals identified with Mental Disorders (MD) or intellectual Disability (ID) are evaluated and received care and services in the most integrated setting appropriate to their needs. Practice Standards on the policy states Social Services will coordinate and/or inform the appropriate agency to conduct the evaluation and obtain results if: 1.1 It is learned after admission that the Pre-admission Screening and Resident Review (PASARR) was not completed or is incorrect b) Resident # 69 On 03/13/23 at 1:24 PM during the initial review of the PASARR dated 05/03/22, it was noted that Resident #69 was required to have a Level II review. During an interview with the Administrator (NHA) on 03/15/23 at 10:33 AM she notified the surveyor that the Level II PASARR was not available. Resident #69 medical diagnoses included anxiety, depression, insomnia, suicidal ideation's, Cerebrovascular Accident (CVA), brain aneurysm with coiling and a partial craniotomy. The above information was confirmed with the NHA on 03/15/23 at 10:33 AM. .

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

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. Based on observation, record review, resident interview and staff interview, the facility failed to ensure residents unable to carry out activities of daily living (ADLs) received necessary services in the areas of personal hygiene. This was true for two (2) of five (5) residents reviewed under the care area of activities of daily living during the long-term care survey process. Resident identifiers: #29 and #69. Facility census: 107. Findings included: a) Resident #29 On 03/13/23 at 8:45 AM, an interview was held with Resident #29. The resident stated, I haven't had a bath in 3 (three) weeks A record review of bathing for the dates of 02/13/23 through 03/13/23 was completed on 03/14/23 at 2:00 PM. The review found no evidence for the following dates regarding showers and/or bed baths: --02/18/23 --02/19/23 --02/25/23 --02/26/23 --03/01/23 --03/04/23 --03/05/23 --03/07/23 --03/10/23 --03/11/23 --03/12/23 An interview with Nurse Aide (NA) #15 was held on 03/15/23 at 8:25 AM. NA#15 stated, the resident refuses showers and refuses to get up. The resident gets bed baths on Monday and Thursdays .if the resident refuses showers or bed baths, we let the nurse know and they chart it. On 03/15/23 at 11:42 AM, the Director of Nursing (DON) stated, I couldn't find any progress notes related to refusals of showers or bed baths. No further information was obtained during the long-term survey process. b) Resident # 69 On 03/13/23 at 1:20 PM Resident #69 stated that the shower chair was uncomfortably and did fit, therefore he did not get showers as scheduled. Record review indicates Resident #69 is scheduled for showers on Tuesday and Friday during the evening shift. Record review shows Resident #69 has received three (3) of the scheduled twelve (12) showers/bed baths in the last thirty (30) days. Observation of the bariatric shower chairs in the facility found they are large enough, however, the one Resident #69 would need does not have a pad on the seat. On 03/15/23 at 9:10 AM, Nurse Aide (NA) #15 and Registered Nurse (RN) #60 stated that the resident refuses to use the chair due to the pain it causes him. During an interview and confirmation of the above findings on 3/15/23 at 10:55 AM, the Administrator stated that she will attempt to get padding for the current reclining chair, or purchase a reclining bariatric shower chair that is padded. .

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0679 (Tag F0679)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review, observation, resident interview, and staff interview, the facility failed to implement an ongoing activity program designed to meet the interests of and support the well-being of each resident. This has to potential to affect more than a limited number of residents residing in the facility. Resident identifiers: #83. Facility census 107. Findings included: a) Resident #83 During an Interview with Resident #83 on 03/13/23 at 10:38 AM, he stated that he has trouble getting books to read. He stated that there is a media room at the facility, but they don't have any books available, and staff don't offer any books or reading materials. Resident #83's was admitted [DATE] with a quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/01/23 noted the resident had a score for Brief Interview for Mental Status (BIMS) of 15. A BIMS score of 15 indicates that the resident is cognitively intact and has capacity. A review of the care plan revealed the following: Focus: --Resident #83 is independently capable of pursuing his own activities without intervention from the facility. Goal: --Resident #83 will plan and choose to engage in preferred activities daily through next review. Staff will offer in room materials to him as needed. Interventions: --Resident #83 is of the Mormon faith and enjoys reading his bible. Continued record review revealed a 02/02/23 quarterly progress note: --Resident #83 enjoys reading books, listening to metal music, watching television, word searches, and doing puzzles. Subsequent record review of the Activities Participation Record found no reading/audio book offered. During an interview on 03/14/23 at 10:00 AM, the Activities Director verified no books have been offered to Resident #83 and stated that the facility didn't have a lot of books/reading material available for residents enjoyment. .

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 follow physicians order to provide humidity on the oxygen concentrator. This was true for one (1) of one (1) Residents reviewed in the Respiratory care area. Resident identifier: #22 Facility census: #107. Findings included: a) Resident #22 On 03/13/23 at 11:34 AM during record review found the following order for Resident #22: Continuous oxygen at 2 L/min via Nasal Cannula w/humidity. The oxygen concentrator was observed to have no humidification device. This was confirmed with Licensed Practical Nurse (LPN) #75 on 03/13/23 at 11:34 AM. Review of Resident #22's care plan read as follows: Encourage resident to wear oxygen at 2L/min with humidity per nasal cannula continuously and may titrate to keep 02 sats >90%. The care plan was not implemented due to the facility failing to provide the humidity to the oxygen concentrator. This was confirmed with LPN #75 on 03/13/23 at 11:34 AM. .

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0698 (Tag F0698)

Could have caused harm · This affected 1 resident

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. Based on record review and staff interview, the facility failed to complete hemodialysis communication records between the facility and the dialysis center. This is true for one (1) of one (1) residents reviewed under the care area of dialysis. Resident identifier: #64. Facility census: 107. Findings included: a) Resident #64 A record review was completed on 03/13/23 at 10:03 AM. The resident is scheduled for hemodialysis at (Name of dialysis center) on Monday, Wednesday, and Fridays at 11:00 AM. The dialysis communication sheets were reviewed from 06/24/22 through 03/13/23. The dialysis communication sheets communicate from the facility to the dialysis center pre-dialysis information. The pre-dialysis information includes vital signs, assessment of the arteriovenous fistula (AV) shunt, and the general condition of the resident. This information also includes the facility licensed nurse's signature and date. The dialysis communication sheets also communicate from the dialysis center to the facility post dialysis information. The post-dialysis information includes pre- and post weights, any medication given during hemodialysis, and any new orders or significant changes in condition of the resident. This information also includes the dialysis licensed nurse's signature and date. Upon return to the facility, the assessment of the access site, vital signs, any post-hemodialysis complications as well as any new orders received from the dialysis center should be documented. This information should also include the receiving licensed nurse's signature and date. The following dates of the dialysis communication sheets were incomplete: --06/29/22 post treatment information and the receiving nurse's signature and date. --07/06/22 post treatment information and the receiving nurse's signature and date. --07/18/22 pre- and post treatment information and the sending and receiving nurse's signature and date. --07/20/22 post treatment information and the receiving nurse's signature and date. --08/08/22 post treatment information and the receiving nurse's signature and date. --08/22/22 post treatment information and the receiving nurse's signature and date. --09/05/22 date of receiving nurse's signature --09/30/22 post treatment information --10/05/22 post treatment information --10/07/22 post treatment information --10/10/22 post treatment information --10/14/22 post treatment information --10/17/23 post treatment information and the receiving nurse's signature and date. --10/19/22 post treatment information --10/24/22 post treatment information --11/04/22 post treatment information --11/07/22 post treatment information --11/09/22 post treatment information and the receiving nurse's signature and date. --11/11/22 post treatment information --11/18/22 post treatment information --11/21/22 post treatment information --11/25/22 post treatment information --12/05/22 post treatment information --12/16/22 post treatment information --01/13/23 post treatment information --01/16/23 post treatment information --01/18/23 post treatment information --01/20/23 post treatment information --01/27/23 post treatment information --01/30/23 post treatment information --02/01/23 post treatment information and the receiving nurse's signature and date --02/06/23 post treatment information --02/15/23 post treatment information --02/17/23 post treatment information --02/20/23 post treatment information --02/22/23 post treatment information and the receiving nurse's signature and date --02/24/23 post treatment information --02/27/23 post treatment information --03/06/23 post treatment information On 03/15/23 at 9:05 AM, the Director of Nursing (DON) confirmed the dialysis communication forms were not completed correctly. The DON stated, I'm aware. No further information was obtained during the long-term survey process. .

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0710 (Tag F0710)

Could have caused harm · This affected 1 resident

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. Based on staff interviews and record reviews, the facility did not ensure timely notification of the physician of a Resident's significant weight loss. This was true for one (1) of two (2) Resident's reviewed for weight loss. Resident identifiers: R #77. Facility census: 107. Findings included: a) Resident #77 A medical record review of Resident #77 on 03/13/23 revealed, significant weight loss of 10.38 % in one (1) month. Resident #77's Weight log showed the following: 03/05/2023 143.4 Lbs. 02/16/2023 149.0 Lbs. 02/09/2023 160.0 Lbs. Subsequent review of the resident's medical record showed no evidence of Resident #77's physician being notified of a significant weight loss. Continued Medical record review of Resident #77's Care Plan found: Focus: --Resident #77 is on a Regular/liberalized diet. Dx include: hypothyroidism, dementia, recent fractures, Chronic Kidney Disease stage three (3). Severe weight loss over past 1 week; question accuracy of admit weight. Range of 140-15 lb. BMI is >19. Goal: -- (Resident name) will consume on average 55% or greater of meals every day through next review. Interventions: -- Weight per physician order. -- Monitor for changes in nutritional status (changes in intake, ability to feed self, unplanned weight loss/gain, abnormal labs) and report to food and nutrition/physician as indicated. -- Monitor weight per protocol and report as indicated. During an interview 03/15/23 at 11:40 AM, the Director of Nursing (DON) verified the facility did not have any evidence of Resident #77's Physician being notified of a significant weight loss. .

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0757 (Tag F0757)

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's drug regimen was free from unnecessary drugs. An unnecessary drug is any drug when used without adequate indications for its use. Resident identifier: # 63. Facility census 107. Findings included: a) Resident # 63 A review of medical records found Resident # 63 is receiving Trimethoprim ( an antibiotic) for prophylactic without a diagnosis or a reason for the use of the drug. The order read as the follows: Start date: 08/10/22 Trimethoprim tablet 100 mg Give 0.5 tablet by mouth at bedtime for prophylactic. During an interview with the Director of Nursing (DON) on 03/15/23 at 11:31 AM, she was asked what the indications was for giving this antibiotic Trimethoprim. The DON stated that she would have to find out. On 03/15/23 at 1:40 PM, the DON provided a report from an outside facility. This report was dated 08/10/22 and stated the medication was for reoccurring Urinary Tract infections. The DON stated she was going the correct the order. .

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0883 (Tag F0883)

Could have caused harm · This affected 1 resident

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. Based on record review and staff interview, the facility failed to ensure each resident was offered a pneumococcal immunization in accordance with the current Centers for Disease Control (CDC). This was true for two (2) of five (5) residents reviewed for immunizations. Resident identifiers: R# 56 and #35. Facility census 107. Findings included: a) Resident #56 During a review of medical records, noted that Resident #56 not eligible for pneumonia vaccine. On 03/15/23 at 8:30 AM, the Infection Preventionist (IP) was asked about Resident #56 not being eligible for a pneumococcal vaccine. The IP said she would have to look into it. On 03/15/23 at 9:31 AM, The IP stated that she was not aware of the new guide lines from the CDC for Prevnar 20. The IP agreed Resident #35 is eligible for the Prevnar 20 because Resident #56 turned 65 on 01/23/23 and was eligible. b) Resident #35 A review of the medical records Resident # 35 received pneumococcal 23 on 9/16 and Prevnar 13 on 8/15 (7 years since the last one). On 03/15/23 at 8:30 AM, the IP was asked if Resident #35 was offered the Prevnar 20 vaccine. The IP stated she would have to look into it. On 03/15/23 at 9:31 AM, the IP stated that she was not aware of the new guideline from the CDC for Prevnar 20. She also said she will be offering the Prevnar 20 to Resident #35. .

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Smoking Policies (Tag F0926)

Could have caused harm · This affected 1 resident

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. Based on record review and staff interview, the facility failed to follow the facility Smoking Policy for smoking evaluations. This was true for one (1) of one (1) residents reviewed in the accident care area for smoking. Resident identifier: #55 Facility census: #107. Findings included: a) Resident #55 On 03/15/23 at 10:44 AM a record review of Resident #55's smoking evaluations, found missing smoking evaluations that were to be completed, according to the Smoking Policy and Procedure (revision date 10/24/22), upon admission, quarterly and with a change in condition. Resident #55 was due for a smoking evaluation in the following months: February 2022, May 2022, August 2022, November 2022 and February 2023. There were no smoking evaluations completed in August 2022 or February 2023. The resident is an independent smoker. According to the care plan she may smoke independently per her smoking assessment. Resident #55 will be allowed to smoke safely through the next review and remain in compliance with the smoking policy. The facility failed to implement the care plan as they failed to do smoking evaluations. This was confirmed with the Administrator on 03/15/23 at 10:50 AM. .

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 and staff interview, the facility failed to ensure a comfortable and homelike environment, in regards of the temperature in the dining room and library used by residents. This failed practice had the potential to affect more than a limited number of residents that currently reside in the facility. Facility census: 107. Findings included: An observation in the dining room and Library,on 03/14/23 at 1:33 PM, found residents were wheeling around wearing coats, sweaters and blankets. In addition, the housekeeping staff were cleaning and wearing sweatshirts over their scrub tops. The thermostat in the Library (doors are open to the dining room) read 70 degrees Fahrenheit (F) . The thermostats are about 50 inches high on the wall. The thermostat in the dining room read 72 degrees F and was set on cooling. The room is a large room and felt much cooler from thigh level down. The Administrator (NHA), facility cooperate nurse were witness to the finding and of the concerns. The NHA was asked for the Maintenance Supervisor (MS) to bring an infrared thermometer to check the ambient temperature of the room. The MS #57 arrived at 1:45 PM, on 03/14/23, he did not bring an infrared thermometer but instead had a contact thermometer. MS#57 said he would have to get a ladder to check the heat coming from the ceiling vents. When it was explained the temperature at the resident's level needed to be checked he said he put the wires from the contact thermometer approximately 36 inches from the floor on an interior wall and it measured the temperature to be 63 degrees F. MA #57 left to find an infrared thermometer. On 03/14/23 at 2:08 PM, MS#57 said the infrared thermometer is broken. MS#57 stated that the thermostat in the dining is kept on cooling because of the kitchen and will change above or below 72 degrees F. MS #57 stated that the heating/cooling unit was turned off in the library and wall unit read 70 degrees F. MS #57 stated that he had told the maintenance staff the temperature should be set between 68 to 72 degrees F. On 03/14/23 at 2:45 PM an observation of the temperature checks found the library was 64 degrees, the temperatures in the dining room were showing between 64-67 degrees. After the temperatures had been increased for 40 minutes or longer MS #57 said he had an infrared thermometer, and he checked the temperatures, and they were all good. An additional observation on 03/15/23 at 8:04 AM found the thermostat set at 74 degrees F in the dining room and the temperature reading 74 degrees F. The Library unit was turned on and the temperature was 74 degrees F and the thermostat was set on 74 degrees F. .

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Comprehensive Care Plan (Tag F0656)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . d) Resident #29 On 03/15/23 at 8:00 AM, a record review was completed for Resident #29. The care plan under the focus area of requires assistance or is dependent for activities of daily living (ADLs) did not list the resident's refusals for showers and/or bed baths. There were no interventions in place or a goal noted. The record review did not find any progress notes related to the refusals of showers and/or bed baths. A review of the documentation regarding bathing from 02/13/23 through 03/13/23 was reviewed on 03/15/23 at 8:05 AM. The following dates found no documentation of a shower or bed bath given or refusal by the resident: --02/18/23 --02/19/23 --02/25/23 --02/26/23 --03/01/23 --03/04/23 --03/05/23 --03/07/23 --03/10/23 --03/11/23 --03/12/23 On 03/15/23 at 11:42 AM, the Director of Nursing (DON) stated, I couldn't find any progress notes related to the refusals of showers or bed baths. The care plan does not indicate refusals of bed baths or showers. No further information was obtained during the long-term survey process. e) Resident #85 On 03/15/23 at 10:00 AM, a record review was completed for Resident #85. The care plan did not list the new diagnosis of cataracts. On 03/15/23 at 10:10 AM, the Clinical Reimbursement Coordinator (CRC) #2 confirmed the diagnosis of cataracts had not been added to the medical record or the quarterly Minimum Data Set (MDS) dated [DATE]. On 03/15/23 at 1:00 PM, the DON confirmed the diagnosis of cataracts had not been added to the care plan. Based on record review, observations and staff interview, the facility failed to implement or develop a care plan. This is true for five (5) of 28 residents reviewed in the care plan care area. Facility identifiers: #55, #68, #22, #29 and #85. Facility census: #107. Findings included: a) Resident #55 On 0/15/23 at 10:44 AM upon record review of Resident #55's smoking evaluations, found missing smoking evaluations that were to be completed, according to the Smoking Policy and Procedure (revision date 10/24/22), upon admission, quarterly and with a change in condition. Resident #55 was due for a smoking evaluation in the following months: February 2022, May 2022, August 2022, November 2022 and February 2023. There were no smoking evaluations completed in August 2022 or February 2023. The resident is an independent smoker. According to the care plan, she may smoke independently per her smoking assessment. She will be allowed to smoke safely through the next review and remain in compliance with the smoking policy. The facility failed to implement this care plan as they failed to do smoking evaluations as stated in their policy. This was confirmed with the Administrator on 03/15/23 at 10:50 AM. b) Resident #68 On 03/13/23 at 9:12 AM during the initial survey interview process it was observed that Resident #68 had a urinary catheter bag at bedside that was not covered for privacy. This was confirmed with Licensed Practical Nurse (LPN) #75 on 03/13/23 at 9:15 AM. According to the care plan he . requires an indwelling Foley catheter due to diverticula in bladder (obstructive uropathy) and the facility will provide privacy and comfort . as well as . provide a privacy bag This was confirmed with the Administrator on 03/15/23 at 10:50 AM. c) Resident #22 On 03/13/23 at 11:34 AM during record review it was determined that Resident #22 had the following current order: Continuous oxygen at 2 L/min via Nasal Cannula w/humidity. An observation found no humidification on the oxygen concentrator. This was confirmed with Licensed Practical Nurse (LPN) #75 on 03/13/23 at 11:34 AM. Review of Resident #22's care plan reads: Encourage resident to wear oxygen at 2L/min with humidity per nasal cannula continuously and may titrate to keep 02 sats >90%. The care plan was not implemented due to the facility failing to provide the humidification to the oxygen concentrator. This was confirmed with Licensed Practical Nurse #75 on 03/13/23 at 11:34 AM. .

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 medical record review, observation, and staff interview, the facility failed to ensure Resident's received treatment and care in accordance with professional standards of practice. Specifically, physician's orders were not followed. This was true for four (4) of 28 residents reviewed during the Long-Term Survey Process (LTCSP). Residents identifiers: R#95, R#3, R#29, and R#28. Facility census: 107. Findings included: a) Resident #95 1) During an observation on 03/14/23 at 9:22 AM Resident #95 was laying in bed with an adductor wedge in place between his legs. A record review for Resident #95 on 03/15/23 at 10:40 AM found no physician order for placement, no care plan, or Nurse Aide (NA) task for the adductor pillow placement. During an interview 03/15/23 at 11:37 AM, the Director of Nursing (DON) verified Resident #95 did not have a physician order for an adductor wedge. The DON stated that she would correct it now. 2) A record review revealed Resident #95's had an unwitnessed fall on 02/24/23 in his room. Continued review for Resident #95's Neurological Evaluation from the fall on 02/24/23 found they were not completed as ordered. During an interview on 03/14/23 at 2:15 PM, the DON acknowledged there was no documentation that Neurological Checks had been completed. The DON verified neurological checks should have been completed per policy for Resident #95's unwitnessed fall on 02/24/23. b) Resident #3 Resident #3 has a current order for: Patient to have lateral wedges to right shoulder and right knee with pillow placement under right lower extremity and heel/foot protector boots on while in bed at all times. Can be removed for dressing/hygiene. Posey boots to bilateral feet when in bed for skin alteration prevention. Patient to have carrot in left hand as needed (PRN) with skin checks everyday every shift. Observations on the following dates found the above order not being followed. 03/13/23 9:00 AM in residents room, no wedge, Posey boots or carrot in place. 03/13/23 11:00 AM in residents room, no wedge, Posey boots or carrot in place 03/13/23 11:30 AM in residents room, no wedge, Posey boots or carrot in place The care plan states Lateral wedges to right shoulder and right knee with pillow under right lowed extremities and heel/foot protector boots while in bed. Carrot in left hand PRN. Observations revealed the care plan was not implemented. This was confirmed with Licensed Practical Nurse #75 on 03/13/23 at 11:32 AM. c) Resident #29 On 03/13/23 at 9:22 AM, the oxygen flow rate for Resident #29 was observed at the setting of 4.5 (four point five) liters per minute (LPM). On 03/13/23 at 9:25 AM, Licensed Practical Nurse (LPN) #75 confirmed the setting for the oxygen should be 4 (four) liters per minute. A current physician's order dated 08/02/22 was found during the record review on 03/13/23 at 9:35 AM. The current physician's order stated, Oxygen at 4L/min (LPM) via nasal cannula continuously. No further information was obtained during the long-term survey process. d) Resident #17 A review of medical records found on 03/14/23 Licensed Practical Nurse (LPN) #3 failed to follow a physicians order for lidocaine injection. The physicians order read as follows: Start date:03/10/23 at 8:00 PM Lidocaine HCL injection solution 1% (Lidocaine a local anesthetic) Inject 2.1 ml intramuscularly two times a day for cellulitis mix 2.1 ml lidocaine with Rocephin. Start date:03/11/23 at 8:00 AM Ceftriaxone Sodium injection solution Reconstituted 1 GM (Rocephin) Inject 1 gram intramuscularly two times a day for cellulitis for 3 days reconstitute with 2.1 mls lidocaine 1% solution A review of the Medication Administration Record (MAR) found Resident #17 received the combination of Rocephin and Lidocaine on 03/11/23 at 8 AM and 8 PM, 03/12/23 at 8 AM and 8 PM, 03/13/23 at 8 PM and resident refused the 8 AM dose. On 03/14/23 LPN #3 injected Resident #17 with 2.1 ml of Lidocaine to the left hip. This was given one day after the order for the Rocephin was completed. On 03/14/23 at 11:59 AM, LPN #3 was asked about the lidocaine injection given this am 03/14/23. LPN #3 looked at the MAR on her computer and stated she made a mistake and thought she checked off an order for a Lidocaine patch. LPN #3 was informed Resident #17 did not have an order for Lidocaine patches and she had documented the Lidocaine was injected into the left hip. LPN #3 was asked to review the order for the Lidocaine to verify the order was missing a stop date. LPN #3 agreed there was not a stop date and agreed that giving the Lidocaine without the Rocephin was not following the order. d) Midline order While observing wound care for Resident #17 with Registered Nurse (RN) #27 on 03/14/23 at 10:32 AM. it was noted Resident #17 had a Midline in her upper right arm. The dressing was dated 03/10/23. RN #27 was asked about the Midline and questioned if there was and order for the Midline along with an order for dressing changes and flushes for the Midline? RN #27 said he was not sure. Another review of the medical chart found there was not an order on the chart for the insertion of the Midline or for the care of the Midline. On 03/14/23 at 11:29 AM, RN #27 reported the midline did not have an order or for the care of the line. RN #27 went on to say he found out the Nurse Practitioner had given a verbal order to a nurse, but the order was never entered into the computer system. RN #27 said he found the information mentioned in the change of conditions, but failed to be entered as an order. After speaking to the provider the Midline is no longer needed and RN #27 is removing it now. On 03/14/23 at 11:39 AM, DON informed of the above findings and did not ask any question. .

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Administration (Tag F0835)

Could have caused harm · This affected multiple residents

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. Based on record review, staff interview and a collection of deficient practices throughout the survey process, the facility failed to be administered in a manner that enables it to use its resources effectively and efficiently to attain and/or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. This failed practice had the potential to affect more than a limited number of residents that currently reside at the facility. Facility census 107. Findings included: a) Quality Assessment and Assurance (QAA)/Quality Assurance and Performance Improvement(QAPI) On 03/15/23 at 1:06 PM, the Administrator (NHA) stated that she only had one (1) QAPI meeting with all of the members present. The NHA provided a sign in sheet with the one (1) and only meeting conducted for the last 12 months, dated 02/06/23. The NHA stated that she came to this facility in August. The NHA said going forward she was going to have the meetings. The NHA was asked after seeing the education sign-in sheets for staff done in the fall of last year on documenting on activities, showers, baths, improving quality of life for the residents. The NHA asked about how monitoring for improvements or not was being done. The NHA stated that obviously the facility will start monitoring those areas monthly. The NHA was asked about the following care areas of concerns: - to protect two (2) residents from an alleged allegation of abuse, by not following their facility policies. -conducting meetings with the QAA/QAPI committee quarterly. An effective QAPI programs are critical to improving the quality of life, and quality of care and services delivered in nursing homes. -Ensuring residents are receiving quality care, in the care areas of showers/baths, -Following physician's orders, -Correctly entering all orders into the chart and ensuring the orders are complete and accurate orders. -Not administering medications outside of the order instructions -Ensuring all dialysis communication are completed. -Ensuring all pneumonia vaccines were offered to meet the current Center for Disease Control (CDC)standards. The NHA stated that going forward she plans on having more QAPI meetings, and monitoring monthly to ensure all of those things are being done. No evidence was given to show that any of the education and/or re-education were monitored or evaluated for improvements or not at the close of the survey. .

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Medical Records (Tag F0842)

Could have caused harm · This affected multiple residents

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. Based on record review and staff interview, the facility failed to ensure four (4) of 19 residents reviewed during the long-term care survey process had a Physician Orders for Scope of Treatment (POST) form completed per directions specified by the [NAME] Virginia Center for End-of-Life Care in conjunction with the [NAME] Virginia Health Care Decisions Act (16-30-1). The POST forms were unsigned by the Resident or Medical Power of Attorney (MPOA). Resident identifiers: Resident #56, R#77, R#66, and R#29. Facility census: 107. Findings included: A review of the [NAME] Virginia End-of-Life Center instructions for completing a POST form was reviewed. The review found the following: If the incapacitated patient's MPOA representative or health care surrogate is unavailable at the time of form completion, this section can be signed by two witnesses for verbal confirmation of agreement from the patient's MPOA representative or health care surrogate. The form should be signed at the earliest available opportunity. (Typed as written.) a) Resident #56 Record review on 03/13/23 at 2:16 PM found, a POST Form on Resident #56's chart was unsigned by the Resident or Medical Power of Attorney (MPOA). (Patient/Patient MPOA representative/surrogate signature Required). A verbal consent was completed on 03/24/22. During an interview on 03/15/23 at 11:40 AM, the Director of Nursing (DON) confirmed Resident #56's POST form was not signed with a Resident or MPOA signature. b) Resident #77 A record review on 03/13/23 at 2:54 PM found, a POST Form on Resident #77's chart was unsigned by the Resident or MPOA. (Patient/Patient MPOA representative/surrogate signature required). A verbal consent was completed on 02/15/23 without witnesses. During an interview on 03/15/23 at 11:40 AM, the DON confirmed Resident #77's POST form was not signed with a resident or MPOA signature or verbal witnesses. c) Resident #66 A record review on 03/13/23 at 1:48 PM found, a POST Form on Resident #66's chart was unsigned by the Resident or MPOA. (Patient/Patient MPOA representative/surrogate signature required). A verbal consent was completed on 10/28/21. During an Interview on 03/15/23 at 11:40 AM, the DON confirmed Resident #66's POST form was not signed with a Resident or MPOA signature. d) Resident #85 On 03/13/23 at 1:00 PM, a review of the POST form for Resident #85 was completed. The POST form noted verbal consent was obtained from the MPOA by two (2) witnesses. The verbal consent was obtained on 06/04/21. On 03/15/23 at 9:10 AM, the DON confirmed it should have been signed by the representative by now. No further information was obtained during the long-term survey process. e) Resident #29 On 03/13/23 at 1:15 PM, a review of the POST form was completed for Resident #29. The review found the resident signed the POST form on 11/22/22. However, the provider's signature and date of the completion of the form was blank. On 03/15/23 at 9:15 AM, the DON confirmed the provider's signature and date of preparation of the form is incomplete and blank. No further information was obtained during the long-term survey process. .

CONCERN (F)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0868 (Tag F0868)

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 conduct meetings with the Quality Assessment and Assurance (QAA)/QAPI (Quality Assurance and Performance Improvement) committee quarterly. An effective QAPI programs are critical to improving the quality of life, and quality of care and services delivered in nursing homes. This failed practice had the potential to affect more than a limited number of residents that currently reside at the facility. Facility census 107. Findings included: a) QAA/QAPI On 03/15/23 at 1:06 PM, the Administrator (NHA) stated that has only had one (1) QAPI meeting with all of the members present. The NHA provided the sign in sheet for the one (1) and only meeting conducted for the last 12 months, dated 02/06/23. The NHA stated that she came to this facility in August going forward was going to have the meetings. .

Feb 2022 17 deficiencies

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0565 (Tag F0565)

Could have caused harm · This affected 1 resident

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. Based on resident interview, Resident Council staff interview and review of Resident Council minutes, resident concerns regarding smoking privileges were not addressed in a timely manner. This practice had the potential to affect a limited number of residents. Resident identifier: #41. Facility census: 108. Findings included: a) Resident #41 An interview with Resident #41 conducted on 02/07/22 at 11:05 AM found this resident is a smoker. He stated that our smoking privileges are now limited to two (2) hours each day. There are ten (10)people who smoke in the building and depending on what time you are scheduled, you have to choose between smoking and eating breakfast and/or dinner. When asked if he had told anyone about this issue, he stated he had complained in Resident Council sometime ago but nothing was done. A review of Resident Council minutes dated 10/25/21 found Resident #41 attended this meeting. In the section titled Discussion of old/unfinished business (include resolution of previous concerns.) found the following: (resident name) was never told if he could have longer smoke time outside. In an interview with the Nursing Home Administrator (NHA) on 02/08/21 at about 2:30 PM, the NHA stated he had dropped the ball on this one. He stated that there was no reason there needed to be restrictions on smoking times for residents except for morning start and day ending times. .

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0578 (Tag F0578)

Could have caused harm · This affected 1 resident

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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 33 residents reviewed during the long-term care survey process had advance directives completed as recognized by State Law. Resident identifier: #10. Facility census: 108. Findings included: a) Resident #10 An electronic medical record review, on 02/07/22 at 1:20 PM, found Resident #10 was admitted to the facility on [DATE] with hospice services. Further record review found a [NAME] Virginia Physician Orders for Scope of Treatment (POST) form signed and dated on 08/12/21, was on file at the nurse's station. The POST form left the section Patient is enrolled in Hospice and Name of Hospice Agency sections blank. In 2002, the POST form was incorporated into the [NAME] Virginia Health Care Decisions Act (16-30-25.) POST forms are standardized forms used to reflect orders by a qualified physician for medical treatment of a person in accordance with that person's wishes. The directions for completing the POST form, compiled by the [NAME] Virginia Center for End of Life, require accurately documenting a patient's treatment preferences, which would include accurate documentation of Resident #10 being a hospice patient. During an interview on 02/08/21 at 10:25 AM, the Director of Nursing confirmed the POST form was not completed in its entirety and the form should be updated. .

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Safe Environment (Tag F0584)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation and staff interviews, the facility failed to ensure a safe, clean homelike environment. These were random opportunities for discovery. Resident identifiers #13, #2. Facility Census 108. Findings included: a) Resident #13 On 2/09/22 at 10:30 AM, observed Resident #13's clock was set at 5:00. An interview with Nurse Aides (NA) #142 and #54 who was in the residents room, asking if clock would need fixed what is the process in getting it fixed. CNA #142 stated, I really don't know I just go to Central Supply and get batteries. CNA #54 agreed with CNA #142 statement. On 2/09/22 at 1:30 PM, resident #13 clock was still at 5 PM. Resident #13 has a diagnosis of Dementia and Anxiety and does not watch Television. Clock is on wall facing resident. b) Resident #2 On 2/8/22 at 1:30 PM, observed signage in the open nursing cove that had Resident #2's name in bright red and yellow lettering stating, Attention CNA get resident up on Monday, Wednesday and Friday by 11:15 AM for family visits. The signage was visible by anyone in the area. Had administrator observe signage and administrator stated, well they need to know and this surveyor stated, could it not be on the [NAME] or in an area not seen by everyone that would come down 300 Hall. Administrator did not agree with signage being there however did take signage down. This same signage is over residents bed per family interview. .

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Transfer Notice (Tag F0623)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review and staff interview, the facility failed to provide evidence a resident/resident's representative was provided a written Notice of Transfer for an acute hospital transfer. The facility also failed to provide evidence a copy of the Notice of Transfer was sent to the Ombudsman. This was true for two (2) of three (3) residents reviewed for hospitalizations during the long-term care survey process. Resident identifiers: #36 and #355. Facility census: 108. Findings included: a) Resident #36 A medical record review was completed on 02/08/22 at 1:28 PM. The record review revealed Resident #36 was transferred to the hospital on [DATE]. The record did not reflect the resident/resident's representative was provided a Notice of Transfer, nor did the record reflect the Notice of Transfer was sent to the Ombudsman. During an interview with the Director of Nursing (DON) on 02/08/22 at 2:00 PM, the DON reported the facility had no evidence a Notice of Transfer had been provided. Additionally, the DON stated that the Ombudsman was not provided a copy of the Notice of Transfer. b) Resident #355 A medical record review was completed on 02/08/22 at 1:16 PM. The record review revealed Resident #355 was transferred to the hospital on [DATE]. The record did not reflect the resident/resident's representative was provided a Notice of Transfer, nor did the record reflect the Notice of Transfer was sent to the Ombudsman. During an interview with the Director of Nursing (DON) on 02/08/22 at 2:01 PM, the DON reported the facility had no evidence a Notice of Transfer had been provided. Additionally, the DON stated that the Ombudsman was not provided a copy of the Notice of Transfer. .

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0625 (Tag F0625)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review and staff interview, the facility failed to provide evidence a resident/resident's representative was provided a written Bed Hold Notice for an acute hospital transfer. This was true for three (3) of three (3) residents reviewed for hospitalizations during the long-term care survey process. Resident Identifiers: #1, #36, and #355. Facility census: 108. Findings included: a) Resident #1 A medical record review was completed on 02/08/22 at 10:30 AM. The record review revealed Resident #1 was transferred to the hospital on [DATE]. The record reflected the resident/resident's representative was provided a Bed Hold Notice. However, the Bed Hold Notice form was left completely blank and did not explain the duration of bed-hold or reserve bed payment policy. During an interview with the Director of Nursing (DON) on 02/08/22 at 1:58 PM, the DON reported the facility had failed to include the necessary information on the Bed Hold Notice. b) Resident #36 A medical record review was completed on 02/08/22 at 1:28 PM. The record review revealed Resident #36 was transferred to the hospital on [DATE]. The record did not reflect the resident/resident's representative was provided a Bed Hold Notice. During an interview with the DON on 02/08/22 at 2:00 PM, the DON reported the facility had no evidence a Bed Hold Notice had been provided. b) Resident #355 A medical record review was completed on 02/08/22 at 1:16 PM. The record review revealed Resident #355 was transferred to the hospital on [DATE]. The record did not reflect the resident/resident's representative was provided a Bed Hold Notice. During an interview with the DON on 02/08/22 at 2:01 PM, the DON reported the facility had no evidence that a Bed Hold Notice had been provided. .

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Assessment Accuracy (Tag F0641)

Could have caused harm · This affected 1 resident

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. Based on medical record reviews and staff interviews, the facility failed to complete accurate Minimum Data Set (MDS) assessments for two (2) of 33 assessments reviewed during the Long Term Care Survey Process (LTCSP). The MDS assessment for Resident #48 did not accurately reflect hospice services and Resident #41's assessment inaccurately recorded anticoagulant therapy. Resident identifiers: #48 and #41. Facility census: 108. Findings included: a) Resident #48 During a medical record review on 02/07/22, revealed a physician's order for hospice services with a start date of 12/20/21. The MDS assessment with an Assessment Reference Date (ARD) of 01/16/22, Section O: Special Treatments did not reflect Resident #48 as receiving hospice services. In an interview with the MDS Coordinator on 02/08/22 at 1:53 PM, verified the MDS assessment, Section O: Special Treatments did not reflect Resident #48 was receiving hospice services. b) Resident #41 On 02/08/22 at 2:12 PM a review of the Electronic Medical Record (EMR) was conducted. The review of the significant change MDS with an ARD of 12/10/21 revealed Section N was marked as Resident #41 was receiving anticoagulants. The physician's orders noted this resident was receiving Aspirin and Plavix. Neither of these medications are classified as an anticoagulant. The MDS Coordinator confirmed at 2:05 PM on 02/08/22 this was an error and would be correctly immediately. .

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 observation, medical record review and staff interview, the facility failed to implement a care plan. Resident (R) #40's lap tray was not secured to his wheel chair. This was found for 1 of 5 residents reviewed for accidents. Resident identifier: #40. Facility census: 108. Findings included: a) Resident #40 A review of the medical record on 02/08/22, found Resident #40 found the care plan was amended on 8/30/21, to include a right sided lap tray to the wheel chair with the goal to prevent serious injury related to falls. Three random observations on 02/07/22, found R#40 sitting in the doorway of his room in a high back chair without a right sided lap tray. On 2/8/22 at 10:00 am, R#40 was observed sitting in the 400 hallway without the right sided lap tray. A follow up observation with Licensed Practical Nurse (LPN) #88 and Nursing Aide (NA) #28 at 2:45 PM on 02/08/22, again found R#40 sitting in the hall without the right sided lap tray. LPN #88 confirmed the plan of care includes the use of a right sided lap tray and then secured the lap tray to the wheel chair. .

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 observation, record review, and staff interview, the facility failed to revise the comprehensive care plan for two (2) of 33 residents reviewed during the long-term care survey process. Resident identifiers: #58, #40. Facility census: #108. Findings included: a) Resident #58 Review of Resident #58's comprehensive care plan showed the following focus, Resident is at risk for alteration in psychosocial well being related to restriction on visitation due to COVID-19. The focus was initiated on 03/15/20. During an interview on 02/09/22 at 8:58 AM, the Director of Nursing (DON) confirmed visitation is no longer restricted in the facility. The DON stated she would ensure this focus was removed from the care plan because it was no longer applicable. No further information was provided through the completion of the survey. B) Resident #40 A review of the medical record on 02/08/22, found Resident #40 (R) care plan was amended on 09/23/21, to include a .pillow behind head for optimal positioning when OOB (out of bed) . Three random observations on 02/07/22, found R #40 sitting in the doorway of his room in a high back chair without a pillow behind his head. On 2/8/22 at 10:00 am, R#40 was observed sitting in the 400 hallway without the pillow behind his head. A follow up observation with Licensed Practical Nurse (LPN) #88 and Nursing Aide (NA) #28 at 2:45 PM on 02/08/22, again found R#40 sitting in the hall without a pillow behind his head. NA #28 reported R #40 has never liked the pillow behind his head and will pull it out and throw it on the floor. LPN #88 confirmed R#40's current care plan states the resident should have a pillow behind his head for optimal positioning. The DON acknowledged the care plan was not revised to reflect R#40's preferences, during an interview on 02/09/22. .

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 and staff interview, the facility failed to provide respiratory care consistent with professional standards of practice. A bi-pap mask was on the bedside table with no protective covering. This observation was a random opportunity for discovery. Resident identifier: #355. Facility Census: 108. Findings included: a) Resident #355 An observation on 02/07/22 at 12:11 PM, found Resident #355's bi-pap mask on the bedside table with no protective covering. At 3:39 PM, Nurse Aide (NA) #109 confirmed Resident #355's bi-pap mask was on top of the bedside and not in a bag and then immediately placed the mask inside the bag. During an interview, on 02/07/22 at 3:58 PM, Licensed Practical Nurse (LPN) #38 acknowledged improper storage of the bi-pap mask may lead to inadvertent contamination and stated facility policy had not been followed. .

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0711 (Tag F0711)

Could have caused harm · This affected 1 resident

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. Based on medical record review and staff interview, the physician and/or nurse practitioner failed to identify medication recommendations made by the mental health consultant to address Resident (R) #63's psychotropic needs. This is true for one (1) of five (5) reviewed for unnecessary medications. Resident identifier #63. Facility census: 108. Findings included: a) Resident (R) #63 Review of the medical record on 02/09/22, revealed R#63's diagnoses include chronic respiratory failure, chronic obstructive pulmonary disease, venous insufficiency, diabetes mellitus, chronic pain, anxiety and major depression. The current physician orders include Cymbalta (Duloxetine Hydrochloride) (antidepressant that helps block pain) 90 milligrams (mg) once a day for pain and Trazadone hydrochloride (HCL) (antidepressant and sedative) 50 mg once day for depression. The mental healthcare consultant report dated 12/03/21, noted R#63 reported having trouble falling asleep and staying asleep and constantly feeling tired. The mental health consultant recommended the facility increase the Trazadone to 100 mg at bedtime to help with sleep. Nurse Practitioner (NP) #148 evaluated R#63 on 12/09/21. Her progress note identifies the reason for her visit as a Follow up visit for medication monitoring. The current medication list includes Trazadone 50 mg once a day. The note lacks any information related to the mental healthcare consultant's recommendation to increase the Trazadone to 100 mg. The mental healthcare consultant report dated 01/18/22, stated that R#63 reports continued difficulty with falling asleep and feeling sadder. The recommendation was to consider increasing the Cymbalta (Duloxetine) to 60 mg twice a day for depression. The Director of Nursing (DON) reviewed the medical record during an interview on 02/09/21 at 10:20 AM. The DON acknowledged she was unaware the mental health care consultant had made medication recommendations during telehealth visits on 12/03/21 and 01/18/22. The DON confirmed the mental health consultant's recommendations to increase the Trazadone was not addressed by NP #148 during her visit and medication review on 12/09/21. In addition, the DON confirmed the recommendation to increase R #63's Cymbalta was never addressed by the physician and/or nurse practitioner. .

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Drug Regimen Review (Tag F0756)

Could have caused harm · This affected 1 resident

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. Based on medical record review and staff interview, the pharmacist failed to identify medication recommendations made by the mental health consultant and/or assure the physician/nurse practitioner addressed the recommendations to increase R#63's psychotropic medications. This was true for one (1) of five (5) residents reviewed for unnecessary medications. Resident identifier #63. Facility census: 108. Findings included: a) Resident (R) #63 Review of the medical record on 02/09/22, revealed R#63's diagnoses include chronic respiratory failure, chronic obstructive pulmonary disease, venous insufficiency, diabetes mellitus, chronic pain, anxiety and major depression. The current physician orders included Cymbalta (Duloxetine Hydrochloride) (antidepressant that helps block pain) 90 milligrams (mg) once a day for pain and Trazadone hydrochloride (HCL) (antidepressant and sedative) 50 mg once day for depression. The mental healthcare consultant report dated 12/03/21, noted R#63 reported having trouble falling asleep and staying asleep and constantly feeling tired. The mental health consultant recommended the facility increase the Trazadone to 100 mg at bedtime to help with sleep. Nurse Practitioner (NP) #148 evaluated R#63 on 12/09/21. Her progress note identifies the reason for her visit as a Follow up visit for medication monitoring. The current medication list includes Trazadone 50 mg once a day. The note lacks any information related to the mental healthcare consultant's recommendation to increase the Trazadone to 100 mg. The Monthly Medication Review (MRR) indicates Pharmacist #147 reviewed R#63's medical record on 12/27/21. She made a recommendation to start Invokana (a Type 2 diabetes medication) per the American Diabetic Association but failed to identify the facility's failure to timely address the mental health care consultant's recommendation to increase the Trazadone to 100 mg at bedtime. The mental healthcare consultant report dated 01/18/22, stated that R#63 reports continued difficulty with falling asleep and feeling sadder. The recommendation was to consider increasing the Cymbalta (duloxetine) to 60 mg twice a day for depression. The Monthly Medication Review (MRR) was completed by Pharmacist #147 on 01/24/22. Her recommendation addressed the need to monitor the resident for side effects related to the administration of Invokana but failed to identify the mental health specialist's recommendation dated 01/18/22 to increase R#63's Cymbalta to 60 mg twice a day for depression. The Director of Nursing (DON) reviewed the medical record during an interview on 02/09/22 at 10:20 AM. The DON confirmed the mental health consultant's recommendations to increase the Trazadone and Cymbalta were not addressed by the physician and/or nurse practitioner. In addition, the DON reviewed the pharmacy logs and MRR and agreed the pharmacist failed to identify the mental healthcare consultant's recommendations and/or the fact that the physician/nurse practitioner failed to acknowledge and/or address these recommendations in a timely manner. .

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0805 (Tag F0805)

Could have caused harm · This affected 1 resident

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. Based on resident interview, record review, and staff interview, the facility failed to provide food in the form to meet the resident's needs. This was true for one (1) of five (5) residents reviewed for nutrition during the long-term care survey process. Resident #37 was on a dysphagia (difficulty swallowing) texture diet but was eating deli sliced turkey. Resident identifier: #37. Facility census: 108. Findings included: a) Resident #37 During an interview, on 02/07/22 at 11:20 AM, Resident #37 stated he did not enjoy all the meals served by the facility and that his daughter would frequently bring in deli sliced turkey for both he and his wife [who was Resident #37's roommate at the facility] to enjoy. On 02/08/22 at 12:37 PM, a medical record review was completed which revealed a diet order, dated 01/02/22, for resident to receive a regular/liberalized diet with dysphagia puree texture. During an interview, on 02/08/22 at 12:58 PM, the Dietician reviewed Resident #37's diet order and stated deli sliced turkey was NOT approved as part of his dysphagia puree diet. The Dietician went on to explain that typically, a speech therapist will recommend a dysphagia pureed diet after evaluating a resident who has problems chewing or swallowing food. All foods should be pureed to a pudding-like consistency. The Dietician stated a new Speech referral would be given to evaluate Resident #37 again. The Dietician explained sometimes Speech will be able to modify a diet order, if appropriate. If deli sliced turkey still couldn't be approved, Resident #37 would be given the opportunity to receive education about choking risks and then would have the right to sign against medical advice paperwork. The Director of Nursing (DON) reviewed Resident #37's diet order on 02/08/22 at 1:09 PM. The DON stated she was not aware Resident #37 was eating deli sliced turkey routinely brought in by a family member. The DON stated she would speak to Resident #37 and nursing staff to ensure he did not eat any more turkey prior to being re-evaluated by Speech. .

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Infection Control (Tag F0880)

Could have caused harm · This affected 1 resident

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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 staff performed hand washing when exiting a resident's room on contact precautions for Clostrium Difficile (C-diff). The facility failed to transport clean linens in a manner that would prevent the spread of infections. Resident identifier: #14. Facility census 108. Findings included: a) Resident #14 On 02/09/22 at 9:30 AM on the 400 hallway, Guest Services Employee (GS) #93 was observed taking a plastic bag with items in it and a box of soda into Resident #14 room. Resident #14 is on contact precautions for a diagnosis of Clostridium Difficile (C-diff). GS #93 did not put on any personal protective equipment (PPE) to enter the room, and when exiting Resident #11 room, GS #93 only used an alcohol based hand rub (ABHR). Record review verified Clostridoides Difficile Infection (CDI) Maintain stringent hand washing and explain precautions of proper handwashing to patient and visitors. Do not use alcohol based hand rub. An interview on 02/09/22 at 9:35 AM with GS #93 stated that she was not thinking. On 02/09/22 at 10:00 AM with the Director of Nursing (DON) stated that she was aware of what happened and confirmed GS #93 should have performed hand washing instead of only using ABHR. b) Linen On 02/09/22 at 9:92 AM on the 400 hallway, GS #93 transported clean linens into room [ROOM NUMBER]. While carrying the linens, GS #93 held the clean linens against her body. Record review verified cleanse hands before handling clean linen, do not allow linen to touch clothing. .

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0883 (Tag F0883)

Could have caused harm · This affected 1 resident

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. Based on record review and staff interview, the facility failed to offer an influenza vaccine to 1 of 5 residents reviewed. Resident identifier #48. Facility census 108. Findings included: a) Resident #48 Record review for resident #48 found no influenza vaccination consent or declination. An interview with the Center Nurse Executive (CNE) on 02/09/22 at 11:45 a.m. confirmed Resident #22 was not offered an influenza vaccine. .

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 observation, record review, resident interview, and staff interview, the facility failed to ensure residents receive treatment and care in accordance with professional standards of practice for four (4) of 33 residents reviewed during the long-term care survey process. Resident #58 did not receive restorative range of motion as ordered by the physician. Additionally, PRN (as needed) hand splints for Resident #58 were not documented. Resident #355 did not have pulse oximeter parameters specified in the physician's order. Resident #71 did not have geri-sleeves applied as ordered by the physician. Resident identifiers: #58, #355, #71. Facility census: 108. Findings included: a) Resident #58 - restorative range of motion Review of Resident #58's medical records showed an order written on 12/09/21 for Nurse Aide (NA) to perform restorative bilateral upper extremity active range of motion for 15 minutes or as tolerated, up to three (3) days a week, three (3) days on and three (3) days off for 12 weeks, until 03/03/22. The Nurse Aide task reports for the preceding 30 days showed only one (1) documentation of restorative range of motion. On 01/27/21, not applicable is documented for restorative range of motion. There was no other documentation regarding restorative range of motion for any other days. During an interview on 02/08/22 at 3:04 PM, the Director of Nursing (DON) confirmed restorative range of motion had not been performed for Resident #58 as ordered by the physician. No further information was provided through the completion of the survey. a2) Resident #58 - hand splints Review of Resident #58's medical records showed a physician's order written on 09/23/21 for the resident to wear carpal tunnel wrist splints for five (5) to six (6) hours during the day as needed as resident will tolerate. Further review of Resident #58's medical records did not show any documentation of when Resident #58 wore carpal tunnel wrist splints. During an interview on 02/08/22 at 3:04 PM, the DON stated Resident #58's carpal tunnel wrist splints were not documented because they are applied as needed. When asked how it could be determined how often the splints were worn if the resident's carpal tunnel symptoms worsened, the DON stated the resident would be able to provide the information. During an interview on 02/08/22 at 3:25 PM, Resident #58 stated her goal was to wear the splints four (4) or five (5) times a week, although she usually didn't wear them that much. She stated the number of times she wears them varies week-by-week. The resident stated the NA periodically asks her if she would like to wear them, but they don't ask her every day. No further information was provided through the completion of the survey process. b) Resident #355 On 02/08/22 at 11:20 AM, a medical record review was completed. The medical record revealed the following physician order, dated 02/04/22 at 12:27 AM, Pulse ox [oximeter] every shift to keep oxygen sats [saturations] greater than or equal to _________. The order did not specify a pulse ox parameter. A pulse ox reading measures the level of blood oxygen saturation, which is a crucial measure of how well the lungs are working. A subsequent review of the February 2022 Medication Administration Record (MAR) reflected nursing staff had signed off on completing the pulse ox order (although there was no parameter specified) on all three shifts for 02/04/22, 02/05/22, 02/06/22, 02/07/22, and the morning of 02/08/22. The DON, during an interview on 02/08/22 at 11:30 AM, stated the pulse ox order was an incomplete order with no parameters. The DON stated the standard is usually a minimum of 90, but a nurse should have addressed the incomplete order by contacting the physician to clarify. The DON stated she would immediately address the issue. c) Resident #71 During the medical record review on 02/07/22, the physician's order for Resident #71 was to wear geri sleeves to aid in maintaining skin integrity and could be removed for hygiene. On 02/09/22 at 8:22 AM, during an observation, it was discovered Resident #71 was not wearing geri sleeves on either arm, this failed practice did not follow physician's orders. Also NA #54, verified the geri sleeves were not present on resident's arms. .

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Food Safety (Tag F0812)

Could have caused harm · This affected multiple residents

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. Based on observation and staff interview, the facility failed to store, prepare, distribute and serve food in accordance with professional standards of practice. This had the potential to affect all residents receiving nutrients from the kitchen and pantries. Facility Census 108. Findings included: a) Foods in kitchen and pantry refrigerators On 02/07/22 at 11 AM, an initial tour of kitchen with the Executive Chef #131 found in a pan, hot dogs wrapped in plastic with no date. The Executive Chef #131 removed the pan immediately. At 11:15 AM, tour of 4C pantry found pizza in plastic zip lock bag with no date or name. In addition, a glass of a glass containing a white substance with no date or name. The Executive Chef thought it was a milkshake. The Executive Chef #131 removed items immediately and agreed the items should not have been in refrigerator unlabeled. b) Temperature logs On 02/07/22 at 11:15 AM, a tour of pantries with Executive Chef #131 on 4C found no temperatures for 02/03/22 and 02/04/22. The Executive Chef #131 agreed kitchen staff did not complete temperature logs for those days. At 11:20 AM, with the Executive Chef #131 on 300 hall pantry found no temperatures on temperature log on the refrigerator for 03/03/22 and 02/04/22. The Executive Chef agreed staff did not complete the temperature log for those days. c) Food Temperatures On 02/08/22 at 12:42 PM, observed the food cart come to 300 hall for lunch. At 1:15 PM, the Executive Chef #131 conducted temperature checks for the last tray on the food cart. ~ tator tots 94 degrees Fahrenheit (F) ~hamburger 96 degrees F ~ Chicken noodle soup 110 degrees F ~Cranberry Juice 46 degrees F The hot foods were not at least 120 degrees F and the juice was above 41 degrees F. The Executive Chef #131 agreed the temperatures were not acceptable. .

CONCERN (F)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0725 (Tag F0725)

Could have caused harm · This affected most or all residents

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. Based on resident interviews, staff interviews, Resident Council minute review, record reviews, and review of the facility assessment, the facility failed to ensure sufficient qualified nursing staff were available at all times to provide nursing and related services to meet the residents' needs safely and in a manner that promoted resident rights, physical, mental and psychosocial well-being. Facility census: 108. Findings included: a) Resident Interviews During an interview on 02/07/22 at 11:56 AM, Resident #67 stated there was not enough staff and the facility needed to do something about it. Resident #67 went on to say, I sat the other night in a soiled brief, and it took over two hours for staff to clean me up. Resident #63, on 02/07/22 at 11:24 AM, reported on night shift there was usually one aide on the hall which means nursing staff frequently must assist with direct care needs. Resident #63 went on to say he/she sometimes goes without wearing the BiPAP (bi-level positive airway pressure) machine because staff forget to come back. During an interview on 02/07/22 02:57 PM, Resident #41 reported there are times on weekends, holidays, and the 11:00 PM - 7:00 AM shift, the facility does not have enough staff. At times there is only one nurse and one aide for 20 plus residents. b) Staff Interview During an interview on 02/07/22 at 3:34 PM, LPN #38 reported there are some holes in direct care staffing which is often exacerbated by staff either calling off or quitting. c) Resident Council Minutes 10/25/21 Resident Council minutes revealed the residents in attendance felt the facility was understaffed and it takes long time to answer lights. 11/02/21 Resident Council minutes revealed residents in attendance wanted to know when staffing was going to be addressed, especially at night. d) 400 Hall The 400 Hall was randomly selected for resident care needs and CNA staffing on the 11:00 PM - 7:00 AM shift. On 02/09/22, the 400 Hall had 29 residents. Review of Section G Functional Status on each resident Minimum Data Set (MDS) found that 18 out of the 29 residents were identified as a two (2) person extensive assist for toileting. Review of the staffing schedule demonstrated the 400 Hall was staffed with one (1) nurse and one (1) Nurse Aide (NA) on the 11:00 PM - 7:00 AM staff. Further investigation revealed there were 15 times, out of the 31 days randomly selected for schedule review, the nurse scheduled to work the 400 Hall was assigned a second hall to cover as well. e) Facility Assessment The facility assessment, dated 05/12/21, stated that based on the facility resident population and their needs for care and support, the facility would utilize the following staffing plan for direct care Certified Nursing Assistants (CNAs) to ensure they had sufficient staff to meet the needs of residents at any given time: 7:00 AM - 3:00 PM - 1:9 Ratio on Days [A census of 100 or above would require 12 CNAs] 3:00 PM - 11:00 PM - 1:10 Ratio on Evenings [A census of 100 or above would require 11 CNAs] 11:00 PM - 7:00 AM - 1:18 Ratio on Nights [A census of 90 or above would require 6 CNAs] The facility assessment also indicated the average daily census was 102. f) Complaint #26302 Complaint #26302 stated the facility was short staffed and was working one (1) to two (2) aides during night shift in a facility with over 100 residents. Review of random weekend staffing, from November 2021 - January 2022, revealed the facility never met the 1:18 Ratio on Nights for CNA coverage. Instead, the facility demonstrated the following CNA coverage on the 11:00 PM - 7:00 AM shift: Friday, 11/12/21, 11:00 PM - 7:00 AM shift reflected 3 CNAs worked Saturday, 11/13/21, 11:00 PM - 7:00 AM shift reflected 4 CNAs worked Sunday, 11/14/21, 11:00 PM - 7:00 AM shift reflected 3 CNAs worked Friday, 11/19/21, 11:00 PM - 7:00 AM shift reflected 2 CNAs worked Saturday, 11/20/21, 11:00 PM - 7:00 AM shift reflected 3 CNAs worked Sunday, 11/21/21, 11:00 PM - 7:00 AM shift reflected 3 CNAs worked Friday, 11/26/21, 11:00 PM - 7:00 AM shift reflected 4 CNAs worked Saturday, 11/20/21, 11:00 PM - 7:00 AM shift reflected 3 CNAs worked Sunday, 11/21/21, 11:00 PM - 7:00 AM shift reflected 3 CNAs worked Friday, 12/17/21, 11:00 PM - 7:00 AM shift reflected 4 CNAs worked Saturday, 12/18/21, 11:00 PM - 7:00 AM shift reflected 4 CNAs worked Sunday, 12/19/21, 11:00 PM - 7:00 AM shift reflected 4 CNAs worked Friday, 12/24/21, 11:00 PM - 7:00 AM shift reflected 4 CNAs worked Saturday, 12/25/21, 11:00 PM - 7:00 AM shift reflected 4 CNAs worked Sunday, 12/26/21, 11:00 PM - 7:00 AM shift reflected 4 CNAs worked + 1 CNA worked 11:00 PM - 3:30 AM Friday, 12/31/21, 11:00 PM - 7:00 AM shift reflected 5 CNAs worked Saturday, 01/01/22, 11:00 PM - 7:00 AM shift reflected 6 CNAs worked Sunday, 01/02/22, 11:00 PM - 7:00 AM shift reflected 4 CNAs worked Friday, 01/14/22, 11:00 PM - 7:00 AM shift reflected 4 CNAs worked Saturday, 01/15/22, 11:00 PM - 7:00 AM shift reflected 3 CNAs + 1 CNA worked 11:00 PM - 3:30 AM Sunday, 01/16/22, 11:00 PM - 7:00 AM shift reflected 4 CNAs worked Friday, 01/21/22, 11:00 PM - 7:00 AM shift reflected 5 CNAs + 1 CNA worked 11:00 - 3:00 AM Saturday, 01/22/22, 11:00 PM - 7:00 AM shift reflected 5 CNAs worked Sunday, 01/23/22, 11:00 PM - 7:00 AM shift reflected 4 CNAs worked Friday, 01/28/22, 11:00 PM - 7:00 AM shift reflected 4 CNAs worked Saturday, 01/29/22, 11:00 PM - 7:00 AM shift reflected 2 CNAs worked Sunday, 01/30/22, 11:00 PM - 7:00 AM shift reflected 3 CNAs worked + 1 CNA worked 3:00 AM -7:00 AM + 1 CNA worked 11:00 PM - 2:00 AM g) Interview with Scheduler During an interview, on 02/09/22 at 11:00 AM, the Scheduler reported when she began employment in September 2021, she was instructed to schedule the following staff on each shift: For the 7:00 AM - 3:00 PM shift, schedule two (2) CNAs for the 200 Hall, two (2) CNAs for the 300 Hall, three (3) CNAs for the 400 Hall, and two (2) CNAs for the 500 Hall, thereby scheduling a total of nine (9) CNAs in the building. For the 3:00 PM - 11:00 PM shift, schedule two (2) CNAs for the 200 Hall, two (2) CNAs for the 300 Hall, three (3) CNAs for the 400 Hall, and two (2) CNAs for the 500 Hall, thereby scheduling a total of nine (9) CNAs in the building. For the 11:00 PM - 7:00 AM shift, schedule one (1) CNA per hall, thereby scheduling a total of four (4) CNAs in the building. h) Interview with Administrator The Administrator was interviewed on 02/09/22 at 12:40 PM and asked to explain the discrepancy between the number of CNAs scheduled to work on a routine basis (as per the interview with the facility Scheduler) compared to what was the outlined staffing plan in the facility assessment. The Administrator acknowledged the facility's CNAs schedule, across all three (3) shifts, consistently fell short of the facility assessment staffing plan. The Administrator then stated, I did that because that is what we are budgeted for, referring to the staffing ratios in the facility assessment. .

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

• 36% turnover. Below West Virginia's 48% average. Good staff retention means consistent care.

Concerns

• 61 deficiencies on record, including 1 serious (caused harm) violation. Ask about corrective actions taken.
• Grade D (43/100). Below average facility with significant concerns.

Bottom line: Trust Score of 43/100 indicates significant concerns. Thoroughly evaluate alternatives.

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About This Facility

What is Tygart Center At Fairmont Campus's CMS Rating?

CMS assigns TYGART 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 Tygart Center At Fairmont Campus Staffed?

CMS rates TYGART 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 36%, compared to the West Virginia average of 46%. This relatively stable workforce can support continuity of care.

What Have Inspectors Found at Tygart Center At Fairmont Campus?

State health inspectors documented 61 deficiencies at TYGART CENTER AT FAIRMONT CAMPUS during 2022 to 2025. These included: 1 that caused actual resident harm and 60 with potential for harm. Deficiencies causing actual harm indicate documented cases where residents experienced negative health consequences.

Who Owns and Operates Tygart Center At Fairmont Campus?

TYGART 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 119 certified beds and approximately 107 residents (about 90% occupancy), it is a mid-sized facility located in FAIRMONT, West Virginia.

How Does Tygart Center At Fairmont Campus Compare to Other West Virginia Nursing Homes?

Compared to the 100 nursing homes in West Virginia, TYGART CENTER AT FAIRMONT CAMPUS's overall rating (2 stars) is below the state average of 2.7, staff turnover (36%) 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 Tygart 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 Tygart Center At Fairmont Campus Safe?

Based on CMS inspection data, TYGART 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 Tygart Center At Fairmont Campus Stick Around?

TYGART CENTER AT FAIRMONT CAMPUS has a staff turnover rate of 36%, which is about average for West Virginia nursing homes (state average: 46%). Moderate turnover is common in nursing homes, but families should still ask about staff tenure and how the facility maintains care continuity when employees leave.

Was Tygart Center At Fairmont Campus Ever Fined?

TYGART CENTER AT FAIRMONT CAMPUS has been fined $8,278 across 1 penalty action. This is below the West Virginia average of $33,162. 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 Tygart Center At Fairmont Campus on Any Federal Watch List?

TYGART 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.

Facility Details

Beds: 119
Avg. Residents: 107
Occupancy: 90.5%
Ownership: For profit - Corporation
Chain: GENESIS HEALTHCARE
Medicare: Yes
Medicaid: Yes
Sprinklers: Yes

Trust Score Breakdown

Base Score: 50
2-Star Rating: +10
1 Actual Harm citation: -5
61 Deficiencies: -10
Fines ($8,278): -2
Final Score: 43/100

Nearby Alternatives

FAIRMONT MEDICAL CENTER 5-star ST. BARBARA'S MEMORIAL NURSING... 4-star Majestic Care of Manchin 4-star

View all in FAIRMONT →

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Data: CMS Medicare Care Compare

Updated: November 2025

Facility ID: 515053