How many inspection deficiencies does GLENVILLE HEALTH & REHAB have?

GLENVILLE HEALTH & REHAB has 49 deficiencies from recent inspections. None are at the Immediate Jeopardy level.

What are the staffing levels at GLENVILLE HEALTH & REHAB?

GLENVILLE HEALTH & REHAB has a two-star staffing rating from CMS with 0.38 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 GLENVILLE HEALTH & REHAB located?

GLENVILLE HEALTH & REHAB is located in GLENVILLE, WV. It is a Medicare and Medicaid certified skilled nursing facility.

How many beds does GLENVILLE HEALTH & REHAB have?

GLENVILLE HEALTH & REHAB has 65 certified beds.

Who owns GLENVILLE HEALTH & REHAB?

GLENVILLE HEALTH & REHAB is a for profit - corporation facility and is part of the HILL VALLEY HEALTHCARE chain.

What questions should families ask when visiting GLENVILLE HEALTH & REHAB?

Families visiting GLENVILLE HEALTH & REHAB should ask about daily routines, communication with families, how they handle medical emergencies. Also ask to speak with current residents or families, tour during mealtime, and request a copy of the most recent inspection report.

How does GLENVILLE HEALTH & REHAB compare to other nursing homes?

GLENVILLE HEALTH & REHAB has a 1-star overall rating, which is below average compared to other nursing homes in WV. Families should carefully review inspection findings and consider alternatives.

GLENVILLE HEALTH & REHAB

Q: What is GLENVILLE HEALTH & REHAB's CMS rating?

GLENVILLE HEALTH & REHAB has a one-star overall rating from CMS (Centers for Medicare & Medicaid Services), based on health inspections, staffing levels, and quality measures.

Q: Is GLENVILLE HEALTH & REHAB safe?

GLENVILLE HEALTH & REHAB has a clean safety record with no substantiated abuse findings, no immediate jeopardy citations, and is not on any federal watch list.

Q: Do nurses at GLENVILLE HEALTH & REHAB stick around?

GLENVILLE HEALTH & REHAB has average staff turnover at 53%, which is typical for the nursing home industry.

Q: Was GLENVILLE HEALTH & REHAB ever fined?

Yes, GLENVILLE HEALTH & REHAB has been fined $39,390 by federal regulators. Fines are issued for serious violations of Medicare and Medicaid requirements.

Q: Is GLENVILLE HEALTH & REHAB on any federal watch list?

No, GLENVILLE HEALTH & REHAB is not on any federal watch list. It is not designated as a Special Focus Facility or SFF Candidate by CMS.

111 FAIRGROUND ROAD, GLENVILLE, WV 26351 · (304) 462-5718

For profit - Corporation 65 Beds HILL VALLEY HEALTHCARE Data: November 2025

Trust Grade

30/100

#99 of 122 in WV

Share this report:

GLENVILLE HEALTH & REHAB nursing home in GLENVILLE, WV - Photo 1 of 2

GLENVILLE HEALTH & REHAB nursing home in GLENVILLE, WV - Photo 2 of 2

Photo by Google Street View

View 360° on Google Maps

Last Inspection: October 2024

Within standard 12-15 month inspection cycle. Federal law requires annual inspections.

Overview

Glenville Health & Rehab has received a Trust Grade of F, which indicates significant concerns about the quality of care provided. Ranking #99 out of 122 facilities in West Virginia places it in the bottom half, while it is the only nursing home in Gilmer County, meaning there are no local alternatives that rank higher. The facility's situation is worsening, with issues increasing from 5 in 2023 to 19 in 2024. Staffing is a concern as it has a 2/5 rating, with a turnover rate of 53%, which is higher than average for the state, suggesting instability among caregivers. The facility has incurred $39,390 in fines, which is higher than 82% of West Virginia facilities, indicating potential compliance problems. Specific incidents included a resident developing new pressure ulcers due to inadequate treatment, which caused actual harm, and multiple residents being left waiting several minutes before receiving their meals, impacting their dignity. Additionally, residents were not given access to recent survey results, which is a breach of transparency. Overall, while there are some staff members who may care about the residents, the significant issues highlighted raise serious concerns about the quality of care at this facility.

Trust Score: F
In West Virginia: #99/122
Safety Record: Moderate
Inspections: Getting Worse
Staff Stability: 53% turnover. Above average. Higher turnover means staff may not know residents' routines.
Penalties: $39,390 in fines. Lower than most West Virginia facilities. Relatively clean record.
Skilled Nurses: Each resident gets only 22 minutes of Registered Nurse (RN) attention daily — below average for West Virginia. Fewer RN minutes means fewer trained eyes watching for problems.
Violations: 49 deficiencies on record. Higher than average. Multiple issues found across inspections.

★☆☆☆☆

1.0

Overall Rating

★★☆☆☆

2.0

Staff Levels

★☆☆☆☆

1.0

Care Quality

★★☆☆☆

2.0

Inspection Score

↔

Stable

2023: 5 issues

2024: 19 issues

The Good

Full Sprinkler Coverage · Fire safety systems throughout facility
No fines on record

Facility shows strength in fire safety.

The Bad

1-Star Overall Rating

Below West Virginia average (2.7)

Significant quality concerns identified by CMS

Staff Turnover: 53%

Near West Virginia avg (46%)

Higher turnover may affect care consistency

Federal Fines: $39,390

Above median ($33,413)

Moderate penalties - review what triggered them

Chain: HILL VALLEY HEALTHCARE

Part of a multi-facility chain

Ask about local staffing decisions and management

The Ugly 49 deficiencies on record

1 actual harm

Oct 2024 17 deficiencies 1 Harm

SERIOUS (G)

Actual Harm - a resident was hurt due to facility failures

Pressure Ulcer Prevention (Tag F0686)

A resident was harmed · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interviews, the facility failed to provide treatment or services to prevent and heal pressure ulcers for one (1) of three (3) residents reviewed for pressure ulcers. The resident suffered actual physical harm when further avoidable facility acquired pressure ulcers developed. Resident identifier: #61 Facility Census: 63. Findings included: a) Resident #61 Resident #61 was admitted on [DATE] with the following identified skin issues noted on the Nursing admission Evaluation dated 07/03/24: Resident #61 had a deep tissue injury measuring 5 centimeters (cm) X 4.5 cm to the left heel. Resident #61 had a pressure ulcer measuring 1 cm X 1.5 cm to the right side of the coccyx. A wound was also noted on the left-hand middle finger. On 08/24/24 a note identified a left heel pressure ulcer/injury or suspected deep tissue injury. This was identified as a new facility acquired unstageable. No size was documented. No description was identified. This area appeared to be the same that was present upon admission but no prior documentation could be found before 08/24/24. On 09/05/24 according to the weekly skin observation sheets a new open area was identified to the right buttock. This was identified as a new skin condition. This wound was not evaluated on any further weekly skin observation sheets or weekly wound evaluation sheets. On 09/11/24 a new facility acquired right heel pressure ulcer/injury or suspected deep tissue injury unstageable with necrotic tissue was identified. No size was documented, the interventions in place were heel protectors. On 09/20/24 the right heel evaluation now was described as necrotic with serosanguinous (thick, watery, pale, red/pink drainage) with no size documented. The interventions in place were to offload heels. 09/28/24 the left heel evaluation showed an unstageable with size documented as 4 cm X 4 cm with slough (yellow, tan, white, stringy) with 60% slough/necrosis and serosanguineous drainage, moderate exudate with moderate dressing saturation. Interventions in place were to off load heels and encourage hydration and mobility. On 10/05/24 the right heel evaluation documented an unstageable 4 cm X 4 cm with slough to the wound bed. 60% slough/necrosis. Wound exudate: serosanguineous with a moderate amount of exudate. Dressing saturation is moderate with 26-75%. interventions in place were off load heels and encourage hydration and nutritional status evaluation. Oon 10/11/24 at 4:15 PM there was a consultation for the wound clinic for bilateral heels for one day. The order was discontinued on 10/12/24. 10/13/24 right heel unstageable 4.5 cm X 6 cm. Wound bed necrotic with 100% slough/necrosis with wound exudate purulent (think, milky, green/yellow/white/brown). Moderate exudate amount of 26-75%. Interventions in place: pressure reducing/relieving mattress, encourage hydration and mobility, nutritional status evaluation, turning and positioning routine On 10/20/24 the right heel Stage III measured 3.5 cm X 2.5 cm X 0.2 cm. The wound bed had granulation with wound exudate serosanguinous with a moderate amount of exudate, dressing saturation moderate 26-75%. Interventions in place were to off-load heels. According to the last wound evaluation dated 10/20/24 the resident had a pressure ulcer/injury or suspected DTI to his right heel which was identified as facility acquired and a Stage III full thickness tissue loss. On 10/21/24 at 12:55 PM observation found Resident #62 in bed. He was observed as tall and thin. His head was to the top of the bed frame and his knees were bent with his heels pressed into the mattress. His knees were bent against the footboard. The bed was too short. When asked, he stated he was 6' 3. On 10/22/24 at 10:10 AM during record review it was noted that Resident #61 had a physician's order dated 07/09/24 for protective heel boots to be worn every day to prevent skin breakdown. On 10/22/24 at 10:10 AM record review shows Resident #61 did not have an order or care plan for an extended length bed. On 10/22/24 at 10:30 AM during an interview with the Administrator she stated she thought he had an extension on his bed. She said she would check and get it placed on the bed or get him a longer bed. On 10/23/24 at 11:00 AM during an interview with Licensed Practical Nurse (LPN) #18 with the resident present the LPN was asked if she felt the resident needed a longer bed, she agreed he probably did. She said she would check why he was not on an extended bed. The resident stated, This is the only bed I have ever had. On 10/22/24 at 1:15 PM the record review shows the following orders: Order Summary: Cleanse right heel with wound cleanser, pat dry, apply Santyl to wound bed, cover with Opti-foam heels then wrap with kling every day shift for wound Order Summary: Clean the left heel with wound cleanser, pat dry, apply Hydrogel, cover with Opti-foam heel protector, wrap with kerlix. every day shift for wound to left heel On 10/23/24 at 11:00 AM during an interview with Licensed Practical Nurse (LPN) #18 with the resident present the LPN was asked if she felt the resident needed a longer bed, she agreed he probably did. She said she would check why he was not on an extended bed. The resident stated, this is the only bed I have ever had. On 10/23/24 at 11:03 AM observation of wound care with Licensed Practical Nurse (LPN) #18 found that wound care on 10/22/24 was not performed as according to the physician's orders. On 10/23/24 at 11:03 AM when LPN #18 removed the previous day's dressing it did not have the Opti-foam feel protector in place on either heel. This was confirmed immediately with LPN #18 who agreed the treatment on 10/22/24 was not performed according to the physicians order. On 10/24/24 at 2:00 PM the resident had an appointment with the Wound Clinic in (name of city). Observation on the following dates and times found the resident to be in bed with his knees bent, heels pressed into the mattress: 10/21/24 at 12:55 PM 10/21/24 at 2:10 PM 10/22/24 at 8:05 AM 10/22/24 at 2:30 PM 10/23/24 at 11:00 AM 10/23/24 at 4:00 PM 10/24/24 at 8:15 AM 10/24/24 at 1:15 PM The following observations found Resident #61 out of bed and not having heel boots on. He had pressure ulcers to bilateral heels. 10/22/24 at 10:10 AM No heel boots on 10/22/24 at 2:05 PM No heel boots on 10/22/24 at 3:20 PM No heel boots on 10/23/24 at 8:30 AM No heel boots on 10/23/24 at 10:22 AM No heel boots on 10/23/24 at 3:15 PM No heel boots on 10/24/24 at 9:05 AM No heel boots on 10/24/24 at 1:15 PM No heel boots on 10/24/24 at 4:35 PM No heel boots on The care plan was reviewed and found an intervention under skin integrity which stated, Heel protectors to be worn when out of bed and as needed (prn). These issues were confirmed with the Administrator on 10/24/24 at 4:45 PM. No futher information was provided.

CONCERN (D)

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

Deficiency F0561 (Tag F0561)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

The facility failed to honor resident choices regarding the things that are important in her life regarding making her bed early in the morning. This is true for one (1) of (1) residents reviewed for choices. Resident Identifier #25. Facility census: 63. Findings included: a) Resident #25 During an observation with Resident #25, on 10/21/20 at 9:02 AM, she was upset about the staff not making her bed. On 10/22/24 at 08:57 AM during an interview, Resident #25 became upset and tearful about her bed not being made. She stated, They don't help me get my bed made in the mornings. She continued to say that she had to ask staff to come and make the bed all the time. On 10/22/24 at 3:36 PM during an interview the Social Services director revealed she was aware that Resident #25 liked her bed made early and got upset when it was not made. During an interview, on 10/23/24 at 1:15 PM, the Physical Therapy director stated that Resident #25 did get upset when staff did not make her bed and would refuse therapy treatment. No further information was provided prior to the end of the survey on 10/24/23 at 6:00 PM.

CONCERN (D)

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

Transfer Notice (Tag F0623)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, family interview, and staff interview, the facility failed to provide appropriate notice of transfers or discharge for one (1) of two (2) residents reviewed for the care area of discharge. The facility failed to provide a facility-initiated discharge notice at least 30 days before the resident was discharged . For one (1) of five (5) residents reviewed for the care area of hospitalizations, the facility failed to notify the resident's representative of a hospital transfer and the reasons for the move in writing. Resident identifiers: #168, #47. Facility census: 63. Findings included: a) Resident #168 The Director of Nursing (DON) and Administrator were interviewed on 10/24/24 at 11:15 AM regarding an anonymous complaint regarding a resident elopement. The resident had not been identified in the complaint. The DON and Administrator identified Resident #168 as a resident who was exit seeking and walked around the facility's campus and surrounding area with staff, but never actually eloped. The DON stated Resident #168 was discharged home with his mother in a safe and orderly manner. The Administrator stated the resident's discharge was not a facility-initiated discharge. Review of Resident #168's medical records showed the resident was admitted on [DATE]. He displayed exit seeking behaviors and was deemed at risk for elopement. A Wanderguard bracelet was ordered and applied to prevent the resident from exiting the facility without staff knowledge. Resident #168's diagnoses included traumatic brain injury. The resident's admission Minimum Data Set (MDS) assessment with Assessment Reference Date (ARD) 06/10/24 indicated the resident had a Brief Interview for Mental Status (BIMS) score of 2, indicating severe cognitive impairment. The physician's determination of capacity dated 06/12/24 determined the resident lacked ability to make medical decisions due to traumatic brain injury, cognitive loss, and inability to understand medical decisions. This was anticipated to be long-term in duration. The resident's mother was his Medical Power of Attorney (MPOA). Resident #168's comprehensive care plan stated, Resident is appropriate for LTC [long-term care] due to the need for 24/7 supervision secondary to MD [physician] DX [diagnosis]. An intervention was The need for LTC is understood by resident and/or POA [Power of Attorney]. D/C [discharge] plan to be discussed at comprehensive assessments. The progress notes documented that the resident refused physical therapy and refused medications at times. A change in condition note written on 06/04/24 at 8:10 AM stated, Resident went out the double doors to sit on front porch bench. Resident was able to be redirected without any issues. Wander guard in place. A change in condition written on 06/06/24 at 8:00 AM stated, Nursing observations, evaluation, and recommendations are: The resident eloped out double doors with staff at side. The resident walked with staff and was not easily distracted. The resident was placed on one-on-one observation. A note written on 06/06/24 at 9:00 AM stated, The resident had another elopement episode at 0900 am. The resident escaped through double front doors with staff at side. Resident ended up setting [sic] in gazebo with staff at side. Resident eventually came back inside and ate lunch with staff member. A note written on 06/06/24 at 2:30 PM stated, The resident eloped for a third time today, resident made way with staff to parking lot of Foodland. Resident easily distracted and re-directed to front porch of SNF [skilled nursing] facility. Resident sitting peacefully on front porch with staff at side. After many attempts of redirection back into the facility, this nurse had to call sheriff department to help escort resident back into facility. A nursing note written on 06/07/24 at 5:54 AM, stated, In DR [dining room] wandering, sitting in other residents' chairs, when asked by another resident to move he yelled loudly F___ you, F___ you, F___ you! Noted to be agitated. A nursing note written on 06/07/24 at 6:30 AM, stated, Resident in DR and noted to cursing [sic] other resident, did draw back fist and attempt to strike other resident. Other resident removed from area. A nursing note written on 06/07/24 at 3:30 PM stated, Up wandering in the hallway. Wandering into other residents' rooms. Redirected unsuccessfully. A physician's note written on 06/08/24 stated, He has a severe dementia and it does not appear he will be able to go home unless there is someone to take care of him around-the-clock. A behavior note written on 06/17/24 at 11:15 PM stated the resident was incontinent and refused to wear incontinence products or have his soiled clothing taken to laundry. A nursing note written on 06/19/24 at 8:15 AM stated, Resident eloped from [facility] with staff at side. This nurse was able to easily redirect resident back to facility. A nursing note written on 06/19/24 at 10:00 AM stated, The resident was sitting on back porch with 1:1 sitter. The resident shoved through gate and 1:1 sitter and started walking toward Exxon station. Resident unable to be easily distracted. Resident escorted back to [facility] by state police vehicle. The next progress note was written on 06/19/24 at 2:00 PM and stated, Transported via facility van to resident home. Mother (POA) signed and understood discharge instructions. Medications called into pharmacy of POA choice for 30 days no refills. MD aware and voiced understanding with verbal readback for discharge order. On 06/21/24, the attending physician wrote a discharge note which stated in part, [Resident #168] is a [AGE] year-old white male who is a resident of this facility for short time. He has a severe dementia and had severe behavioral problems while he was here. He tried to elope from the facility. It was decided that the facility could no longer handle him, and he was discharged .Facility Course: He was here a few days but had severe behavioral difficulties, and it was decided he could not be taking [sic] care of at this facility. Resident #168's Notice of Transfer or discharge date d 06/19/24 stated the basis of the discharge was The transfer or discharge is appropriate because your health has improved sufficiently that you no longer need the services provided by this facility and The transfer or discharge is necessary for your welfare and your needs cannot be met in this facility. The discharge planning review dated 06/19/24 indicated the facility initiated discharged . The reason for discharge was safety reason for discharge. The recap of the resident's stay was The resident has had multiple elopement attempts, the resident is a safety risk for resident safety. Resident refuses therapy. On 10/24/24 at 12:30 PM, Resident #168's mother was interviewed by telephone. She stated she had not planned on taking the resident home. She stated she had not expressed to the facility a willingness or ability to take the resident home. She stated the facility called on the day of the discharge to tell her that the resident was being sent home that day because the facility could not take care of him anymore. She stated she could not think of anything she needed the facility to arrange before they sent him home. The resident was in the hospital once since discharge, but she could not provide details. She stated her son was doing okay. She stated she was happy that the resident had a new physician who was adjusting his medication. On 10/24/24 at 3:31 PM, the Director of Nursing and the Administrator were re-interviewed. The DON stated the facility had decided to send Resident #168 out of the facility for a psychological evaluation. When they contacted the resident's mother to inform her, she stated she wanted the resident to come home instead. The DON acknowledged this was not documented in the resident's record. The Administrator and DON acknowledged Resident #168's Discharge Planning Review stated the discharge was facility initiated, but stated this was a documentation error. The Administrator acknowledged a 30-day notice of discharge was not given to the resident's Medical Power of Attorney but stated this was because the resident's mother had requested the resident be sent to her home instead of for psychiatric evaluation. No further information was provided through the completion of the survey. b) Resident #47 Review of Resident #47's medical records showed the resident was transferred to the hospital on [DATE] due to fever and increased secretions. The resident did not have capacity to make medical decisions. The transfer form provided to the receiving hospital documented the resident's Medical Power of Attorney (MPOA) was notified of the hospital transfer. The resident returned to the facility 04/14/24. Further review of Resident #47's medical records showed a Notice of Transfer or discharge date d 03/24/24. The areas on the form to indicate the date of verbal notification and the date of written notification were left blank. On 10/23/24 at 4:25 PM, the Director of Nursing (DON) stated Resident #47's MPOA was notified of the hospital transfer before the transfer occurred. The DON stated the Notice of Transfer or Discharge was sent to the hospital with the resident. The DON confirmed the MPOA had not received a written Notice of Transfer or Discharge with appeal instructions unless she went to the hospital to get the form that was sent to the hospital. She confirmed the facility's usual practice did not include mailing Notices of Transfers or Discharges to residents' representatives. No further information was provided through the completion of the survey.

CONCERN (D)

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

Deficiency F0625 (Tag F0625)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, family interview, and staff interview, the facility failed to provide a written bed hold notice to the Medical Power of Attorney (MPOA) for one (1) of five (5) residents reviewed for the care area of hospitalizations. Resident identifier: #47. Facility census: 63. Findings included: a) Resident #47 Review of Resident #47's medical records showed the resident was transferred to the hospital on [DATE] due to fever and increased secretions. The resident did not have capacity to make medical decisions. The resident returned to the facility 04/14/24. Further review of Resident #47's medical records showed a Bed Hold Notice of Policy and Authorization. The notice had been signed by a Licensed Practical Nurse, as the representative for the Center. However, the notice was not signed by the Resident Representative. On 10/23/24 at 4:25 PM, the Director of Nursing (DON) stated Resident #47's representative was called and informed of the bed hold policy. She stated the Bed Hold Notice of Policy and Authorization would not have been mailed to the representative, unless the representative expressed interest in guaranteeing a bed hold. She stated the facility's usual practice was to not provide a written copy of the bed hold notice after verbal explanation unless the family expresses interest in the bed hold. No further information was provided through the completion of the survey.

CONCERN (D)

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

Deficiency F0657 (Tag F0657)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

Based on resident interview, medical record review and staff interview the facility failed to ensure they facilitated a resident's involvement and invited him in advance to his care plan meeting. Resident identifier: #54. Facility census: 63. Findings included: a) Resident #54 During an interview with Resident #54 on 10/22/24 at 11:59 AM he commented that he did not know anything about care plan meetings. Review of the medical record did not reveal any documentation regarding the facility's invitation to Resident #54 for care plan meetings or their facilitation to involve him in these meetings. During an interview with the social worker on 10/23/24 at 9:00 AM she said she goes around the day of the care plan and talks to the resident and asks him if he wants to attend the meeting. The medical record review revealed an invitation to the care conference scheduled for 10/24/24. The social worker said this invitation was mailed to the legal representative. Care plan conference sign in sheets for meetings held on 05/09/24, 02/08/24, 11/08/23, and 08/16/23 did not reveal the resident had attended any of these meetings.

CONCERN (D)

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

Deficiency F0679 (Tag F0679)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** b) Resident #12 On 10/21/24 at 3:19 PM Resident #12 stated she liked to listen to gospel music. She stated she did not do much because she was blind and cannot see to do much but she loved gospel music. The following observations of Resident #12 were as follows: 10/22/24 8:10 AM the resident was observed sitting in her wheelchair in her room looking out the window. The television was not on. 10/22/24 12:15 PM the resident was observed sitting in her wheelchair in her room, looking out the window , waiting for lunch. The television was not on. 10/22/24 2:45 PM the resident was observed in her wheelchair rolling in the hallway 10/23/24 10:10 AM the resident was observed in her wheelchair rolling in the hallway 10/23/24 4:15 PM the resident was observed sitting in her wheelchair in her room, looking out her window. The television was not on. 10/24/24 10:00 AM the resident was observed sitting in her wheelchair in her room, looking out her window. The television was not on. 10/24/24 2:15 PM Resident observed sitting in her wheelchair in her room looking out the window. Administrator observed as well. No TV on. On 10/23/24 at 2:41 PM the activity calendar and activity logs were reviewed for July-October 2024 with findings as follows:. The activity calendar for July 2024 had ten (10) opportunities for gospel music provided by the activities team. The activity log documentation for July 2024 under Spiritual/Emotional Activities showed twenty-two (22) out of thirty-one (31) days were marked as N/A for Not applicable. The additional nine (9) days were blank. The activity calendar for August 2024 had eleven (11) opportunities for gospel music provided by the activities team. The activity log documentation for August 2024 under Spiritual/Emotional Activities showed twenty-four (24) out of thirty-one (31) days were marked as N/A for Not applicable. The additional seven (7) days were blank. The activity calendar for September 2024 had twelve (12) opportunities for gospel music provided by the activities team. The activity log documentation for September 2024 under Spiritual/Emotional Activities showed twenty (20) out of thirty (30) days were marked as N/A for Not applicable. The additional ten (10) days were blank. The activity calendar reviewed for October through 10/22/24 has had nine (9) opportunities for gospel music provided by the activities team. The activity log documentation thus far for October 2024 under Spiritual/Emotional Activities showed sixteen (16) out of twenty-two (22) days were marked as N/A for Not applicable. The additional six (6) days were blank. During an interview with the Director of Activities #49, on 10/23/24 at 2:54 PM, she explained the coding system on the activity logs. She explained that gospel music would fall under Spiritual/Emotional Activities. That was when a church or individual pastor comes in, has Bible study and a sing a long hymn session or they turn on church on the television which usually has gospel music. She explained the code for N/A meant not applicable. This meant the resident was not taken to the activity and would probably not be interested in it. When asked if the resident was invited, the Director stated, no, probably not. Resident #16's care plan initiated on 04/17/24 was reviewed and the intervention was: Focus: (Residents name) exhibits limited engagement related to Alzheimer. Goal: (Residents name) will demonstrate engagement of interest as evidenced by socialization, specify limited and focus attention for a period of 15 minutes or less during activities by next review. Interventions: Encourage (residents name) participation in activity preferences of TV, special events, visiting family and friends, 1:1, music, sensory, being read to. Invite residents to activities. The quarterly activity assessment dated [DATE] described the resident's favorite activities, special accomplishments, and/or new interests. They were identified as bingo, church, tv, music, drawing, tactile, visits, mail, outings, special events, cooking groups. The above findings were confirmed on 10/23/24 04:30 PM with the Director of Activities and the Administrator. They both agreed Resident #12 did not have enough activities to keep her involved in something. 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 had the potential to affect a limited number of residents residing at the facility. Resident identifiers: #34 and #12. Facility census: 63. Findings included: a) Resident #34 During multiple observations of Resident #34 on 10/21/24, 10/22/24 and 10/23/24, the resident was lying in bed with no activities being provided. Record review revealed an activities participation sheet. The activities assessments revealed one (1) on one (1) activities were required. During an interview on 10/23/22 at 12:48 PM with the facility Activities Director (AD) she stated that there was not any documentation of one (1) on one (1) activities being provided. She stated she only had one other staff member to provide activities seven (7) days a week.

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

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** b) Resident #61 On 10/22/24 at 1:15 PM record review shows the following orders: Order Summary: Cleanse right heel with wound cleanser, pat dry, apply Santyl to wound bed, cover with opti-foam heels then wrap with kling every day shift for wound Order Summary: Clean left heel with wound cleanser, pat dry, apply Hydrogel, cover with opti-foam heel protector, wrap with kerlix. every day shift for wound to left heel On 10/23/24 at 11:03 AM observation of wound care with Licensed Practical Nurse (LPN) #18 found that wound care on 10/22/24 was not performed as according to the physicians orders. On 10/23/24 at 11:03 AM when LPN #18 removed the previous days dressing it did not have the opti-foam feel protector in place on either heel. This was confirmed immediately with LPN #18 who agreed the treatment on 10/22/24 was not performed according to the physicians order. c) Resident #61 - Specialty mattress On 10/21/24 at 12:10 PM during the initial long term care survey process interview it was observed that Resident #61 was on a specialty mattress. On 10/22/24 at 9:05 AM during record review it was noted that Resident #61 has pressure ulcers with treatments ordered. There is no Physicians order or care plan initiated for the specialty mattress. This was confirmed with the Administrator on 10/23/24 at 9:00 AM. d) Resident #61 - heel boots On 10/22/24 at 10:10 AM during record review it was noted that Resident #61 has a physicians order as follows: 07/09/24 Order Summary: Apply protective heel boots every day (QD) to prevent skin breakdown. The following observations found Resident #61 out of bed and not have heel boots on as ordered. He currently has pressure ulcers to bilateral heels. 10/22/24 at 10:10 AM No heel boots on 10/22/24 at 2:05 PM No heel boots on 10/22/24 at 3:20 PM No heel boots on 10/23/24 at 8:30 AM No heel boots on 10/23/24 at 10:22 AM No heel boots on 10/23/24 at 3:15 PM No heel boots on 10/24/24 at 9:05 AM No heel boots on 10/24/24 at 1:15 PM No heel boots on 10/24/24 at 4:35 PM No heel boots on The care plan was reviewed and found an intervention under skin integrity which states heel protectors to be worn when out of bed and as needed (prn). This was confirmed with the Administrator on 10/24/24 at 4:45 PM. Based on observation, staff interview, and record review the facility failed to ensure two (2) residents had received care and treatment in accordance with professional standards of practice, and the comprehensive care plan. For Resident #61 they failed to follow a physician's order for wound care and failed to provide. For Resident #33 they failed to follow the care plan for the use of a palm protector. Resident identifiers: #61, #33. Facility census: 63. Findings included: a) Resident #33 An observation on 10/21/24 at 2:57 PM revealed Resident #33 had a contracture to his left hand. The resident said she had suffered a stroke. The resident's medical record revealed she had a left hand contracture. Observations throughout the day on 10/21/24 and 10/22/24 revealed the resident's palm protector was not in place. On 10/24/24 at 11:15 AM during an interview with Certified Occupational Therapy Assistant (COTA) #66 he stated he had recommended the palm protector when he worked with Resident #33. A palm protector can help with hand contractures by preventing skin breakdown and keeping fingers from digging into the palm. On 10/24/24 at 11:30 AM during observations in Resident #33's room it was noted that a palm protector was lying on the resident's over bed table. The resident was asked about the palm protector and at that time she tried to put it on her right hand. A review of the [NAME] for Resident #33 revealed an intervention which stated, Palm protector in left hand. A review of the resident's care plan revealed a focus area which stated the resident was at risk for skin breakdown related to limited mobility. One of the interventions for this focus area was Clean left hand with wound cleanser, gently dry, apply maxorb Mon., Wed., and Friday.

CONCERN (D)

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

Deficiency F0692 (Tag F0692)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

Based on record review and staff interview the facility failed to monitor weights as ordered by the physician for a resident at risk for weight loss. This deficient practice had the potential to affect one (1) of seven (7) residents reviewed for the care area of nutrition. Resident identifier: #64. Facility census: 63. Findings included: a) Resident #64 Review of Resident #64's comprehensive care plan showed the following focus initiated on 09/04/24, The resident has nutritional problem or potential nutritional problem r/t [related to] poor po [oral] intakes, need for mechanically altered diet, T2DM [type II diabetes mellitus], anxiety, PCM [protein calorie malnutrition], dementia, depression, Alzheimer's, underweight, presence of wound increasing needs. Review of Resident #64's physicians' orders showed an order written on 08/31/24 for the resident to be weighed daily for three (3) days, weekly for four (4) weeks, then monthly. Resident #64's documented weights were as follows: - 08/31/24: 128.2 pounds (lbs) - 09/01/24: 128.2 lbs - 09/23/24: 122.2 lbs - 10/01/24: 121.8 lbs Resident #64's Medication Administration Record (MAR) indicated the resident refused to be weighed on 09/16/24. The MAR indicated the resident was scheduled to be weighed on 09/02/24 and 09/09/24. However, the areas to indicate the weight was left blank on these two (2) days. No weight was documented, nor did the MAR indicate the resident had been unavailable or refused to be weighed on 09/02/24 and 09/09/24. On 10/23/24 03:07 PM, the Director of Nursing stated she was unable to locate documented weights for Resident #64 on 09/02/24 and 09/09/24.

CONCERN (D)

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

Deficiency F0775 (Tag F0775)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

Based on record review and staff interview, the facility failed to have laboratory reports filed in the resident 's clinical record. This deficient practice had the potential to affect one (1) of five (5) residents reviewed for the care area of unnecessary medications. Resident identifier: #64. Facility census: 63. Findings included: a) Resident #64 Review of Resident #64's physicians' orders showed an order for laboratory testing written on 09/03/24. The laboratory testing to be performed was complete blood count (CBC), comprehensive metabolic panel (CMP), thyroid-stimulating hormone (TSH), and Hemoglobin A1c (HgA1c). Resident #64's medical records contained the results for a CBC and HgA1c obtained on 09/05/24. The results contained the notation that the records were reviewed by [physician's initials] on 09/06/24. On 10/23/24, the Director of Nursing (DON) brought the CMP and TSH results to the surveyor. She stated she had obtained the results from the hospital laboratory who had tested the blood sample. The DON stated she didn't know why these results were not in the resident's records. The glucose level was elevated at 257. (Normal is 74-111.) The carbon dioxide was slightly elevated at 32. (Normal is 23-30). The alkaline phosphatase was slightly elevated at 122 and the aspartate aminotransferase (AST) was slightly elevated at 48. (Normal levels are 38-120 and 8-40, respectively.) Because the results were obtained directly from the hospital laboratory, there was no notation indicating the records were reviewed by the resident's physician.

CONCERN (D)

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

Food Safety (Tag F0812)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

Based on observation and staff interviews, the facility failed to store a resident's beverages in accordance with professional standards for food service safety related to storage. This has the ability to affect more than a limited number of Residents. Facility census: 63. Findings included: a) Nutrition pantry During the initial kitchen tour on 10/21/24 at 11:30 AM an observation of the nutrition pantry found a Residents 12 pack of Coke cans and two (2) six (6) packs of bottled Dr Pepper, and a coffee pot stored under the sink by the sewer/waste disposal pipe. On 10/21/24 at11:35 AM during an interview with the Dietary Manager (DM) verified that resident's soda or coffee pot should not be stored under any sink. The soda and the coffee pot were removed at this time.

CONCERN (D)

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

Medical Records (Tag F0842)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of the Electronic Medical Record (EMR) and staff interview, the facility failed to maintain an accurate medical record for Resident #6. This was true for one (1) of three (3) residents reviewed for pressure ulcers. This had the potential to affect a limited number of residents. Resident identifier: #6. Facility census: 62. Findings included: a) Resident #6 A review of the EMR on 12/18/24 at approximately 2:15 PM found pressure ulcer measurements for Resident #6 on 11/26/24, 11/29/24, 12/06/24, 12/13/24, and 12/17/24. The resident was in the hospital from [DATE] through 12/08/24 when the Resident returned to the facility. At approximately 3:00 PM on 12/18/24, the Director of Nursing (DON) stated that she had made a mistake and there were no measurements during the time in which Resident #6 was in the hospital. In addition the DON stated that the measurements on 12/13/24 and 12/17/24 were correct and that the measurements on 11/26/24, 11/29/24, 12/06/24 had been struck out.

CONCERN (E)

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

Resident Rights (Tag F0550)

Could have caused harm · This affected multiple residents

Read full inspector narrative →

Based on observation and staff interviews, the facility failed to provide each resident the right to be treated with dignity and respect when passing meal trays. This was true for four (4) of thirty-three (33) residents observed in the dining room. Resident identifiers: #9, #28, #31 and #61. Facility census: 63 Findings include: a) On 10/23/24 at 12:05 PM during observation of the noon meal tray pass in the dining room there were five (5) residents observed at one table. Resident #5 received her lunch at 12:05 PM. The remaining four (4) residents were not served their tray and staff members continued to serve residents at the other three (3) tables. At 12:08 PM Resident #31 asked, Can we have our food now? The staff member walking past responded, We are getting it. At 12:12 PM staff members began serving the remaining residents sitting at this table. The last meal was served to Resident #61 at 12:16 PM. This left the four (4) residents sitting at the table for seven to eleven (7-11) minutes with Resident #5 while she ate her meal. On 10/23/24 at 12:17 PM Licensed Practical Nurse #26, was asked if all residents at a table were to be served prior to serving the next table, she stated, She comes in late sometimes (speaking of Resident #5), I don't know why that happened. However Resident #5 was observed to be the first resident to arrive and sit at this table.

CONCERN (E)

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

Deficiency F0577 (Tag F0577)

Could have caused harm · This affected multiple residents

Read full inspector narrative →

Based on observation and staff interview, the facility failed to ensure residents were able to examine the results of the most recent survey. This had the potential to affect more than an isolated number of residents. Facility census: 63. Findings included: a) An observation of the survey book in the facility revealed the last survey results that were in the survey book were from the annual inspection in November 2022. On 10/24/24 at 1:00 PM the administrator said one of the residents in the facility keeps getting papers out of the book. A review of the facility's survey history revealed complaints investigated in February 2023, September 2023 and February 2024 all had citations associated with them.

CONCERN (E)

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

Safe Environment (Tag F0584)

Could have caused harm · This affected multiple residents

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview the facility failed to provide a home like environment. This was true for four (4) of nine (9) rooms observed. Room identifiers: #104, #108, #110, #213. Facility Census: 63 Findings included: a) room [ROOM NUMBER] On 10/23/24 at 1:30 PM observation of nine (9) rooms in the facility found that four (4) rooms did not have a homelike environment. room [ROOM NUMBER] had two (2) residents residing in the room and there were no comforters or chairs provided for them. On 10/23/24 at 2:45 PM during an interview with the resident in (B bed), she was asked if she felt like her room was like her home prior to coming to the facility. She said it was not. b) room [ROOM NUMBER] room [ROOM NUMBER] had two (2) residents residing in the room and there were no comforters or chairs provided for them. On 10/23/24 at 3:00 PM during an interview with the resident in (B bed) he was asked if he felt like his room was like his home prior to coming to the facility. He said it was not. c) room [ROOM NUMBER] room [ROOM NUMBER] had two (2) residents residing in the room and there were no comforters or chairs provided for them. There had been plaster repairs that were uneven and unfinished. There were no pictures in the room. There were paper signs taped to the wall listing mealtimes and there were no personal items in her room. On 10/23/24 at 3:30 PM during an interview with the resident in (B bed) she was asked if she felt like her room was like her home prior to coming to the facility. She said it was not. d) room [ROOM NUMBER] room [ROOM NUMBER] had one (1) resident residing in the room and there were no comforters, or a chair provided for her. On 10/24/24 at 9:10 AM during an interview with this resident she was asked if she felt like her room was like her home prior to coming to the facility. She said it was not. On 10/24/24 at 10:49 AM during observations of the rooms listed above and interview with the Administrator she agreed the furniture did not reflect a home-like environment.

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

Read full inspector narrative →

b) Resident # 61 On 10/21/24 at 12:10 PM during the initial long term care survey process interview, Resident #61 stated he had a dentist appointment later today as he was having some issues. Record review found the following Progress notes: -10/18/24 12:49 PM Resident POA (power of attorney) notified of appt (appointment) date and time at (name) family dentistry. -10/21/24 2:26 PM Resident returned to facility from dentist appointment. Resident has multiple teeth that are non-restorable. Resident elects to have no treatment done at this time and has no pain. Physician Orders: October 21, 2024, at 1300 (1:00) pm with (name of dentist). Facility to transport. Please have the resident ready no later than 1200 pm. one time only for dentist appointment for 1 Day Other Completed 10/20/24 23:00 (11:00 pm). On 10/22/24 at 3:25 PM during a follow up interview with Resident #61, he stated he was not sure when his dental problems started. He did not want a bunch of dental work done. He said that if his teeth that were bad started to bother him he would just have them pulled. Record review of the care plan found there was no focus, goals or interventions initiated in his care plan for dental. This was confirmed with the Administrator on 10/23/24 at 9:00 AM. c) Resident #61 On 10/21/24 at 12:10 PM during the initial long term care survey process interview it was observed that Resident #61 was on a specialty mattress. On 10/22/24 at 9:05 AM during record review it was noted that Resident #61 has pressure ulcers with treatments ordered. There was no order or care plan initiated for the specialty mattress. This was confirmed with the Administrator on 10/23/24 at 9:00 AM. Based on medical record review and interview, the facility failed to develop person-centered comprehensive care plans. The facility failed to develop care plans for a lap tray, dental issues, specialty mattress and failed to develop a resident centered care plan. This practice affected four (4) of (24) resident's care plans reviewed during the Long-Term Care Survey Process (LTCSP). Resident identifiers: #2, #61, and #64. Facility census: 63. Findings included: a) Resident #2 An observation on 10/21/24 12:45 PM Resident #2 had a lap tray in place in the dining room while eating lunch. A second observation on 10/22/24 at 845 AM Resident #2 had a lap tray in place when eating breakfast. A review of the current care plan showed there was no care plan addressing a lap tray during meals with interventions and goals. This showed it was not updated to reflect the residents' current status. A third observation on10/22/24 at 12:03 PM found the lap tray in place during lunch. On 10/22/24 at 12:14 PM during an interview the Administrator stated the tray was used for a table to eat only. During an interview on 10/24/22 at 11:29 AM the Administrator confirmed there was no care plan addressing Resident #2's lap tray until surveyor intervention. d) Resident #64 Resident #64's Five (5) Day Minimum Data Set (MDS) assessment with Assessment Reference Date (ARD) 09/27/24 showed the resident had a Brief Interview for Mental Status (BIMS) score of 00, indicating severe cognitive impairment. Review of Resident #64's comprehensive care plan showed the following focus initiated on 08/30/24, The resident has impaired cognitive function/dementia or impaired thought processes AEB (as evidenced by). The as evidenced by portion had not been completed. The goal initiated 08/30/24 stated, The resident will remain oriented to (SPECIFY: person, place, situation, time) through the review date. The target date was 12/22/24. No review or revision dates were documented for the focus or goal. On 10/23/24 at 1:13 PM, the Administrator confirmed for the resident to be oriented to person, place, situation, and time was not a realistic goal for Resident #64. No further information was provided through the completion of the survey. e) Resident #64 Review of Resident #64's medical records showed the resident experienced a fall on 09/03/24 and received a skin tear on his left elbow. Further review of Resident #64's medical records showed the resident experienced another fall on 09/08/24 and received a skin tear to right outer forearm. Review of Resident #64's comprehensive care plan showed the following focus initiated on 09/03/24 and revised on 09/08/24, [Resident's name] has had actual falls with minor injury and is at risk for further falls related to cognitive deficits, poor safety awareness, hx [history] of falls, impaired mobility. The goal initiated 08/30/24 stated, The resident's (Specify: injured areas) will resolve without complication by review date. The target date was 12/22/24. On 10/23/24 at 1:13 PM, the administrator confirmed the resident's injured areas were not specified in the goal. No further information was provided through the completion of the care plan.

CONCERN (E)

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

Infection Control (Tag F0880)

Could have caused harm · This affected multiple residents

Read full inspector narrative →

Based on observation and staff interview the facility failed to maintain an infection prevention program to help prevent the development and transmission of communicable diseases and infections by not providing hand hygiene prior to meals. Facility Census: #63 Findings include: On 10/23/24 at 11:55 PM during the noon meal pass it was observed that residents in the dining room were not provided hand hygiene prior to their meal. On 10/23/24 at 12:17 PM It was confirmed with Licensed Practical Nurse #26 that the residents are to be offered hand hygiene prior to their meal. She stated it is usually either a towelette or a pump of hand sanitizer (anti bacterial disinfectant), I am not sure why they did not offer it to the residents today.

MINOR (C)

Minor Issue - procedural, no safety impact

Staffing Information (Tag F0732)

Minor procedural issue · This affected most or all residents

Read full inspector narrative →

Based on observation and staff interview the facility failed to ensure the daily nursing posting was completed accurately for 13 of 16 days. This was a random opportunity for discovery. Facility census: 63. Findings included: a) Staffing data An observation on 10/21/24, 10/22/24, and 10/23/24 of the facility posted staffing data, found the facility name was not on the document. A facility record review of posted staffing data for 11/18/23, 11/19/23, 11/20/23, and 05/25/34 found the required shift census was not documented. On 05/26/24, 10/04/24, 10/05/24, 10/06/24, 10/19/24 and 10/20/24 found the required facility name not documented. During an interview on 10/24/24 at 10:08 AM the administrator verified the census and facility name was not documented. She stated that she would add the facility name now.

Feb 2024 2 deficiencies

CONCERN (D) 📢 Someone Reported This

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

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

Report Alleged Abuse (Tag F0609)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure alleged violations involving resident abuse were reported, not later than 2 hours after the events / allegations were brought to the facility's attention, to appropriate state agencies as required. This was a random opportunity for discovery during a complaint survey. Resident identifier: #29. Facility census: 61. Findings iincluded: a) Resident #29 On 02/20/24 at 12:25 PM, a review of facility reportables from September 2023 - Present was completed. There was an abuse reportable, dated 02/05/24, which revealed the following details: -An allegation of abuse was made against Licensed Practical Nurse (LPN) #70. -The victim of abuse was Resident #29. Resident #29 was an [AGE] year-old white female who was admitted as a long-term care resident on 04/04/22. Resident #29 had a diagnosis of Alzheimer's/Dementia and lacked capacity to make decisions for herself. -LPN #3 witnessed the incident between LPN #70 and Resident #29. LPN #3's gave the following statement, Shift change, this LPN to give report to [LPN #70's First and Last Name]. [LPN #70's First Name] was demonstrating irritable behavior, picking papers up frantically and slamming down folders . A resident who has dementia and confusion began to feel things at the desk. The resident then stood up from wheelchair. [LPN #70's First Name] abruptly went over to resident and grabbed the resident by arm forcefully pushed resident in downward motion into wheelchair. Resident had shocked looked on face. Resident had 'word salad' in reply to [LPN #70's First Name]. [LPN #70's First Name] yelled at resident stating that she did not care. -LPN #55 witnessed the incident between #70 and Resident #29. LPN #55 gave the following statement, She (LPN #70) kind of grabbed her (resident's) arms and put her in the chair . she (LPN #70) was aggressive with the resident . She (LPN #70) pushed the wheelchair letting go of it forcefully down the hall . the chair propelled by itself after the push from the end of the nurses' station close to the 200 hall and ended up just past the double doors on the 200 hall. -LPN #57 witnessed the incident between LPN #70 and Resident #29. LPN #57 gave the following statement, Nurse [LPN's Last Name] become aggressive with resident while sitting her down in chair. When asked if she thought it was intentional, she stated, Yes. She (LPN #70) sat her down aggressively. LPN #57 also stated that LPN #70's tone was aggressive. -The allegation of abuse was substantiated, and LPN #70 was terminated from employment. The facility reported this incident to the Office of Health Facility Licensure and Certification (OHFLAC), Adult Protective Services (APS), and the Long-Term Care Ombudsman and shared the results of their investigation/the five (5) day follow-up with all three agencies. There was no evidence the substantiated abuse incident had been reported to the WV LPN Board. Review of the National Council of State Boards of Nursing (NCSBN) pamphlet titled, A Health Care Consumer's Guide - Your State Board of Nursing Works for You revealed a complaint can be filed at any time by anyone who feels that a nurse has provided incompetent, negligent, or unsafe care. Examples of cases where a nurse should be reported immediately included abusing a patient physically, emotionally, verbally, or sexually. During an interview, on 02/21/24 at 9:57 AM, the Social Worker reported that according to the facility's investigative process she served as an advocate for the residents and interviewed only the residents involved. The Social Worker stated it was part of the facility's investigative process that the administration interviews employees. During an interview, on 02/21/24 at 9:58 AM, the Administrator reported she could not recall if it was discussed on a corporate level about reporting the abuse incident to the LPN Licensing Board. The Administrator stated she would check to see if corporate staff had reported the incident to the licensing board or not. The Administrator stated, during an interview on 02/21/24 at 10:10 AM, that the LPN Licensing Board had not been notified of the substantiated abuse incident between LPN #70 and Resident #29. The Administrator added, It is being reported now.

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

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview the facility failed to develop or implement a comprehensive person-centered care plan with measurable objectives for behaviors. This was true for one (1) of three (3) residents reviewed during the Complaint Survey Process. Resident Identifiers: Resident #63 Facility Census 61. Findings Included: a) Resident #63 On 02/20/24 at 12:05 PM, a brief medical record review found Resident #63 was admitted to the facility on [DATE] with a Brief Interview of mental status (BIMS) of 3 and lacking capacity. Further review of the medical record found the following physician order: behaviors - monitor for the following: itching, picking at skin, restlessness (agitation), hitting, increase in complaints, biting, kicking, spitting, cussing, racial slurs, elopement, stealing, delusions, hallucinations, psychosis, aggression and refusing care. A review of Resident #63's care plan found no goals, focus statements or interventions related to Resident #63's behaviors or behavior monitoring. During an interview with the Director of Nursing (DON), on 02/21/24 at 10:45 AM, the DON confirmed the care plan did not include behavior monitoring.

Sept 2023 4 deficiencies

CONCERN (D) 📢 Someone Reported This

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

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

Notification of Changes (Tag F0580)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

. Based on medical record review and staff interview the facility failed to ensure when (1) of three (3) residents reviewed had a change in medication and issues with sexually inappropriate behaviors the medical power of attorney was notified. Resident #59. Facility census: 58. Findings included: a) Resident #59 A review of Resident #59's medical record revealed an order dated 03/06/23 for Cimetidine Oral Tablet 200 milligram (mg). The medication was ordered to be given as follows: One (1) tablet by mouth two (2) times a day for sexually inappropriate behaviors. Medication Administration Record (MAR) for March 2023 revealed Resident #59 received Cimetidine as ordered on 03/07/23, 03/08/23, 03/09/23, 03/10/23, 03/11/23, 03/12/23, 03/13/23, 03/14/23 and once on 03/15/23. Further medical record review revealed Cimetidine was discontinued on 03/15/23 per family request. A review of Resident #59's progress notes, and care plan did not reveal any sexually inappropriate behaviors. The minimum data set (MDS) review included a review of the admission assessment and quarterly MDS review. Section E which assessed behaviors did not reveal any sexually inappropriate behaviors on either assessment. The medical record did not reveal the medical power of attorney being notified of the medication being prescribed. The medical record also did not reflect that the medical power of attorney had been notified of any sexually inappropriate behaviors. An interview with the administrator on 09/13/23 at 1:00 PM did not reveal any additional information regarding why this medication had been prescribed and administered to this resident. The administrator revealed the resident was discharged to another long-term care facility in May 2023. .

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

Read full inspector narrative →

. Based on medical record review, observations and staff interview the facility failed to ensure three (3) randomly observed residents received the assistance needed to promote adequate grooming. Residents were observed with long, dirty fingernails. Resident identifiers: #23, #51, and #47. Facility census: 58. Findings included: a) Resident #23 An observation of Resident #23 on 09/11/23 at 4:17 PM, revealed the resident had long fingernails. He said he would like to have them cut shorter. A Minimum Data Set (MDS) review revealed a quarterly assessment with an Assessment Reference Date (ARD) of 07/03/23. Under Section E which assesses a residents need for assistance with activities of daily living the resident was assessed as needing extensive assistance with personal hygiene. b) Resident #51 The resident was observed on 09/11/23 at 1:40 PM. He was observed to have long fingernails. He was interviewed and said he would like to have them cut. He said sometimes his family would cut them for him. His MDS with an ARD of 06/30/23 revealed he was extensive assist with personal hygiene. C) Resident #47 On 09/11/23 at 2:00 PM, an observation found the resident sitting in the hallway with long nails. A quarterly review MDS with an ARD of 07/05/23 revealed the resident needed extensive assistance with personal hygiene. Record review did not reveal the three (3) residents resisted care. On 09/12/23 at 4:00 PM the administrator was informed of the observations made of residents needing nail care. At the conclusion of the survey no further information was provided.

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 F0757 (Tag F0757)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

Based on medical record review and staff interview the facility failed to ensure one (1) of three (3) resident's drug regimen was free from unnecessary drugs. Resident #59 had been prescribed a medication without indication for use. Resident identifier: #59. Census: 58. Findings included: A review of Resident #59's medical record revealed an order dated 03/06/23 for Cimetidine Oral Tablet 200 milligram (mg). The medication was ordered to be given as follows: One (1) tablet by mouth two (2) times a day for sexually inappropriate behaviors. The Medication Administration Record (MAR) for March 2023 revealed Resident #59 received Cimetidine as ordered on 03/07/23, 03/08/23, 03/09/23, 03/10/23, 03/11/23, 03/12/23, 03/13/23, 03/14/23 and once on 03/15/23. Further medical record review revealed Cimetidine was discontinued on 03/15/23 per family request. A review of Resident #59's progress notes, and care plan did not reveal any sexually inappropriate behaviors. The minimum data set (MDS) review included a review of the admission assessment and quarterly MDS review. Section E which assessed behaviors did not reveal any sexually inappropriate behaviors on either assessment. An interview with the administrator on 09/13/23 at 1:00 PM did not reveal any additional information regarding why this medication had been prescribed and administered to this resident. The administrator revealed the resident was discharged to another long-term care facility in May 2023.

CONCERN (E) 📢 Someone Reported This

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

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

Safe Environment (Tag F0584)

Could have caused harm · This affected multiple residents

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation and staff interview the facility failed to ensure they maintained housekeeping and maintenance necessary to maintain a sanitary, orderly and comfortable interior. Environmental issues were found on both of the facility's hallways. These observations were random opportunities for discovery. Facility census: 58. Findings included: a) On 09/13/23 at 10:15 AM the environmental supervisor and later the housekeeping supervisor accompanied the surveyor to the rooms with concerns. room [ROOM NUMBER], #115, #202, and #214 had been identified on 09/11/23 as having issues that needed addressed. The following was observed in room [ROOM NUMBER]: holes in the wall near the bed, chipped Formica in the window seal. The following was observed in room [ROOM NUMBER]: Cracked floor tile near the air conditioning unit, cracked Formica on the window seal and dirt and debris inside the heating/air conditioning unit. The following was observed in room [ROOM NUMBER]: Splashes on the wall underneath the sink. The environmental supervisor said the trash can sitting under the sink most likely contributed to these stains. The following was observed in room [ROOM NUMBER]: The wall by the heat/air condition unit had dirty splashes and the bathroom floor appeared to be dirty. A mechanical lift was observed in the hallway on the 200 hall. The mechanical lift had dirt and debris on the bottom part. At the conclusion of these observations the environmental supervisor and housekeeping supervisor both acknowledged these findings. .

Feb 2023 1 deficiency

CONCERN (E) 📢 Someone Reported This

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

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

Notification of Changes (Tag F0580)

Could have caused harm · This affected multiple residents

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review, staff interview, resident interview and family interview, the facility failed to notify the resident's family when the resident had a significant change in health status. This was true for three (3) of four (4) sampled residents. Resident Identifiers: #61, #59 and #60. Facility Census: 59. Findings Included: a) Resident #61 On 02/28/23 at at 11:00 AM, a record review was completed for Resident #61. The resident was admitted to the facility on [DATE] for short-term rehabilitation. The resident was sent to an acute care facility per the resident's request on 11/10/22 for increased wheezing with shortness of breath and abdominal pain. The resident was noted with medical decision-making capacity on 11/02/22. The resident, also, completed an Physician's Orders for Scope of Treatment (POST) form on 11/09/22. The POST form indicated the resident's wishes were for cardiopulmonary resuscitation and full treatment. The admission packet was reviewed on 02/27/23 at 1:00 PM with no indication of an emergency contact and telephone number listed. Also, reviewed were the admission record, profile screen and social services admission and documentation assessment with no indication of an emergency contact. However, a home telephone number was listed on the admission record. The Administrator stated there is no admission packet completed for the resident. On 02/27/23 at 1:40 PM, the Social Services Specialist (SS) #14 stated I don't have any of the social services paperwork for the resident. A progress note dated 11/11/22 at 9:47 AM, stated Facility was notified by residents family that he passed away at the hospital this morning and that they will be coming to pick up his personal belongings today. (Typed as written.) After reviewing the records, there was no indication the resident's spouse was contacted regarding the significant change in the resident's health status. The resident's spouse stated if I wouldn't have called to check on him I wouldn't have known he was at the hospital or how bad he was. On 02/28/23 at 10:03 AM, the Director of Nursing (DON) stated, we wouldn't contact anyone else unless they (resident) say they want us to. b) Resident #59 On 02/28/23 at 11:30 AM, a record review was completed for Resident #59. The resident was admitted to the facility on [DATE] for short-term rehabilitation. The resident was sent to an acute care facility on 02/13/23 after suffering a witnessed fall with injury. The resident was noted with medical decision-making capacity on 01/06/23. The resident, also, completed a POST form on 01/06/23. The POST form indicated the resident's wishes were for cardiopulmonary resuscitation and full treatment. There is no indication on the profile screen, admission record or the social services admission and documentation assessment to indicate an emergency contact or telephone number. A progress note dated 02/13/23 at 12:00 am stated, observed him have a fall in the hallway. He was walking with a cane, and fell forward on his face. He has a large forehead laceration and a bleeding nose. The Emergency Squad was called, and he is being taken out to the Emergency Room. (Typed as written.) After reviewing the record, there is no indication anyone was contacted regarding the fall with injury. The resident stated, I don't think they called anyone .damn straight I wanted my son and daughter-in-law to know .I didn't know whether I was going to live or die. c) Resident #60 On 02/28/23 at 12:00 PM, a record review was completed for Resident #60. The resident was admitted to the facility on [DATE] for long-term care. The resident was sent to an acute care facility on 02/23/23 for elevated temperature, pulse, blood pressure, chills and lethargy. A progress note dated 02/24/23 at 10:51 AM stated, Spoke with (Name of the acute care facility) and resident was admitted for Pneumonia and Dehydration. (Typed as written.) The resident was noted with medical decision-making capacity on 11/24/22. The resident, also, completed a POST form on 11/23/22. The POST form indicated the resident's wishes were for cardiopulmonary resuscitation and full treatment. There is no indication on the admission packet, profile screen, admission record or the social services admission and documentation assessment to indicate an emergency contact or telephone number. After reviewing the record, there is no indication anyone was contacted regarding the significant change in the resident's health status. .

Nov 2022 13 deficiencies

CONCERN (D)

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

Deficiency F0655 (Tag F0655)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review and staff interview, the facility failed to complete a baseline care plan in a timely manner. This was true for one (1) of ten (10) new admissions reviewed. Resident identifier #258. Facility Census: 57. Findings Included: a) Resident #258 A review of Resident #258's medical record found the resident was admitted on [DATE] with a femur fracture and urinary tract infection (UTI) as well as Alzheimer's disease, a history of falls, hypertension, coronary artery disease, muscle weakness and difficulty walking. Further review of the medical record on 11/30/22 found no baseline care plan for Resident #258. An interview with the Administrator on 11/30/22 at 1:00 pm confirmed Resident #258 did not have a baseline care plan and should have. .

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

Read full inspector narrative →

. Based on record review and staff interview, the facility failed to develop a comprehensive care plan to meet Resident #20's mental and psychosocial needs. This is true for one (1) of five (5) residents reviewed for the care area of unnecessary medications during the long term survey process. Resident identifier: #20. Facility census: 57. Findings included: a) Resident #20 Review of the medical record on 11/30/22 revealed Resident #20's hospital after visit summary notes he takes Buspirone (antianxiety medication) twice a day for repeated episodes of anxiety. The physician admission orders include Buspirone hydrochloride 10 milligrams (mg) twice a day for anxiety. The care plan identifies a focus of limited engagement related to a diagnosis of depression, but lacks any goals or interventions. In addition, the care plan is silent for Residnet #20's diagnosis of anxiety and the administration of his psychotropic medications. During an interview on 11/30/22 at 09:24 AM, the Director of Nursing (DON) confirmed Resident #20 has diagnoses of anxiety and depression. The DON acknowledged the care plan lacks the diagnosis of anxiety and fails to include measurable goals or interventions for anxiety or depression. .

CONCERN (D)

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

Deficiency F0657 (Tag F0657)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

. Based on medical record review and staff interview the facility failed to review and revise the care plan in relation to the Resident's nutrition assessment orders. This was true for One (1) of 21 sampled residents reviewed during the long term care process. Resident Identifier: #41 Facility Census: 57 Findings Included: a) Resident #41 A review of Resident #41's medical record found the following current physician orders: -- House Supplement two times a day house shake 2 time/day at 10 AM and evening snack providing 400 calories/12 gm protein r/t (related to) weight loss. Order date 7/26/22 -- Regular diet Regular Texture texture. Order date 10/28/22 -- Obtain Monthly weight every day shift every 1 month(s) starting on the 10th for 1 day(s). Order date 11/01/22 Resident #41's current care plan (created on 6/28/22) read as follows: Focus: Resident is at nutritional risk related to dementia with new environment, hx (history) of significant weight loss. Goal: Resident will receive and tolerate diet as ordered without s/s (signs or symptoms) aspiration or dysphagia and will consume adequately to promote stable weight trend, aid in skin integrity and promote adequate hydration through next review. Interventions included: 1) Provide 2 planned snacks r/t recent weight loss. Therefore, as of 11/29/22, the care plan does not reflect revisions in relation to the current orders, as the Resident does not have orders for nor receive snacks, she only receives supplements. This was confirmed with the Administrator on 11/29/22 at 1:42 PM. No additional information was provided. .

CONCERN (D)

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

Deficiency F0660 (Tag F0660)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review and staff interview the facility failed to follow their own policies, or state law as related to discharges which are Against Medical Advice (AMA) for Resident # 55. These practices affected one (1) of two (2) resident's reviewed for the care area of discharges during the Long-Term Care Survey Process (LTCSP). Resident Identifier #55. Facility census 57. a) Resident #55 A review of Resident #55's medical record on 11/29/22 found Resident #55 was discharged from the facility on 11/12/22. Contained in the medical record was a Voluntary Discharge Against Medical Advice form that was signed by Resident #55 dated 11/12/22. A review of the facility's policy titled, Discharge Against Medical Advice (AMA) with an effective date 06/01/96, found the following: . Documenting the AMA : . 7. The discharge transition plan will be provided to the patient or resident representative. Efforts will be made to make referrals to community resources and agencies to the extent possible. The Nursing Home Administrator (NHA) was asked to provide a copy of the discharge transition plan which was provided to Resident #55 at the time of her AMA discharge on [DATE]. On 11/29/22 at 11:54 am the NHA stated they did not complete a discharge transition plan for Resident #55. She confirmed the facility did not follow their AMA policy and stated she was not sure how they could. .

CONCERN (D)

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

Deficiency F0692 (Tag F0692)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

. Based on medical record review and staff interview the facility failed to obtain a re-weight after the Resident experienced a significant weight loss. This was true for one (1) of four (4) residents reviewed for weight loss. Resident Identifier: #41 Facility Census: 57 Findings Included: a) Resident #41 Resident #41 has current orders for: -- House Supplement two times a day house shake 2 time/day at 10 AM and evening snack providing 400 calories/12 gm protein r/t weight loss. Order date: 07/26/22 -- Regular diet Regular Texture texture. Order date: 10/28/22 -- Obtain Monthly weight every day shift every 1 month(s) starting on the 10th for 1 day(s). Order date 11/01/22 The medical record contained the following weights: 11/10/22 at 4:55 pm 149.0 Pounds(Lbs) 11/1/22 at 5:00 pm 147.6 Lbs 10/10/22 at 09:04 am 147.6 Lbs 10/3/22 at 6:07 pm 147.0 Lbs 09/26/22 at 10:21 am 146.0 Lbs 09/19/22 at 11:23 am 146.0 Lbs 09/12/22 at 4:27 pm 145.6 Lbs 09/5/22 at 09:08 am 145.8 Lbs 08/29/22 at 09:24 am 146.2 Lbs 08/22/22 at 10:19 am 144.0 Lbs 08/15/22 at 07:52 am 144.4 Lbs 08/08/22 at 4:37 pm 143.2 Lbs 08/01/22 at 11:42 am 144.0 Lbs 07/25/22 at 6:04 pm 145.8 Lbs 07/18/22 at 6:25 pm 146.0 Lbs 07/11/22 at 11:20 am 145.6 Lbs 07/04/22 at 2:07 pm 149.4 Lbs 06/26/22 at 09:13 am 150.8 Lbs 05/23/22 at 4:45 pm 160.4 Lbs 05/16/22 at 08:26 am 157.4 Lbs 05/02/22 at 08:56 am 159.0 Lbs 04/25/22 at 1:50 pm 164.6 Lbs Significant weight loss is described as: 5% change in weight in 1 month (30 days) 7.5% change in weight in 3 months (90 days) 10% change in weight in 6 months (180 days) On 06/26/22 the documented weight is 150.8 Lbs reflected a 9.6 pound weight loss since 5/23/22 (160.4 pounds) in 30 days. There was no re-weight completed as per the standard practice. The facility failed to monitor the residents weight and re- weigh the resident when there was a drastic weight fluctuation to either confirm or rule out a significant weight loss which could be addressed by physician and/or dietician. This was confirmed with the Administrator on 11/29/22 at 1:42 PM. No further information was provided. .

CONCERN (D)

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

Food Safety (Tag F0812)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

. Based on observation and staff interview the facility failed to serve food in a safe and sanitary manner in accordance with professional standards of practice. During the kitchen tour it was discovered dietary staff had not used proper hand sanitation. This failed practice had the potential to affect a limited number of residents. Facility census: 57. Findings included: a) Kitchen tour During the kitchen tour an observation on 11/28/22 at 12:01 PM, revealed Dietary Aide (DA) #5 had picked up mustard packets, that had fallen to the floor. DA #5 did not wash her hands before returning to the beverage and dessert area of the tray service line, and began serving food and/or beverages. An interview with DA #5 on 11/28/22 at 12:02 PM, verified she picked up the mustard packets from the floor and did not wash her hands before resuming the service of food. .

CONCERN (D)

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

Deficiency F0849 (Tag F0849)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

. Based on medical record review and staff interview, the facility failed to collaborate with hospice services to develop a coordinated care plan for one (1) of one (1) residents reviewed for the care area of hospice during the Long Term Care Survey Process. The care plan for Resident #34 did not specify when and what services were to be provided by the hospice staff. Resident identifier: #34. Facility census: 57. Findings included: a) Resident #34 A medical record review on 11/30/22 for Resident #34, revealed the care plan did not include any information regarding when the hospice nurse aides and nurses would visit and what specific services they would provide. An interview with the Nursing Home Administrator (NHA) on 11/30/22 at 12:29 PM, verified the care plan for Resident #34 did not specify care and services to be provided by the hospice staff. .

CONCERN (E)

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

Assessment Accuracy (Tag F0641)

Could have caused harm · This affected multiple residents

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review and staff interview the facility failed to ensure the Minimum Data Set (MDS) for Resident #13, #5 and #20 was coded to accurately reflect the residents status. This was true for three (3) of 21 sampled residents during the long term care survey process. Resident Identifiers: #13, #5 and #20. Facility Census: 57. Findings Included: a) Resident #13 A review of Resident #13's medical record on 11/28/22 found the resident was sent to an acute care hospital on [DATE]. Further review of the record found a Minimum Data Set (MDS) with an Assessment Reference Date of 08/06/22. This MDS was coded under section A0310. Type of Assessment F. Entry/discharge reporting with a number 10 indicating the resident was discharged with a return not anticipated. An interview with the Director of Nursing (DON) on 11/30/22 at 10:06 am confirmed the MDS should have been coded Discharge Return Anticipated because the resident was sent to the hospital for an acute illness and was expected to return once her condition stabilized. b) Resident #5 During a medical record review on 11/28/22, it was discovered the MDS with an assessment reference date (ARD) of 11/10/22 for a significant change was not coded correctly in the area of skin conditions. The MDS assessment did not include the pressure reducing device to Resident #5's chair. A physician's order written on 05/18/22 prescribed a pressure-redistribution cushion to resident's chair. In an interview with the Director of Nursing (DON) on 11/29/22 at 2:02 PM, verified the pressure reducing device was not coded correctly on the MDS with an ARD of 11/10/22. c) Resident #20 Review of the medical record on 11/30/22 revealed Resident #20's hospital after visit summary states he takes Buspirone (antianxiety medication) twice a day for repeated episodes of anxiety. The physician admission orders include Buspirone hydrochloride 10 milligrams (mg) twice a day for anxiety. The admission Minimum Data Set (MDS) with and assessment reference date of 08/15/22 was not marked to reflect the diagnosis of anxiety under the section titled Psychiatric/Mood disorder I5700. During an interview on 11/30/22 at 09:24 AM, the Director of Nursing (DON) confirmed the initial/admission MDS is incorrectly coded under section I5700, and does not reflect Resident #20's active diagnosis of anxiety. .

CONCERN (E)

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

Deficiency F0730 (Tag F0730)

Could have caused harm · This affected multiple residents

Read full inspector narrative →

. Based on record review and staff interview the facility failed to ensure all nurse aides had an employee performance review completed at least annually. This was true for five (5) of five (5) Nurse Aides reviewed. This failed practice had the potential to effect more than an isolated number of residents. Employee Identifiers: Nurse Aide (NA) # 49, NA # 53, NA #54, NA #30 and NA #40. Facility Census: 57. Findings Included: a) Employee Performance Reviews On 11/29/22 the Nursing Home Administrator (NHA) was asked to provide the current nurse aide performance reviews for Nurse Aide (NA) #49, NA #53, NA #54, NA #30, and NA #40. On 11/30/22 at 8:20 am the NHA was asked if she had the requested NA performance reviews. She stated, We have not done those within the last year. When asked when the last one was completed she stated, The last one was done before COVID. .

CONCERN (E)

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

Staffing Information (Tag F0732)

Could have caused harm · This affected multiple residents

Read full inspector narrative →

. Based on record review and staff interview the facility failed to ensure the nurse staffing information posted daily contained the correct number of staff working including the actual hours worked for each licensed and unlicensed staff directly responsible for resident care per shift. This failed practice had the potential to more than a limited number of residents currently residing in the facility. Facility Census: 57. Findings included: a) Nurse Staff Postings A record review of the Nurse Staff Postings maintained by the facility as well as the facility's Hours Per Patient Day (HPPD) report for the time frame of 04/01/22 to 06/30/22, found on the following occasions the nurse staff posting hours were more than the actual hours worked on the HPPD report which is generated from the time clock hours when the staff punch in and out for their shift. The HPPD report contains the acutal number of hours worked by those providing direct care to the residents. -- 04/01/22 the staff posting indicated a total of 167 hours of direct care, but the HPPD report indicated a total of 143.75 total hours. -- 04/02/22 the staff posting indicated a total of 183 hours of direct care, but the HPPD report indicated a total of 178.95 total hours. -- 04/03/22 the staff posting indicated a total of 194.50 hours of direct care, but the HPPD report indicated a total of 180.02 total hours. -- 04/04/22 the staff posting indicated a total of 164 hours of direct care, but the HPPD report indicated a total of 159.53 total hours. -- 04/08/22 the staff posting indicated a total of 167.50 hours of direct care, but the HPPD report indicated a total of 157.50 total hours. -- 04/09/22 the staff posting indicated a total of 170.50 hours of direct care, but the HPPD report indicated a total of 158.33 total hours. -- 04/10/22 the staff posting indicated a total of 156 hours of direct care, but the HPPD report indicated a total of 146.43 total hours. -- 04/11/22 the staff posting indicated a total of 152.50 hours of direct care, but the HPPD report indicated a total of 130.73 total hours. -- 04/13/22 the staff posting indicated a total of 160 hours of direct care, but the HPPD report indicated a total of 156.38 total hours. -- 04/15/22 the staff posting indicated a total of 155 hours of direct care, but the HPPD report indicated a total of 146.32 total hours. -- 04/22/22 the staff posting indicated a total of 179 hours of direct care, but the HPPD report indicated a total of 152.58 total hours. -- 04/23/22 the staff posting indicated a total of 159.50 hours of direct care, but the HPPD report indicated a total of 157.40 total hours. -- 04/24/22 the staff posting indicated a total of 159 hours of direct care, but the HPPD report indicated a total of 149.72 total hours. -- 04/27/22 the staff posting indicated a total of 147.50 hours of direct care, but the HPPD report indicated a total of 141.87 total hours. -- 04/28/22 the staff posting indicated a total of 167.50 hours of direct care, but the HPPD report indicated a total of 148.65 total hours. -- 04/29/22 the staff posting indicated a total of 156 hours of direct care, but the HPPD report indicated a total of 152.15 total hours. -- 04/30/22 the staff posting indicated a total of 143.50 hours of direct care, but the HPPD report indicated a total of 141.40 total hours. -- 05/03/22 the staff posting indicated a total of 163.50 hours of direct care, but the HPPD report indicated a total of 154.23 total hours. -- 05/04/22 the staff posting indicated a total of 167 hours of direct care, but the HPPD report indicated a total of 163.83 total hours. -- 05/07/22 the staff posting indicated a total of 172 hours of direct care, but the HPPD report indicated a total of 156.82 total hours. -- 05/08/22 the staff posting indicated a total of 172 hours of direct care, but the HPPD report indicated a total of 137.05 total hours. -- 05/11/22 the staff posting indicated a total of 157.50 hours of direct care, but the HPPD report indicated a total of 153.75 total hours. -- 05/13/22 the staff posting indicated a total of 168 hours of direct care, but the HPPD report indicated a total of 159.10 total hours. -- 05/14/22 the staff posting indicated a total of 173 hours of direct care, but the HPPD report indicated a total of 159.55 total hours. -- 05/17/22 the staff posting indicated a total of 160 hours of direct care, but the HPPD report indicated a total of 157.13 total hours. -- 05/22/22 the staff posting indicated a total of 164 hours of direct care, but the HPPD report indicated a total of 158.67 total hours. -- 05/25/22 the staff posting indicated a total of 171 hours of direct care, but the HPPD report indicated a total of 164 total hours. -- 05/26/22 the staff posting indicated a total of 163 hours of direct care, but the HPPD report indicated a total of 157.05 total hours. -- 05/27/22 the staff posting indicated a total of 156.50 hours of direct care, but the HPPD report indicated a total of 139.15 total hours. -- 06/01/22 the staff posting indicated a total of 153 hours of direct care, but the HPPD report indicated a total of 143.27 total hours. -- 06/02/22 the staff posting indicated a total of 163.50 hours of direct care, but the HPPD report indicated a total of 160.42 total hours. -- 06/03/22 the staff posting indicated a total of 186.50 hours of direct care, but the HPPD report indicated a total of 169.18 total hours. -- 06/04/22 the staff posting indicated a total of 160 hours of direct care, but the HPPD report indicated a total of 151.45 total hours. -- 06/05/22 the staff posting indicated a total of 147.50 hours of direct care, but the HPPD report indicated a total of 116.73 total hours. -- 06/07/22 the staff posting indicated a total of 173 hours of direct care, but the HPPD report indicated a total of 145.28 total hours. -- 06/08/22 the staff posting indicated a total of 184.50 hours of direct care, but the HPPD report indicated a total of 181.82 total hours. -- 06/09/22 the staff posting indicated a total of 175.50 hours of direct care, but the HPPD report indicated a total of 159.22 total hours. -- 06/10/22 the staff posting indicated a total of 188 hours of direct care, but the HPPD report indicated a total of 171.43 total hours. -- 06/12/22 the staff posting indicated a total of 178.5 hours of direct care, but the HPPD report indicated a total of 157.85 total hours. -- 06/14/22 the staff posting indicated a total of 165.50 hours of direct care, but the HPPD report indicated a total of 141.52 total hours. -- 06/24/22 the staff posting indicated a total of 176.50 hours of direct care, but the HPPD report indicated a total of 165.72 total hours. -- 06/25/22 the staff posting indicated a total of 195 hours of direct care, but the HPPD report indicated a total of 159.93 total hours. -- 06/26/22 the staff posting indicated a total of 191.50 hours of direct care, but the HPPD report indicated a total of 155.02 total hours. -- 06/27/22 the staff posting indicated a total of 176.50 hours of direct care, but the HPPD report indicated a total of 171.52 total hours. -- 06/07/22 the staff posting indicated a total of 173 hours of direct care, but the HPPD report indicated a total of 145.28 total hours. -- 06/30/22 the staff posting indicated a total of 187 hours of direct care, but the HPPD report indicated a total of 177.18 total hours. The time frame of 04/01/22 through 06/30/22 was chosen for review because the Payroll Based Journal (PBJ) report indicated the facility had a one (1) star staff rating for this quarter. An interview with the Nursing Home Administrator (NHA) on 11/29/22 at 11:54 am confirmed the nurse staff postings were not updated to reflect the actual number of hours worked for each of the days listed above. She agreed the HPPD report and the nurse staff postings should match. .

CONCERN (E)

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

Medication Errors (Tag F0758)

Could have caused harm · This affected multiple residents

Read full inspector narrative →

. Based on record review and staff interview the facility failed to ensure Resident #49's drug regimen was free from unnecessary psychotropic medications. Resident #49's physician agreed to decrease Resident #49's antipsychotic medication on 06/20/22. This medication was not decreased until 07/18/22 which was 28 days after the physician agreed to discontinue the medication. In addition nursing staff was identifying on the Medication Administration Record (MAR) that Resident #49 had side effects related to psychotherapeutic medications, but failed to identify what the side effect was and/or to implement an alternative plan of care without side effects. This was true for one (1) of five (5) residents reviewed for the care area of unnecessary medications during the Long Term Care Survey Process. Resident Identifier: #49. Facility Census: 57. Findings Included: a) Resident #49 1. Gradual Dose Reduction of Seroquel A review of Resident #49's medical record found a Consultation Report issued by the pharmacist containing a recommendation date 07/18/22. The comment on the recommendation report read as follows: (First and Last name of Resident #49) prescriber accepted a pharmacy recommendation to decrease Seroquel to 25 mg (milligrams) afternoon and 75 mg HS (at night) on 06/20/22, but the order has not yet been processed. Further review of the record found another Consultation Report issued by the pharmacist containing a recommendation dated 06/20/22. The comment on the recommendation report read as follows: (First and Last name of Resident #49) has experienced a recent fall or is at moderate or high risk of falls, and receives the following psychotropic medications that may increase risk of falls: Seroquel Recommendation: Please consider the following actions to reduce the future risk of falls: decrease to 25 mg afternoon and 75 mg HS. The form indicated the physician accepted this recommendation on 06/20/22. A review of Resident #49's Seroquel orders found the following pertinent orders: Seroquel Tablet 50 mg Give one tablet by mouth at 2:00 pm. This order had a start date of 04/05/22 and an end date of 07/18/22. Seroquel Tablet 25 mg Give one tablet by mouth at 2:00 pm. This order had a start date of 07/19/22 and an end date of 09/28/22. A review of the Medication Administration Record (MAR) from 06/21/22 through 07/18/22 found Resident #49 was administered Seroquel 50 mg daily for the referenced time frame. An interview with the Director of Nursing (DON) on 11/30/22 at 10:06 am confirmed the Seroquel was not decreased in June 2022 when the physician accepted the pharmacist recommendation. He stated, My best guess would be because he had marked I decline the recommendation first and then scribbled it out then marked I accept the recommendation. He stated, I was not the DON then so I am not sure exactly why the GDR was not implemented. 2. Side Effect Monitoring A review of Resident #49's medical record found on the Medication Administration Record (MAR) for the month of 11/2022 the following order, Resident free from side effects of psychotherapeutic medications? If no, Document side effects in PN (progress notes,) Every day and night shift. A review of the 11/2022 MAR found on the following dates the nurses documented no indicating Resident #49 was having side effects from the psychotherapeutic medications: -- 11/04/22 both day and night shift. -- 11/05/22 both day and night shift. -- 11/19/22 both day and night shift. -- 11/21/22 both day and night shift. -- 11/22/22 both day and night shift. -- 11/23/22 both day and night shift. -- 11/24/22 both day and night shift. -- 11/25/22 both day and night shift. -- 11/26/22 both day and night shift. A review of Resident #49's progress notes from 11/01/22 through 11/29/22 found no side effects documented for the above mentioned dates. An interview with the Director of Nursing (DON) on 11/30/22 at 10:06 am confirmed the nurses were not documenting the side effects in Resident #49's progress notes. He indicated anytime they answer the question no they should write a progress note describing what the side effect was. .

CONCERN (E)

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

Medical Records (Tag F0842)

Could have caused harm · This affected multiple residents

Read full inspector narrative →

. c) Resident (R) #20 Review of the medical record on 11/30/22 revealed R #20's hospital after visit summary notes he takes Buspirone (antianxiety medication) twice a day for repeated episodes of anxiety. The physician's history and physical dated 08/05/2022 states past medical history: As above, and see hospital records and no change in condition under the psychiatric system. The physician admission orders include Buspirone hydrochloride 10 milligrams (mg) twice a day for anxiety. The diagnosis section of the medical record and the admission minimal data set (MDS) assessment with an assessment reference date of 08/15/20 are silent for the diagnosis of anxiety. During an interview on 11/30/22 at 09:24 AM, the Director of Nursing (DON) confirmed R#20's active diagnosis of anxiety is not listed in the diagnosis section of the medical record or in the admission MDS assessment. Based on medical record reviews and staff interviews the facility failed to provide complete and accurate medical records. Resident #34 had incomplete hospice interventions on the care plan and Resident #20 had no diagnosis for anxiety. These incorrect medical records were discovered for two (2) of 21 sample residents records reviewed. Resident identifiers: #34 and #20. Facility census: 57. Findings included: a) Resident #34 A medical record review on 11/28/22 for Resident #34, revealed the care plan did not include any information regarding when hospice nurse aides and nurses would visit and what specific services to be provided. An interview with the Nursing Home Administrator (NHA) on 11/30/22 at 12:29 PM, verified the care plan for Resident #34 did not specify care and services to be provided by hospice staff. b) Resident #20 Review of the medical record on 11/30/22 revealed Resident #20's hospital after visit summary notes he takes Buspirone (antianxiety medication) twice a day for repeated episodes of anxiety. The physician's history and physical dated 08/05/2022 states past medical history: As above, and see hospital records and no change in condition under the psychiatric system. The physician admission orders include Buspirone hydrochloride 10 milligrams (mg) twice a day for anxiety. The diagnosis section of the medical record and the admission minimal data set (MDS) assessment with an assessment reference date of 08/15/20 are silent for the diagnosis of anxiety. During an interview on 11/30/22 at 09:24 AM, the Director of Nursing (DON) confirmed Resident #20's active diagnosis of anxiety is not listed in the diagnosis section of the medical record or in the admission MDS assessment. .

CONCERN (E)

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

Infection Control (Tag F0880)

Could have caused harm · This affected multiple residents

Read full inspector narrative →

. Based on observation, resident interview and staff interview, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Staff were unaware of the correct procedures to follow for residents in isolation, isolation carts for soiled gowns were not hands free, and medications were not administered safely in an isolation room. This practice has the potential to affect more than a limited number of residents currently residing in the facility. Facility census: 57. Findings include: a) Staff isolation practices A random observation on 11/28/22 revealed a resident room marked with a stop sign stating Standard plus Contact precautions to prevent the spread of infection. Please see the nurse before entering the room. When asked, Licensed Practical Nurse (LPN) #29 reported the isolation was for Resident (R) #159's foot wound which contains Vancomycin Resistant Enterococci (VRE). LPN #29 reported anyone entering the room are to wear gowns, goggles and gloves. During an interview on 11/28/22 at 10:00 AM, Resident # 159 asked this surveyor why she was wearing a gown, gloves and goggles. Resident #159 stated no one wears a gown when entering his room, even when they perform his dressing changes. On 11/28/22 at 12:09 PM, Nurse Aide (NA) #33 placed Resident #159's lunch tray on top of the soiled linen cart outside of the isolation room, put on an isolation gown and carried the tray to Resident #159's bedside table. Without cleaning or sanitizing her hands, NA #33 obtained Resident #45's tray (the roommate) from the doorway, carried it to his bedside table and assisted him with sitting up and getting ready to eat. NA #33 exited the room, lifted the lid off of the soiled linen cart and disposed of her gown, replaced the lid, closed the residents' door and then cleaned her hands with hand sanitizer. The above concerns and observations were reviewed with the Director of Nursing (DON), during an interview on 11/28/22 at 12:25 PM. The DON acknowledged the staff were not familiar with what isolation should be used for Resident #159. The DON reported the isolation gowns and gloves should be utilized for Resident #159's wound care. The DON agreed staff should have cleaned their hands between tray services for Resident #159 and Resident #45. b) Isolation linen carts A random observation on 11/28/22 revealed the soiled linen cart outside of an isolation room was not hands free. NA #33 lifted the lid with her hands to place her isolation gown into the container during an observation at 12:09 pm on 11/28/22. The Director of Nursing (DON) confirmed the soiled linen carts outside the isolation rooms were not hands free during an interview on 11/28/22 at 12:25 PM. The DON agreed touching the lid increases the risk of spreading infections. c) Medication administration An observation of medication administration to a resident in an isolation room on 11/29/22 at 9:00 AM revealed the following: Licensed Practical Nurse (LPN) #20 donned an isolation gown and gloves and carried the medications to Resident #45's bedside. She placed the oral tablets and Voltaren gel on the bedside table. LPN #20 administered the liquid risperidone into Resident #45's mouth and then carried the oral syringe back to the med cart. LPN #20 unlocked the med cart with her gloved hands and returned the oral syringe to the medication box inside the med cart. LPN #20 returned to the bedside and administered the remainder of the medications. LPN #20 removed her gloves, washed her hands, and removed her gown when exiting the room. During an interview immediately after this observation, LPN #20 acknowledged the resident's room was marked as isolation. LPN #20 agreed returning to the medication cart without removing her gloves or gown was an incorrect practice and could contaminate the entire medication cart and increase the risk of spreading infection. .

Jun 2021 12 deficiencies

CONCERN (D)

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

Free from Abuse/Neglect (Tag F0600)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, observation, and staff interview; the facility failed to identify possible abuse/neglect. Resident #49 had an injury of unknown origin causing skin tear/abrasions on left great toe and second left toe. This was true for one (1) of one (1) resident reviewed for skin conditions (non-pressure related) during the Long-Term Care Survey Process (LTCSP). Resident identifier: #49. Facility census: 65. Findings included: a) Resident #49 Resident #49's medical record review found he was admitted to the facility on [DATE]. His diagnosis includes cerebral palsy, spina bifida, and traumatic brain injury and quadriplegia from motor vehicle accident. He has been non-ambulatory and mostly non-verbal with occasional mumbling speech. He has contractures of bilateral upper extremities and bilateral foot drop. Observation on 06/21/21 at 2:30 pm, found the resident sitting in a wheelchair with legs extended outward in front of his chair and shoulder support straps intact to ensure the resident's posture due to his inability to maintain an erect position. Resident was non-verbal and did not open his eyes during the observation. He had notable contractures of bilateral upper extremities and bilateral foot drop. It was noted his bed was against the wall and when resident is in bed his right side is against the wall. He had a scab covered areas noted on his left great toe and second left toe. Review of Resident #49's nurses notes found a note entered on 03/07/21 at 3:30 pm, written by the Director of Nursing (DON), read: Called to residents' room by (Employee #21's name) Nursing Assistant (NA). Dried blood noted to the wall, dried blood noted to left foot. New orders received to cleanse left foot with normal saline, pat dry and apply skin prep and cover with band aids. Abrasion/skin tear measuring 0.5 centimeters (cm) in length, 0.5 cm in width and less than 0.1 cm in depth to left great toe and a skin tear/abrasion measuring 0.25 cm in length, 0.25 cm in depth, less than 0.1 cm in depth to second left toe. Review of Physical and Occupational Therapy notes reveal, Resident #49 is unable to maintain erect position, turn and reposition in chair and bed due to grossly impaired core muscles. On 03/08/21, Employee # 38, Physical Therapy Assistant, PTA note read: Patient presented in bed. Patient dependent for rolling. Patient also dependent for transition to sitting. Patient attempts to raise head but unable to engage in any further movement. Interview with Employee #16, a Licensed Practical Nurse (LPN) on 06/23/21 at 11:15 am. She was asked about Resident #49's ability to move his extremities. She said he is unable to move his upper and lower extremities. She further explained he experiences slight movement due to spasms. During an interview with the DON and Nursing Home Administrator (NHA) on 06/23/21 at 9:45 am, they both agreed the incident which occurred on 03/07/21, was an injury of unknown origin. The incident was not witnessed, and the resident is unable to explain what had occurred. Additionally, the resident is unable to move his extremities and unable to have received these injuries on his own. They both agreed it should have been reported and investigated to rule out abuse/neglect. .

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

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, policy review, observation and staff interview the facility failed to implement their Abuse Policy as it pertained to the reporting and investigating of allegations of possible abuse. Resident #49 experienced injury (Abrasion/Skin tears) to left great toe and left second toe. This incident was not witnessed, and the resident is unable to explain what occurred as well as physically being unable to move his lower extremities due to quadriplegia. This incident was not reported and/or investigated to rule out possible abuse. Resident Identifier: #49. Facility census: 65. Findings included: a) Resident #49 Resident #49's medical record review found he was admitted to the facility on [DATE]. His diagnosis includes cerebral palsy, spina bifida, and traumatic brain injury and quadriplegia from motor vehicle accident. He has been non-ambulatory and mostly non-verbal with occasional mumbling speech. He has contractures of bilateral upper extremities and bilateral foot drop. Observation on 06/21/21 at 2:30 pm, found the resident sitting in a wheelchair with legs extended outward in front of his chair and shoulder support straps intact to ensure the resident's posture due to his inability to maintain an erect position. Resident was non-verbal and did not open his eyes during the observation. He had notable contractures of bilateral upper extremities and bilateral foot drop. It was noted his bed was against the wall and when resident is in bed his right side is against the wall. He had a scab covered areas noted on his left great toe and second left toe. Review of Resident #49's nurses notes found a note entered on 03/07/21 at 3:30 pm, written by the Director of Nursing (DON), read: Called to residents' room by (Employee #21's name) Nursing Assistant (NA). Dried blood noted to the wall, dried blood noted to left foot. New orders received to cleanse left foot with normal saline, pat dry and apply skin prep and cover with band aids. Abrasion/skin tear measuring 0.5 centimeters (cm) in length, 0.5 cm in width and less than 0.1 cm in depth to left great toe and a skin tear/abrasion measuring 0.25 cm in length, 0.25 cm in depth, less than 0.1 cm in depth to second left toe. Review of Physical and Occupational Therapy notes reveal, Resident #49 is unable to maintain erect position, turn and reposition in chair and bed due to grossly impaired core muscles. On 03/08/21, Employee # 38, Physical Therapy Assistant, PTA note read: Patient presented in bed. Patient dependent for rolling. Patient also dependent for transition to sitting. Patient attempts to raise head but unable to engage in any further movement. Interview with Employee #16, a Licensed Practical Nurse (LPN) on 06/23/21 at 11:15 am. She was asked about Resident #49's ability to move his extremities. She said he is unable to move his upper and lower extremities. She further explained he experiences slight movement due to spasms. Review of the facility's abuse prohibition policy (effective 06/01/96 and revised on 07/01/19) read: . Facility will report allegations involving neglect, exploitation or mistreatment (including injuries of unknown source) During an interview with the DON and Nursing Home Administrator (NHA) on 06/23/21 at 9:45 am, they both agreed the incident which occurred on 03/07/21, was an injury of unknown origin. The incident was not witnessed, and the resident is unable to explain what had occurred. Additionally, the resident is unable to move his extremities and unable to have received these injuries on his own. They both agreed it should have been reported and investigated to rule out abuse/neglect. .

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

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, observation, and staff interview; the facility failed to ensure that all alleged violations involving abuse/neglect, including injuries of unknown source, are reported immediately to the appropriate entities. Resident #49 had an injury of unknown origin causing skin tear/abrasions on left great toe and second left toe. This was true for one (1) of one (1) resident reviewed for skin conditions (non-pressure related) during the Long-Term Care Survey Process (LTCSP). Resident identifier: #49. Facility census: 65. Findings included: a) Resident #49 Resident #49's medical record review found he was admitted to the facility on [DATE]. His diagnosis includes cerebral palsy, spina bifida, and traumatic brain injury and quadriplegia from motor vehicle accident. He has been non-ambulatory and mostly non-verbal with occasional mumbling speech. He has contractures of bilateral upper extremities and bilateral foot drop. Observation on 06/21/21 at 2:30 pm, found the resident sitting in a wheelchair with legs extended outward in front of his chair and shoulder support straps intact to ensure the resident's posture due to his inability to maintain an erect position. Resident was non-verbal and did not open his eyes during the observation. He had notable contractures of bilateral upper extremities and bilateral foot drop. It was noted his bed was against the wall and when resident is in bed his right side is against the wall. He had a scab covered areas noted on his left great toe and second left toe. Review of Resident #49's nurses notes found a note entered on 03/07/21 at 3:30 pm, written by the Director of Nursing (DON), read: Called to residents' room by (Employee #21's name) Nursing Assistant (NA). Dried blood noted to the wall, dried blood noted to left foot. New orders received to cleanse left foot with normal saline, pat dry and apply skin prep and cover with band aids. Abrasion/skin tear measuring 0.5 centimeters (cm) in length, 0.5 cm in width and less than 0.1 cm in depth to left great toe and a skin tear/abrasion measuring 0.25 cm in length, 0.25 cm in depth, less than 0.1 cm in depth to second left toe. Review of Physical and Occupational Therapy notes reveal, Resident #49 is unable to maintain erect position, turn and reposition in chair and bed due to grossly impaired core muscles. On 03/08/21, Employee # 38, Physical Therapy Assistant, PTA note read: Patient presented in bed. Patient dependent for rolling. Patient also dependent for transition to sitting. Patient attempts to raise head but unable to engage in any further movement. Interview with Employee #16, a Licensed Practical Nurse (LPN) on 06/23/21 at 11:15 am. She was asked about Resident #49's ability to move his extremities. She said he is unable to move his upper and lower extremities. She further explained he experiences slight movement due to spasms. During an interview with the DON and Nursing Home Administrator (NHA) on 06/23/21 at 9:45 am, they both agreed the incident which occurred on 03/07/21, was an injury of unknown origin. The incident was not witnessed, and the resident is unable to explain what had occurred. Additionally, the resident is unable to move his extremities and unable to have received these injuries on his own. They both agreed it should have been reported and investigated to rule out abuse/neglect. .

CONCERN (D)

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

Investigate Abuse (Tag F0610)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, observation, and staff interview; the facility failed to ensure that all alleged violations involving abuse/neglect, including injuries of unknown source, are investigated to rule out abuse/neglect. Resident #49 had an injury of unknown origin causing skin tear/abrasions on left great toe and second left toe. This was true for one (1) of one (1) resident reviewed for skin conditions (non-pressure related) during the Long-Term Care Survey Process (LTCSP). Resident identifier: #49. Facility census: 65. Findings included: a) Resident #49 Resident #49's medical record review found he was admitted to the facility on [DATE]. His diagnosis includes cerebral palsy, spina bifida, and traumatic brain injury and quadriplegia from motor vehicle accident. He has been non-ambulatory and mostly non-verbal with occasional mumbling speech. He has contractures of bilateral upper extremities and bilateral foot drop. Observation on 06/21/21 at 2:30 pm, found the resident sitting in a wheelchair with legs extended outward in front of his chair and shoulder support straps intact to ensure the resident's posture due to his inability to maintain an erect position. Resident was non-verbal and did not open his eyes during the observation. He had notable contractures of bilateral upper extremities and bilateral foot drop. It was noted his bed was against the wall and when resident is in bed his right side is against the wall. He had a scab covered areas noted on his left great toe and second left toe. Review of Resident #49's nurses notes found a note entered on 03/07/21 at 3:30 pm, written by the Director of Nursing (DON), read: Called to residents' room by (Employee #21's name) Nursing Assistant (NA). Dried blood noted to the wall, dried blood noted to left foot. New orders received to cleanse left foot with normal saline, pat dry and apply skin prep and cover with band aids. Abrasion/skin tear measuring 0.5 centimeters (cm) in length, 0.5 cm in width and less than 0.1 cm in depth to left great toe and a skin tear/abrasion measuring 0.25 cm in length, 0.25 cm in depth, less than 0.1 cm in depth to second left toe. Review of Physical and Occupational Therapy notes reveal, Resident #49 is unable to maintain erect position, turn and reposition in chair and bed due to grossly impaired core muscles. On 03/08/21, Employee # 38, Physical Therapy Assistant, PTA note read: Patient presented in bed. Patient dependent for rolling. Patient also dependent for transition to sitting. Patient attempts to raise head but unable to engage in any further movement. Interview with Employee #16, a Licensed Practical Nurse (LPN) on 06/23/21 at 11:15 am. She was asked about Resident #49's ability to move his extremities. She said he is unable to move his upper and lower extremities. She further explained he experiences slight movement due to spasms. During an interview with the DON and Nursing Home Administrator (NHA) on 06/23/21 at 9:45 am, they both agreed the incident which occurred on 03/07/21, was an injury of unknown origin. The incident was not witnessed, and the resident is unable to explain what had occurred. Additionally, the resident is unable to move his extremities and unable to have received these injuries on his own. They both agreed it should have been reported and investigated to rule out abuse/neglect. .

CONCERN (D)

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

Assessment Accuracy (Tag F0641)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

. Based on record review and staff interview, the facility failed to ensure complete and accurate Minimum Data Set (MDS) assessments for two (2) of four (4) residents reviewed for the care area of nutrition. Resident identifiers: #29, #5. Facility census: 65. Findings included: a) Resident #29 Resident #29's MDS assessment with Assessment Reference Date (ARD) 05/03/21 documented the resident's weight was 85 pounds and had weight loss of 5% or more in the last month or loss of 10% or more in the last six (6) months. The MDS also indicated the resident was on a prescribed weight loss diet. Review of Resident #29's medical records revealed she had a 5% weight loss in the last month. However, the physician's orders did not include an order for a weight loss diet. During an interivew on 06/22/21 at 2:10 PM, the Director of Nursing (DON) acknowledged Resident #29's MDS with ARD 05/03/21 was erroneous. The DON stated the resident was not on a prescribed weight loss diet. No further information was provided through the completion of the survey. b) Resident #5 A review of Resident #5's minimum data set (MDS) assessment with an assessment reference date (ARD)of 03/15/21(Quarterly) and 03/29/21(Significant Change) found that Resident #5's weight had been coded in section K (the nutritional section of the MDS) as - pounds (This indicates no weights available). A review of Resident #5's medical record found that a weight measurement was not obtained and/or recorded in February or March 2021. Resident #5 had a physician order for monthly weights. Interview of the Director of Nursing (DON) on 06/22/21 at 11:19 AM. During this interview she confirmed the resident had not been weight since 01/2021. She further stated a weight should have been obtained prior to the completion of the above mentioned MDSs. No further information was provided prior to exit. .

CONCERN (D)

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

Deficiency F0660 (Tag F0660)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

. Based on record review and staff interview, the facility failed to ensure the Voluntary Discharge Against Medical Advice form was completed. This failed practice had the potential to affect one (1) of one (1) residents reviewed for the care area of discharge. Resident identifier: #56. Facility census: 65. Findings included: a) Resident #56 Record review of the facility's policy titled, Discharge Against Medical Advice (AMA), revised 01/31/20, showed that residents leaving the facility against medical advice would sign a Voluntary Discharge Against Medical Advice form. If the resident refused to sign, the refusal would be documented and the nurse and another staff member would sign the form. The form would be placed in the clinical record. Review of Resident #56's medical records showed the resident had left the facility AMA on 03/30/21. No Voluntary Discharge Against Medical Advice form could be located in the resident's clinical record. During an interview on 06/23/21 at 12:28 PM, the Director of Nursing acknowledged Resident #56's clinical record did not contain a Voluntary Discharge Against Medical Advice form. No further information was provided through the completion of the survey. .

CONCERN (D)

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

Deficiency F0692 (Tag F0692)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

. Based on record review and staff interview, the facility failed to monitor nutritional parameters for two (2) of four (4) residents reviewed for the care area of nutrition. Resident identifiers: #44, #29. Facility census: 65. Findings included: a) Resident #44 Review of Resident #44's weight assessments revealed the resident's admission weight on 05/19/21 was 169 pounds. The resident's weight on 05/29/21 was 156 pounds. This was an 8% weight loss since admission. The resident received all nutrition through a gastostromy tube (G tube). There was no documentation in the records that the 8% weight loss was recognized by the staff and reported to the physician and dietician. Record review of the facility's policy titled, Weights and Heights, revised 06/01/21, showed the physician and dietician would be notified of significant weight changes. However, the policy defined weight changes as a loss of 5% in one month or 10% in six (6) months. Weight loss occurring in a time period of less than one (1) month was not addressed in the policy. During an interview on 06/23/21 at 2:39 PM, the Director of Nursing acknowledged Resident #44's weight loss was significant and confirmed there was no documentation that the physician and dietician were notified. No further information was provided through the completion of the survey. b) Resident #29 Review of Resident #29's clinical record on 06/22/21 showed the following weight recordings: --04/28/21: 83.4 pounds --05/01/21: 85.4 pounds --05/9/21: 75.8 pounds --05/12/21: 74.6 pounds --05/17/21: 70.2 pounds --05/23/21: 73.8 pounds --05/30/21: 73.8 pounds Resident #29 had an order written on 5/3/21 to obtain weekly weights. This order had been completed on 05/31/21. She had no current weight order. The resident was a full code and had no orders for palliative or comfort care. During an interview on 06/22/21 at 3:29 PM, the Director of Nursing (DON) acknowledged Resident #29 did not have a current weight order. The DON stated that this was probably an oversight and she would contact the doctor to obtain an order to weigh the resident. No further information was provided through the completion of the survey. .

CONCERN (D)

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

Tube Feeding (Tag F0693)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

. Based on record review and staff interview the facility failed to obtain a complete physician's order for an enteral feeding. This was true for one (1) of two (2) residents reviewed for tube feeding during the Long Term Care Survey Process (LTCSP). Resident identifier: #28 Facility census: 65. Findings included: a) Resident #28 A medical record review on 06/23/21 revealed an order for (as written) Enteral Feed five times a day for dysphagia jevity 1.5 five times per day Enteral Feed. The incomplete order does not indicate the amount of Jevity to be received per feeding or the mechanism of administration. During an interview with the DON on 06/23/21 at 10:30 AM, verified the order did not contain the milliliters (ml) of Jevity to be consumed or the mechanism of administration. .

CONCERN (D)

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

Deficiency F0761 (Tag F0761)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

. Based on observation and staff interview, the facility failed to ensure there were no expired medications in the med storage room. This was true for one of one medication storage rooms observed. Facility census: 65. Findings included: a) Medication storage room On 06/22/21 at 2:15 PM, an inspection conducted in the presence of the Assistant Director of Nursing (ADON), found the following: --Influenza vaccine afluria Quadrivalent- four (4) boxes with an expiration date of 06-10-2021 --Humulin kwik Pen- two (2) pens with an expiration date of 03-2021 --Insulin Lispro Kwik Pen- one (1) pen with an expiration date of 05-2021 --Vitamin K 10 milligrams/milliliter (mg/ml) ampules- two (2) ampules with an expiration date of 01-2021 --Epinephrine 1 mg/ml ampules- three (3) ampules with an expiration date of 04-2021 10 ml luer lock disposable syringe with 20 Gauge (G) x 1.5 needle- three (3) syringes with an -expiration date of 04-2018 --Filter needle 19 G X 1.5 with five (5) micron filter- five (5) needles with an expiration date of 07-2013 --Magellan hypodermic safety needle- five (5) needles with an expiration date of 06-2020 --Safety needle 22G x 1.5- one (1) needle with an expiration date of 07-02-2020 --Vitamin D 400 International Units (IU)- two (2) bottles with an expiration date of 08-2020 --D5 NS (5% dextrose and normal saline) 1000 ML Intravenous (IV) bags- five (5) bags with an expiration date of 04-2021 --Povidone Iodine Antiseptic swabs sticks- three (3) packages with an expiration date of 05-2018 On 06/22/21 at 2:45PM, the ADON confirmed all medications, syringes and IV bags were expired. .

CONCERN (D)

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

Food Safety (Tag F0812)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

. Based on observations and staff interview the facility failed to store food in accordance with professional standards for food service safety. During the kitchen tour, a deeply dented can of green beans was found on the storage rack. This deficient practice had the potential to affect a limited number of residents receiving nourishment from the kitchen. Facility census: 65. Findings included: a) Kitchen tour During the kitchen tour on 06/21/21 at 11:19 AM, a deeply dented #10 can of green beans was discovered on the storage rack, this dent also included a deep crease in the seam. This dent may have compromised the contents of the can. On 06/21/21 at 11:25 AM, the Dietary Manager verified the #10 can of green beans was badly dented and should be discarded and not used for consumption. .

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

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . d) Resident #32 On March 16th a new physicians order dated March 16, 2021 for a Keppra level in the AM (March 17th). No results that the Keppra level was completed nor were results available as Per the Director of Nursing (DON) on 6/23/2021 at 12:35PM. Medical diagnoses included seizures, dementia/alzheimers, CVA, history of falls. Based on medical record review and staff interview, the facility failed to provide care and services according to physician orders and professional standards of care. This was true for five (5) of fifteen reviewed during the Long-Term Care Survey Process (LTCSP). Resident identifiers: #155, #5, #49, #32 and #30. Facility census: 56. Findings include: a) Resident #155 a1.) Review of Resident #155's medical records found she was admitted to the facility on [DATE]. Resident #155 had an order written on 06/14/21 for Metformin 500 milligrams (mg) by mouth twice a day with food. Review of the Medication Administration Record (MAR) for June 2021 found the resident was receiving the Metformin at 9:00 am and 9:00 pm. Review of mealtimes found the resident received her meals at 7:30 am, 12:00 noon, and 5:00 pm. a.2.) Further review found an order written 06/17/21 for Fingerstick blood glucose in the morning at 6:00 am; notify physician if blood sugar is greater than 400 or below 70 initiate hypoglycemic protocol. Review of the MAR for June 2021 found on 06/18/21 at 6:00 am the residents fingerstick was 64. Additional review of records found no indication the physician was notified of the blood glucose being below 70. a.3.) Interview with the DON on 06/22/21 at 2:00 pm, review of Resident #155's physician orders and the June 2021 MAR with the DON during this interview. She confirmed the resident should receive the Metformin twice daily with meals and she confirmed there was no indication the physician had been notified of the blood sugar of 64 on 06/18/21. b) Resident #5 Review of Resident #5's medical record found an order dated 06/23/20 read: Weigh monthly. Weights summary for R#5 reviewed and found the following: --01/12/21- weight 166.2 --02/21 No weight recorded --03/21 No weight recorded --04/29/21- weight 176.6. Interview on 06/23/21 at 9:15 am with the DON. She confirmed the resident had not been weighed in February and March 2021 and she could find no documentation indicting the weights were not obtained. No further information provided. c) Resident #49 Review of Resident #49's nurses notes found a note entered on 03/07/21 at 3:30 pm, written by the Director of Nursing (DON), which read: Called to residents' room by (Employee #21's name) Nursing Assistant (NA). Dried blood noted to the wall, dried blood noted to left foot. New orders received to cleanse left foot with normal saline, pat dry and apply skin prep and cover with band aids. Abrasion/skin tear measuring 0.5 centimeters (cm) in length, 0.5 cm in width and less than 0.1 cm in depth to left great toe and a skin tear/abrasion measuring 0.25 cm in length, 0.25 cm in depth, less than 0.1 cm in depth to second left toe. Review of the weekly skin checks for Resident #49 found: --03/08/21- No skin injury/wound identified. --03/15/21- No skin injury/wound identified. --03/22/21- No skin injury/wound identified. --03/29/21- No skin injury/wound identified. --04/05/21- No skin injury/wound identified. --04/12/21- No skin injury/wound identified. --04/19/21- No skin injury/wound identified. --04/26/21- No skin injury/wound identified. --05/03/21- No skin injury/wound identified. --05/10/21- No skin injury/wound identified. --05/17/21- No skin injury/wound identified. --05/24/21- No skin injury/wound identified. Weekly skin checks were reviewed with the DON on 06/23/21 at 10:20 am. She confirmed the weekly skin checks from 03/08/21 through 05/24/21 were inaccurate. e) Resident #30 A medical record review on 06/22/21 revealed physician's orders (as written) Humalog 100 UNIT/ML Inject 8 units subcutaneously three times a day for diabetes. Hold if finger stick is less than 150 and Basaglar Kwik Pen Solution Pen-injector 100 UNIT/ML Inject 25 units subcutaneously one time a day for diabetes. Hold if FS is less than 150. On 05/21/21 a finger stick (FS) completed prior to the noon meal had a blood sugar (BS) reading of 139. Humalog was to be held if BS was less than 150. Resident #30 received 8 units of Humalog. The FS completed at bedtime on 05/27/21 had a BS reading of 122. The Kwik Pen 25 units was to be held if BS was less than 150, instead the resident was given the Kwik Pen 25 units. In an interview with the CNE (Center Nurse Executive) on 06/22/21 at 1:57 PM, verified the insulin had been administered incorrectly to Resident #30 on 05/21/21 and on 05/27/21. .

MINOR (C)

Minor Issue - procedural, no safety impact

Staffing Information (Tag F0732)

Minor procedural issue · This affected most or all residents

Read full inspector narrative →

. Based on observation and staff interview, the facility failed to ensure the Daily Nurse Staffing Form was posted in a location readily accessible to residents. This failed practice had the potential to affect all residents who wanted to check staffing levels for the facility. Facility census: 65. a) Sufficient and Competent Nurse Staffing Facility Task Upon observations on 06/22/21 and 06/23/21, the Daily Nurse Staffing form was posted between the double doors at the main entrance to the facility. The Daily Nurse Staffing form listed the nurses and nurse aides working at the facility for each shift for the day. A pass code needed to be entered into a key pad to open the door from the facility leading to the posting area. During an interview on 06/23/21at 12:23 PM, the Administration stated that this is the only location the Daily Nurse Staffing form was posted. The Administrator acknowledged the posting was not readily accessible for resident review. No further information was provided through the completion of the survey. .

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

• Licensed and certified facility. Meets minimum state requirements.

Concerns

• 49 deficiencies on record, including 1 serious (caused harm) violation. Ask about corrective actions taken.
• $39,390 in fines. Higher than 94% of West Virginia facilities, suggesting repeated compliance issues.
• Grade F (30/100). Below average facility with significant concerns.

Bottom line: Trust Score of 30/100 indicates significant concerns. Thoroughly evaluate alternatives.

Email me this report

About This Facility

What is Glenville Health & Rehab's CMS Rating?

CMS assigns GLENVILLE HEALTH & REHAB an overall rating of 1 out of 5 stars, which is considered much below average nationally. Within West Virginia, this rating places the facility higher than 0% of the state's 100 nursing homes. A rating at this level reflects concerns identified through health inspections, staffing assessments, or quality measures that families should carefully consider.

How is Glenville Health & Rehab Staffed?

CMS rates GLENVILLE HEALTH & REHAB's staffing level at 2 out of 5 stars, which is below average compared to other nursing homes. Staff turnover is 53%, compared to the West Virginia average of 46%.

What Have Inspectors Found at Glenville Health & Rehab?

State health inspectors documented 49 deficiencies at GLENVILLE HEALTH & REHAB during 2021 to 2024. These included: 1 that caused actual resident harm, 46 with potential for harm, and 2 minor or isolated issues. Deficiencies causing actual harm indicate documented cases where residents experienced negative health consequences.

Who Owns and Operates Glenville Health & Rehab?

GLENVILLE HEALTH & REHAB 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 HILL VALLEY HEALTHCARE, a chain that manages multiple nursing homes. With 65 certified beds and approximately 62 residents (about 95% occupancy), it is a smaller facility located in GLENVILLE, West Virginia.

How Does Glenville Health & Rehab Compare to Other West Virginia Nursing Homes?

Compared to the 100 nursing homes in West Virginia, GLENVILLE HEALTH & REHAB's overall rating (1 stars) is below the state average of 2.7, staff turnover (53%) is near the state average of 46%, and health inspection rating (2 stars) is below the national benchmark.

What Should Families Ask When Visiting Glenville Health & Rehab?

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 Glenville Health & Rehab Safe?

Based on CMS inspection data, GLENVILLE HEALTH & REHAB has a clean safety record: no substantiated abuse findings (meaning no confirmed cases of resident harm), no Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death), and is not on the Special Focus Facility watch list (a federal program monitoring the lowest-performing 1% of nursing homes). The facility has a 1-star overall rating and ranks #100 of 100 nursing homes in West Virginia. While no facility is perfect, families should still ask about staff-to-resident ratios and recent inspection results during their visit.

Do Nurses at Glenville Health & Rehab Stick Around?

GLENVILLE HEALTH & REHAB has a staff turnover rate of 53%, which is 7 percentage points above the West Virginia average of 46%. Moderate turnover is common in nursing homes, but families should still ask about staff tenure and how the facility maintains care continuity when employees leave.

Was Glenville Health & Rehab Ever Fined?

GLENVILLE HEALTH & REHAB has been fined $39,390 across 1 penalty action. The West Virginia average is $33,473. 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 Glenville Health & Rehab on Any Federal Watch List?

GLENVILLE HEALTH & REHAB 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: 65
Avg. Residents: 62
Occupancy: 95.7%
Ownership: For profit - Corporation
Chain: HILL VALLEY HEALTHCARE
Medicare: Yes
Medicaid: Yes
Sprinklers: Yes

Trust Score Breakdown

Base Score: 50
1-Star Rating: +0
1 Actual Harm citation: -5
49 Deficiencies: -10
Fines ($39,390): -5
Final Score: 30/100

Nearby Alternatives

No other facilities found in this area.

Check Bed Availability

Data: CMS Medicare Care Compare

Updated: November 2025

Facility ID: 515103