KEYSER HEALTHCARE CENTER
For profit - Limited Liability company
122 Beds
COMMUNICARE HEALTH
Data: November 2025
Trust Grade
50/100
#72 of 122 in WV
Photo by Charlie McDonald
Photo by Charlie McDonald
Photo by Charlie McDonald
1 / 5 photos
Last Inspection: January 2024
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
Keyser Healthcare Center has received a Trust Grade of C, which means it is average, placing it in the middle of the pack among nursing homes. It ranks #72 out of 122 facilities in West Virginia, indicating it is in the bottom half, and is the second-best option in Mineral County. The facility is experiencing a worsening trend, with reported issues increasing from 8 in 2023 to 20 in 2024. Staffing is rated average with a turnover rate of 48%, which aligns closely with the state average, but there are concerns regarding RN coverage, as there were days without an RN present. Specific incidents included not designating a charge nurse for each shift, failing to have an RN on-site for a full day, and not making grievance forms accessible to residents, highlighting both staffing challenges and communication issues that could impact resident care.
- Trust Score
- C
- In West Virginia
- #72/122
- Safety Record
- Low Risk
- Inspections
- Getting Worse
- Staff Stability ⚠ Watch
- 48% turnover. Above average. Higher turnover means staff may not know residents' routines.
- Penalties ✓ Good
- No fines on record. Clean compliance history, better than most West Virginia facilities.
- Skilled Nurses ○ Average
- Each resident gets 38 minutes of Registered Nurse (RN) attention daily — about average for West Virginia. RNs are the most trained staff who monitor for health changes.
- Violations ⚠ Watch
- 51 deficiencies on record. Higher than average. Multiple issues found across inspections.
50/100
Bottom 41%
No red flags
8 → 20 violations
★★☆☆☆
2.0
Overall Rating
★★★☆☆
3.0
Staff Levels
★★★☆☆
3.0
Care Quality
★★☆☆☆
2.0
Inspection Score
↔
Stable
2023: 8 issues
2024: 20 issues
The Good
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
Facility shows strength in fire safety.
The Bad
2-Star Overall Rating
Below West Virginia average (2.7)
Below average - review inspection findings carefully
Staff Turnover: 48%
Near West Virginia avg (46%)
Higher turnover may affect care consistency
Chain: COMMUNICARE HEALTH
Part of a multi-facility chain
Ask about local staffing decisions and management
The Ugly 51 deficiencies on record
Jan 2024
20 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, and staff interview, the facility failed to ensure a safe, clean, comfortable, home-li...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, and staff interview, the facility failed to ensure a safe, clean, comfortable, home-like environment. Window curtains were dirty in room [ROOM NUMBER] and privacy curtains were dirty in room [ROOM NUMBER]. These were random opportunities for discovery. Resident identifiers: #90, #58. Facility census: 110.
Findings included:
a) room [ROOM NUMBER]
During observation on 01/03/24 at 9:49 AM, the window curtains in room [ROOM NUMBER] were noted to have brown stains on them. Resident #90, who occupied the bed beside the window, stated the curtains had been dirty for a long time.
On 01/08/24 at 3:08 PM, the Housekeeping Director confirmed the curtains were dirty and stated they would be changed immediately.
b) room [ROOM NUMBER]
During an observation on 01/08/24 at 3:00 PM, both privacy curtains in room [ROOM NUMBER] were noted to have brown stains on them. Resident #58 stated that the curtains were filthy.
On 01/08/24 at 3:10 PM, the Housekeeping Director confirmed the curtains were dirty and stated they would be changed immediately.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Assessment Accuracy
(Tag F0641)
Could have caused harm · This affected 1 resident
b) Resident #115
During a record review on 01/08/24 at 12:41 PM, Resident # 115's medical record revealed the following social service note dated 11/8/23 at 11:19 AM, typed as written (Resident #115's...
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b) Resident #115
During a record review on 01/08/24 at 12:41 PM, Resident # 115's medical record revealed the following social service note dated 11/8/23 at 11:19 AM, typed as written (Resident #115's name) who requested to speak to SS via therapy. Resident #115's name) is requesting to go home tomorrow because that is when she is able to get a ride. She will be discharged on Thursday 11/9/2023 at PM.
During a record review on 01/08/24 at 12:46 PM, Resident #115' medical record revealed a MDS ARD 11/09/23. Section A, section A2105 (Discharge Status) was coded 04 Short term general hospital (acute hospital)
During an interview, on 01/08/23 at 1:51 PM, Social Worker #111 stated Resident #115 went home.
During an interview, on 01/08/23 at 2:03 PM, the Director of Nursing (DON) acknowledged the resident went home and the MDS was coded incorrectly for discharge.
Based on record review and staff interview, the facility failed to complete an accurate Minimum Data Set (MDS) assessment for two (2) of 24 residents reviewed in the long-term care survey sample. Resident identifiers: #69, #115. Facility census: 110.
Findings included:
a) Resident #69
Review of Resident #69's medical records showed the resident had a tracheostomy since being admitted to the facility in 2021.
Resident #69's quarterly Minimum Data Set (MDS) assessment with Assessment Reference Date (ARD) 10/13/23 indicated the resident did not have a tracheostomy.
During an interview on 01/08/24 at 2:13 PM, the Director of Nursing (DON) confirmed Resident #69's MDS assessment with ARD 10/13/23 was incorrect and should have coded the resident had a tracheostomy.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
PASARR Coordination
(Tag F0644)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** b) Resident #40
During a record review on 01/02/23 at 3:00 PM Resident #40's medical records revealed the following diagnosis:
...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** b) Resident #40
During a record review on 01/02/23 at 3:00 PM Resident #40's medical records revealed the following diagnosis:
-Alcohol abuse with Alcohol- induced psychotic disorders on 08/08/19.
During a record review on 01/03/24 09:03 AM, Resident #40's PASARR dated 04/21/20 was void of the diagnosis.
During an interview on 01/08/23 at 1:40 PM, Social Worker #111 stated, I did not know that I had to do a PASARR when they have a new diagnosis. The SW acknowledged the PASARR was void of the diagnosis and needed to be updated.
Based on record review and staff interviews, the facility failed to ensure that the resident's Pre-admission Screening (PAS) reflected pre-admission diagnoses for two (2) of three (3) residents reviewed for the category of PASARR, during the long-term care survey. Resident identifier #43 and #40. Census 110.
Findings Included:
a) Resident #43
On 01/08/24, a record review of the resident's electronic medical record (EMR), the resident's admission PASARR, dated 04/18/23, indicated no level II was needed. Section lll #30 MI/MR Assessment indicated None.
A continued record also revealed the resident received a psych diagnosis of Major Depression and Schizophrenic Disorder on the diagnosis listed on admission [DATE] but did not receive a new PAS to address whether or not specialized services were needed.
On 01/09/24 at 10:50 AM, an interview with Director of Nursing confirmed the PAS presented to the surveyor did not indicate Major Depression and Schizophrenic Disorder was missed on admission.
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
Based on record review, and staff interview, the facility failed to ensure two (2) of four (4) residents had a person-centered comprehensive care plan developed and implemented to meet his activities ...
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Based on record review, and staff interview, the facility failed to ensure two (2) of four (4) residents had a person-centered comprehensive care plan developed and implemented to meet his activities preferences and goals and address the resident's quality of life needs. The failure to ensure the comprehensive care plan was developed for the resident's highest practicable well-being placed the residents at risk of not receiving services that would meet their desires or wants and a decreased quality of life. Resident identifier: #49. Facility census: 110.
Findings included:
a) Resident #49
During an Interview with Resident #49 on 01/02/24 at 11:26 AM, he stated there were no activities offered in the evening. He continued to say the only thing to do in the evenings was watch television. Resident #49 stated there were only two (2) activities a day and he would like to have more or even be offered evening activities.
An observation, on 01/03/24 at 10:09 AM, revealed Resident #49 sitting outside the activities room asking staff passing by to help him find something to do.
A record review of Resident #49's participation sheets revealed he participated in scheduled group activities.
A continued record review of Resident #49's Annual 12/06/24 Minimum Data Set (MDS), found the resident's brief interview for mental status was fifteen (15) the highest score obtainable.
A review of the current care plan showed:
Focus:
(Resident #49) prefers independent activities on occasion he does join the group for higher level activities d/t his age and ability.
Goal:
(Resident #49) will attend group activities of his choice through next review date
(Resident #49) will pursue independent activities of his choice daily through next review date.
Interventions:
Provide resident with any information or assistance required needed for independent pursuits
Provide resident with copy of monthly activity calendar
During an Interview on 01/09/24 at 10:00 AM the Activities Director verified Resident #49s care plan was not person centered. She stated she just used the care plans in the drop-down list.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
Based on observation, record review, and staff interview, the facility failed to follow the physician's orders to label a tube feeding formula container and administration set with the resident's name...
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Based on observation, record review, and staff interview, the facility failed to follow the physician's orders to label a tube feeding formula container and administration set with the resident's name, date, time, and nurse's initials. This deficient practice had the potential to affect one (1) of one (1) residents reviewed for the care area of tube feeding. Resident identifier: #97. Facility census: 110.
Findings included:
a) Resident #97
Review of Resident #97's physician's orders showed the resident had an order for enteral (tube) feedings to infuse at 70 milliliters (ml) an hour, for 21 hours a day.
The resident also had an order written on 11/15/23 to label the tube feeding formula container and administration set with resident's name, date, time, and nurse's initials.
On 01/08/24 at 1:02 PM, Resident #97 was noted to be resting in bed with tube feeding infusing. The tube feeding formula container and administration set had no labels on them. Registered Nurse (RN) #47 confirmed the tube feeding formula container and administration set had not been labeled with the resident's name, date, time, and nurse's initials as ordered by the physician.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Incontinence Care
(Tag F0690)
Could have caused harm · This affected 1 resident
Based on record review, observation and staff interview the facility failed to provide appropriate treatment for urinary catheter care, specifically to ensure the resident's catheter had an anchor str...
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Based on record review, observation and staff interview the facility failed to provide appropriate treatment for urinary catheter care, specifically to ensure the resident's catheter had an anchor strap to prevent trauma. This is true for one of one reviewed for catheter care. Facility Census: 110.
Findings Included:
a) Resident #97
Medical record review found Physician Orders for Resident #97:
-
Foley Cath #18fr /10ML to Continuous drain.
-
Indwelling urinary Foley catheter is in privacy bag and leg strap on at all times.
-
Secure indwelling catheter tubing using anchoring device to prevent movement and urethral traction.
A review of the current care plan with the initiated date of 11/ 06/2023 showed the care plan:
-Focus: Resident has indwelling 18fr/10ml Foley Catheter, renal failure / hematuria/ nephrology referred.
Goal:
- Resident will be/remain free from catheter-related trauma through review dat.
Interventions:
-Position catheter bag and tubing below the level of the bladder and provide privacy bag. Secure catheter to leg with security device.
Observation of catheter care on 01/09/24 at 8:13 AM revealed Resident #97 did not have a security device anchoring her catheter tubing to prevent movement in place. A redden area to her right upper leg from the pressure of tubing was observed.
During an interview on 01/09/24 at 8:36 AM Nurse Aide (NA)#24 and NA #62 verified there was no anchor or catheter strap on Resident #97 prior to care.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0710
(Tag F0710)
Could have caused harm · This affected 1 resident
Based on a medical record review, resident interview and staff interview the facility failed to ensure the attending physician supervises the resident medical care. The facility failed to notify the p...
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Based on a medical record review, resident interview and staff interview the facility failed to ensure the attending physician supervises the resident medical care. The facility failed to notify the physician of weight loss for one (1) of two (2) residents reviewed for the care area of nutrition. Resident identifier: #40. Facility Census: 110.
Findings included:
a) Resident #40
During a record review on 01/03/24 at 9:28 AM Resident#40's medical records revealed the following. On 11/09/2023, the resident weighed 140 pounds (lbs.). On 12/11/2023, the resident weighed 124 pounds which is a -11.43 % Loss.
Further record review was void of any notification to the physician of the 16-pound weight loss in a month.
During an interview on 01/09/24 09:34 AM the Director of Nursing acknowledged there was no documentation of notification to the physician.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, the facility failed to ensure storage of point-of-care testing devices within acceptab...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, the facility failed to ensure storage of point-of-care testing devices within acceptable standards of practice. Two vials of urine reactant strips stored in the medication room had expired. Facility census: 110.
Findings included:
a) North medication room
On [DATE] at 10:00 AM, the north medication room was inspected with Licensed Practical Nurse (LPN) #82 in attendance.
Two (2) vials of urine reactant strips stored in the medication room had expired according to the expiration dates on the bottles. A vial of Immunostics urine reactant strips had a labeled expiration date of [DATE]. A vial of Medline urine reactant strips had a labeled expiration date of [DATE].
Urine reactant strips are used to test for abnormalities in the urine. Expired strips could give inaccurate results.
LPN #82 stated she would dispose of the expired urine reactant strips.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Laboratory Services
(Tag F0770)
Could have caused harm · This affected 1 resident
Based on record review and staff interview, the facility failed to obtain laboratory services to meet the needs of its residents. This deficient practice had the potential to affect one (1) of six (6)...
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Based on record review and staff interview, the facility failed to obtain laboratory services to meet the needs of its residents. This deficient practice had the potential to affect one (1) of six (6) residents reviewed for the care area of behavioral/emotional. Resident identifier: #47. Facility census: 110.
Findings included:
a) Resident #47
Review of Resident #47's physician's orders showed the resident was ordered the medication Depakote (divalproex sodium), 250 mg, twice a day, on 10/25/22 as recommended by the psychiatrist for agitation. The psychiatrist recommended a Depakote level be checked in one (1) week. High Depakote levels can lead to altered mental status, central nervous system depression, and death.
On 10/30/22, an order was written to increase Resident #47's Depakote to three (3) times a day.
Further review of Resident #47's physician's orders showed orders for Depakote levels to be checked on 11/01/22, 04/03/23, and 09/29/23.
A nurse's note written on 04/03/23 at 2:03 PM stated, Labs received and faxed to MD [physician] for review.
A nurse's note written on 09/29/23 at 2:55 PM stated, MD [physician] notified of results received and that Mg [magnesium] and Depakote not drawn this AM. Lab called and Mg added to labs from today. Note to MD to clarify when Depakote to be drawn. There was no additional information regarding when the Depakote level was to be drawn.
On 01/03/24 at 2:00 PM, the Director of Nursing (DON) was asked for Depakote level results for Resident #47. The DON provided medical records that showed the resident refused to allow blood to be drawn for laboratory testing on 11/01/22.
Further review of Resident #47's medical records showed laboratory testing for a Depakote level had been performed on 01/04/24. The Depakote level was non-toxic.
On 01/09/24 at 11:25 AM, the DON confirmed the resident had not had Depakote level laboratory testing until 01/03/24. The DON stated laboratory testing for Depakote had not been performed by the laboratory as ordered by the physician on 04/03/23 or 09/29/23 but she did not know why.
No further information was provided through the completion of the survey.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Garbage Disposal
(Tag F0814)
Could have caused harm · This affected 1 resident
Based on observation and staff interview, the facility failed to ensure trash was disposed of properly and dumpster lids were closed. This was a random observation. Facility census: 110.
Findings incl...
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Based on observation and staff interview, the facility failed to ensure trash was disposed of properly and dumpster lids were closed. This was a random observation. Facility census: 110.
Findings included:
On 01/03/24 at 11:34 AM an observation of the three (3) dumpster's found a pair of gloves, two (2) cold cup lids and a white substance leaking from beneath two (2) of the three (3) dumpster's. Two (2) of the dumpster's had open lids and one (1) had garbage bags exposed.
On 01/03/24 at 1:45 PM during an interview with the Dietary Manager (DM) the findings at the dumpsters were discussed. The DM stated that she would take care of this.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Medical Records
(Tag F0842)
Could have caused harm · This affected 1 resident
Based on record review and staff interview, the facility failed to ensure a complete and accurate medical record. The indication for Resident #47's psychotropic medication, Depakote, was incorrect. Th...
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Based on record review and staff interview, the facility failed to ensure a complete and accurate medical record. The indication for Resident #47's psychotropic medication, Depakote, was incorrect. This deficient practice had the potential to affect one (1) of six (6) residents reviewed for the care area of behavioral/emotional. Resident identifier: #47. Facility census: 110.
Findings included:
a) Resident #47
Review of Resident #47's medical records showed a psychiatrist note written on 10/25/22 recommending Depakote for agitation. The psychiatrist's note stated the resident had been having the following behaviors: crying, yelling, kicking, hitting, pushing, and grabbing. The psychiatrist stated the resident had a diagnosis of anxiety. The psychiatrist also stated the resident's medical record also showed a diagnosis of post-traumatic stress disorder.
The resident's current order for Depakote was written on 12/08/22 and gave the indication for the medication as post-traumatic stress disorder.
During an interview, on 01/09/24 at 1:07 PM, the Director of Nursing (DON) stated the indication for Resident #47's Depakote was incorrect. The DON stated the resident was not receiving Depakote for post-traumatic stress disorder.
No further information was provided through the completion of the survey process.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Grievances
(Tag F0585)
Could have caused harm · This affected multiple residents
Based on observation, resident council meeting and staff interviews the facility failed to make grievances forms accessible to all residents and/or residents family/representatives residing in the fac...
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Based on observation, resident council meeting and staff interviews the facility failed to make grievances forms accessible to all residents and/or residents family/representatives residing in the facility. This had the potential to affect more than a limited number of residents living in the facility. Facility Census: 110
Findings Included:
A review of the facility policy titled Grievance/Concern with an effective date of 01/12/17 read as follows.
.Policy:
.The facility will make available to all residents posting in a prominent location in the facility information of the right to file grievances orally or in writing; the right to file grievances anonymously.
a) Grievance Forms
During the Long-Term Care Survey Process from 01/02/24 to 01/10/24 many observations throughout the facility revealed no evidence of grievance forms being made accessible to the residents and/or resident representatives.
During the Resident Council Meeting held on 01/09/24 at 10:05 AM, the residents as a group were asked the question, Do you know how to file a grievance? Do you know where to access your grievance forms? The residents as a group stated No, we don't. Did not know we could fill out the form.
We usually must tell somebody so they know it is us that is having the issue.
During an interview on 01/09/24 11:17 AM, Registered Nurse (RN) #132 stated the grievance forms were kept in the drawer. RN #132 said, We fill them out, and turn them into the appropriate department manager. RN #132 was asked What if a resident and/or representatives wants to file an anonymous complaint? RN #132 said, We tell them to speak to the social worker or administrator. They have to ask for the forms that are not available to the public or the family.
During an interview on 01/09/24 at 11:21 AM, the Social Worker(SW) #111 stated, I am the grievance official, the residents come to me or the nurses and tell us the issues they are having. The grievance forms are at the nurses' station and the residents have to ask for the form.
This surveyor asked, What if they wanted to file a grievance anonymously? The SW #111 stated, They can write it on a piece of paper and put it under my door.
During the interview SW #111 acknowledged the residents should have access to grievance forms to file anonymously.
During an interview, on 01/09/24 11:23 AM, the Administrator acknowledged there were grievance forms accessible to the residents and/or the representatives. We will get a box and display them.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected multiple residents
Based on medical record review, resident interview and staff interview the facility failed to provide care required to maintain hygiene to a resident who was dependent for Activities Of Daily Living (...
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Based on medical record review, resident interview and staff interview the facility failed to provide care required to maintain hygiene to a resident who was dependent for Activities Of Daily Living (ADL) care. This is true for three (3) of four (4) reviewed for the ADL care area. Resident Identifiers: Resident #70, Resident #52 and Resident #90. Facility Census: 110.
Findings Included:
a) Resident #70
During an interview on 01/03/24 at 8:29 AM, Resident # 70 stated they never follow the shower schedule. I get mine on Monday and Thursday. I had visitors on Christmas day, so I refused to take a shower at that time and the staff never came back and asked to get a shower, and did not get one on Thursday. I should have been showered on Monday New Year's Day but not enough staff for showers.
During a record review reviewed 01/03/23 at 2:00 PM, Resident # 70's medical records revealed the showers were scheduled on Mondays and Thursdays. The records revealed documentation for the following showers:
-01/01/24 not applicable
-12/28/23 not applicable
-12/25/23 Resident Refused
-12/21/23 Tub Bath
-12/18/23 Tub Bath
-12/14/23 not applicable
-12/11/23 tub bath
-12/07/23 shower
Further record review revealed a Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 09/04/23 revealed the following: Section G, titled Activities of Daily Living Assistance, Section G0120 titled Bathing
A. Bathing: Self Performance coded 3) Physical help in part of the bathing activity
B. Bathing: Support provided coded 2) one person physical assist.
During an interview on 01/03/23 at 2:45 PM the Director of Nursing (DON) stated I will look for more information for the missed showers.
During an interview on 01/03/23 at 3:30 PM the DON did not provide any other information of the showers not being received. The DON acknowledged the showers were not given as scheduled and needed.
b) Resident #52
During an interview on 01/02/24 at 1:43 PM, Resident # 52 stated we get no baths they are suppose to be two times a week but I have received one. I have surgery on Thursday, if they don't bathe me before I go, the roof is going to come off this place. It is so embarrassing to go to the hospital and doctor's appointments not bathed.
During a record review on 01/03/24 12:45 PM Resident # 52 medical records revealed scheduled showers on Mondays and Thursday. The record revealed documentation for the following showers:
-01/03/24 bed bath
-01/02/24 not applicable
-01/01/24 not applicable
-12/30/23 not applicable
-12/29/23 activity not attempted
-12/28/23 not applicable
-12/27/23 not applicable
-12/26/23 not applicable
-12/25/23 activity not attempted
-12/23/23 not applicable
-12/22/23 activity not attempted
-12/21/23 not applicable
-12/20/23 not applicable
-12/19/23 not applicable
-12/18/23 resident refused
-12/16/23 activity not attempted
-12/15/23 not applicable
-12/14/23 not applicable
-12/13/23 not applicable
-12/12/23 not applicable
-12/11/23 activity not attempted
-12/09/23 not applicable
-12/08/23 not applicable
-12/07/23 not applicable
-12/06/23 not applicable
-12/05/23 not applicable
Further record review revealed a Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 07/24/23 revealed the following: Section G, titled Activities of Daily Living Assistance, Section G0120 titled Bathing
A. Bathing: Self Performance coded 4) Total dependence.
B. Bathing: Support provided coded 3) two person physical assist.
During an interview on 01/03/23 at 2:45 PM the Director of Nursing (DON) stated I will look for more information for the missed showers.
During an interview on 01/03/23 at 3:30 PM the DON did not provide any other information of the showers not being received. The DON acknowledged the showers were not given as scheduled and needed.
Based on medical record review, resident interview and staff interview the facility failed to provide care required to maintain hygiene to a resident who was dependent for Activities of Daily Living (ADL) care. This is true for three (3) of four (4) reviewed for the ADL care area. Resident Identifiers: Resident #70, Resident #52, and Resident #90. Facility Census: 110.
Findings Included:
a) Resident #70
During an interview on 01/03/24 at 8:29 AM, Resident # 70 stated they never follow the shower schedule. Resident #70 said, I get mine on Monday and Thursday. I had visitors on Christmas day, so I refused to take a shower at that time and the staff never came back and asked me to get a shower and did not get one on Thursday. I should have been showered on Monday New Year's Day but not enough staff for showers.
During a record review reviewed 01/03/23 at 2:00 PM, Resident # 70's medical records revealed the showers were scheduled on Mondays and Thursdays.
The records revealed documentation for the following showers:
-01/01/24 not applicable
-12/28/23 not applicable
-12/25/23 Resident Refused
-12/21/23 Tub Bath
-12/18/23 Tub Bath
-12/14/23 not applicable
-12/11/23 tub bath
-12/07/23 shower
Further record review revealed a Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 09/04/23 revealed the following: Section G, titled Activities of Daily Living Assistance, Section G0120 titled Bathing.
A. Bathing: Self Performance coded 3) Physical help in part of the bathing activity
B. Bathing: Support provided coded 2) one person physical assist.
During an interview on 01/03/23 at 2:45 PM the Director of Nursing (DON) stated I will look for more information for the missed showers.
During an interview on 01/03/23 at 3:30 PM the DON did not provide any other information of the showers not being received. The DON acknowledged the showers were not given as scheduled and needed.
b) Resident #52
During an interview on 01/02/24 at 1:43 PM, Resident # 52 stated we get no baths they are supposed to be two times a week but I have received one. I have surgery on Thursday, if they don't bathe me before I go, the roof is going to come off this place. It is so embarrassing to go to the hospital and doctor's appointments not bathed.
During a record review on 01/03/24 12:45 PM Resident # 52 medical records revealed scheduled showers on Mondays and Thursday. The record revealed documentation for the following showers:
-01/03/24 bed bath
-01/02/24 not applicable
-01/01/24 not applicable
-12/30/23 not applicable
-12/29/23 activity not attempted
-12/28/23 not applicable
-12/27/23 not applicable
-12/26/23 not applicable
-12/25/23 activity not attempted
-12/23/23 not applicable
-12/22/23 activity not attempted
-12/21/23 not applicable
-12/20/23 not applicable
-12/19/23 not applicable
-12/18/23 resident refused
-12/16/23 activity not attempted
-12/15/23 not applicable
-12/14/23 not applicable
-12/13/23 not applicable
-12/12/23 not applicable
-12/11/23 activity not attempted
-12/09/23 not applicable
-12/08/23 not applicable
-12/07/23 not applicable
-12/06/23 not applicable
-12/05/23 not applicable
Further record review revealed a Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 07/24/23 revealed the following: Section G, titled Activities of Daily Living Assistance, Section G0120 titled Bathing.
A. Bathing: Self Performance coded 4) Total dependence.
B. Bathing: Support provided coded 3) two-person physical assist.
During an interview, on 01/03/23 at 2:45 PM, the Director of Nursing (DON) stated, I will look for more information for the missed showers.
During an interview on 01/03/23 at 3:30 PM the DON did not provide any other information about the showers not being received. The DON acknowledged the showers were not given as scheduled and needed.
c) Based on medical record review, resident interview and staff interview the facility failed to provide care required to maintain hygiene to a resident who was dependent for Activities of Daily Living (ADL) care. This is true for three (3) of four (4) reviewed for the ADL care area. Resident Identifiers: Resident #70, Resident #52, and Resident #90. Facility Census: 110.
Findings Included:
a) Resident #70
During an interview on 01/03/24 at 8:29 AM, Resident # 70 stated they never follow the shower schedule. Resident #70 said, I get mine on Monday and Thursday. I had visitors on Christmas day, so I refused to take a shower at that time and the staff never came back and asked me to get a shower and did not get one on Thursday. I should have been showered on Monday New Year's Day but not enough staff for showers.
During a record review reviewed 01/03/23 at 2:00 PM, Resident # 70's medical records revealed the showers were scheduled on Mondays and Thursdays.
The records revealed documentation for the following showers:
-01/01/24 not applicable
-12/28/23 not applicable
-12/25/23 Resident Refused
-12/21/23 Tub Bath
-12/18/23 Tub Bath
-12/14/23 not applicable
-12/11/23 tub bath
-12/07/23 shower
Further record review revealed a Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 09/04/23 revealed the following: Section G, titled Activities of Daily Living Assistance, Section G0120 titled Bathing.
A. Bathing: Self Performance coded 3) Physical help in part of the bathing activity.
B. Bathing: Support provided coded 2) one-person physical assist.
During an interview on 01/03/23 at 2:45 PM the Director of Nursing (DON) stated I will look for more information for the missed showers.
During an interview on 01/03/23 at 3:30 PM the DON did not provide any other information of the showers not being received. The DON acknowledged the showers were not given as scheduled and needed.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0679
(Tag F0679)
Could have caused harm · This affected multiple residents
Based on record review, Resident Council meeting, resident Interviews and staff interviews, the facility failed to implement an ongoing resident centered activities program designed to meet the intere...
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Based on record review, Resident Council meeting, resident Interviews and staff interviews, the facility failed to implement an ongoing resident centered activities program designed to meet the interest of and support the physical, mental and psychosocial well-being of each resident. This was true three (3) out of four (4) reviewed in the care area for Activity. This had the potential to affect an unlimited amount of residents residing in the facility. Resident Identifiers: Resident #40, Resident #70 and Resident #49. Facility Census:110.
Findings included:
a) Resident #40
During a tour of the facility on 01/03/24 at 9:11 AM, Resident # 40 was standing in the hallways wandering around.
During a record review on 01/03/24 at 10:30 AM, Resident #40's medical record was void of an Activity Preference Interview.
Further record review revealed a significant Minimum Data Set (MDS) completed on 10/17/23 and Annual MDS was completed on 05/03/23.
During an interview on 1/03/24 at 1:50 PM, the Activity Director (AD) stated we complete the Activity Preference Interview on the initial admission, annual readmission on certain occasions and significant change of MDS. The AD acknowledged the Activity Preference Interview.
should have been completed on 10/17/23 and 05/23/23.
b) Resident #70
During an interview on 01/03/24 at 8:29 AM, Resident # 70 stated there is nothing to do after 2:00 PM. We just lay in bed after dinner. We only have two (2) activities a day if they even do those.
During a review of the monthly activity calendar January 2024 calendar has a 10:00 Am activity and a 2:00 PM activity every Tuesday there is a 4:00 PM Small group for the North or South Hall.
During a record review on 01/08/24 at 1:30 PM Resident #70's medical record revealed activity participation records for the month of January 2024. The activity records revealed the following.
-01/01/24 no documentation of the Church activity offered
-01/03/24 no documentation of games being offered
-01/04/24 no documentation of any group activity being offered
-01/05/24 no documentation of any group activity being offered
-01/07/23 no documentation of the Church activity offered.
Further record review revealed a Activity Preference Interview dated 03/23/23, Resident #70 Activity Pursuit Patterns are as follows:
-Monopoly
-Gin/Rummy
-Bingo
-loves arts and crafts wants to learn to knit
-Bible Study
-sitting outside
-Gardening
During the Resident Council Meeting held on 01/09/24 at 10:00 AM the Residents as a group were asked the question, are you satisfied with your involvement in group activities? The following concerns were voiced.
-there is nothing to do I stay up late
-Mot of us stay up late, but with nothing to do everyone goes to bed
-I am up till 10:00 or 11:00 PM with nothing to do to keep us busy. I visit everyone because I have nothing to do.
-We all enjoy doing crafts. We could do those in the evening but everyone(Activity) leaves at 5:00 PM.
-We are not asking for a big function, just something to do would be nice.
During an interview, on 01/09/24 at 2:29 PM, the AD stated, I have two (2) full time and one (1) part time staff. Their hours are 9:00 PM to 5:00 PM, 10;00 AM to 6:00 PM and I am her from 8:oo AM 30 PM. The 10:00 AM activity hsd poor attendance because no one is up and ready, or they are getting ready for the day. After 10:00 AM activity the activity room turns into the dining room and residents start coming in. The 2:00 activity goes till 3:00.
The AD was asked Why is there no other group related activity after 2:00? No response was given.
c) Resident #49
During an Interview with Resident #49 on 01/02/24 at 11:26 AM, he stated that there are no activities offered in the evening. He continued to say that the only thing to do in the evenings is watch television. Resident #49 stated that there are only two activities a day and he would like to have more or even be offered evening activities.
An observation on 01/03/24 at 10:09 AM, Resident #49 sitting outside the activities room asking staff passing by to help him find something to do.
A record review of Resident #49's participation sheets revealed he participated in scheduled group activities.
A continued record review of Resident #49's Annual 12/06/24 Minimum Data Set (MDS), found the resident's brief interview for mental status was fifteen (15) the highest score obtainable.
A review of the current care plan showed:
Focus:
o prefers independent activities on occasion he does join the group for higher level activities d/t his age and ability.
Goal:
o
will attend group activities of his choice through next review date
o
will pursue independent activities of his choice daily through next review date.
Interventions:
o
Provide resident with any information or assistance required needed for independent pursuits
o
Provide resident with copy of monthly activity calendar
A review of the activity schedule found no evening activities were scheduled.
During an Interview on 01/09/24 at 10:00 AM the Activities Director verified no scheduled or group evening activities were available and she only schedules 2 activities a day.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0698
(Tag F0698)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, record review and staff interview, the facility failed to ensure dialysis services were provided in...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, record review and staff interview, the facility failed to ensure dialysis services were provided in accordance with professional standards of care. This deficient practice had the potential to affect one (1) of (1) residents reviewed for the care area of dialysis. Resident identifier: #24. Facility census: 110.
Findings included:
a) Resident #24
During an interview, on 01/02/24 at 4:20 PM, Resident #24 stated he received dialysis treatments on Mondays, Wednesdays, and Fridays. The resident stated he had two (2) dialysis access sites, a central venous catheter in his left chest and a graft in his right upper arm.
Review of Resident #24's comprehensive care plan showed the resident was on fluid restrictions.
On 01/09/24 at 10:07 AM, Resident #24 stated he didn't know if he was on fluid restrictions. The resident stated he received a renal diet.
On 01/09/24 at 10:39 AM, Nurse Aide (NA) #105 stated the resident was on fluid restrictions.
A nutritional assessment completed on 01/02/24 showed Resident #24's diet orders were two (2) grams sodium, regular texture, thin liquids, no potatoes, tomatoes, oranges, orange juice or bananas.
Resident #24's lunch tray ticket for 01/09/24 showed the resident was on fluid restrictions. The resident's diet orders on the tray ticket were two (2) grams sodium, no potatoes, tomatoes, oranges, orange juice or bananas.
Review of Resident #24's physician's orders showed no orders to receive dialysis treatments. There were no orders to monitor the resident's dialysis access sites. There were no orders for fluid restrictions. The resident's diet order was two (2) grams sodium, regular texture, thin liquids consistency.
Review of Resident #24's treatment administration record (TAR) for December 2023 and January 2024 showed the resident had an order started 10/12/23 and discontinued 12/20/23 to check the dialysis site every shift. There was no indication the resident's dialysis sites had been monitored after 12/20/23.
During an interview, on 01/09/23 at 10:51 AM, the Director of Nursing (DON) confirmed Resident #24 did not have orders for dialysis treatments or for his dialysis sites to be monitored. The DON stated the resident had been transferred to the hospital on [DATE] and these orders had not been restarted upon the resident's return to the facility on [DATE]. The DON confirmed there was no documentation that the resident's dialysis sites had been routinely monitored since 12/22/23.The DON also confirmed the resident's diet order did not match the diet order on the resident's tray ticket and the resident did not have orders for fluid restrictions.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Medication Errors
(Tag F0758)
Could have caused harm · This affected multiple residents
Based on resident interview, record review, and staff interview the facility failed to monitor efficacy of psychotrophic medication via monitoring behavior and symptoms. This deficient practice had th...
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Based on resident interview, record review, and staff interview the facility failed to monitor efficacy of psychotrophic medication via monitoring behavior and symptoms. This deficient practice had the potential to effect 1 of 5 residents reviewed for the care area of Behavioral-Emotional wellbeing. Resident identifier: #48. Census: 110.
Findings included:
a) Monitoring
Resident interview (#48) conducted on 01/02/24, at 12:57PM revealed feelings of frustration with the facility, decreased activity participation, and food avoidance.
Progress notes documented on 12/04/23 at 11:32AM, indicated R#48 has a history of depression and suicide attempts/ideation.
Review of the medication administration record (MAR) confirmed R#48 is on multiple psychotropic medications (Celexa, Trazodone, Risperidone, Buspar).
Review of the care plan dated 12/20/22, with revision on 11/08/23, identified goals of decreased depressed mood and behavior through psychotropic medication management.
Interview with the Director of Nursing (DON) on 01/09/24 at 9:43AM, confirmed the MAR does not currently monitor behaviors related to psychotropic medications despite being addressed in the care plan.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected multiple residents
Based on observation, policy review and staff interview the facility failed to store food in accordance with professional standards for food safety. The facility failed to label and date food items th...
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Based on observation, policy review and staff interview the facility failed to store food in accordance with professional standards for food safety. The facility failed to label and date food items that were open and failed to dispose of expired food items. The facility also failed to record accurate food temperatures and failed to ensure hot foods were held at 135.0 degrees Fahrenheit or higher on the steam table. The facility also failed to keep utensils stored appropriately and equipment clean and sanitized. This failed practice had the potential to affect all residents currently receiving nourishment from the facility's kitchen. Facility Census: 110.
Findings Included:
a) Labeling and Dating
During the initial tour of the kitchen on 01/02/23 at 12:58 PM, with the Culinary Director (CD) #95 revealed the following issues:
-Ice Cream Freezer
two (2) 1-gallon cartons of ice cream no received date
-Pantry
a container with an opened 50-pound bag of sugar not dated or labeled.
-Dessert Refrigerator
two (2) uncovered cakes with icing not labeled and/or dated.
- Walk in refrigerator
a container of ham salad dated 01/01/23.
An immediate interview with the CD acknowledged the failure to label food items with a Date Opened and/or Use by Date. Also indicated the item needed to be discarded because they were out of date or not dated.
A review of the facility policy titled Food Storage with a revision date of 04/2018 read as follows.
.Procedures .5. All foods will be stored wrapped or in covered containers, labeled and dated and arranged in a manner to prevent cross contamination.
b) Food temperature logs
A review of the December 2023 Serving Line temperature record on 01/03/24 at 11:15 AM, revealed the documentation was incomplete. The following dates did not have temperatures checked and logged for the serving line.
-On 12/19/23 dinner was void temperature
-On 12/20/23 breakfast was void temperature
An immediate interview with CD, on 01/03/24 at 11:20 AM acknowledged the serving line temperature records were incomplete and should have been completed daily for each meal.
c) Serving line temperatures
During the kitchen following up visit on 01/03/24 at 11:23 AM with [NAME] #100 the follow temperatures were obtained using the facility thermometer:
The steam table temperatures were as follows:
-Brown Beans 170-degree Fahrenheit (F)
-Ground Ham: 120-degree Fahrenheit (F)
-Sweet Potatoes 130-degree Fahrenheit (F
-Peas: 165-degree Fahrenheit (F)
- Sliced Ham 120-degree Fahrenheit (F)
An immediate interview with [NAME] #100 stated Everything needs to go back in the steamer, nothing is the appropriate temperature.
During an immediate interview the CD stated the meals on the serving line are always 180 degrees. She acknowledged the food was not at the appropriate temperatures.
A review of the facility policy titled Food Preparation with a revision date of 09/2017 read as follows.
Procedures .
13. All foods will be held at appropriate temperatures, greater than 135 degrees F for hot holding.
14. Temperatures for the Temperature Control for Safety (TCS) will be recorded at time of service .
d) Serving utensils:
During the initial tour of the kitchen on 01/02/23 at 12:58 PM, with the CD #95 revealed
the serving utensils were in storage bins not turned properly and were not stored appropriately.
The Culinary Manager acknowledged the failure to store serving utensils appropriately.
e) Clean and sanitized equipment
During the initial tour of the kitchen on 01/02/23 at 12:58 PM, CD #95 revealed the thermal plate warmer contained a large amount of food debris.
In an immediate interview with CD #95 the CD stated, We clean it weekly.
This surveyor requested documentation of the cleaning of kitchen equipment.
During the review of the documentation provided by CD on 01/02/23 at 3:53 PM it was void of cleaning of the thermal plate warmer.
A review of the facility policy titled Equipment with a revision date of 09/2017 read as follows.
Procedures .
4. All non-food contact equipment will be clean and free of debris .
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0847
(Tag F0847)
Could have caused harm · This affected multiple residents
Based on facility record review and interview the facility failed to explain Binding Arbitration Agreement accurately and, in a form, and manner residents or Resident Representatives can understand. T...
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Based on facility record review and interview the facility failed to explain Binding Arbitration Agreement accurately and, in a form, and manner residents or Resident Representatives can understand. This has the potential to affect all residents or Residents Representatives that sign a Binding Arbitration Agreement. Facility Censes: 110.
Findings included:
a) Binding Arbitration Agreement
A facility record review of the found 47 Residents or Residents Representatives signed a Binding Arbitration Agreement.
During an interview 01/03/24 at 1:22 PM the admission Coordinator was unable to explain a Binding Arbitration Agreement accurately. He stated the resident or representatives could rescind their decision at any time. When the admission Coordinator was asked questions about the Binding Arbitration Agreement, he was unable to explain. The admission Coordinator currently stated residents do not usually ask questions about the form. He continued to say the form was not worth the paper it was written on and that he would need to better familiarize himself with the Agreement.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0725
(Tag F0725)
Could have caused harm · This affected most or all residents
Based on observation, record review, and staff interview, the facility failed to designate a licensed nurse to serve as a charge nurse on each tour of duty. Additionally, the facility failed to ensure...
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Based on observation, record review, and staff interview, the facility failed to designate a licensed nurse to serve as a charge nurse on each tour of duty. Additionally, the facility failed to ensure sufficient staffing to allow residents to dine in the communal areas for breakfast and dinner. This deficient practice had the potential to affect all residents residing in the building. Census: 110.
Findings included:
a) Charge Nurse
Review of staff postings from 12/01/23, to 12/31/23, and further confirmed on 01/02/24, revealed no licensed nurse designated as a charge nurse on any shift in the building.
Interview with the Director of Nursing (DON) on 01/03/24, at 12:01 PM confirmed the facility does not formally designate charge nurses. Instead, staff rely on the on-duty RNs for supervision. However, this system lacked a clearly identified individual with leadership and accountability for each tour of duty.
b) Sufficient Staffing
Observations on 01/03/24, 01/04/24, and 01/09/24, confirmed all residents ate breakfast in their rooms, with no residents using the communal dining areas.
Interview with the DON on 01/09/24, at 4:00 PM revealed that communal dining had been suspended since the COVID-19 outbreak in 2020 due to insufficient staffing. Recent staff additions do not yet have training in communal dining procedures.
Communal dining for dinnertime is planned to resume on 01/15/24.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0727
(Tag F0727)
Could have caused harm · This affected most or all residents
Based on record review and staff interview, the facility failed to have an RN at least 8 hours a day, 7 days a week. This deficient practice had the potential to affect all residents in the building. ...
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Based on record review and staff interview, the facility failed to have an RN at least 8 hours a day, 7 days a week. This deficient practice had the potential to affect all residents in the building. Census: 110.
Findings included:
a) Registered Nurse
Review of staff postings from 12/1/23, to 12/31/23, confirmed no Registered Nurse (RN) designated in the building on 12/23/23.
Subsequent review of staff time punches verified RN#35 was on-call but not physically present in the building on 12/23/23.
Interview with the Director of Nursing (DON) on 01/09/24 at 12:01PM, confirmed no RN was available on-premises during any shift on December 23, 2023.
At 5:00PM on 1/9/24 the DON clarified that RN#35 was scheduled for that shift but ultimately did not cover due to LPN#80 picking up the shift, resulting in an oversight on an alternate staffing matrix.
Apr 2023
8 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
.
Based on record review and staff interview, the facility failed to notify the resident's representative in a timely fashion when care was altered. This failed practice was true for two (2) of the th...
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.
Based on record review and staff interview, the facility failed to notify the resident's representative in a timely fashion when care was altered. This failed practice was true for two (2) of the three (3) residents reviewed for notification of change in the complaint survey process. Resident Identifiers: #116 and #28. Facility Census: 114.
Findings included:
a) Resident #116
Electronic medical record review, completed on 04/24/23 at 5:30 PM, revealed Resident #116 had been placed on isolation precautions beginning 04/12/23 due to testing positive for the Human Metapneumovirus. There was no evidence the reason for isolation was explained to the resident and/or resident's legal representative.
During an interview on 04/26/23 at 12:40 PM, the Administrator and the Director of Nursing (DON) reported they were unable to provide evidence that Resident #116's responsible party was notified.
b) Resident #28
Electronic medical record review, completed on 04/24/23 at 6:15 PM, revealed Resident #28 had been placed on isolation precautions beginning 11/14/22 due to testing positive for CRE [Carbapenem-resistant Enterobacteriaceae] of the urine. There was no evidence the reason for isolation was explained to the resident and/or resident's legal representative.
During an interview on 04/26/23 at 12:44 PM, the Administrator and the Director of Nursing (DON) reported they were unable to provide evidence that Resident #28's responsible party was notified.
.
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
.
Based on record review and staff interview, the facility failed to ensure one (1) resident received treatment and care in accordance with professional standards of practice. The facility failed to e...
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.
Based on record review and staff interview, the facility failed to ensure one (1) resident received treatment and care in accordance with professional standards of practice. The facility failed to ensure a physician order was followed for Resident #83. This failed practice was true for one (1) of three (3) residents reviewed in the complaint care survey process. Resident Identifier: #83. Facility Census: 114.
Findings included:
a) Physician Order
A brief record review, completed on 04/25/23 at 5:37 PM, found the following physician order, dated 04/18/23 at 5:00 PM, Vital Signs Q Shift (every shift) x 10 days three times a day for Acute Charting.
b) April 2023 Medication Administration Record (MAR)
Review of the April 2023 MAR for Resident #83 revealed:
--On Wednesday, 04/19/23 Licensed Practical Nurse (LPN) #6 failed to record Resident #83's vital signs during the 3:00 PM - 11:00 PM shift.
--On Thursday, 04/20/23 LPN #6 failed to record Resident #83's vital signs during the 3:00 PM - 11:00 PM shift.
--On Monday, 04/24/23 LPN #6 failed to record Resident #83's vital signs during the 3:00 PM - 11:00 PM shift.
c) Director of Nursing (DON) Interview
During an interview on 04/26/23 at 8:50 AM, the Director of Nursing acknowledged LPN #6's failure to follow the physician order to obtain vital signs every shift and agreed this failed practice was not in accordance with professional standards of practice.
.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
.
Based on observation and staff Interview, the facility failed to ensure the facility was free from accident hazards over which it had control. Two (2) treatment carts were left unlocked and unattend...
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.
Based on observation and staff Interview, the facility failed to ensure the facility was free from accident hazards over which it had control. Two (2) treatment carts were left unlocked and unattended, allowing access to medications and medical supplies by residents and unauthorized persons. This practice was a random opportunity for discovery and had the potential to affect a limited number of residents. Facility Census: 114.
Findings included:
a) 300 Treatment Cart
On 04/24/23 at 11:47 AM, Surveyor observed that the 300 Hall treatment cart was unlocked and unattended. Surveyor remained with the unlocked cart until Housekeeping Director #168 approached Surveyor who was standing by the treatment cart with the drawers open and questioned, It wasn't locked? She then confirmed with a nurse further down the hallway to be sure the staff had a key. Then Housekeeping Director #168 stated, The treatment nurse must have left it open prior to locking it.
The Director of Nursing (DON), during an interview on 04/24/23 at 12:20 PM, acknowledged the accident hazard created by the unlocked treatment cart being unattended and that it was always facility protocol to secure treatment carts.
b) 400 Treatment Cart
On 04/24/23 at 11:55 AM, Surveyor observed that 400 Hall treatment cart was unlocked and unattended. Surveyor remained with the unlocked cart until Licensed Practical Nurse (LPN) #77 approached Surveyor who was standing by the treatment card with the drawers open, stated the treatment nurse must have left it open, and then locked the cart.
The Director of Nursing (DON), during an interview on 04/24/23 at 12:21 PM, acknowledged the accident hazard created by the unlocked treatment cart being unattended and that it was always facility protocol to secure treatment carts.
.
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
Staffing Information
(Tag F0732)
Could have caused harm · This affected 1 resident
.
Based on observation and staff interview, the facility failed to post the daily nurse staffing in a prominent place readily accessible to residents and visitors. This was a random opportunity for di...
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.
Based on observation and staff interview, the facility failed to post the daily nurse staffing in a prominent place readily accessible to residents and visitors. This was a random opportunity for discovery. Facility census 114.
Findings included:
a) No Daily Nurse Staffing Posted
Observation on 04/24/23 at 11:53 AM, did not find the daily nurse staffing posted by the 300/400 Hall Nurses Station in a prominent place readily accessible to residents and visitors. During an interview on 04/24/23 at 12:00 PM, Licensed Practical Nurse (LPN) #77 stated nurse staffing is supposed to be posted on a daily basis on the billboard across from the nurse's station. LPN #77 confirmed there was no daily nurse staffing posted on this date and the facility had failed to act in accordance with federal and state regulations which guides long-term care facilities to post the census, shift hours, number of staff, and total actual hours worked by licensed and unlicensed nursing staff who are directly responsible for patient care for each shift and on a daily basis.
.
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
Medical Records
(Tag F0842)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on record review and staff interview, the facility failed to maintain a complete and accurate medical record for one (1)...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on record review and staff interview, the facility failed to maintain a complete and accurate medical record for one (1) of three (3) sampled residents during the complaint survey process. Specifically, the facility failed to re-evaluate the Resident's capacity for medical decision making once the Residents' cognitive abilities declined. Resident identifier: #28. Facility census: 114.
Findings included:
a) Resident #28
A record review, completed on 04/24/23 at 6:15 PM, revealed the following details:
--Resident was admitted to the facility on [DATE].
--A physician determination of capacity, dated 02/03/22, was on file and stated resident demonstrated capacity to make her own medical decisions.
--Resident #28 had a gradual decline in health and the 5 Day Medicare Minimum Data Set (MDS, with an Assessment Reference Date (ARD) of 12/06/22, noted resident's Cognitive Skills for Daily Decision Making were Severely Impaired.
--A Quarterly MDS, with an ARD of 01/18/23, noted resident's Brief Interview for Mental Status (BIMS) Score was 00, indicating resident had severely impaired cognitive abilities.
--A Quarterly MDS, with an ARD of 04/18/23, noted resident's Cognitive Skills for Daily Decision Making were Severely Impaired.
--Nurses Notes reflected the facility had begun notifying the Medical Power of Attorney (MPOA) with new orders, changes in condition, etc.
During an interview, on 04/25/23 at 4:00 PM, the Director of Social Services acknowledged the facility had begun to defer to resident's Medical Power of Attorney (MPOA) since her decline in health, but the facility did not have a physician's determination of incapacity in the resident's medical record.
.
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
Resident Rights
(Tag F0550)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on observation and staff interview, the facility failed to ensure resident rights for a dignified existence. Two (2) res...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on observation and staff interview, the facility failed to ensure resident rights for a dignified existence. Two (2) residents, Resident #41 and Resident #55, had uncovered urinary catheter bags. Two (2) residents, Resident #5 and Resident #47, requiring assistance with dressing were noted to be wearing non-skid socks that had the residents' names in conspicuous locations and readily visible by any visitor. These were random opportunities for discovery. Resident Identifiers: #41, #55, #5, and #47. Facility Census: 114.
Findings included:
a) Resident #41
Observation, on 04/24/23 at 12:03 PM, revealed Resident #41's urinary catheter bag hanging from the bed, ½ filled with urine and visible from the doorway.
During an interview, on 04/24/23 at 12:07 PM, CNA #120 reported it was facility protocol to have a privacy bag on all urinary catheters and acknowledged it was a dignity issue that Resident #41's was uncovered.
b) Resident #55
Observation, on 04/24/23 at 1:45 PM, revealed Resident #55 was in his wheelchair in the hallway outside his room. His urinary catheter bag was hanging from the wheelchair. The bag was uncovered, and it was readily visible that the bag was ½ full of urine.
During an interview, on 04/24/23 at 1:48 PM, CNA #50 confirmed it was facility protocol to cover urinary catheter bags to protect resident dignity. CNA #50 went on to say that Resident #50 Prefers it that way. He likes to look at it.
Record review, completed on 04/24/23 at 2:15 PM, revealed Resident #55 had been admitted to the facility on [DATE]. Resident #55's care plan failed to address the resident's alleged preference. Additionally, the 5-day Minimum Data Set (MDS), with an Assessment Reference Date of 02/01/23, reflected a Brief Interview for Mental Status (BIMS) score of 9 which indicates resident's cognition is moderately impaired.
c) Resident #5
Observation on 04/25/23 at 1:08 PM, found Resident #5 being wheeled by staff to therapy. Resident was wearing non-skid socks with her name visible on the upper part of both socks where the resident's calves were.
A brief record review, completed on 04/25/23 at 1:28 PM, found Resident #5 required staff extensive assistance with dressing.
A second observation on 04/25/23 at 2:36 PM, the Director of Social Services found Resident #5 sitting in her room. Resident was sitting in her wheelchair wearing non-skid socks with her name visible. The Director of Social Services acknowledged this was a dignity issue.
d) Resident #47
Observation on 04/25/23 at 3:35 PM, found Resident #47 wheeling himself in the hallway by the 300 / 400 hall. Resident was wearing non-skid socks with his name visible on the upper part of his feet.
A brief record review, completed on 04/25/23 at 3:46 PM, found Resident #47 required staff extensive assistance with dressing.
A second observation on 04/25/23 at 03:58 PM, the Director of Social Services found Resident #47 sitting in his wheelchair in the hallway. The Resident was still wearing the non-skid socks with his name visible. The Director of Social Services acknowledged this was a dignity issue.
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CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on record review and staff interview, the facility failed to ensure resident allegations of verbal abuse / staff neglect...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on record review and staff interview, the facility failed to ensure resident allegations of verbal abuse / staff neglect were reported in a timely fashion and/or to the appropriate state agencies. This was a random opportunity for discovery while reviewing facility records in the complaint survey process. This deficient practice had the potential to affect more than a limited number of residents. Resident identifiers: #31, #83, #13, #115, #64, #100, #30. Facility census: 114.
Review of the facility's Abuse, Neglect & Misappropriation Policy revealed the following guidance:
--In the event an allegation is made, the facility will take measures to protect residents from harm during an investigation. Accurate and timely reporting of incidents, both alleged and substantiated, will be sent to officials in accordance with the state law.
--An event may not be perceived by staff to constitute resident abuse, neglect or misappropriation of resident property; however, if a resident, family member or visitor perceives an event to be abuse, neglect or misappropriate, the facility must report the event.
Findings included:
a) Resident #31 and Resident #83
The following allegations were made by Resident #31 and Resident #83 in the 01/26/23 Resident Council Meeting, 200 Hall won't see aides for hours. Has own schedule to help you. Don't answer call lights. Aides go to break at the same time. 3-11 staff.
Review of the 12/21/22 Quarterly Minimum Data Set (MDS) revealed Resident #31 had a Brief Interview of Mental Status (BIMS) score of 15, indicating that he was cognitively intact.
Review of the 01/03/23 Quarterly MDS revealed Resident #83 had a BIMS score of 14, indicating that she was cognitively intact.
There was no documentation on file that the facility noted these allegations on a resident grievance/concern log. There was no documentation on file to indicate the facility had reported the allegations of neglect to the appropriate state agencies in accordance with state law.
b) Resident #13
Resident #13 reported in the 01/26/23 Resident Council Meeting that a CNA working the 11:00 PM - 7:00 AM shift had told her to shut up.
Review of the 11/03/22 Quarterly MDS revealed Resident #13 had a BIMS score of 14, indicating that she was cognitively intact.
There was no documentation on file that the facility noted these allegations on a resident grievance/concern log. There was no documentation on file to indicate the facility had reported the allegations of neglect to the appropriate state agencies in accordance with state law.
c) Resident #115
Resident #115 filed a grievance/concern on 01/13/23 indicating that a CNA came into his room on 01/12/23 and yelled at him. Resident #115 stated the CNA was nasty and mean. Resident #115 further stated that the same CNA is rough when providing care.
Review of the 12/27/22 admission MDS revealed Resident #115 had a BIMS score of 15, indicating that he was cognitively intact.
There was no documentation on file to indicate the facility had reported the allegation to the appropriate state agencies in accordance with state law.
d) Resident #64
Resident #64 filed a grievance/concern on 04/04/23 indicating that a NA was rude to him when his call light was on. The Resident reported that he needed to be changed and he needed a breathing treatment. The NA told Resident to stop pushing his call light.
Review of the 02/27/23 Quarterly MDS revealed Resident #64 had a BIMS score of 15, indicating he was cognitively intact.
There was no documentation on file to indicate the facility had reported the allegation to the appropriate state agencies in accordance with state law.
e) Resident #100
Resident #100's family member filed a grievance/concern on 04/24/23 indicating the Resident's sheets had not been changed in the 10 days since she had been admitted . The daughter stated she knew this because of the blood stains that have been on them since the day of her mother's admission. Additionally, it was reported that resident had not had a bath during the 10 days she had been at the facility.
A review of the CNA task documentation on file for bathing found that Resident #100 had not received a bath since her admission on [DATE] (in 10 days).
There was no documentation on file to indicate the facility had reported the allegations to the appropriate state agencies in accordance with state law.
f) Resident #30
Resident #30 filed a grievance/concern on 04/24/23 indicating that on Friday, 04/21/23 Occupational Therapist #90 had asked nursing staff to get resident up and out of bed on the weekend. Occupational Therapist #90 also discussed the importance of getting up out of bed with resident. Resident reported the CNAs working on Saturday, 04/22/23 would not get her up. One (1) CNA told her, If therapy really wants you up, they can come in on the weekend and do it themselves. Resident was not up and out of bed until the second shift on Saturday. The CNA on second shift told Resident #30 they (the CNAs) will decide when resident goes back to bed since she wasn't out of bed until later that afternoon.
A brief record review found that Resident #30 had the capacity to make her own medical decisions.
There was no documentation on file to indicate the facility had reported the allegation to the appropriate state agencies in accordance with state law.
g) Interview with the Director of Social Services
During an interview on 04/26/23 at 9:22 AM, the Director of Social Services confirmed that none of the above-mentioned reports/concerns/grievances had been identified as allegations of abuse and/or neglect and had not been reported to the appropriate state agencies in accordance with state law.
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CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on observation, record review, and staff interview, the facility failed to provide and maintain an infection prevention ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on observation, record review, and staff interview, the facility failed to provide and maintain an infection prevention and control program designed to provide a safe, sanitary environment to help prevent the development and transmission of communicable diseases and infections in the facility. Facility staff failed to follow instructions on signage related to the facility's outbreak status. The facility did not store clean linens in a safe, clean, and sanitary manner. Staff failed to properly donn and doff personal protective equipment (PPE) upon entering and exiting rooms with residents on transmission-based precautions (TBP). These failed practices had the potential to affect more than a limited number of residents and were random opportunities for discovery. Facility census: 114.
Findings included:
a) Staff's Failure to Follow the Facility's Infection Prevention and Control Protocol Until the Metapneumovirus Outbreak Was Cleared on Each Hallway
A brief general observation tour, conducted on 04/24/23 at 11:35 AM, revealed the following signage regarding the Metapneumovirus Outbreak within facility:
--Signage to Visitors and Staff, dated 04/07/23, indicating the 100 Hall was experiencing a Metapneumovirus Outbreak. Visitors and Staff were asked to wear a clean surgical mask and practice good hand hygiene upon entering and exiting the hall. There was also signage on the unit's doors instructing, Keep Doors Closed at All Times.
--Signage to Visitors and Staff, dated 04/07/23, indicating the 200 Hall was experiencing a Metapneumovirus Outbreak. Visitors and Staff were asked to wear a clean surgical mask and practice good hand hygiene upon entering and exiting the halls. There was also signage on the unit's doors instructing, Keep Doors Closed at All Times.
--Signage to Visitors and Staff, dated 04/11/23 indicating the 300 Hall was experiencing a Metapneumovirus Outbreak. Visitors and Staff were asked to wear a clean surgical mask and practice good hand hygiene upon entering and exiting the halls. There was also signage on the unit's doors instructing, Keep Doors Closed at All Times.
--Signage to Visitors and Staff, dated 04/12/23 indicating the 400 Hall was experiencing a Metapneumovirus Outbreak. Visitors and Staff were asked to wear a clean surgical mask and practice good hand hygiene upon entering and exiting the halls. There was also signage on the unit's doors instructing, Keep Doors Closed at All Times.
During an interview, on 04/24/23 at 12:13 PM, the Director of Nursing (DON) confirmed the doors were open and the staff on all four (4) units were not following the posted infection prevention and control instructions. The DON then telephoned the Infection Control Associate to determine the 100 Hall, 300 Hall and 400 Hall could be taken off outbreak status. It was reported by the Infection Control Associate that the 200 Hall still needed to have the doors closed and the infection prevention and control instructions needed to be followed. The DON acknowledged until the moment of her call which cleared the three above-mentioned halls that staff should have been following all posted guidance.
b) Linen Carts
Observation on 04/24/23 at 2:30 PM found the following items stored with the linens on the 400 Hall Linen Cart:
-Blood Pressure Cuff
-Stethoscope
-Pulse Oximeter
-Thermometer
-Tablet
-Hand Sanitizer
-Shampoo/Body wash
During an interview on 04/24/23 at 2:37 PM, the DON confirmed the presence of the above-mentioned items and reported they did not belong on the linen cart. DON explained to the floor nurse that the items needed to be removed and that the linen cart was now considered dirty.
Observation on 04/24/23 at 2:38 PM found Certified Nursing Assistant (CNA) #86 stepping away from the 300 Hall Linen Cart with a tablet in her hand. CNA #86 confirmed the tablet had been removed from the 300 Hall Linen Cart. The CNA also confirmed there was a thermometer and blood pressure cuff still on the linen cart. CNA #86 acknowledged staff had failed to follow the facility's protocol and that the linen cart should now be considered dirty.
Observation on 04/24/23 at 2:41 PM found Clinical Manager RN #102 stepping away from the 200 Hall Linen Cart with a container of items. RN #102 confirmed the three (3) blood pressure cuffs, two (2) stethoscopes and a box of disposable gloves had been in the linen cart and acknowledged the above-mentioned items should not have been stored there.
c) 200 Hall Staff Not Wearing Surgical Masks While in Outbreak
Observation on 04/24/24 at 3:35 PM found the following staff unmasked on the 200 Hall:
--CNA #51
--LPN #6
--Speech Language Pathologist #59
--CNA Student #23
When asked why they were not wearing surgical masks, Speech Language Pathologist #59 reported, They [administration] said we didn't have too anymore. LPN #6 stated, Guidance changes from day to day. As of right now, it's not necessary.
The Infection Control Associate, during an interview on 04/24/23 at 3:45 PM, confirmed the 200 Hall outbreak had not been cleared. She reported it is the expectation that staff on any unit in outbreak would be wearing a surgical mask and practicing good hand hygiene.
d) Staff's Failure to Donn and Doff Appropriate PPE
Observation on 04/25/23 at 8:08 AM found room [ROOM NUMBER] signage instructed, STOP. Droplet Precautions. Everyone must: clean their hands, including before entering the room and when leaving the room. Make sure their eyes, nose, and mouth are fully covered before room entry. Remove face protection before room exit. Gowns, gloves, eye protection, and 2nd surgical mask must be worn.
Further observation identified there was no PPE immediately available. PPE was not hung on door (as with other rooms under isolation precautions.)
CNA #136 and CNA #27 were observed leaving room [ROOM NUMBER] at 8:10 AM wearing only surgical masks. Both CNAs confirmed they were not certain what the necessary precautions were prior to entering the room. They stated most rooms would have PPE available if it was necessary to wear it. Both agreed the sign outside room [ROOM NUMBER] did instruct staff to wear gowns, gloves, eye protection and a 2nd surgical mask. Both CNAs acknowledged they had not donned the appropriate PPE prior to entering the resident's room.
During an interview on 04/25/23 at 8:15 AM, the DON reported the Infection Control Associate had already reported there was a failure in the isolation protocol for room [ROOM NUMBER] and it was being addressed.
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Dec 2022
16 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
Deficiency F0552
(Tag F0552)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on record review and staff interview, the facility failed to ensure a resident representative was informed of medical tr...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on record review and staff interview, the facility failed to ensure a resident representative was informed of medical treatment and allowed to make treatment decisions for a resident who lacked decision making capacity. There was a delay in appointing a Health Care Surrogate (HCS) decision maker for Resident #115. This was a random opportunity for discovery. Resident identifier: #115. Facility census: 109.
Findings included:
a) Resident #115
A medical record review, completed on 12/07/22 at 11:53 AM, identified the following details:
-Prior to admission to the facility, a neurologist completed a Physician's Determination of Capacity and stated Resident #115 demonstrated a lack of capacity to make medical decisions. The neurologist did not appoint a Health Care Surrogate (HCS) at that time. A [NAME] Virginia Department Health and Human Resources (WVDHHR) Adult Protective Services (APS) Worker was trying to resolve this issue when resident was hospitalized for an acute illness.
-Following a brief hospitalization, Resident #115 was admitted to the facility on [DATE]. Resident diagnoses were: Cognitive Communication Deficit, Unspecified Intellectual Disabilities, Auditory Hallucinations, Cerebral Palsy, Anxiety Disorder, Schizophrenia, and Bipolar Disorder.
-On 02/02/22 at 10:42 AM, Social Worker (SW) #100 talked to the APS Worker and was aware of the information above. SW #100 agreed to complete a Mini-Mental State Examination (MMSE) and report back to the APS Worker. A Mini-Mental State Examination (MMSE) is used to check for cognitive impairment (problems with thinking, communication, understanding and memory).
-On 02/02/22 at 12:50 PM, Resident #115's score on the MMSE was 12 which identified moderate cognitive impairment. Social Worker #100 documented, DHHR was notified along with (physician name) who will complete the HCS form and APS will be the HCS.
-On 02/03/22 (physician name) completed Physician's Determination of Capacity and indicated Resident #115 had capacity.
-SW #100 reported that (physician name) had been resident's physician in the community and requested the Psychiatrist evaluate resident.
-On 02/07/22 the resident was seen by Psychiatrist (name). He requested previous mental health records from the community. SW #100 assisted with the assessment process and asked medical records to obtain the mental health records from the community.
-On 02/15/22 SW #100 sent all community mental health records to Psychiatrist (name). Resident #115 requested an appointment to speak with the doctor because she was hearing voices.
-On 02/16/22 at 10:43 AM, SW #100 met with Resident #115 and discussed the voices resident had been hearing. The Resident identified the voices were starting to bother her more since she has changed her environment moving to the facility. The Resident went on to say with the voices she visualized going outside and then coming back in the window with a woman and two (2) men that she does not know.
-02/28/22 at 1:37 PM, SW #100 worked with the doctor to determine if capacity was going to be given back to resident. SW #100 documented, After review of her MMSE and progress notes, it was determined that she does not have capacity. Additionally it was determined that the Social Worker would seek someone to become a Health Care Surrogate decision-maker for resident.
-The Checklist for Surrogate Selection was signed by the physician on 03/03/22.
-On 03/25/22 at 12:32 PM, SW #100 documented, [First Name of Resident #115's family member] had decided to be her health care surrogate. Papers were signed. by the attending physician who was previously in agreement and was also notified at this time.
During an interview on 12/07/22 at 12:21 PM with SW #100 acknowledged there was a delay in the HCS form being signed by the physician [03/03/22] and the HCS appointment being accepted by resident's family member [03/25/22].
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CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected 1 resident
.
Based on record review, family interview, resident interview, facility documentation of reportable occurrences review, and staff interview, the facility failed to ensure that all alleged violations ...
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.
Based on record review, family interview, resident interview, facility documentation of reportable occurrences review, and staff interview, the facility failed to ensure that all alleged violations of abuse and neglect, were reported immediately, and failed to ensure the results of the investigation were reported within five (5) working days of the occurrence, to other officials (including to the State Survey Agency and Adult Protective Services (APS) where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures. This deficient practice was identified through a random opportunity for discovery and had the potential to affect more than a limited number of residents. Two (2) residents were found to have reported allegations of abuse to facility staff; however, the allegations were not reported in accordance with State law and results of a five-day follow-up were not reported accordingly. Resident identifiers: Resident #53 and #68. Census: 109.
Findings included:
a) Policy Review
A review of the policy titled: Policy and Procedure: Compliance with Reporting Allegations of Abuse/Neglect/Exploitation, revision date, 05/03/21, showed the definition of an Alleged violation as being a situation or occurrence that is observed or reported by staff, patient, relative, visitor or others but has not yet been investigated and, if verified, could be noncompliance with the Federal requirements and the center will report all alleged violations and all substantiated incidents to the state agency and to all other agencies as required and take corrective action.
Under Section 4.(b), verbal abuse was defined as the use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to patients, or their families or within their hearing distance regardless of their age, ability to comprehend or disability .
Under section 1, titled: Procedures for Response and Reporting Allegations of Abuse/Neglect/Exploitation, showed the Licensed Nurse or designee will:
a) Respond to the needs of the resident and protect him/her from further incident.
b) Remove the accused employee from patient care areas.
c) Notify the Director of Nursing and CEO Administrator
d) Notify the physician, patient's family/legal representative and Medical Director
e) Monitor and document the patient's conation including response to medical treatment or nursing interventions
f) Complete an incident report and initiate an investigation.
g) Report to the state nurse aide registry or nursing board any knowledge of abuse, neglect or exploitation
Under section 2, showed the Director of Nursing Services, CEO/Administrator, or designee will
a) Notify the appropriate agencies immediately: as soon as possible, but no later than 24 hours after discovery of the incident.
b) Obtain statements from direct care staff
c) Suspend the accused employee pending completion of the investigation.
d) Follow-up with appropriate agencies to confirm report was received
Under section 3, showed the CEO/Administrator should followup with government agencies and to report results of the investigation when final is required by state agencies.
b) Resident #53
A family interview, on 12/05/22 at 02:40 PM, revealed the spouse had come to the facilty for a visit on a Friday, , Resident #53, who could not propel himself, was found sitting in the hallway. The family member stated staff often had Resident #53 sit in the hallway because of being able to monitor the resident a little closer. Resident #53 was identified as a fall risk and had cognitive impairment. On the day of the visit, Resident #53's family member sat down beside the resident for their visit, While seated in the hall with the resident, the spouse stated a staff member had come down the hall and snapped at them , stating the resident nor her were to be in the hall. The spouse stated the staff member had no right to say this in front of her husband which made her very upset and she left the facility. After reaching home, the spouse contacted the facilty by phone and spoke to a staff member at the nursing desk who told her she would have to call Monday to speak to someone in the office. The spouse stated she did call the facilty on Monday as directed.
A review of the Grievance/ Concern file showed no evidence of a complaint being filed based on the spouse contacting the facility with the complaint of a staff member speaking harshly to her in the presence of her husband.
A review of the electronic medical record showed a progress note dated 11/25/22 at 15:50, that read:
Wife {name} was in to visit today. Patient was sitting in the hall conversing with spouse. {named staff member} from infection came down hall and states, Why is {resident } in the hall. She then stated {resident} needed to go to his room and the visit needed to be ended short. {spouse} left the facility and {resident} was taken into the room. {Spouse} then called back very upset and crying stating that she did not know {resident} was sick until this nurse told her today and the lady that came down the hall was mean and rude. Apologized for the actions of staff and suggested that {spouse} follow up with {administrator} on Monday for any additional concerns.
A review of the reportable incidents provided by the facilty , contained no evidence the spouse's concern had been reported as an allegation of abuse/mistreatment.
An interview on 12/06/22 at 1:52 PM, with the Assistant Director of Nursing (ADON), verified the resident was present during the allegation but confirmed the incident was not reported because Resident #53 had dementia and the staff member had called the Resident's spouse and apologized.
It was also stated at this time, the facility had not completed any investigation nor reported in the form of a 5-day follow-up. The ADON also verified during this interview, the incident was brought up during the morning meeting as an issue. It was also verified the facility failed to use the Reasonable Person Concept when being told of the allegation. After discussion, the ADON stated she had not considered the Reasonable Person Concept and could see how this type of incident should be evaluated differently in the future.
On 12/07/22 at 11:08 AM, Staff #71 was interviewed. Staff #71 verified staff had placed Resident #53 in the hallway and when the spouse came to visit , she sat down beside the resident where he was seated. Staff #71 stated she spoke to the spouse, in the presence of the resident, informing her the resident was not to be in the hall and needed to return to the room. Staff #71 stated the spouse became visibly upset and left the facilty . Staff #71 stated the Director of Nursing (DON) informed her the spouse felt like she and her husband had been chastised. Staff #71 stated she contacted the spouse, by phone, to discuss the incident, after the conversation with the DON.
c) Resident #68
During an interview on 12/05/22 at 12:43 PM, Resident # 68 stated the night time staff had answered a call light the resident had activated, proceeded to turn the light off and informed the resident they would return. Resident #68 stated it was five (5) hours before they returned to check on her. Resident #68 stated the incident had happened a few days ago and she had reported this to a nurse and a nursing assistant.
Resident #68 was assessed by facilty staff to have a Brief Interview for Mental Status (BIMS) of 14 which determined the resident was cognitively intact.
A review of the grievance file/concerns and reportable incidents provided by the facilty showed no evidence the resident's concern had been reported as an allegation of abuse/neglect.
An interview with the ADON, on 12/06/22 at 2:00 PM, revealed the allegation should have been reported in accordance with State law and she would check to see if she could find any information .
An interview with the ADON, on 12/06/22 at 2:42 PM, confirmed the allegation made by Resident #68 had not been reported immediately nor results of any investigation reported in a form of a 5-day follow-up. The ADON stated further, the allegation should have been reported when the resident reported it but we would begin the process of reporting at this time
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CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Investigate Abuse
(Tag F0610)
Could have caused harm · This affected 1 resident
.
Based on family interview, resident and staff interview, record review and review of facility documentation of reportable incidents, the facility failed to ensure, in the response to allegations of ...
Read full inspector narrative →
.
Based on family interview, resident and staff interview, record review and review of facility documentation of reportable incidents, the facility failed to ensure, in the response to allegations of abuse, neglect, exploitation or mistreatment, evidence that all alleged violations were thoroughly investigated for two (2) residents reviewed during the Long Term Care Survey Process. This deficient practice was based on a random opportunity of discovery and had the potential to affect more than a limited number of residents residing in the facility. Resident #53 and Resident #68 were found to have allegations of abuse reported to facility staff and had not been investigated and evidence of the investigation maintained by the facility. Resident identifiers: Resident #53 and #68. Census: 109.
Findings included:
a) Policy Review
A review of the policy titled: Policy and Procedure: Compliance with Reporting Allegations of Abuse/Neglect/Exploitation, revision date, 05/03/21, showed the definition of an Alleged violation as being a situation or occurrence that is observed or reported by staff, patient, relative, visitor or others but has not yet been investigated and, if verified, could be noncompliance with the Federal requirements and the center will report all alleged violations and all substantiated incidents to the state agency and to all other agencies as required and take corrective action.
Under Section 4.(b), verbal abuse was defined as the use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to patients, or their families or within their hearing distance regardless of their age, ability to comprehend or disability .
Under section 1, titled: Procedures for Response and Reporting Allegations of Abuse/Neglect/Exploitation, showed the Licensed Nurse or designee will:
a) Respond to the needs of the resident and protect him/her from further incident.
b) Remove the accused employee from patient care areas.
c) Notify the Director of Nursing and CEO Administrator
d) Notify the physician, patient's family/legal representative and Medical Director
e) Monitor and document the patient's conation including response to medical treatment or nursing interventions
f) Complete an incident report and initiate an investigation.
g) Report to the state nurse aide registry or nursing board any knowledge of abuse, neglect or exploitation
Under section 2, showed the Director of Nursing Services, CEO/Administrator, or designee will
a) Notify the appropriate agencies immediately: as soon as possible, but no later than 24 hours after discovery of the incident.
b) Obtain statements from direct care staff
c) Suspend the accused employee pending completion of the investigation.
d) Follow-up with appropriate agencies to confirm report was received
Under section 3, showed the CEO/Administrator should follow up with government agencies and to report results of the investigation when final is required by state agencies.
b) Resident #53
A family interview, on 12/05/22 at 2:40 PM, it was learned when the spouse came in for a visit on a Friday, Resident #53, who could not propel himself, was found sitting in the hallway. The family member stated the staff often had Resident #53 sit in the hallway because of being able to monitor the resident a little closer. Resident #53 was identified as a fall risk and had cognitive impairment. On the day of the visit, Resident #53's family member sat down beside the resident for their visit. While seated in the hall with the resident, the spouse stated a staff member had come down the hall and snapped at them, stating the resident nor her were to be in the hall. The spouse stated the staff member had no right to say this in front of her husband which made her very upset and she left the facility. After reaching home, the spouse contacted the facility by phone and spoke to a staff member at the nursing desk who told her she would have to call Monday to speak to someone in the office. The spouse revealed she did call the facility on Monday as directed.
A review of the Grievance/ Concern file showed no evidence of a complaint being filed based on the spouse contacting the facility with the complaint of a staff member speaking harshly to her in the presence of her husband.
A review of the electronic medical record showed a progress note dated 11/25/22 at 15:50 (3:50 PM)that read:
Wife {name} was in to visit today. Patient was sitting in the hall conversing with spouse. {named staff member} from infection came down hall and states, Why is {resident } in the hall. She then stated {resident} needed to go to his room and the visit needed to be ended short. {spouse} left the facility and {resident} was taken into the room. {Spouse} then called back very upset and crying stating that she did not know {resident} was sick until this nurse told her today and the lady that came down the hall was mean and rude. Apologized for the actions of staff and suggested that {spouse} follow up with {administrator} on Monday for any additional concerns.
A review of the reportable incidents provided by the facility for review, contained no evidence the spouses concern had been reported as an allegation of abuse/mistreatment with safety measures put in place to prevent further abuse during an investigation. Additionally, there was no evidence of an investigation being conducted when the facility was made aware of the allegation.
An interview on 12/06/22 at 1:52 PM, with the Assistant Director of Nursing (ADON), verified the resident was present during the allegation but confirmed the incident was not reported because Resident #53 had dementia and the staff member had called the Resident's spouse and apologized.
It was also stated at this time, the facility had not completed any investigation nor reported in the form of a 5-day follow-up. The ADON also verified during this interview, the incident was brought up during the morning meeting as an issue. It was also verified the facility failed to use the Reasonable Person Concept when being told of the allegation. After discussion, the ADON stated she had not considered the Reasonable Person Concept and could see how this incident should be evaluated differently in the future.
On 12/07/22 at 11:08 AM, Staff #71 was interviewed. Staff #71 verified staff had placed Resident #53 in the hallway and when the spouse came to visit , she sat down beside the resident where he was seated. Staff #71 stated she spoke to the spouse, in the presence of the resident, informing her the resident was not to be in the hall and needed to return to the room. Staff #71 stated the spouse became visibly upset and left the facility . Staff #71 stated the Director of Nursing (DON) informed her the spouse felt like she and her husband had been chastised. Staff #71 stated she contacted the spouse, by phone, to discuss the incident, after the conversation with the DON.
c) Resident #68
During an interview on 12/05/22 at 12:43 PM, Resident # 68 stated the night time staff had answered a call light the resident had activated, proceeded to turn the light off and informed the resident they would return. Resident #68 stated it was five (5) hours before they returned to check on her. Resident #68 stated the incident had happened a few days ago and she had reported this to a nurse and a nursing assistant.
Resident #68 was assessed by facility staff to have a Brief Interview for Mental Status (BIMS) of 14 which determined the resident was cognitively intact.
A review of the grievance file/concerns and reportable incidents provided by the facility showed no evidence the resident concern had been reported as an allegation of abuse/neglect and thoroughly investigated, with documentation of the investigation maintained at the facility.
An interview with the ADON, on 12/06/22 at 2:00 PM, revealed the allegation should have been reported and investigated, in accordance with State law, and she would check to see if she could find any information .
An interview, with the ADON, on 12/06/22 at 2:42 PM, confirmed the allegation made by Resident #68 had not been reported, therefore, no investigation of the allegation by the resident had been completed. The ADON stated further, the allegation should have been reported to State Agencies when the resident reported it to staff and an investigation should have been done at that time.
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CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Transfer Notice
(Tag F0623)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on medical record review and staff interview, the facility failed to provide evidence a resident/resident's representati...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on medical record review and staff interview, the facility failed to provide evidence a resident/resident's representative was provided a written Notice of Transfer for an acute hospital transfer. This was true for one (1) of two (2) residents reviewed for hospitalizations/discharges during the long-term care survey process. Resident identifier: #101. Facility census: 109.
Findings included:
a) Resident #101
An electronic medical record review was completed on 12/06/22 at 1:00 PM. Resident #101 was discharged to the hospital on [DATE]. There was no evidence a written Notice of Transfer/Discharge was provided to Resident #101 or legal representative. A subsequent review of the resident's paper chart at the nurses station found there was no written Notice of Transfer/discharge on the paper chart.
During an interview on 12/06/22 at 1:25 PM, Medical Records Director #53 stated she was unable to find a scanned Notice of Transfer/Discharge in the electronic medical record. She went on to state that typically their office would receive such a form and it would the be scanned into the record. Medical Records Director #53 confirmed the medical records office did not have any written paperwork for Resident #101 to be scanned.
Additionally, during an interview on 12/06/22 at 1:30 PM, Medical Records Worker #105 stated she checked the paper chart at the nurses station and did not find the form. Both Medical Record Workers stated the facility was unable to produce any evidence that a Notice of Transfer/Discharge was given.
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CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0625
(Tag F0625)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on medical record review and staff interview, the facility failed to provide evidence a resident/resident's representati...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on medical record review and staff interview, the facility failed to provide evidence a resident/resident's representative was provided a written Bed Hold Notice for an acute hospital transfer. This was true for one (1) of two (2) residents reviewed for hospitalizations/discharges during the long-term care survey process. Resident identifier: #101. Facility census: 109.
Findings included:
a) Resident #101
An electronic medical record review was completed on 12/06/22 at 1:00 PM. Resident #101 was discharged to the hospital on [DATE]. There was no evidence a written Bed Hold Notice was provided to Resident #101 or legal representative. A subsequent review of the resident's paper chart at the nurses station found there was no written Bed Hold Notice on the paper chart.
During an interview on 12/06/22 at 1:25 PM, Medical Records Director #53 stated she was unable to find a scanned Bed Hold Notice in the electronic medical record. She went on to state that typically their office would receive such a form and it would the be scanned into the record. Medical Records Director #53 confirmed the medical records office did not have any written paperwork for Resident #101 to be scanned.
Additionally, during an interview on 12/06/22 at 1:30 PM, Medical Records Worker #105 stated she checked the paper chart at the nurses station and did not find the form. Both Medical Record Workers stated the facility was unable to produce any evidence that a written Bed Hold Notice was given.
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CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
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Based on medical record review and staff interview, the facility failed to develop a care plan for a resident with long term antibiotic use. This is true for one (1) of one (1) reviewed for antibiot...
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Based on medical record review and staff interview, the facility failed to develop a care plan for a resident with long term antibiotic use. This is true for one (1) of one (1) reviewed for antibiotics. Resident identifier: #113. Facility census: 109.
Findings included:
a) Resident (R) #113
Review of the medical record on 12/06/22 revealed R #113 was admitted to the facility from an acute care center on 11/13/22. Diagnoses included stroke, high risk for endocarditis, high risk for prosthetic valve infection and infection of the implanted cardiac defibrillator, persistent staphylococcus epidermis bacterium with a possible central nervous system septic emboli. admission medications included the following antibiotics: Vancomycin 1 gram intravenous (IV) every 12 hours x 6 weeks, Gentamycin 100 milligrams every 12 hours x 14 days, and Rifampin 300 milligrams every 8 hours by mouth x 6 weeks. The admission Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 11/20/22 identifies the long term use of antibiotics in section 18000F. The care plan with a completion date of 11/29/22 identifies R#113's peripherally inserted central catheter for the administration of fluids or medications. The care plan lacks any information related to the long term use of the antibiotics, the risks or complications of these medications, or the need to monitor levels to prevent complications.
During an interview on 12/06/22 at 12:30 PM, the MDS Nurse #44 reviewed R #113's record and confirmed the care plan does not identify the long term use of antibiotics. MDS nurse #44 acknowledged she should have identified the antibiotics and noted side effects or possible reactions nurses need to watch for.
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CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
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Based on record review, resident interview and staff interview, the facility failed to notify the physician of abnormal blood glucose readings for two (2) of two (2) Residents reviewed for insulin. ...
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Based on record review, resident interview and staff interview, the facility failed to notify the physician of abnormal blood glucose readings for two (2) of two (2) Residents reviewed for insulin. The facility also failed to complete neurological checks for one (1) of four (4) Residents reviewed for accidents. These failed practices had the potential only affect a limited number of residents. Resident identifiers: #36, #54, #53. Facility census: 109.
Findings included:
a) Resident #36
On 12/05/22 at 12:20 PM Resident #36 stated that his blood sugars had been running high, and he could not eat the cake sent on lunch tray, he was a diabetic.
Review of Resident #36's orders showed an order Finger stick blood sugar four times a day for DMII. Notify physician if blood glucose less than 60mg/dl or over 400 milligrams per deciliter (mg/dl)
Review of Resident #36's Medication Administration Record (MAR) for October and November 2022 indicated the Residents blood glucose readings were above 400 mg/dl without any physician notification on the following dates:
10/11/22 6:00 AM - 594 mg/dl
10/11/22 11:30 AM - 475 mg/dl
10/16/22 8:00 PM - 471 mg/dl
10/17/22 8:00 PM - 431 mg/dl
10/17/22 11:30 AM - 437 mg/ml
10/18/22 6:00 AM - 425 mg/ml
10/19/22 6:00 AM - 424 mg/ml
10/26/22 6:00 AM - 434 mg/ml
10/26/22 8:00 PM - 446 mg/ml
10/29/22 6:00 AM - 460 mg/ml
11/15/22 11:30 AM - 413 mg/ml
11/16/22 11:30 AM - 425 mg/ml
During an interview on 12/07/22 at 10:33 AM Registered Nurse (RN) #94 stated if they get a high glucose reading above 400 mg/dl they are supposed to contact the physician, get an order and then write a progress note. RN #94 stated a couple of times she had put the high glucose readings on a communication board, and a designated nurse would call once or twice a shift and speak with physician about issues. RN #94 further stated the communication board was where they put non-emergent things, it was like a piece of paper on a clip board.
During an interview on 12/07/22 at 11:21 AM, the Assistant Director of Nursing (ADON) stated, You are right there no progress notes or documentation to indicate they contacted physician about the high blood sugars [blood glucose readings]. The ADON further stated that a high blood glucose reading over 400 mg/dl should be reported timely and is not something that should be put on a communication board awaiting a call sometime later that day.
b) Resident #54
During a resident representative interview on 12/05/22 at 8:54 PM, it was discovered Resident #54 frequently had high blood sugar levels.
On 12/06/22 at 10:57 AM, a review of the October 2022 and November 2022 MARS indicated Resident #54's blood sugar level was over 400 the following fifteen (15) times without notification of the attending physician:
-10/01/22 at 7:00 AM
-10/14/22 at 11:30 AM
-10/16/22 at 7:00 AM
-10/24/22 at 7:00 AM
-10/25/22 at 11:30 AM
-10/27/22 at 4:00 PM
-10/31/22 at 11:30 AM
-11/05/22 at 11:30 AM
-11/07/22 at 11:30 AM
-11/11/22 at 11:30 AM
-11/12/22 at 11:30 AM
-11/14/22 at 7:00 AM
-11/21/22 at 11:30 AM
-11/25/22 at 11:30 AM
-11/27/22 at 11:30 AM
During an interview on 12/06/22 at 12:25 PM, the DON was stated she was unable to locate evidence the physician was notified, but would bring it if it was found.
On 12/07/22 at 9:36 AM, the Administrator reported the facility had utilized a secure care system to communicate with physician, but that system did not carry over to the medical record. The Administrator reported they no longer had access to the former secure care system when the facility transferred over to a new electronic medical record on December 1, 2022.
c) Resident #53
A review of the policy titled: Neurological Assessment, revision date of 05/03/21, showed neurological assessments were indicated when ordered by a physician, when a resident experienced an unwitnessed fall, following a fall or other accident /injury involving head trauma, or when indicated by the resident's condition. The policy, on page two (2) , showed the frequency of the neurological assessments were to be completed every 15 minutes times (x) four (4), every 30 minutes x six (6), every hour x four (4), every four (4) hours x five (5), and every eight (8) hours x six (6) and the physician was to be notified of any change in the resident's neurological status, supervisor was to be notified of any resident refusal and other information reported in accordance with the facility policy and professional standards of practice.
An electronic record review revealed Resident #53 had been identified as having a history of falling. Resident #53's fall history was reviewed from 10/01/22 through 12/01/22.
Resident #53 was noted to have an unwitnessed fall occurring on 11/13/22 at 14:39 (12:39 PM). A hematoma was noted on the right side of the head during the assessment of the resident after the fall.
A review of the Neurological Assessment Flow Sheet for the 11/13/22 unwitnessed fall, showed an incomplete neurological assessment for the 10:25 AM assessment , in which the level of consciousness, the pupil response, motor function and pain had not been assessed. Additionally, there was no evidence of an assessment for 10:25 AM or 2:25 PM. On 11/15/22 at 12:25 PM, there was no evidence a neurological assessment had been completed. On 11/16/22 an incomplete assessment was completed at 4:25 AM, in which the level of consciousness, the pupil response, motor function and pain had not been assessed and at 12:25 PM, no evidence of an assessment had been completed.
An interview with Registered Nurse (RN) #11 on 12/07/22 at 9:26 AM, verified the neurological assessments required all areas to be assessed and confirmed staff had missed completing some of the neurological assessments for Resident #53 as a result of the unwitnessed fall on 11/13/22.
Resident #53 was noted to have an unwitnessed fall occurring on 11/25/22 at 00:49 with the progress note showing neurological checks had been initiated. A review of the Neurological Assessment Flow Sheet for the unwitnessed fall occurring on 11/25/22 showed an incomplete assessment at 7:30, 8:30 and 12:30 in which the level of consciousness, the pupil response, motor function and pain had not been assessed.
An interview with RN #11 on 12/07/22 at 9:26 AM, verified the neurological assessments required all areas to be assessed and confirmed staff had missed completing some of the neurological assessments for Resident #53 as a result of the unwitnessed fall on 11/25/22.
Resident #53 was noted to have an unwitnessed fall occurring on 11/29/22 at 3:30 with the progress note showing neuro checks were intimated per facility protocol. A review of the Neurological Assessment Flow Sheet for the unwitnessed fall occurring on 11/29/22 showed an incomplete assessment at 15:15 (3:15 PM) and 19:15 (7:15 PM) in which the pupil response, motor function and pain had not been assessed and there was no evidence staff had completed the neurological assessment at 23:15 (11:15 PM). There was no evidence of a neurological assessment being completed on 11/30/22 at 3:15 or 7:15.
An interview with RN #11 on 12/07/22 at 9:26 AM, verified the neurological assessments required all areas to be assessed and confirmed staff had missed completing some of the neurological assessments for Resident #53 as a result of the unwitnessed fall on 11/29/22.
An interview, with the Assistant Director of Nursing (ADON), on 12/07/22 at 12:04 PM, confirmed no additional information was found showing evidence the assessments had been completed and confirmed staff had missed completing some of the neurological assessments required after an unwitnessed fall.
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CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Incontinence Care
(Tag F0690)
Could have caused harm · This affected 1 resident
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Based on observation and staff interview the facility failed to properly anchor Resident #50's indwelling catheter with a leg band. This failed practice was random opportunity for discovery and had ...
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Based on observation and staff interview the facility failed to properly anchor Resident #50's indwelling catheter with a leg band. This failed practice was random opportunity for discovery and had the potential to affect only a limited number of Residents. Resident identifier: #50. Facility census: 109.
Findings included:
Observation on 12/06/22 at 11:06 AM found Resident #50 to be laying on her left side in bed with her bent. The indwelling catheter drainage tube was noted to be coming out of her intergluteal cleft leading to the bed side collection bag that was hanging on the right side of the bed . The Resident did not have a leg band secure device in place for the indwelling catheter. Registered Nurse (RN) #101 verified no catheter secure leg strap was in place, and stated the resident usually had one.
During an interview on 12/07/22 at 11:30 AM the Assistant Director stated that the facility's policy for appropriate use of indwelling catheters did not mention the leg strap secure device, however Resident #50 should have one. The ADON further stated, She [resident #50] has had all kinds of bladder trouble and she has history of bladder cancer, so yea she needs a leg strap for sure. I make sure it gets put on.
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CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0725
(Tag F0725)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on resident council minutes, resident interviews, resident representative interviews, grievances, resident council, and ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on resident council minutes, resident interviews, resident representative interviews, grievances, resident council, and review of the Payroll Based Journal staffing report, and the CMS Nursing Home Compare's Report, the facility failed to ensure sufficient qualified nursing staff were available at all times to provide nursing and related services to meet the residents' needs safely and in a manner that promoted resident rights, physical, mental and psychosocial well-being. Facility census: 109.
Findings included:
a) Resident Council Minutes
On 12/06/22 at 8:40 AM, a review of resident council minutes from January 2022 - November 2022 identified the following resident concerns:
--03/23/22 Resident Council Minutes revealed residents were concerned their beds were not being made.
--04/27/22 Resident Council Minutes revealed residents were concerned their beds were not being made.
b) Anonymous Resident Interviews
Anonymous Resident Interview #1
Resident stated the facility was a little short in evening after supper and early in the morning. They do their best but there is not enough staff.
Anonymous Resident Interview #2
Resident reported, Some times it takes a long time to have the call lights answered.
Anonymous Resident Interview #3
Resident reported freqently having at least a 1/2 hour wait. Nights are worse. That's when staff will turn your light off, leave without offering help, and won't come back for hours.
c) Anonymous Resident Representative Interviews
Anonymous Resident Representative Interview #1
They are understaffed. I have seen a lot of staff leave because they are unhappy with Administration. My loved one has been found wearing the same clothes on Saturday that he was wearing on Friday when family visited. Family has scheduled Zoom calls for a certain date and time, but then staff do no answer the call. Family has found it necessary to change our loved one's sheets because staff don't do it. Staff members frequently report they are working short. The facility frequently works with only 2 CNAs [certified nursing assistants] on evenings and weekends.
Anonymous Resident representative Interview #2
Evenings are worse. Thet are very short staffed.
d) Review of Concern/Grievance Forms
On 12/06/22 at 2:24 PM, a review of concern/grievance forms from January - November 2022 was completed and found the following issues.
03/17/22 Grievance - A staff member entered resident's room and found her seated at the edge of the bed. Resident stated, I'm embarassed to tell you but I'm sitting in a wet diaper. I was told last nights when I asked to go to the bathroom that I had a diaper and to use that.
04/11/22 - A resident representative reported that on the evening shift of 04/10/22 her loved one asked to be put to bed at a certain time. He was not put into bed for quite some time later. The LPN duty stated the facility had four (4) staff total with two (2) CNAs per hall. During their breaks they continued to go as if they would if they were fully staffed.
05/25/22 - A resident reported that he is not being positioned appropriately on the toilet and in his wheelchair. He state he asks the CNA to reporsition him and the CNA leaves the room without doing so.
07/11/22 - Resident reported he is not being told when his apporintments are. The doctor's office is calling him the day before as a reminder call and it's the first time he is aware of his appointment. He would like to know earlier when his appointments are schedule.
09/27/22 - On Saturday, resident reported to nursing staff and CNAs that it was burning when he peed. His family member also told multiple staff his pee was dark and had sedements. His urine was not tested until Monday evening. Additionally, the family member reported it can take up to two (2) hours for resident to be moved into bed once he requests to go to bed.
09/27/22 - Spouse reported that he had requested staff toilet his wife and was told, She can go in her pants.
10/24/22 - Complaint filed saying on evening shift, resident waits to be changed for 2-3 hours. THe CNAs will give excuses such as partner is on break or I will come right back and they don't.
e) Resident Council Interview
Anonyouus resident council interview - They work short a lot on weekends. Staff will say they will get to requests as soon as they can but we wait quite some time to have our needs met. Sometimes it can be over an hour or more. The ones that are working are doing the best they can. It's not their fault their short staffed.
f) Review of Payroll-Based Journal (PBJ) Staffing Data
On 12/06/22 at 9:46 AM, a review of the Payroll-Based Journal (PBJ) Staffing Data report revealed the facility had a one (1) star staff rating and low staffing on weekends in the 3rd quarter (April 1, 2022 - June 20, 2022).
g) CMS Nursing Home Compare's Report for the Facility
On 12/06/22 at 10:00 AM, a review of the CMS Nursing Home Compare's report for Stonerise [NAME] Nursing Home revealed:
The total number of nurse staff hours (including Registered Nurse [RN], Licensed Practical Nurse [LPN], and Certified Nursing Assistant [CNA]) per resident per day on the weekend was 2 hours and 46 minutes, less than the national average of 3 hours and 15 minutes, and the [NAME] Virginia average of 3 hours and 15 minutes.
The facility's Registered Nurse hours per resident per day on the weekend was 10 minutes, less than national average of 27 minutes, and the [NAME] Virginia average of 22 minutes.
h) Administrative Interview
During an interview on 12/07/22 at 11:03 AM, the Administrator acknowledged the fact the PBJ Staffing data report revaled low staffing on weekends during the 3rd quarter.
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CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0744
(Tag F0744)
Could have caused harm · This affected 1 resident
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Based on medical record review and staff interview. The facility failed to develop an individualized, person-centered approaches to address the care and treatment for a resident with dementia. This ...
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Based on medical record review and staff interview. The facility failed to develop an individualized, person-centered approaches to address the care and treatment for a resident with dementia. This practice affected one (1) of one (1) residents reviewed for dementia during the Long-Term Care Survey Process (LTCSP). The failure to ensure the comprehensive care plan was developed for the resident's highest practicable well-being placed the residents at risk resulting in the Residents inability to achieve the highest level of functioning. Resident Identifier: #6. Facility census: 109.
Findings included:
a) Resident #6
On 12/06/22 a review of Resident (R#6's) medical records revealed, the diagnoses of Alzheimer's and Dementia.
A review of the current care plan with the initiated date of 12/06/22 showed there was no care plan addressing dementia care, with interventions and goals. This showed it was not updated to reflect the resident's current status.
During an interview on 12/07/22 at 11:10 AM the Assistant Director of Nursing (ADON) confirmed Resident #6 has a diagnosis of Alzheimer's and Dementia. The ADON verified there was no dementia care plan developed for Resident #6.
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CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Drug Regimen Review
(Tag F0756)
Could have caused harm · This affected 1 resident
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Based on record review, staff interview, and policy the facility failed to have drug regimen reviews available on the resident medical record. This was true for two (2) of five (5) reviewed for unne...
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Based on record review, staff interview, and policy the facility failed to have drug regimen reviews available on the resident medical record. This was true for two (2) of five (5) reviewed for unnecessary medications. Resident identifier #2 and #6. Facility census: 109.
Findings included:
Record review of the facility's policy titled, Medication Monitoring, with an effective date 06/21/17 showed:
-- The consultant Pharmacist shall document the Medication Regimen Review on the individual Resident's Chronological Record of Medication Regimen review form or the designated are of the Resident 's Electronic Health Record (EHR).
-- A Record of off-site Medication Regimen Reviews, such as those that may be necessary for residents with acute changes of condition or expected stays of less than 30 days, will be documented and forwarded to the facility in accordance with that policy and procedure, and placed into the Resident's medical record in a location consistent with the documentation of other medication regimen reviews.
--If no irregularities are identified, the consultant Pharmacist will document No Irregularities In the Resident's Chronological Record of Medication Regimen review form or the designated are of the Resident 's Electronic Health Record (EHR).
a) Resident #2
An unnecessary medication regimen review (MRR) for Resident #2 on 12/06/22 found, No MMR were available in the medical record for October 2022.
During an interview on 12/07/22 9:45 AM the Administrator stated that no MRR's were available for resident #2 for the month of October 2022.
b) Resident #6
An unnecessary medication regimen review (MRR) for Resident #6 on 12/06/22 found, No MMR were available in the medical record for June 2022, August 2022, October 2022, or November 2022.
During an interview on 12/07/22 9:45 AM the Administrator stated that no MRR's were available for resident #6 for the month of June 2022, August 2022, October 2022, or November 2022.
During an interview on 12/07/22 9:48 AM the Administrator stated that the missing MRRs had to be printed from the pharmacy for Resident's #2 and #6.
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CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0800
(Tag F0800)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on observation, Resident interview, and medical record review the facility failed to provide a nourishing diet to Reside...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on observation, Resident interview, and medical record review the facility failed to provide a nourishing diet to Resident #30. This is true for one (1) of five (5) reviewed for diet preferences. Facility census: 109.
Findings included:
a) Resident #30
An observation and interview with Resident #30 on 12/05/22 at 12:30 PM found the lunch meal of only a peanut butter and jelly sandwich, a piece of cake and a ginger ale. When ask about her noon meal, Resident #30 stated that she asked for a peanut butter and jelly sandwich, one time and that's all she gets for lunch every day. Resident #30 stated that she would like to have something else for lunch.
A medical record review for Resident #30 found a physician order for a regular diet, regular texture with ground meats, an order date 8/27/20.
A second observation and interview on 12/06/22 at 12:44 PM with resident #30 revealed she had received a peanut butter and jelly sandwich, a cup of fruit cocktail and a ginger ale. During the interview she stated that she would prefer to have a cheeseburger and tater tots like everyone else received. Continued observation of Resident #30's tray card found the lunch menu, a peanut butter sandwich, fruit cocktail and a can of ginger ale soda.
During an interview with the Dietary Manager (DM) on 12/06/22 at 2:30PM, she confirmed Resident #30 only receives a peanut butter and jelly sandwich, dessert, and a ginger ale for lunch. She also stated that Resident #30 only receives a pimento cheese sandwich, dessert, and a ginger ale for dinner. The DM stated that a month ago, the nurses called and told the kitchen staff to only send Resident #30 sandwiches for lunch and dinner. The DM stated that the kitchen used to send sandwiches with her regular meal.
Review of Resident #30s medical record found a Quarterly Nutritional Notes:
--8/13/2022 07:01
Quarterly Nutritional Note Text: 81y, Female alert and oriented, NKFA, Independent with feeding intake 26-50%, Current diet Regular, regular texture, thin liquids. Current weight 100.8#, BMI 19.0. Visited, Resident #30 to discuss food concerns no new ones at this time. [NAME] does state the cheese salad and egg salad is her favorite sandwiches and does enjoy getting it with her meals. No edema noted at this time. Current diet is appropriate and adequate for her at this time. (Transcribed as written).
--11/13/2022 07:01
Quarterly Nutritional Note
Late Entry: Note Text: 81y, Female alert and oriented, NKFA, Independent with feeding intake 76-100%, Current diet Regular, regular texture, thin liquids. Current weight 101.7#, BMI 19.1. Visited Resident #30 to discuss food concern no new ones at this time. No edema noted at this time. Current diet is appropriate and adequate for her at this time. (Transcribed as written).
An interview on 12/07/22at 9:40 AM with the Assistant Director of Nursing (ADON) verified Resident #30 should be getting regular meal with an added sandwich. The ADON stated that she will get Resident #30's meals fixed.
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CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected multiple residents
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Based on observation and staff interview, the facility failed to ensure each resident had the right to a clean, comfortable homelike environment that was in good repair. Walls were observed to be sc...
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Based on observation and staff interview, the facility failed to ensure each resident had the right to a clean, comfortable homelike environment that was in good repair. Walls were observed to be scarred and/or with missing or torn wallpaper for Resident # 107 and #53. Cove base trim was missing from Resident #59's room. Wallpaper and cove base trim , in the hallway adjacent to the North Nursing Station, was gaped and/or torn not allowing for effective cleaning. This deficient practice was true through a random opportunity for discovery and had the potential to affect more than a limited number of residents. Resident identifiers: Resident #107, #53 and #59, Census: 109.
Findings included:
a) Resident #107
An observation, during the initial tour, on 12/05/22 at 1:08 PM, revealed a large piece of wallpaper to be missing directly behind Resident #107's bed.
An interview with the facility's Maintenance Director, on 12/06/22 at 12:05 PM, revealed there was an area behind Resident #107's bed that measured three (3) feet by four (4) feet where the wallpaper was torn off exposing the bare wall. The Maintenance Director stated the wall needed to be repaired.
b) Resident #53
An observation, during the initial tour on 12/05/22 at 1:31 PM, revealed a large circular scraped area behind the bed in Resident #53's room.
An interview, on 12/06/22 at 12:02 PM with the facility's Maintenance Director, verified the large scraped area was present in Resident #53's room and was not sure why that had not been repaired.
c) Resident #59
An observation, of Resident #59's room on 12/05/22 at 12:00 PM, revealed a large area of cove base trim missing from the residents wall near the door. The wall had a large crack allowing a gap from the wall to the floor, which did not allow for effective cleaning.
An interview, on 12/06/22 at 12:00 PM with the facility's Maintenance Director, revealed no knowledge of the cove base missing in Resident #59's room. However, the Maintenance Director stated there had been a piece of Cove base found in the hall a couple of weeks ago and added, that may be the room it came from.
d) Wall adjacent to North Nursing Station
An observation, in the presence of the Maintenance Director, on 12/06/22 at 12:15 PM, revealed the wall adjacent to the North Nursing Station, had ruffled wallpaper down the wall and a gap where the two ends of the cove base were applied, not allowing for effective cleaning.
An interview with the Maintenance Director , on 12/06/22 at 12:15 PM, revealed the wallpaper had shrunk creating a rippled look and confirmed the cove base trim was gaped and both areas would not allow for proper cleaning of the wall. The Maintenance Director added, at this time, there was no time frame in which the area would be repaired.
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CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected multiple residents
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c) Resident (R) #9
On 12/06/22 at 11:38 AM, a review of the 100 hall medication cart with Licensed Practical Nurse (LPN) #85 revealed an undated open vial of Novolog insulin for R#9. During this ob...
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c) Resident (R) #9
On 12/06/22 at 11:38 AM, a review of the 100 hall medication cart with Licensed Practical Nurse (LPN) #85 revealed an undated open vial of Novolog insulin for R#9. During this observation LPN #85 acknowledged vials are to be dated when opened. LPN #85 stated she would replace the vial immediately to ensure the efficacy of the insulin.
Based on observation and staff interview, the facility failed to label medications when opened and administered to residents to ensure the safety and effective use of medications. This failed practice was identified through a random opportunity for discovery and was found to be true for two (2) of two (2) medication carts observed. Insulin pens, currently being administered to residents, were not dated when opened to provide staff administering the insulin, a reference date, based on manufacture's guidelines, for safe usage date. Over the Counter medications were not dated when opened. This failed practice had the potential to affect more than a limited number of residents.
Resident identifiers: Resident # 168, #57, # 59 and #9. Facility census: 109
Findings included:
a) Insulin Quick Pens (North Hall)
An observation, of the North Hall Medication Cart, on 12/06/22 at 08:02 AM, revealed three (3) Insulin Quick pens were noted to be open and being administered to residents. The Insulin Quick pens had no date on the pen of when it was initially opened, inorder for staff to know the date for disposa,l according to manufacture's use by date of the specific insulin.
An interview with LPN #2, 12/06/22 at 08:02 AM, verified there was no date on the medication to indicate when the insulin pens were opened for Resident's #59, #168 and #57. LPN #2, added the pens were supposed to labeled with the date by the staff member who opened the pen initially for administration.
b) Stock medications (North Hall Medication Cart)
An observation, on 12/06/22 at 07:58 AM , of the North Hall Medication Cart, revealed the following :
- an open bottle of Senna 8.6 mg, with no date when opened and being administered to residents.
- an open bottle of Fiber Therapy 500 mg, with no date when opened and being administered to residents.
-an open bottle of Aspirin 325 mg, with no date when opened and being administered to residents.
An interview, with LPN #2, on 12/06/22 at 08:00 AM, confirmed medications were required to be labeled with the date of when the staff member opened the stock medication and put into use. LPN #2 confirmed the Senna, Fiber Therapy and Aspirin had not been dated.
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CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Menu Adequacy
(Tag F0803)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on observation and interview the facility failed to honor residents' personal dietary choices and preferences. This affe...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on observation and interview the facility failed to honor residents' personal dietary choices and preferences. This affected five (5) of (31) resident reviewed, during the Long-Term Care Survey Process (LTCSP). Resident identifier #2, #30, #85, #68 and #95. Facility census: 109.
Findings included:
a) Resident #85
During an Interview on 12/05/22 at 12:43 PM, Resident #85 stated that the kitchen always sends her items that's on her dislikes list. She stated that for breakfast they sent her scrambled eggs, that is on her dislike list. She stated that the staff will get her other items, but it takes awhile and everything else gets colder.
A review of Resident #85's tray card on 12/05/22 found, no dislikes listed on her tray card.
A second Interview on 12/06/22 at 9:45 AM with resident #85 revealed she received scrambled eggs again this morning for breakfast and received Turkey for her 12/05/22 evening meal. This is also, an item on her dislike list.
A medical record review of Resident # 85's current 11/01/22 care plan found, no likes or dislikes in her dietary care plan. Continued review revealed a diet order Regular diet,
Regular texture with the order date 08/01/22.
An Interview on 12/06/22 at 2:30 PM with the Dietary Manager (DM), verified Resident #85 should not receive items form her allergies / dislike list.
b) Resident #30
An observation and interview with Resident #30 on 12/05/22 at 12:30 PM found the lunch meal of only a peanut butter and jelly sandwich, a piece of cake and a ginger ale. When ask about her noon meal, Resident #30 stated that she asked for a peanut butter and jelly sandwich, one time and that's all she gets for lunch every day. Resident #30 stated that she would like to have something else for lunch.
A medical record review for Resident #30 found a physician order for a regular diet, regular texture with ground meats, an order date 8/27/20.
A second observation and interview on 12/06/22 at 12:44 PM with resident #30 revealed she had received a peanut butter and jelly sandwich, a cup of fruit cocktail and a ginger ale. During the interview she stated that she would prefer to have a cheeseburger and tater tots like everyone else received. Continued observation of Resident #30's tray card found the lunch menu, a peanut butter sandwich, fruit cocktail and a can of ginger ale soda.
During an interview with the Dietary Manager (DM) on 12/06/22 at 2:30PM, she confirmed Resident #30 only receives a peanut butter and jelly sandwich, dessert, and a ginger ale for lunch. She also stated that Resident #30 only receives a pimento cheese sandwich, dessert, and a ginger ale for dinner. The DM stated that a month ago, the nurses called and told the kitchen staff to only send Resident #30 sandwiches for lunch and dinner. The DM stated that the kitchen used to send sandwiches with her regular meal.
Review of Resident #30s medical record found a Quarterly Nutritional Notes:
--8/13/2022 07:01
Quarterly Nutritional Note Text: 81y, Female alert and oriented, NKFA, Independent with feeding intake 26-50%, Current diet Regular, regular texture, thin liquids. Current weight 100.8#, BMI 19.0. Visited, Resident #30 to discuss food concerns no new ones at this time. [NAME] does state the cheese salad and egg salad is her favorite sandwiches and does enjoy getting it with her meals. No edema noted at this time. Current diet is appropriate and adequate for her at this time. (Transcribed as written).
--11/13/2022 07:01
Quarterly Nutritional Note
Late Entry: Note Text: 81y, Female alert and oriented, NKFA, Independent with feeding intake 76-100%, Current diet Regular, regular texture, thin liquids. Current weight 101.7#, BMI 19.1. Visited Resident #30 to discuss food concern no new ones at this time. No edema noted at this time. Current diet is appropriate and adequate for her at this time. (Transcribed as written).
An interview on 12/07/22at 9:40 AM with the Assistant Director of Nursing (ADON) verified Resident #30 should be getting regular meal with an added sandwich. The ADON stated that she will get Resident #30's meals fixed.
c) Resident #2
During an Interview and observation on 12/05/22 at 1:13 PM, Resident #2 stated that the kitchen always sends her items that's on her dislikes list. She stated that she doesn't like the smoked sausage that is on her lunch tray today and they send it sometimes. She stated that they do send other items she doesn't like.
A review of Resident #2's tray card on 12/05/22 found, no dislikes listed on her tray card.
An Interview on 12/06/22 at 2:30 PM with the Dietary Manager (DM), verified Resident #85 should not receive items form her allergies / dislike list.
d) Dietary Interviews
During the second kitchen tour on 12/06/22 at 11:10 AM the DM and [NAME] #159 revealed, there is no likes or dislikes on the Resident tray cards. [NAME] #159 stated that they dip and serve what ever the card has printed. The DM stated that the computer system is supposed to pick the menu for the residents using their likes and dislikes. The DM also stated that the staff on the tray line does not see resident's preferences or dislikes.
e) Resident # 68
During a resident interview, on 12/05/22 at 12:47 PM, Resident #68 was observed to be eating the lunch meal. Resident #68 was picking carrot pieces out of what she was eating and placing them on the table. When questioned, Resident #68 stated I do not like carrots and have told them in the kitchen but the resident stated she continued to receive food items the resident had expressed as a dislike.
A record review showed Resident #68 to have a Brief Interview for Mental Status of a score of 14 which assessed the resident to be cognitively intact.
f) Resident # 95
An interview with Resident #95, on 12/05/22 at 03:02 PM, revealed when the dietary department has been told of a food preference or a dislike, the item when it is offered on the menu is sent on the tray.
A record review showed Resident #95 to have a Brief Interview for Mental Status of a score of 15 which assessed the resident to be cognitively intact.
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CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Medical Records
(Tag F0842)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on record review and staff interview, the facility failed to maintain an accurate medical record for one three (3) of 32...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on record review and staff interview, the facility failed to maintain an accurate medical record for one three (3) of 32 sampled residents reviewed during the Long-Term Care Survey process. Resident identifiers: #43, #54, and #81. Facility census: 109.
Findings included:
a) Resident #43
A brief record review, completed on [DATE] at 2:31 PM, identified resident had a Physician Orders for Treatment (POST) form on file. The facility had obtained verbal consent from resident's Health Care Surrogate (HCS) on [DATE].
The 2021 POST Form Guidance instructs, If the incapacitated patient's MPOA representative or Health Care Surrogate is unavailable at the time of form completion, this section can be signed by two witnesses for verbal confirmation of agreement from the patient's MPOA representative or health care surrogate. The form should be signed at the earliest available opportunity.
During an interview on [DATE] at 8:38 AM, Social Worker #152 acknowledged verbal consent had been accepted over a year ago and the facility had failed to obtain a written signature from the HCS.
b) Resident #54
A brief record review completed on [DATE] at 2:19 PM, identified a red NO CODE paper in the front of resident's chart. Additionally, there was a POST form instructing resident wished to receive CPR.
During an interview on [DATE] at 2:26 PM, Licensed Practical Nurse (LPN) #113 confirmed there was a physician order for Resident #54 to be a Full Code. LPN #113 confirmed the conflicting red NO CODE directive was on the chart and stated, I'm not sure how that got there.
c) Resident #81
A brief record review, completed on [DATE] at 2:38 PM, identified resident had a POST form on file directing that resident wished to receive selective treatments and to transfer to hospital if treatment needs cannot be met in current location. The record also reflected that resident was enrolled in hospice on [DATE].
A complete record review was completed on [DATE] at 2:40 PM. Resident's care plan was updated on [DATE] to include hospice services. The care plan instructed, Avoid hospitalization if condition worsens. DO NOT CALL 911 - CALL HOSPICE and ask to speak to Hospice nurse on call.
During an interview on [DATE] at 8:34 AM, Social Worker #152 acknowledged the POST form had not been reviewed or updated when the care plan was updated to reflect the resident did NOT wish to be hospitalized if his condition worsened.
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Aug 2021
7 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0551
(Tag F0551)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on record review and staff interview, the facility failed to ensure a resident who lacked capacity to make medical decis...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on record review and staff interview, the facility failed to ensure a resident who lacked capacity to make medical decisions had a resident representative appointed for them in accordance with state laws/professional standards of care. This was a random opportunity for discovery. Resident identifier: #51. Facility census: 102.
Findings included:
a) Resident #51
An electronic medical record review was completed on 08/10/21 at 2:51 PM. Resident #51 was admitted to the facility on [DATE]. Resident #51 diagnoses included Multiple Sclerosis, Muscular Dystrophy, Cognitive Communication Deficit, and Quadriplegia. Section C of the admission Minimum Data Set (MDS), dated [DATE], listed Resident #51's cognitive skills for daily decision making as severely impaired. There was a scanned Physician's Determination of Capacity form, dated 06/17/21, noting Resident #51 lacks capacity to make medical decisions. Additionally, there was also a scanned Medical Power of Attorney (MPOA) form dated 10/18/18. The Patient or Patient Representative signature line on MPOA read [Resident #51's First and Last Name] by [Resident #51's Mother's First and Last Name].
The WV Center for End-of-Life Care guidance states if an individual cannot designate a medical power of attorney (MPOA) representative through a MPOA form your health care providers will assign a representative to make medical decisions on your behalf. This individual is your health care surrogate [HCS]. The guidance further explains that a HCS form is used when a patient lacks capacity to appreciate the nature and implications of a health care decision, to make an informed choice regarding the alternatives presented, and to communicate that choice in an unambiguous manner.
During an interview on 08/11/21 at 12:46 PM, Social Worker #93 reported upon Resident #51's admission, she recognized the MPOA form presented had not been completed by an individual who had capacity to appoint a decision-maker to make medical decisions; rather, Resident #51's mother had completed and assigned the form. Social Worker #93 provided evidence she posted a note for the doctor to review which stated: FYI-The MPOA is not valid because the mother signed for him. It should be a HCS [Health Care Surrogate]. Social Worker #93 reported the physician failed to respond and she failed to follow-up on the concern. The facility only had the MPOA and POST form (completed with Resident #51's mother) on file. Social Worker #51 acknowledged the paperwork they had on file was not in accordance with state laws/professional standards of care.
During an interview on 08/11/21 at 1:00 PM, the Administrator stated she understood the facility failed to ensure a resident who lacked capacity to make medical decisions had a resident representative appointed for them and the facility would immediately request that the physician appoint a Health Care Surrogate to act on Resident #51's behalf.
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CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0558
(Tag F0558)
Could have caused harm · This affected 1 resident
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Based on observation, resident interview and staff interview, the facility failed to provide a safe homelike environment for Resident #42. This was a random opportunity for discovery. Resident ident...
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Based on observation, resident interview and staff interview, the facility failed to provide a safe homelike environment for Resident #42. This was a random opportunity for discovery. Resident identifier: #42. Facility census 102.
Findings included:
a) Resident #42
On 8/12/21 at 9:16 AM Resident #42 voiced concerns with the dresser being to large and having bed extender on bed which resident #42 stated, I do not need bed extender on my bed I am only five (5) foot eight (8). I have to put my hands inside the wheelchair and move with my feet to get out of my room. I have gotten skin tears on my arms from trying to get through the small area. In addition, this resident also stated, the environmental supervisor had promised to get a smaller dresser for a long time and as you can see I still do not have one.
On 8/12/21 at 10:05 AM an observation/interview was conducted with the Environmental Supervisor (ES) #75 in Resident #42's room to witness concerns with the dresser and bed extender causing Resident #42 to have a difficult time getting out of the room. The ES #75 stated, I have ordered dressers almost a year ago from (store name) and they are on back order. I do have a dresser out in storage that just needs to be put together. The ES #75 agreed that with the larger dresser and bed extender in Resident #42's room, it does make it hard for the resident to get through the small space in order to leave room. ES #75 stated, I will see about getting a smaller dresser in Resident #42's room and about removing the bed extender.
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CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0578
(Tag F0578)
Could have caused harm · This affected 1 resident
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Based on record review and staff interview, the facility failed to ensure one (1) of 21 residents reviewed during the long-term care survey process had a Physician Orders for Scope of Treatment (POS...
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Based on record review and staff interview, the facility failed to ensure one (1) of 21 residents reviewed during the long-term care survey process had a Physician Orders for Scope of Treatment (POST) form completed correctly per directions specified by the [NAME] Virginia Center for End-of-Life Care. Resident identifier: #51. Facility census: 102.
Findings included:
a) Resident #51
An electronic medical record review was completed on 08/10/21 at 2:51 PM. There was a scanned Physician's Determination of Capacity form, dated 06/17/21, noting Resident #51 lacks capacity to make medical decisions.
Additionally, a completed 2021 Edition of the POST form was also found in Resident #12's medical record. On the back of the POST form, the Patient's Emergency Contact information section was left blank.
Review of the Using the POST Form Guidance for Health Care Professionals, 2021 Edition, revealed all sections of the POST form being completed leads to providing the most accurate information related to the patient. This information can be highly beneficial in the continuum of patient care.
During an interview on 08/11/21 at 12:45 AM, Social Worker #93 acknowledged the importance of including Resident #51's emergency contact information since he lacked capacity to make his own medical decisions.
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CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Transfer Notice
(Tag F0623)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on medical record review and staff interview, the facility failed to ensure a written Notice of Transfer / Discharge was...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on medical record review and staff interview, the facility failed to ensure a written Notice of Transfer / Discharge was provided for two (2) of two (2) residents reviewed for hospitalizations during the long-term care survey process. This had the potential to affect a limited number of residents. Resident identifiers: #98 and #102 . Facility census: 102.
Findings included:
a) Resident #98
A medical record review was completed on 08/12/21 at 9:25 AM. The record review revealed Resident #98 was transferred to the hospital on [DATE]. The record did not reflect the resident/resident's representative was provided with a written Notice of Transfer indicating the reason for transfer, the effective date of transfer, the location to which the resident was being transferred, and a statement of the resident's appeal rights.
During an interview on 08/12/21 at 9:58 AM, Social Worker (SW) #93 reported there was no evidence a written Notice of Transfer was provided to Resident #98. Additionally, SW #93 reported there was no evidence the long-term care Ombudsman was notified of the transfer.
b) Resident #102
A medical record review was completed on 08/11/21 at 2:13 PM. The record review revealed Resident #102 was transferred to the hospital on [DATE]. The record did not reflect the resident/resident's representative was provided with a written Notice of Transfer indicating the reason for transfer, the effective date of transfer, the location to which the resident was being transferred, and a statement of the resident's appeal rights.
During an interview on 08/11/21 at 2:45 PM, SW #93 reported there was no evidence a written Notice of Transfer was provided to Resident #102. Additionally, SW #93 reported there was no evidence the long-term care Ombudsman was notified of the transfer.
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CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
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Based on observation, interview, and policy review, the facility failed to ensure the residents' environment was free of accident hazards over which it had control. A bottle of hand sanitizer, trays...
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Based on observation, interview, and policy review, the facility failed to ensure the residents' environment was free of accident hazards over which it had control. A bottle of hand sanitizer, trays of bread, and bottles of fountain syrup were stored in the dining room and accessible to residents. This had the potential to affect a limited number of residents. Facility Census: 102.
Findings included:
a) Dining Room
On 08/10/21 at 3:49 PM, a dining room observation found nine (9) trays of bread uncovered, four (4) gallon jug bottles of fountain syrup stored on top of a rolling storage cart, and a bottle of hand sanitizer with the wording keep out of reach of children stored in an unlocked drawer.
The Dietary Manager reported the bread was temporarily stored in the dining room, but acknowledged the bread was accessible to anyone entering the dining room and could be a choking hazard for any resident on a restricted / modified diet.
The Activity Director acknowledged the activity department had stored jugs of fountain syrup in the corner of the dining room. The Activity Director acknowledged the fountain syrup was accessible to anyone entering the dining room and could be a choking hazard for any resident on a restricted / modified diet.
The bottle of hand sanitizer was discovered in an unlocked drawer in the dining room. It was also accessible to any resident. Review of the facility's Environmental Services Safety Procedures states Staff will ensure equipment (e.g., cords, ladders, or chemicals) is properly stored and not left unattended in areas that are accessible to residents. Both the Dietary Manager and the Activity Director acknowledged the hand sanitizer was accessible to any resident who may enter the dining room and could pose a health risk if ingested by a cognitively impaired resident.
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CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected 1 resident
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Based on observation and staff interview, the facility failed to properly store food items within professional standards of practice. This had the potential to affect a limited number of residents b...
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Based on observation and staff interview, the facility failed to properly store food items within professional standards of practice. This had the potential to affect a limited number of residents being served by the kitchen. Facility Census: 102
Findings included:
a) Food stored in dining room
On 08/10/21 at 3:49 PM, a dining room observation found nine (9) trays of bread uncovered and four (4) gallon jug bottles of fountain syrup stored on top of a rolling storage cart.
The Dietary Manager reported the bread was temporarily stored in the dining room. The Dietary Manager acknowledged the bread was accessible to anyone entering the dining room and could be contaminated by a resident should they open a loaf to retrieve a slice.
The Activity Director acknowledged the activity department had stored jugs of fountain syrup in the corner of the dining room. The Activity Director acknowledged the fountain syrup was accessible to anyone entering the dining room and could be contaminated by a resident should they open the jug to taste the syrup.
A second dining room observation, on 08/11/21 at 3:25 PM, revealed six (6) trays of bread uncovered on a rack and a cart full of trays with individually packaged cereal as well as individual bowls of cereal covered with saran wrap in the far corner of the dining room. The bread and the cereal would be accessible to anyone entering the dining room and could be contaminated by a resident should they open the items.
At approximately 3:55 PM, an unidentified resident wheeled herself into the dining room in search of ice cream and a drink. The resident found it necessary to knock multiple times on the adjoining kitchen door before being heard. Kitchen staff then entered the dining room and began to assist resident with the request for ice cream and a drink.
Review of the facility's list of confused and wandering residents revealed there were eleven (11) residents in this category that could potentially find their way to the dining room unattended and unsupervised.
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CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
e) Resident #42
On 8/12/21 at 9:20 AM in an interview with Resident #42 voiced a concern the commode in the bathroom is leakin...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
e) Resident #42
On 8/12/21 at 9:20 AM in an interview with Resident #42 voiced a concern the commode in the bathroom is leaking at the base and has for some time. Resident #42 stated, my feet get wet every time I go to the bathroom.
On 8/12/21 at 10:15 AM in the presence of the Environmental Supervisor (ES) #75 agreed the commode in Resident #42 had water laying around the base and needed repaired.
Based on observation and staff interview, the facility failed to honor the residents' right to a safe, clean, comfortable, and homelike environment. The facility failed to ensure the dining room floor was free from sticky residue, walls in resident rooms were not in good repair, and 2 (two) toilets were not in good working order. Room identifiers: Dining Room, room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], and room [ROOM NUMBER]. Facility Census: 102.
Findings included:
a) Dining Room Floor
During a dining room observation on 08/10/21 at 3:40 PM, multiple rolling storage carts were stored on the left side of the dining room while not in use.
While walking across the same portion of the dining room floor the next day, on 08/11/21 at 2:50 PM, this Surveyor noted the floor had several dark, sticky residue areas that were visibly noticeable. The stickiness resulted in Surveyor's shoes squeaking and adhering to the floor as it was crossed. Additionally, there were approximately five (5) black, glue-like residue areas in the shape of X's noticeable throughout the entire dining room floor.
An interview with Dietary Worker #28, on 08/11/21 at 3:48 PM, confirmed the presence of sticky residue spots on the left side of the dining room. Dietary Worker #28 also acknowledged the black, glue-like residue areas in the shape of X's noting those were from tape residue remaining from the removal of several taped X's from the facility's COVID-19 social distancing days. Dietary Worker #28 recognized the sticky floors failed to honor the residents rights to a clean and homelike environment.
On 08/12/21 at 9:00 AM, the Administrator reported that housekeeping staff were responsible for cleaning the dining room floor and were addressing the sticky residue.
b) room [ROOM NUMBER]
On 08/10/21 at 12:06 PM, it was observed the wall to the left of Resident #353's headboard had two (2) scraped square areas approximately 8 inches in length. Additionally, there was a long scrape on the lower part of the wall to the left of the bed.
The Environmental Supervisor was interviewed on 08/11/21 at 1:12 PM. At that time, the Environmental Supervisor acknowledged the scrapes on the wall and mentioned they more than likely had been caused by bed armatures. The Environmental Supervisor agreed the scrapes did not ensure a homelike environment and stated they would be addressed promptly.
c) room [ROOM NUMBER]
On 08/10/21 at 12:09 PM, it was observed Resident #354's toilet was running. Resident #354 acknowledged the tank frequently runs and suggested Surveyor Jiggle the handle. They sometimes get it to stop that way. CNA #139 was asked to come to the room. CNA #139 jiggled the handle then lifted the tank lid to investigate further. CNA #139 stated It must be the thing inside the tank. I will put in a work order for it to be fixed. CNA #139 confirmed the running toilet, the need to jiggle the handle, and it working intermittently failed to provide a homelike environment.
d) room [ROOM NUMBER]
On 08/10/21 at 12:16 PM, it was observed the towel rack in Resident #102's bathroom had large blotches of plaster around the two parts where it was anchored to the wall. Additionally, the wall by the toilet had scrapes / deep gouge marks.
During an interview with the Environmental Supervisor on 08/11/21 at 1:15 PM, the Environmental Supervisor confirmed the scrapes were patched plaster area around the towel rack and the scrapes on the wall in the bathroom were not very homelike and would be addressed. The Environmental Supervisor added she thought the scrapes probably came from the use of a mechanical lift.
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Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated
K - Pattern
L - Widespread
Actual Harm
G - Isolated
H - Pattern
I - Widespread
Potential for Harm
D - Isolated
E - Pattern
F - Widespread
No Harm (Minor)
A - Isolated
B - Pattern
C - Widespread
Questions to Ask on Your Visit
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • No major safety red flags. No abuse findings, life-threatening violations, or SFF status.
- • No fines on record. Clean compliance history, better than most West Virginia facilities.
Concerns
- • 51 deficiencies on record. Higher than average. Multiple issues found across inspections.
- • Grade C (50/100). Below average facility with significant concerns.
Bottom line: Mixed indicators with Trust Score of 50/100. Visit in person and ask pointed questions.
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About This Facility
What is Keyser Healthcare Center's CMS Rating?
CMS assigns KEYSER HEALTHCARE CENTER an overall rating of 2 out of 5 stars, which is considered below average nationally. Within West Virginia, this rating places the facility higher than 0% of the state's 100 nursing homes. A rating at this level reflects concerns identified through health inspections, staffing assessments, or quality measures that families should carefully consider.
How is Keyser Healthcare Center Staffed?
CMS rates KEYSER HEALTHCARE CENTER's staffing level at 3 out of 5 stars, which is average compared to other nursing homes. Staff turnover is 48%, compared to the West Virginia average of 46%.
What Have Inspectors Found at Keyser Healthcare Center?
State health inspectors documented 51 deficiencies at KEYSER HEALTHCARE CENTER during 2021 to 2024. These included: 51 with potential for harm. While no single deficiency reached the most serious levels, the total volume warrants attention from prospective families.
Who Owns and Operates Keyser Healthcare Center?
KEYSER HEALTHCARE CENTER is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility is operated by COMMUNICARE HEALTH, a chain that manages multiple nursing homes. With 122 certified beds and approximately 113 residents (about 93% occupancy), it is a mid-sized facility located in KEYSER, West Virginia.
How Does Keyser Healthcare Center Compare to Other West Virginia Nursing Homes?
Compared to the 100 nursing homes in West Virginia, KEYSER HEALTHCARE CENTER's overall rating (2 stars) is below the state average of 2.7, staff turnover (48%) is near the state average of 46%, and health inspection rating (2 stars) is below the national benchmark.
What Should Families Ask When Visiting Keyser Healthcare Center?
Based on this facility's data, families visiting should ask: "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" "Can I speak with family members of current residents about their experience?"
Is Keyser Healthcare Center Safe?
Based on CMS inspection data, KEYSER HEALTHCARE CENTER has a clean safety record: no substantiated abuse findings (meaning no confirmed cases of resident harm), no Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death), and is not on the Special Focus Facility watch list (a federal program monitoring the lowest-performing 1% of nursing homes). The facility has a 2-star overall rating and ranks #100 of 100 nursing homes in West Virginia. While no facility is perfect, families should still ask about staff-to-resident ratios and recent inspection results during their visit.
Do Nurses at Keyser Healthcare Center Stick Around?
KEYSER HEALTHCARE CENTER has a staff turnover rate of 48%, which is about average for West Virginia nursing homes (state average: 46%). Moderate turnover is common in nursing homes, but families should still ask about staff tenure and how the facility maintains care continuity when employees leave.
Was Keyser Healthcare Center Ever Fined?
KEYSER HEALTHCARE CENTER has no federal fines on record. CMS issues fines when nursing homes fail to meet care standards or don't correct problems found during inspections. The absence of fines suggests the facility has either maintained compliance or corrected any issues before penalties were assessed. This is a positive indicator, though families should still review recent inspection reports for the full picture.
Is Keyser Healthcare Center on Any Federal Watch List?
KEYSER HEALTHCARE CENTER is not on any federal watch list. The most significant is the Special Focus Facility (SFF) program, which identifies the bottom 1% of nursing homes nationally based on persistent, serious quality problems. Not being on this list means the facility has avoided the pattern of deficiencies that triggers enhanced federal oversight. This is a positive indicator, though families should still review the facility's inspection history directly.