MARMET CENTER
For profit - Corporation
90 Beds
GENESIS HEALTHCARE
Data: November 2025
1 Immediate Jeopardy citation
Trust Grade
18/100
#105 of 122 in WV
Photo by Marmet Center
Photo by Marmet Center
Photo by Marmet Center
1 / 5 photos
Last Inspection: December 2024
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
Marmet Center in Marmet, West Virginia has received a Trust Grade of F, indicating significant concerns about the quality of care provided, which places them in the poor category. With a state rank of #105 out of 122 facilities, they are in the bottom half of West Virginia, and they are ranked last in Kanawha County with #11 out of 11. Although the facility is showing improvement, having reduced issues from 25 in 2024 to 7 in 2025, there are still many serious problems to address. Staffing is a concern with a 1 out of 5 stars rating and RN coverage lower than 84% of state facilities, which means residents may not receive adequate oversight and care. The facility has faced $72,205 in fines, higher than 90% of facilities in West Virginia, signaling ongoing compliance issues. Specific incidents of concern include a resident not receiving appropriate medical care despite critical needs and failure to maintain sanitary food storage and cleanliness in common areas, which could pose health risks to residents. Overall, while there are some signs of improvement, families should weigh these serious deficiencies carefully.
- Trust Score
- F
- In West Virginia
- #105/122
- Safety Record
- High Risk
- Inspections
- Getting Better
- Staff Stability ○ Average
- 42% turnover. Near West Virginia's 48% average. Typical for the industry.
- Penalties ○ Average
- $72,205 in fines. Higher than 59% of West Virginia facilities. Some compliance issues.
- Skilled Nurses ⚠ Watch
- Each resident gets only 24 minutes of Registered Nurse (RN) attention daily — below average for West Virginia. Fewer RN minutes means fewer trained eyes watching for problems.
- Violations ⚠ Watch
- 79 deficiencies on record. Higher than average. Multiple issues found across inspections.
18/100
Bottom 14%
Review needed
25 → 7 violations
★☆☆☆☆
1.0
Overall Rating
★☆☆☆☆
1.0
Staff Levels
★★★★☆
4.0
Care Quality
★★☆☆☆
2.0
Inspection Score
↔
Stable
2024: 25 issues
2025: 7 issues
The Good
-
4-Star Quality Measures · Strong clinical quality outcomes
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
-
Staff turnover below average (42%)
6 points below West Virginia average of 48%
Facility shows strength in quality measures, fire safety.
The Bad
1-Star Overall Rating
Below West Virginia average (2.7)
Significant quality concerns identified by CMS
Staff Turnover: 42%
Near West Virginia avg (46%)
Typical for the industry
Federal Fines: $72,205
Well above median ($33,413)
Moderate penalties - review what triggered them
Chain: GENESIS HEALTHCARE
Part of a multi-facility chain
Ask about local staffing decisions and management
The Ugly 79 deficiencies on record
1 life-threatening
Jun 2025
2 deficiencies
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected multiple residents
Based on observation, document review, and staff interviews, the facility failed to ensure they stored food in accordance with professional standards for food quality. The facility failed to maintain ...
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Based on observation, document review, and staff interviews, the facility failed to ensure they stored food in accordance with professional standards for food quality. The facility failed to maintain proper refrigerator temperatures of the refrigerator located in the Rehab pantry room. This deficiency has the potential to affect more than an isolated number of residents, staff and visitors within the Facility census: 84.
Findings include:
a) On 06/25/25 at approximately 10:30 a.m., the Rehab Pantry room refrigerator had temperatures documented greater than 41 degrees Fahrenheit on the PM temperature check on the following dates with no documentation of the corrective issue (06/09/25, 06/14/25, 06/17/25, 06/21/25, 06/22/25, and 06/24/25).
On 06/25/25 at approximately 10:30 a.m., there was no documented temperature for the AM temperature check on 06/24/25.
Interview with the facility's Director of Nursing verified these findings at the time of discovery. The finding was also acknowledged by the facility Administrator at the time of discovery and upon exit on 06/25/25 at approximately 12:45 p.m.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0921)
Could have caused harm · This affected multiple residents
Based on observation and staff interviews, the facility failed to maintain a sanitary environment related to gnats and a damaged countertop located in the Rehab pantry room. This deficiency has the po...
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Based on observation and staff interviews, the facility failed to maintain a sanitary environment related to gnats and a damaged countertop located in the Rehab pantry room. This deficiency has the potential to affect more than an isolated number of residents. Facility census: 84.
Findings include:
On 06/25/25 at approximately 11:05 a.m., this surveyor observed several gnats on the left hand side of the Rehab pantry room sink countertop .
On 06/25/25 at approximately 11:05 a.m., this surveyor observed exposed damp wood on the left hand side of the countertop sink located in the Rehab Pantry room.
Interview with the facility's Maintenance Director verified the findings at the time of discovery. The finding was also acknowledged by the facility Administrator at the time of discovery and upon exit on 06/25/25 at approximately 12:45 p.m.
Feb 2025
5 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
Resident Rights
(Tag F0550)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, resident interview and staff interview the facility failed to provide a dignified and respe...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, resident interview and staff interview the facility failed to provide a dignified and respectful existence for Resident #84. This was true for one (1) resident of one (1) residents reviewed during the survey process. Resident identifier: #84. Facility census: 88.
Findings include:
a) Resident #84
On 02/03/25 at 10:00 AM, a record review was completed for Resident #84. The review found the resident had been placed on one-on-one (1:1) monitoring on 01/17/25 at 6:00 PM. The reason for the 1:1 monitoring was noted in the change in condition dated 01/17/25. The reason noted was resident trashed his room, kicking heater, letting the water run in his sink trying to flood room, cursing, throwing razors all over his room. The 1:1 monitoring was for 24 hours daily since 01/17/25. The resident's door was always left open; including during toileting, bathing and changing clothes.
On 02/03/25 at approximately 12:30 PM, the resident was interviewed regarding the 1:1 monitoring. The resident stated, They will not let me shut my door any time .even when I'm using the bathroom or changing clothes .it's embarrassing knowing anyone can walk by and see me anytime. They (staff) accused me of having a temper tantrum .that's not what happened .I accidentally knocked over the tray table in the bathroom while trying to maneuver my wheelchair .which knocked everything off including razors .I was pushing them with my feet so I would not run over them .they are too expensive .when the Director of Nursing (DON) or the Assistant Director of Nursing (ADON) come in, they speak to me like I'm a child .it's like they want to make me mad .just saying things over and over again .I have told them I don't want to talk and they continue to keep hashing it over and won't leave me alone until I calm down.
On 02/03/25 at 1:15 PM, an interview with the Administrator was held. The Administrator stated, (Name of resident) is always yelling and cursing at staff .the staff is afraid to be in the room with him by themselves. The Administrator was asked, Do you think he should have privacy while bathing, dressing and using the bathroom? The Administrator stated, We have offered a privacy curtain and he doesn't want it. The Administrator was then asked, Do you think a privacy curtain is sufficient for an alert and orient [AGE] year-old man who has capacity? The Administrator stated, I don't know what else to do when the staff are afraid of him because of his behaviors . The Administrator was then asked, How long will he remain on 1:1 monitoring? The Administrator stated, The DON and I were going to look at that today .
A review of the behaviors from 01/17/25 through 02/03/25 was completed. The resident had three (3) documented behaviors during this time. The behaviors noted were yelling or cursing but within the next 15 minutes the resident had calmed down with no additional interventions needed.
An additional interview was held with the DON on 02/03/25 at 3:30 PM. The DON stated, They can crack the door .and still see him. The Administrator stated, We will review the records and see if we can discontinue the 1:1 monitoring.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected 1 resident
Based on record review and staff interview, the facility failed to report two (2) changes in conditions for reasonable suspicion of a crime to the appropriate State agencies for Resident #84. This was...
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Based on record review and staff interview, the facility failed to report two (2) changes in conditions for reasonable suspicion of a crime to the appropriate State agencies for Resident #84. This was true for one (1) of one (1) residents reviewed during the survey process. Resident identifier: #84. Facility Census: 88.
Findings include:
a) Resident #84
On 02/03/25 at 10:00 AM, a record review was completed for Resident #84. The review found two (2) changes in conditions for the resident regarding behaviors; and the staff calling the local police to report a suspicion of a crime on 01/17/25 and 01/24/25.
The incident on 01/17/25 was related to resident trashed his room, kicking heater, letting water run in his sink trying to flood room, cursing, throwing razors all over his room. (Typed as written.) The facility physician recommended sending the resident to an acute care facility for a psychiatric evaluation. The resident had the capacity to make medical decisions and refused to go out of the facility. The staff called the local police department due to the resident's behaviors.
The incident on 01/24/25 was related to resident wanted to keep his door shut and residents being on 1:1 observation from previous behavior. When opening the door, the resident started screaming and cussing towards staff. Resident then proceeded to slam the door and then kicking it, causing harm to a coworker. (Typed as written.)
An interview was held with Resident #84 on 02/03/25 at 12:30 PM. The resident was interviewed regarding the 1:1 monitoring. The resident stated, They will not let me shut my door any time .even when I'm using the bathroom or changing clothes .it's embarrassing knowing anyone can walk by and see me anytime. They (staff) accused me of having a temper tantrum .that's not what happened .I accidentally knocked over the tray table in the bathroom while trying to maneuver my wheelchair .which knocked everything off including razors. I was pushing them with my foot so I would not run over them .they are too expensive. When the Director of Nursing (DON) or the Assistant Director of Nursing (ADON) comes in, they speak to me like I'm a child. It is like they want to make me mad just saying things over and over again. I have told them I don't want to talk, and they continue to keep hashing it over and won't leave me alone until I calm down. The resident was then asked about the incident on 01/24/24. The resident stated, I wanted my door closed. I was using the phone, and I couldn't hear because of the noise in the hallway. The ADON opened my door and yelled at me saying (Name of resident) you know you have to keep your door open. The resident stated, I did shut my door, and I was upset. I was talking on the phone. (Name of ADON) did not get hurt and I did not slam her hand in the door.
On 02/03/25 at 2:20 PM, the Administrator was interviewed regarding the two (2) incidents when the local police were called. The Administrator stated, We called the police because of (Name of Resident)'s behaviors. The staff was upset and afraid. The second time was because he hurt a staff member . The Administrator was then asked, What injuries did the staff member receive from this incident? The Administrator stated, The staff member did not have any injuries from this encounter with the resident. The Administrator stated, The police department did make reports, but we haven't received anything yet. The Administrator stated, the Director of Nursing (DON) and I were going to discuss the 1:1 monitoring and if it could be discontinued. The Administrator stated, I didn't feel this was something to report . The Administrator was asked, Why did you call the police? Did you feel like a suspected crime had taken place? The Administrator stated, I guess I really didn't look at it that way.
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 obtain a Physicians order to place a resident on one-on-one observation status. There was also no indication the facility updated the ...
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Based on record review and staff interview the facility failed to obtain a Physicians order to place a resident on one-on-one observation status. There was also no indication the facility updated the physician when the resident refused to go out for evaluation. These issues were found for one (1) of one (1) residents reviewed. Resident identifier: #84 Facility census: 88
Findings Include
a) Resident #84
On 01/17/25 at 6:00 PM the facility placed Resident #84 on a one-on-one observation status due to behavior. This continued to be in place as of 02/03/25 at the time of the complaint investigation.
The incident on 01/17/25 was related to resident trashed his room, kicking heater, letting water run in his sink trying to flood room, cursing, throwing razors all over his room. (Typed as written.) The facility physician recommended sending the resident to an acute care facility for a psychiatric evaluation. The resident had the capacity to make medical decisions and refused to go out of the facility. The staff called the local police department due to the resident's behaviors.
Record review of the current physician's orders for Resident #84 showed there was no order in place for a one-on-one status for this resident. Review of the change in condition on 01/17/25 stated: Recommendations: send out for psych eval. There was no documentation of an order for a one on one sitter.
On 02/03/25 at 3:30 PM it was confirmed with the Administrator that there was no current order for a one-on-one observation. No additional information was provided throughout the entirety of the investigation.
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
Based on record review and staff interview, the facility failed to maintain accurate and complete medical records for Resident #84. This was true for one (1) of one (1) residents reviewed during the s...
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Based on record review and staff interview, the facility failed to maintain accurate and complete medical records for Resident #84. This was true for one (1) of one (1) residents reviewed during the survey. Resident identifier: #84. Facility Census: 88.
Findings Include:
a) Resident #84
On 02/03/25 at 10:00 AM, a record review was completed for Resident #84. The review found the [NAME] Virginia (WV) Physician Order for Scope of Treatment (POST) form did not have documentation of the preparer's signature or date.
On 02/03/25 at 10:10 AM, the Administrator stated, We will get this corrected.
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
Based on observation, policy review and staff interview the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable ...
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Based on observation, policy review and staff interview the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. This had the potential to affect more than an isolated number of residents. Facility census: 88.
Findings Include:
a) Upon entry of the facility on 02/03/25 there was a sign in place on the main entrance door that indicated the facility was in a COVID outbreak. This was confirmed with the Administrator.
On 02/03/25 at 12:20 PM Nurse Aides #40 and #51 were seen on C Hall with their N-95 mask off their face and down under their chin.
According to the facility policy for Infection Control (IC405 COVID-19) revision date of 07/01/24 under General Standard Precautions: .follow Center for Disease Control and Prevention (CDC) published guidance related to the use of facemask, respirators, gowns, gloves and eye protection . The CDC recommends general standard precautions to prevent and control the spread of COVID-19. These precautions include: wearing well-fitting masks .
During an interview with the Administrator on 02/03/25 at 12:22 PM the Administrator stated all staff members were to wear N-95 respirators when they have an active case of COVID in the building. It was confirmed with the Administrator that the two (2) staff members listed above did not have face masks in place on the residents' hall
Dec 2024
17 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0645
(Tag F0645)
Could have caused harm · This affected 1 resident
Based on record review and staff interview the facility failed to ensure a resident's Preadmission Screening and Resident Review (PASARR) reflected the pre admission diagnoses sheet for schizophrenia ...
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Based on record review and staff interview the facility failed to ensure a resident's Preadmission Screening and Resident Review (PASARR) reflected the pre admission diagnoses sheet for schizophrenia and anxiety disorder, This was true for one (1) of three (3) PASRR's reviewed. Resident identifier: #37. Facility Census: #89.
Findings include:
a) Resident #37
On 12/16/24 at 9:10 AM record review of the PASARR for Resident #37 showed a preadmission diagnosis of schizophrenia and anxiety disorder. Review of the PASRR provided by the facility which was submitted on 04/02/19, when the resident was transferred from another facility, did not have a preadmission diagoses of schizophrenia or anxiety disorder.
Resident #37 had the following active orders:
Ativan Oral Tablet 0.5 milligram (MG) (Lorazepam) Give 1 tablet by mouth at bedtime for Anxiety/agitation As evidenced by (AEB): pulling out PEG tube
RisperiDONE Oral Solution (Risperidone) Give 0.125 mg via G-Tube at bedtime for schizophrenia AEB: poor impulse control
On 12/16/24 at 2:10 PM, during an interview with Social Worker #98, she confirmed the missing diagnosis on the PASRR and stated it definitely should have been re-submitted. She attempted to locate an up to date PASRR but could not produce the document.
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 develop a comprehensive care plan in the area of anticoagulant medication for one (1) of five (5) residents reviewed for the care are...
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Based on record review and staff interview, the facility failed to develop a comprehensive care plan in the area of anticoagulant medication for one (1) of five (5) residents reviewed for the care area of unnecessary medications. Resident identifier: #34. Facility census: 89.
Findings included:
a) Resident #34
Review of Resident #34's physician's orders showed the resident had been receiving the anticoagulation medication apixaban (Eliquis) for atrial fibrillation since 07/19/24. Bleeding is a side effect of anticoagulation medication. Residents receiving anticoagulation medication must be monitored for signs and symptoms of bleeding such as bloody stool or urine, nosebleeds, bruising, or changes in mental status or vital signs.
Review of Resident #34's comprehensive care plan showed the care plan did not have a focus related to anticoagulation medication with interventions to monitor for signs and symptoms of bleeding.
On 12/17/24 at 1:43 PM, the Clinical Resource Nurse confirmed Resident #34 had not been care planned for the use of anticoagulant medication.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected 1 resident
Based on resident interview, family interview, record review, and staff interview, the facility failed to provide oral care to a dependent resident. This deficient practice had the potential to affect...
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Based on resident interview, family interview, record review, and staff interview, the facility failed to provide oral care to a dependent resident. This deficient practice had the potential to affect one (1) of four (4) residents reviewed for the care area of activities of daily living. Resident identifier: #69. Facility census: 89.
Findings included:
a) Resident #69
During an interview on 12/15/24 at 3:29 PM, Resident #69 stated she is not getting her teeth brushed twice a day per her wishes. She stated her teeth had not been brushed last night or this morning.
The resident's family member was in the room for the interview and stated oral care was addressed at a recent care plan meeting but still was not being done twice a day.
A grievance and concern form had been completed on 12/10/24. The form stated, Resident stated teeth not getting brushed at times. The recommended corrective action was for the activities director to ensure each morning that teeth were getting brushed and for the Director of Nursing to spot check this.
A note written on the grievance/concern form stated, NHA [nursing home administrator] spoke to resident on 12/16/24. Resident stated [activities director] has come down to her room to ensure this is getting complete. Resident said night shift has also been brushing her teeth. NHA confirmed with resident this morning. CNA [certified nursing assistant] brushed her teeth and was satisfied. Will continue to monitor.
Review of Resident #69's comprehensive care plan showed the following focus: Resident exhibits or is at risk for oral health or dental care problems as evidenced by potential carious teeth. An intervention initiated 06/20/23 was to Encourage resident to brush teeth and gums with verbal cues as needed by staff. Provide assistance as needed.
The resident's care plan also indicated the resident required assistance with activities of daily living due to limited mobility and was dependent for transfer to her wheelchair.
Resident #69's quarterly Minimum Data Set (MDS) assessment with Assessment Reference Date (ARD) 11/25/24 showed the resident's Brief Interview for Mental Score (BIMS) score was 10, indicating mild cognitive impairment. The resident did not have capacity to make her own medical decisions.
Review of Resident #69's medical records showed a nurse aide task report for mouth care every morning and at bedtime. The task report gave the following documentation for oral care for December 2024:
- 12/01/24: no documentation that oral care was performed
- 12/02/24: documentation at 11:46 AM that the resident performed oral care; no documentation in the evening that oral care was performed.
- 12/03/24: documentation at 12:37 PM that oral care was not applicable; no documentation in the evening that oral care was performed.
- 12/04/24: documentation at 2:59 PM that the resident performed oral care; no documentation in the evening that oral care was performed.
- 12/05/24: documentation at 2:59 PM that oral care was not applicable; no documentation in the evening that oral care was performed.
- 12/06/24: documentation at 9:55 AM that the resident performed oral care; no documentation in the evening that oral care was performed.
- 12/07/24: documentation at 1:38 PM that the resident performed oral care; no documentation in the evening that oral care was performed.
- 12/08/24: documentation at 10:07 AM that the resident performed oral care; no documentation in the evening that oral care was performed.
- 12/09/24: documentation at 11:52 AM that the resident performed oral care; no documentation in the evening that oral care was performed and documentation at 10:49 PM that the staff performed oral care for the resident.
- 12/10/24: documentation at 2:59 PM that the resident performed oral care; no documentation in the evening that oral care was performed.
- 12/11/24: documentation at 11:59 AM that staff performed oral care for the resident; no documentation in the evening that oral care was performed.
- 12/12/24: no documentation that oral care was performed that day.
- 12/13/24: no documentation that oral care was performed that day.
- 12/14/24: no documentation that oral care was performed that day.
- 12/15/24: documentation at 2:59 PM that the resident performed oral care; no documentation in the evening that oral care was performed.
- 12/16/24: no documentation that oral care was performed that day.
- 12/17/24: documentation at 12:07 PM that the resident performed oral care; no documentation in the evening that oral care was performed.
On 12/18/24 at 11:23 AM, the Administrator confirmed the nurse aid task report did not document twice daily mouth care was being performed for Resident #69.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
Based on record review and staff interview the facility failed to follow physician's orders to obtain weights on a weekly basis and to apply a hand splint. This was true for two (2) of twenty six (26)...
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Based on record review and staff interview the facility failed to follow physician's orders to obtain weights on a weekly basis and to apply a hand splint. This was true for two (2) of twenty six (26) residents reviewed in the survey sample. Resident identifier #6, #58. Facility Census: #89.
a) Resident #6
On 12/17/24 at 10:02 AM record review shows a Physician's order dated 12/10/24 for weekly weights X's four (4) weeks due to weight loss.
Review of the documented weights show the facility did not get a weight until 12/16/24.
On 12/18/24 at 10:02 AM it was confirmed with the Director of Nursing and the Clinical Resource Nurse #96, who agreed that the weight should have been obtained on 12/10/24 or 12/11/24, depending on the time the order was placed.
b) Resident #58
On 12/15/24 at 12:53 PM during an interview with Resident #58 it was observed that her right hand was severely contracted. There was no splint in place.
On 12/16/24 at 12:45 PM record review showe Resident #58 had a medical diagnosis of contractures to the right hand and a Physician's order for resting hand splint to right hand when out of bed for four (4) hours daily. Monitor for redness, licensed nurse to assure skin integrity prior to apply and after removal every day shift.
On 12/16/24 at 1:00 PM review of the November and December 2024 Treatment Administration Record (TAR) shows the following dates the splint was not applied:
11/03/24
11/06/24
11/08/24
11/13/24
11/20/24
11/22/24
11/28/24
12/01/24
12/06/24
12/11/24
12/14/24
12/15/24
During an interview with the resident on 12/18/24 at 11:56 AM, she states it is over there (pointing to the bedside table) but they do not put it on me.
Observation of Resident #58 on the following dates and times found the resident did not have a splint on her right hand.
Observations:
12/15/24 12:53 PM no splint on.
12/15/24 03:53 PM no splint on
12/16/24 09:10 AM no splint on
12/16/24 11:30 AM no splint on
12/16/24 02:20 PM no splint on
12/17/24 09:10 AM no splint on
12/17/24 02:15 PM no splint on
12/18/24 09:25 AM no splint on
12/18/24 11:56 AM no splint on
On 12/18/24 at 12:10 PM the above findings were confirmed with the Director of Nursing and the Clinical Resource Nurse #96 who agreed the resident should have her splint on at least 4 (four) hours a day.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0692
(Tag F0692)
Could have caused harm · This affected 1 resident
Based on record review and staff interview the facility failed to ensure the residents maintained acceptable parameters of nutrition to prevent weight loss, by not documenting accurate meal intakes. T...
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Based on record review and staff interview the facility failed to ensure the residents maintained acceptable parameters of nutrition to prevent weight loss, by not documenting accurate meal intakes. This failed practice was found true for (1) one of (4) four residents reviewed for nutrition during the Long-Term Care Survey Process. Resident identifier #82. Facility Census 89.
Findings Include:
a) Resident #82
A record review on 12/15/24 at 3:44 PM, revealed that Resident #82 had the following weights recorded since 09/06/24:
11/28/24-108.8 Pounds (Lbs)
11/26/24 -110.0 Lbs
11/19/24 -110.0 Lbs
11/11/24 -110.0 Lbs
11/7/24 -110.2 Lbs
11/1/24-116.0 Lbs
11/1/24-116.0 Lbs
10/28/24 -115.6 Lbs
10/21/24-116.0 Lbs
10/14/24-118.6 Lbs
10/7/24-120.4 Lbs
9/30/24-122.6 Lbs
9/25/24-122.8 Lbs
9/6/24-140.8 Lbs
This averaged out to 22.73% percent weight loss in (2) two months.
Further record review of Resident #82's medical record revealed that her Ideal Body weight (IBW) was 125.1 Lbs.
A record review on 12/16/24 at 11:33 AM, of Resident #82's meal intake from 09/01/24 to present revealed that out of a possible 318 meals, 45 were not recorded. 75 of the 273 that were recorded revealed that Resident #82 had eaten 25% percent or less of her meal.
During an interview, on 12/16/24 at 1:48 PM, Clinical Resource Nurse (CRN) #96 stated, We feel like we had a problem with her admission weight. We think they just put the weight in from the hospital rather than weighing her. We do have a Performance Improvement Plan (PIP) for this issue.
During an interview, on 12/16/24 at 2:20 PM, the Registered Dietician (RD) stated, They do have a PIP on recording weights from the hospital rather than getting the actual weight. I feel like that might have happened.
During an interview, on 12/16/24 at 2:40 PM, the administrator confirmed the proper meal intake had not been recorded to get an actual picture of the cause of the weight loss.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0697
(Tag F0697)
Could have caused harm · This affected 1 resident
Based on record review and staff interview, the facility failed to monitor and treat pain in occurrence with professional standards of practice. This deficient practice had the potential to affect one...
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Based on record review and staff interview, the facility failed to monitor and treat pain in occurrence with professional standards of practice. This deficient practice had the potential to affect one (1) of five (5) residents reviewed for the care area of unnecessary medications. Resident identifier: #34. Facility census: 89.
Findings included:
a) Resident #34
The facility's policy titled Pain Management with effective date 01/01/04 and revision date 11/01/23 stated reasons for PRN (as needed) pain medication would be documented.
Review of Resident #34's physician's orders showed an order written on 08/04/24 for acetaminophen (Tylenol) 650 milligrams (mg) by mouth every six (6) hours as needed for pain.
Review of Resident #34's Medication Administration Record (MAR) showed the resident had received acetaminophen one (1) time, on 12/15/24 at 2:08 PM. The MAR documents the medication was effective in relieving the resident's pain. However, the location and the severity of the resident's pain was not recorded on the MAR or in the nurse's progress notes.
On 12/17/24 at 1:42 PM, the Clinical Resource Nurse confirmed assessment of Resident #34's pain had not been documented prior to administration of PRN medication on 12/15/24.
No further information was provided through the completion of the survey.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0806
(Tag F0806)
Could have caused harm · This affected 1 resident
Based on observation, resident interview and staff interview the facility failed to ensure residents special dietary requirements including preferences were met. This failed practice was a random oppo...
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Based on observation, resident interview and staff interview the facility failed to ensure residents special dietary requirements including preferences were met. This failed practice was a random opportunity for discovery during the Long-Term Care Survey Process. Resident identifier #54. Facility Census 89.
Findings Include:
a) Resident #54
An observation, on 12/15/24 at 1:04 PM, of Resident #54 eating lunch revealed that Resident #54 was served turkey, stuffing, and peas.
Further observation revealed a meal ticket that indicated Resident #54 was to receive a chicken sandwich, lettuce and tomato, chef salad and a baked potato.
During an interview on 12/15/24 at 1:04 PM, Resident #54 stated, I am supposed to get a salad. I don't always like what they give me but I try to eat it.
During an interview, on 12/15/24 at 1:06 PM, Dietary Aide #30 stated, We don't have the chicken sandwich. I took her a salad and put the baked potato in now.
A record review on 12/16/24 at 11:30 AM, revealed a Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/04/24, section C, that had a Brief Interview for Mental Status (BIMS) of 14. This score indicated the resident's cognitive response was intact.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected multiple residents
Based on observation and staff interview, the facility failed to ensure the resident environment over which it had control was as free from accident hazards as possible when a medication cart was left...
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Based on observation and staff interview, the facility failed to ensure the resident environment over which it had control was as free from accident hazards as possible when a medication cart was left unlocked and unattended and razors were found at the bedside. This was a random opportunity for discovery. This deficient practice had the potential to affect more than a limited number of residents. Resident identifiers: #69 and Facility. Facility Census: #89
Findings include:
a) Medication carts
On 12/16/24 at 7:55 AM upon arriving on the C-hall it was observed that the medication cart parked between Rooms #C-24 and #C-26 was unlocked and unattended. Licensed Practical Nurse (LPN) #26 came out of Room #C-22 which she had been in with the door closed.This was confirmed with LPN #26 at this time.
At 8:01 AM LPN #26 retrieved medications for the resident in #C-26 and went into the room, leaving the medication cart unattended and did not lock the medication cart.
On 12/16/24 8:30 AM it was confirmed with the Director of Nursing who confirmed the medication carts should remain locked when unattended.
b) Resident #69
On 12/17/24 at 10:22 AM, Resident #69's resident representative reported to the surveyo that the resident had razors in her bedside table.
On 12/17/24 at 10:25 AM, the Director of Nursing (DON) accompanied the surveyor into Resident #69's room and found two (2) razors in the resident's bedside table. The DON stated razors were not to be kept in residents' rooms unless they are in locked boxes for residents who are safe to use razors by themselves. She agreed other residents could have access to the razors in Resident #69's bedside table. She removed the razors from the resident's room and stated she would speak with the resident.
Resident #69's quarterly Minimum Data Set (MDS) assessment with Assessment Reference Date (ARD) 11/25/24 showed the resident's Brief Interview for Mental Score (BIMS) score was 10, indicating mild cognitive impairment. The resident did not have capacity to make her own medical decisions. The resident was independent for eating and was not on an anticoagulant medication.
No further information was provided through the completion of the survey process.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Drug Regimen Review
(Tag F0756)
Could have caused harm · This affected multiple residents
d) Resident #54
A record review on 12/17/24 at 1:00 PM, revealed that Resident #54 had no indications of a pharmacy review for the months of 01/2024, 02/2024, and 03/2024 in the medical record.
Durin...
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d) Resident #54
A record review on 12/17/24 at 1:00 PM, revealed that Resident #54 had no indications of a pharmacy review for the months of 01/2024, 02/2024, and 03/2024 in the medical record.
During an interview on 12/17/24 at 2:00 PM, the Clinical Resource Nurse (CRN) #96 stated, I ain't gonna lie. I can't find the pharmacy reviews for January, February or March.
Based on record review and staff interview, the facility failed to ensure the pharmacist completed monthly medication regimen reviews and that the physician addressed recommendations made by the pharmacist. This deficient practice had the potential to affect three (3) of five (5) residents reviewed for the care area of unnecessary medications. Resident identifiers: #34, #16, #54. Facility census: 89.
Findings included:
a) Policy review
The facility's policy titled Medication Regimen Review and Reporting dated January 2024 stated the consultant pharmacist would review the medication regimen and medical chart of each resident at least monthly.
The policy also stated the facility would follow up on pharmacy recommendations to verify appropriate action had been taken within thirty calendar days for issues that did not require urgent action. For issues requiring physician intervention, the attending physician would accept or reject recommendations, documenting rationale for rejections.
b) Resident #34
Review of Resident #34's pharmacist medication regimen reviews showed a review performed on 07/26/24. The review stated as follows:
Dear Dr. [name redacted]:
The resident has experienced a recent fall. After reviewing the current medications, please consider evaluating use of the following medications for possible discontinuation or change as it has a high potential for causing or contributing to falls and possible fracture.
Bupropion HCL (XL) tablet extended release 24 hour 300 mg [milligrams] daily
Duloxetine HCL capsule delayed release particles 60 mg daily
Trazodone 50 mg at bedtime.
The bottom of the review form contained a section for the physician or prescriber to agree or disagree with the recommendations, and to provide clinical rationale for disagreement if applicable. The section was blank.
Review of Resident #34's current physician's orders showed the resident's bupropion dosage had been decreased to 150 mg on 12/17/24. The resident's duloxetine dosage remained at 60 mg and the resident's Trazodone dosage remained at 50 mg.
On 12/17/24 at 11:39 AM, the Clinical Resource Nurse stated there was no documentation the physician had reviewed the pharmacy recommendations for Resident #34 on 07/26/24 and documented agreement or disagreement with the recommendations.
No further information was provided through the completion of the survey.
c) Resident #16
On 12/18/24 at 9:10 AM during a review for unnecessary medications, record review shows Resident #16 had dagnoses of dementia, severe with agitation, schizophrenia and anxiety disorder. There were also the following Physicians order:
Quetiapine Fumarate Tablet 50 milligram (MG) Give 1 tablet by mouth one time a day for schizophrenia as evidenced by (AEB): throwing things and using profanity.
Quetiapine Fumarate Oral Tablet 100 MG (Quetiapine Fumarate) Give 100 mg by mouth one time a day for schizophrenia AEB: throwing things and using profanity
Divalproex Sodium Oral Tablet Delayed Release 500 MG (Divalproex Sodium) Give 500 mg by mouth at bedtime for dementia w/behaviors AEB: throwing things and using profanity
Divalproex Sodium Oral Tablet Delayed Release 500 MG (Divalproex Sodium) Give 500 mg by mouth one time a day for behaviors supervised self-administration AEB: throwing things and using profanity
Record review of the last twelve (12) months of pharmacy Medication Regimen Reviews (MRR) found the January through March MRRs' not available.
On 12/17/24 at 1:02 PM the Clinical Resource Nurse #96 confirmed the January through March MRR's were not available.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected multiple residents
Based on observation and staff interview, the facility failed to store medications in accordance with professional standards of practice. Multi-use vials of medications stored in the D hallway med car...
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Based on observation and staff interview, the facility failed to store medications in accordance with professional standards of practice. Multi-use vials of medications stored in the D hallway med cart were past the manufacturer's expiration dates. Additionally, insulin pens for three (3) residents were not dated when first accessed. These were random opportunities for discovery during the medication storage and labeling facility task investigation. Resident identifiers: #390, #34, #7. Facility census: 89.
Findings included:
a) Expired medications
On 12/16/24 at 8:40 AM, Licensed Practical Nurse #24 was observed preparing medications for Resident #80. The resident poured a vitamin C tablet from a multi-use bottle. The manufacturer's expiration date on the bottle was September 2024. The bottle had been dated as opened by the facility on 10/24/24. LPN #24 confirmed the vitamin C tablets were past the manufacturer's expiration date.
Examination of the D hallway medication cart also found the following multi-dose medication bottles were past the manufacturer's expiration dates:
- Senna Syrup, expired March 2024, dated as opened by the facility on 11/09/24.
- Loratadine 10 mg, expired June 2024, dated as opened by the facility on 10/03/24.
- Guaifenesin 400 mg, expired August 2024, dated as opened by the facility on 01/20/24.
LPN #24 confirmed these multi-dose bottles of medications were past the manufacturer's expiration dates.
b) Undated Insulin Pens
On 12/16/24 at 9:20 AM, the D hallway medication cart was inspected with LPN #24 in attendance.
Three (3) insulin pens were noted to not have been dated when first accessed. It is important to document when insulin pens were first accessed because they must be discarded after 28 days of use.
The undated insulin pens were as follows:
- Lispro insulin for Resident #390, delivered from the pharmacy on 12/05/24
- Glargine insulin for Resident #34, delivered from the pharmacy on 12/07/24
- Glargine insulin for Resident #7, delivered from the pharmacy on 11/25/24
LPN #24 verified these three (3) insulin pens had not been dated when first accessed.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Menu Adequacy
(Tag F0803)
Could have caused harm · This affected multiple residents
Based on observation, policy review, and staff interview the facility failed to follow the menus by not providing the appropriate serving size to residents.This failed practice was a random opportunit...
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Based on observation, policy review, and staff interview the facility failed to follow the menus by not providing the appropriate serving size to residents.This failed practice was a random opportunity for discovery and had the potential to affect more than a limited number of residents during the Long-Term Care Survey Process. Facility Census 89.
Findings Include:
a) Food service in the Alzheimer's unit
A dining observation on 12/15/24 at 12:30 PM, in the Alzheimer's unit, revealed that the Activity Directory (AD) was in a kitchen area fixing the plates for the lunch meal for the residents on that unit.
Further observation revealed that the AD was serving the turkey with a mouth sized fork, serving the stuffing with a spatula, and serving the peas with a ladle.
During an interview on 12/15/24 at 12:32 PM, the AD stated, I don't have the right size utensils over here. The kitchen did not send them.
During an interview on 12/15/24 at 12:40 PM, the administrator confirmed that the appropriate utensils for portion size were not being used.
A review on 12/16/24 at 2:30 PM, of the corporate recipe for the lunch meal on 12/15/24 indicates that (3) three ounces of turkey, a 1/2 cup of dressing and a 1/2 of cup of peas were to be served for the meal.
A review on 12/16/24 at 2:40 PM, of the policy titled {3.0 Menu Standards}, under purpose, reads as follows:
To ensure nutritional adequacy, regulatory compliance, operational efficiencies, and patient/resident quality of life.
Under process, number (1) one reads as follows:
Menus are developed by the food Advisory Council (FAC) according to established, national guidelines.
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, staff interview, and policy review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. This was a...
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Based on observation, staff interview, and policy review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. This was a random opportunity for discovery and had the potential to affect more than a limited number of residents during the Long-Term Care Survey Process. Facility Census 89.
Findings Include:
a) Alzheimer's unit refrigerator
The initial tour of the Alzheimer's unit on 12/15/24 at 11:44 AM, revealed a kitchen area with a refrigerator that had 14 apple crisp in it on a tray with no date.
During an interview on 12/15/24 at 11:45 AM, Licensed Practical Nurse (LPN) #33 stated, I am not sure when the Apple crisp was put in here. Maybe this morning. I really don't know.
LPN #33 confirmed that the apple crisp did not have a date on them.
A review on 12/16/24 at 3:00 PM, of the policy titled {5.7 Refrigerated/Frozen Storage}, under Process, refrigeration, 1.5 reads as follows:
Prepared foods are labeled and dated with name of product, date opened, and use by date.
b) Kitchen walk-in freezer
The initial tour of the kitchen on 12/15/24 at 11:48 AM, revealed (4) four boxes stored on the floor in the walk-in freezer.
During an interview on 12/15/24 at 11:49 AM, Kitchen Aide #30 stated, Our chef put those up. I guess he left some on the floor. Kitchen Aide #30 confirmed the items were on the floor.
A review on 12/16/24 at 3:00 PM, of the policy titled {5.7 Refrigerated/Frozen Storage}, under process, freezer, 2.1 reads as follows:
All shelves, storage racks and platforms are at least (6) six inches off the floor or per state regulation and 18 inches below the sprinkler head or ceiling and away from pipes and vents.
c) Kitchen serving area
The initial tour of the kitchen on 12/15/24 at 11:48 AM, revealed a white blanket behind the kitchen door in the food service area.
During an interview on 12/15/24 at 11:49 AM, Kitchen Aide #30 stated, When it rains, a lot of water seeps up there from a drain, so we put the blanket there.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0836
(Tag F0836)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and observation the facility failed to operate and provide services in compliance with ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and observation the facility failed to operate and provide services in compliance with all applicable Federal, State, and local laws, regulations and codes by not ensuring staff serving food had a food handlers card. This failed practice was a random opportunity for discovery and had the potential to affect more than a limited number of residents. Facility Census 89.
Findings Include:
a) Food Handlers Card
A dining observation on 12/15/24 at 12:30 PM, in the Alzheimer's unit, revealed that the Activity Directory (AD) was in a kitchen area fixing the plates for the lunch meal for the residents on that unit.
During an interview on 12/15/24 at 12:32 PM, the surveyor asked the AD if she had a food handlers card. The AD replied, No, I do not.
A review on 12/16/24 at 2:30 PM, of the Kanawha-[NAME] Health Department web site revealed the following requirement for Food Handlers in Kanawha county:
If you handle, prepare, serve. sell or give away food for human consumption, even if you bus tables or wash dishes, you are a food worker and need this training within 30 days of starting to work.
During an interview on 12/16/24 at 2:40 PM, the administrator confirmed that the AD did not at the time have a food handlers card as the county requires.
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** b) Resident #10
On 12/15/24 at 2:06 PM record review shows the Physician Order for Scope of Treatment (POST) with a verbal appro...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** b) Resident #10
On 12/15/24 at 2:06 PM record review shows the Physician Order for Scope of Treatment (POST) with a verbal approval signature from the resident's wife which was his Medical power of Attorney (MPOA). The verbal approval was obtained over the telephone on 10/01/24.
During a family interview with Resident #10's wife on 12/15/24, she stated she came to visit often, and actually was in the facility for a Christmas dinner last week.
On 12/17/24 at 10:04 AM during an interview with the Social Worker #98 she confirmed the POST should have a physical signature obtained by this time.
Based on record review and staff interview, the facility failed to ensure medical records were complete and accurate. This deficient practice had the potential to affect two (2) of 26 residents in the long-term care survey sample. Resident #34's skilled nursing evaluations were inaccurate in the area of genitourinary status. Resident #10's Physician Orders for Scope of Treatment form was not signed by the resident's representative. Resident identifiers: #34, #10. Facility census: 89.
Findings included:
a) Resident #34
Review of Resident #34's medical records showed the resident was admitted on [DATE] with an indwelling urinary catheter that had been inserted in the hospital. A physician's order was written on 06/22/24 to remove the catheter and monitor the resident's urine output.
However, Resident #34's skilled nursing evaluations on 06/23/24, 06/24/24, 06/25/24, 06/26/24, 06/27/24, and 07/02/24 continued to document the resident had an indwelling urinary catheter.
On 12/18/24 at 10:08 AM, the Clinical Resource Nurse confirmed Resident #34's skilled nursing evaluations were inaccurate in the area of genitourinary status.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected multiple residents
c) Resident #37
On 12/15/24 at 12:03 PM, Resident #37 was observed to have a tube feeding pump in her room. The resident was non-verbal and unable to interview. There was no Enhanced Barrier Precautio...
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c) Resident #37
On 12/15/24 at 12:03 PM, Resident #37 was observed to have a tube feeding pump in her room. The resident was non-verbal and unable to interview. There was no Enhanced Barrier Precaution (EBP) sign on the door or near the entry to the resident's room. Personal Protective Equipment (PPE) was available in a plastic caddy outside the doorway.
Review of Resident #37's progress notes show the resident had a percutaneous endoscopic gastrostomy (PEG) tube for enteral nutrition.
Review of Resident #37's current orders showed she receives enteral tube feeding 16 hours per day.
A review of the comprehensive care plan showed Resident #37 was totally dependent on staff for enteral nutrition as well as care at the PEG tube site.
On 12/15/24 at 12:55 PM the above findings were confirmed with the Clinical Regional Nurse #96 who agreed the EBP sign should be placed on the door due to the PEG tube being placed.
Based on observation, record review and staff interview, the facility failed to implement Enhanced Barrier precautions in accordance with professional standards of care and the facility's policies and procedures. These were random opportunities for discovery that had the potential to affect more than a limited number of residents. Resident identifiers: #22, #37. Facility census: 89.
Findings included:
a) Policy and Procedures
The facility's policy and procedure titled Enhanced Barrier Precautions with effective date 01/06/24 and revision date 12/16/24 stated Enhanced Barrier Precautions (EBP) would be used for residents with an indwelling medical device without secretions or excretions that are unable to be covered or contained and not known to be infected or colonized with any multi-drug resistant organisms. The procedure also stated the appropriate EBP sign would be posted on the patient's room door.
b) Resident #22
On 12/15/24 at 12:23 PM, Resident #22 was observed to have a tube feeding pump in her room. The resident was non-interviewable. There was not an EBP sign on the door or near the entry to the resident's room. Personal Protective Equipment (PPE) was available in a plastic caddy further down in the hallway.
Review of Resident #22's progress notes show the resident had a percutaneous endoscopic gastrostomy (PEG) tube for enteral nutrition.
Review of Resident #22's comprehensive care plan showed the resident had been care planned for having enhanced barrier precautions since 07/26/24.
Upon further observation on 12/16/24 at 2:25 PM, Resident #22's room had a sign on the door indicating the resident was on enhanced barrier precautions.
On 12/16/24 at 4:04 PM, the Clinical Resource Nurse confirmed the Enhanced Barrier Precautions sign had been placed on Resident #22's door that day.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Room Equipment
(Tag F0908)
Could have caused harm · This affected multiple residents
Based on observation, staff interview, and policy review the facility failed to maintain all electrical equipment in safe operating condition. This failed practice was a random opportunity for discove...
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Based on observation, staff interview, and policy review the facility failed to maintain all electrical equipment in safe operating condition. This failed practice was a random opportunity for discovery and had the potential to affect more than a limited number of residents. Facility census 89.
Findings include:
a) Stove in the Alzheimer's unit
The initial tour of the Alzheimer's unit on 12/15/24 at 12:30 PM, revealed an electric cooking stove in a kitchen area. The stove had (4) four places for stove eyes. (1) one stove eye was in place. The other (3) three stove eyes were missing and replaced with a glass serving plate.
During an interview on 12/15/24 at 12:38 AM, Licensed Practical Nurse (LPN) #33 stated, It's been like this for a while. We don't use the stove. Activities use it sometimes.
During an interview on 12/15/24 at 12:40 PM, The administrator confirmed that the stove eyes were not in place and the holes were covered with glass plates.
A review on 12/16/24 at 2:30 PM, of the policy titled {FNS411 Department Mainenance}, revealed:
To ensure the environment and equipment are in good working condition in order to store, prepare, and serve food in a safe and sanitary manner.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0925
(Tag F0925)
Could have caused harm · This affected multiple residents
Based on observation and staff interview the facility failed to ensure a physical environment with an effective pest control program. Observations were made of gnats in two (2) different resident room...
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Based on observation and staff interview the facility failed to ensure a physical environment with an effective pest control program. Observations were made of gnats in two (2) different resident rooms.
Room identifiers: #A01, #B11. Facility census: 89.
Findings included:
a) Observations during the initial tour on 12/15/24 revealed gnats were observed flying in the bathrooms of Rooms #A01, #B11; and the administrative conference room. The observation in Room #A01 was at 11:30 AM and #B11 was12:30 AM.
In an interview with facility administrator on 12/16/24 at 1:20 PM administrator stated she would request housekeeping to take care of this.
Nov 2024
3 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
Safe Environment
(Tag F0584)
Could have caused harm · This affected 1 resident
Based on observation, record review, staff interview and resident interview, the facility failed to ensure that it maintained an environment that allowed the residents to receive care and services saf...
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Based on observation, record review, staff interview and resident interview, the facility failed to ensure that it maintained an environment that allowed the residents to receive care and services safely and that the physical layout of the facility maximizes residents independence and does not pose a safety risk. This failed practice was a random opportunity for discovery during the survey process. Resident identifier: #80. Facility Census 85.
Findings Included:
a) Resident #80
An observation on 11/11/24 at 3:30 PM, found in Resident #80's personal bathroom a hole in the wall on the right side of the sink at the bottom of the wall.
Further observation of Resident #80 pulling up to his sink in his wheelchair to wash his hands revealed that he could not get up to the sink properly without putting his foot through the sheet rock.
During an interview on 11/11/24 at 3:30 PM, Resident #80 stated, I cannot get in there very good because my right arm is paralyzed. It's hard for me to make the turn so my foot goes through the wall. You should see it when I brush my teeth.
A record review on 11/12/24 at 10:00 AM, revealed that Resident #80 has a diagnoses that included Hemiplegia, affecting the right dominant side.
During an observation and interview on 11/12/24 at 11:00 AM, with the Administrator and Maintenance Supervisor (MS) in Resident #80's room the MS stated, I was unaware that the hole was there. The State Agency (SA) explained to the Administrator and the MS the struggle that Resident #80 was having getting to the bathroom sink. The Administrator stated, I can see the problem. We will see if we can get a sink that goes in catty corner so it will make it easier for him.
An observation on 11/11/24 at 3:30 PM, found in Resident #80's room a hole in the wall beside the Packaged Terminal Air Conditioner (PTAC) unit.
Further observation revealed a hole in the wall where the door knob had gone through the sheet rock. The hole was covered with a round hard plastic piece, but had multiple cracks around the plastic piece.
During an interview on 11/11/24 at 3:30 PM, Resident #80 stated, That hole beside the air conditioner is water damaged. My foot barely hit it and the sheet rock crumbled. I can't get anything fixed.
During an observation and interview on 11/12/24 at 11:00 AM, with the Administrator and MS in Resident #80's room the MS stated, I did not know these hole's were in here. We will get them fixed today.
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 obtain neurological checks for three (3) unwitnessed falls. Resident identifier: #80 Facility Census: #85.
Findings Included:
Record ...
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Based on record review and staff interview, the facility failed to obtain neurological checks for three (3) unwitnessed falls. Resident identifier: #80 Facility Census: #85.
Findings Included:
Record review on 11/12/24 at 9:15 AM found that Resident #80 has had three (3) unwitnessed falls. They were on 06/03/24, 08/17/24 and 08/28/24. According to the change in condition supplied by the facility, they were all unwitnessed falls.
According to the Falls Management Policy #NSG215 (5) Post Fall Management: 5.3 Any patient who has a fall unwitnessed by staff will be observed for neurological abnormalities by performing neurological check, per policy
According to the Neurological Evaluation Policy #NSG204 . Neurological evaluations will be performed as indicated or ordered. When a patient sustains an injury to the head or face and/or has an unwitnessed fall, neurological evaluation will be performed:
Every 15 minutes x two (2) hours, then
Every 30 minutes x two (2) hours, then
Every 60 minutes x four(4) hours, then
Every eight (8) hours until at least 72 hours has elapsed .
On 11/12/24 at 10:10 AM the Administrator stated we have no neuro checks for these falls. She agreed they should have been performed as policy due to the falls being unwitnessed.
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
Grievances
(Tag F0585)
Could have caused harm · This affected multiple residents
Based on record review, resident interview and staff interview, the facility failed to effectively make prompt efforts to resolve grievances made by the residents. This failed practice was a random op...
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Based on record review, resident interview and staff interview, the facility failed to effectively make prompt efforts to resolve grievances made by the residents. This failed practice was a random opportunity for discovery and had the potential to affect more than a limited number of residents living in the facility during the survey process. Facility Census 85.
Findings included:
a) Call light response time.
A review on 11/11/24 at 1:30 PM, of the Grievance/Concerns log revealed that on 10/08/24 The Resident Council made a complaint about call light response time.
Further review of the Grievance/Concern log, revealed that the call light response time issue was resolved on 10/14/24.
During an interview on 11/11/24 at 2:30 PM, the State Agency (SA) asked Resident #68 if he had to wait for long periods of time to get his call light answered? Resident #68 stated, Yes, sometimes I have to wait an hour or longer. Resident #68 could not specify any particular time that it was worse than others.
During an interview on 11/11/24 at 3:00 PM, SA asked Resident #44 if she had to wait for long periods of time to get her call light answered? Resident #44 stated, Sometimes, night shift is the worst. About a month ago I waited over 2 1/2 hours. I reported it to (Registered Nurse (RN) # 74 named).
During an interview on 11/11/24 at 3:12 PM, The Administrator stated, Yes, we did staff education and a call light response log. I will get it for you.
A review on 11/11/24 at 3:30 PM of the staff in-service sign in sheet regarding call light response time revealed a sign in sheet that had 15 staff members signed in for attendance.
Further review of the monitoring sheets for call lights titled {We will monitor call light response times across all shifts as a result of a concern by a resident},reveals that call light response times were monitored from 10/08/24 to 10/11/24 and then again on 10/14/24. All call light response times were recorded for day shift only, with the exception of one that was recorded on 10/08/24 at 5:45 PM.
During an interview on 11/13/24 at 10:20 AM, The Resident Council President Resident #5 stated ,
Day shift is ok, but you never see anybody on night shift, you might as well forget it.
During an interview on 11/13/24 at 11:40 AM, the Administrator confirmed that only one time indicates that monitoring of call lights were done on any other shift other than day shift.
Jul 2024
3 deficiencies
1 IJ
CRITICAL
(J)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Immediate Jeopardy (IJ) - the most serious Medicare violation
Quality of Care
(Tag F0684)
Someone could have died · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to ensure one (1) of seven (7) residents did not receive doses of...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to ensure one (1) of seven (7) residents did not receive doses of medications that had errors in the dose ordered by the physician assistant. Resident #201 received a larger dose of morphine sulfate than what the physician assistant intended to prescribe. This created an immediate jeopardy situation. Resident identifier: #82. Facility census: 82.
Findings included:
a) Resident #201
Record review revealed the resident was admitted to the facility on [DATE]. The resident expired at the facility on [DATE] at 9:05 PM. The resident had the following diagnoses: Sick Sinus Syndrome, History of Urinary Tract Infections, Erythematous, Diabetes Type 2, Dementia, Dysphagia, Atrial Fibrillation, Hypertension, Atherosclerotic Heart Disease, Hyperlipidemia, and Kidney Failure.
A progress note on [DATE] at 9:02 PM revealed that the resident's power of attorney wished for him to have comfort measures and that they were unable to bring his oxygen level above 80%. He was also noted to not be eating or drinking. The recommendations at that time were for medications to be discontinued and new orders for Ativan and Morphine.
A progress note on [DATE] at 9:02 PM revealed that the resident's power of attorney wished for him to have comfort measures and that they were unable to bring his oxygen level above 80%. He was also noted to not be eating or drinking. The recommendations at that time were for medications to be discontinued and new orders for Ativan and Morphine.
The resident had an order dated [DATE] at 12:30 PM for Morphine Sulfate Oral Solution 20 MG (milligram)/5 ML (milliliter) (Morphine Sulfate) Give 2.5 ml by mouth every four (4) hours as needed for shortness of breath. The resident received two (2) doses of this medication. The first dose was administered on [DATE] at 9:00 PM and the second dose was given on [DATE] at 12:00 AM.
A progress note by the physician assistant dated [DATE] reflected:
Morphine dose was evaluated and adjustments made. Morphine 20 mg/5 ml 0.25 ml every 4 hour as needed for SOB. Nurse was advised and asked to give dose of Morphine at this time in addition to Ativan if he has not had it this morning. This note described the resident as being an elderly man in mild respiratory distress. The Medication Administration Record (MAR) showed this order was entered on [DATE] at 8:30 AM.
During a confidential employee interview by phone on [DATE] at 10:00 AM the employee stated they felt the 2.5 ml dose was excessive but this resident was not on their assignment. The employee also stated the nurse administering the medication said this dose was justified because the resident was on comfort care. The licensed pratcial nurse who administered the medication was interviewed on [DATE] at 8:00 AM. This nurse said she did not question the order when administering the medication on [DATE] and [DATE]. She said she knew the resident was comfort care and was following the order as it was listed on the medication administration record (MAR).
During an interview with the Physician Assistant and Director of Nursing on [DATE] at 1:15 PM the Director of Nursing (DON) stated she was unaware of this situation until the surveyor brought it to her attention. The physician assistant said she realized the order was in error on [DATE] and corrected the order at that time. The DON mentioned that the progress note written by the Physician Assistant on [DATE] revealed the order should have been for 2.5 mg not 2.5 ml. A progress note dated [DATE] at 12:12 PM reflected this to be accurate. The progress note stated, He was started on O 2 via NC at 2L and increased to 5L to maintain an O 2 of 90%. Representative was contacted and did not want him sent to the hospital. She requested that comfort care be carried out. Morphine 20 mg/5 ml 2.5 mg every 4 hours as needed for respiratory distress and Ativan 0.5 mg every 4 hours as needed. Medications were placed on hold. Discussed with nurse, continue to monitor.
The Medication Administration Record (MAR) showed the corrected order was put in on [DATE] at 8:30 PM. The original order was put in on [DATE] at 12:30 PM.
The facility was notified of the immediate jeopardy and the template was presented at [DATE] at 2:01 PM. A plan of correction was received at 2:35 PM. Modifications were made to the plan of correction and it was accepted at 2:50 PM on [DATE].
Resident #201 no longer resides in the facility.
All residents of the facility havethe potential to be affected.
The Director of Nursing (DON) designee conducted an audit on [DATE] for all residents with controlled substance/medications to ensure order is accurately entered in resident's medical record with any corrective action immediately upon discovery.
Re-education was provided by the Director of Nursing (DON)/Designee to all licensed nurses and medical provideres regarding controlled substances/medication for a resident that is accurately entered in the resident's medical record. A Post test to validate understanding. Any licensed nurses and medical providers not available during this time frame will be provided re-education, including post test upon the begining of the next shift to work. New licensed nurses will be provided education including post-test during orientation by the DON/designee.
The Unit Manager (UM)/designee will monitor starting on or before [DATE] new orders and medical provider progress notes to ensure residents ordered controlled substances/medications is accurately entered in resident's medical record daily across all shifts for 2 weeks including weekends and holidays, then 5 times a week for 4 weeks, then 3 times a week for 4 weeks then randomly therafter.
Results of monitors will be reported by the Director of Nursing (DON)/designee monthly to the Quality Improvement Committee (QIC) for any additional follow up and or in servicing until the issue is resolved, then randomly thereafter as deterimend by the QIC committee.
The immediate jeopardy was abated on [DATE] at 4:45 PM.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected multiple residents
Based on observation and staff interview the facility failed to ensure the resident environment was clean, comfortable and homelike. Issues such as black marks, scuffs and pealing paint was found with...
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Based on observation and staff interview the facility failed to ensure the resident environment was clean, comfortable and homelike. Issues such as black marks, scuffs and pealing paint was found with the interior of the facility (doors, walls,) were found on three (3) of the four (4) hallways of facility. There were also issues with scuffs, black marks and pealing paint on the doors near the nursing station. Facility census: 82.
Findings included:
a) On 07/03/24 at 2:00 PM a walk trough of the facility with Maintenance Director #59 and Maintenance Assistant #64 issues with scuffs, black marks, and peeling paint was found on several doors on D hall. Issues were identified in Room D #32, D #33, D #35, D #40, D #28 and B #10.
The issues identified were black scuff marks, pealing paint around the door frames. A pile of shingles were found outside the B/C hall. Evidence of spiders were found under the heat/air unit in the D wing fine dining area.
The Maintenance Director and Assistant both confirmed they were aware of the issues. They both stated they were new at the facility and trying to get some kind of order in the facility. They said they were taking care of the safety issues first.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0712
(Tag F0712)
Could have caused harm · This affected multiple residents
Based on medical record review and staff interview the facility failed to ensure three (3) residents had been seen by a physician at least once every 30 days for the first 90 days after admission, and...
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Based on medical record review and staff interview the facility failed to ensure three (3) residents had been seen by a physician at least once every 30 days for the first 90 days after admission, and at least once every 60 thereafter. Resident identifiers: #28, #72, and #44. Facility census: 82.
Findings included:
a) Resident #28
During a review of Resident #28's medical record it was determined the physician had not seen the resident every 60 days. The physician had seen the resident on 11/10/23, 08/25/23, 05/19/23, 03/17/23, 01/06/23. The physician assistant had seen the resident on 06/19/24, 04/24/24, 04/19/24, 03/27/24, 03/21/24, 03/04/24, 03/01/24, 02/29/24, 01/26/24, 12/27/24, 11/14/23, 11/13/23, 11/07/23, 10/31/23, 10/29/23, 10/19/23, 10/16/23, 10/15/23, 10/12/23, 10/11/23, 07/14/23.
b) Resident #72
During a review of Resident #72's medical record it was determined the physician had not seen the resident every 60 days. The physician had seen the resident on 02/10/24, 11/11/23, 05/26/23, 02/24/23, 12/02/22, 10/01/22, and on 09/09/22. The physician assistant had seen the resident on 06/04/24, 04/16/24, 04/09/24, 04/05/24, 04/03/24, 01/24/24 and 12/23/23.
c) Resident #44
During a review of Resident #44's record it was determined the physician had seen the resident on 10/30/23, on 02/10/24.
The physician assistant (PA) had seen the resident on 06/12/24 for an acute visit, on 05/23/24 for a follow up visit, and on 05/16/24 for an acute visit. The PA also seen the resident on 03/19/24.
During an interview with the administrator and director of nursing (DON) on 07/03/24 at 4:00 PM they indicated the physician assistant had seen the residents but not as alternate visits with the physician. It was confirmed that the physician had not seen the resident every 60 days as required.
Apr 2024
2 deficiencies
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected multiple residents
Based on observation and resident and staff interview, the facility failed to provide a safe, clean, homelike environment for Resident #3, 54, 50, 46, 58, and 36. This was a random opportunity for dis...
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Based on observation and resident and staff interview, the facility failed to provide a safe, clean, homelike environment for Resident #3, 54, 50, 46, 58, and 36. This was a random opportunity for discovery. This has the potential to affect more than a limited number of residents. Resident identifiers: 3, 54, 50, 46, 58, 36. Room identifiers: B10, B14, C26, D31. Facility census: 88.
Findings included:
A) Room #B10
At approximately 10:45 AM on 04/09/24, an observation was conducted of Room B10, where Resident #3 and 54 reside. During the observation, it was noted that the trim underneath the heating and cooling unit in the room was detached from the wall and was lying flat on the floor, exposing the wall behind the trim. Resident #54 stated It's been like that for a while but no one has come in to fix it yet.
At approximately 01:00 PM on 04/10/24, the Administrator acknowledged the trim coming off the wall.
At approximately 10:52 AM on 04/09/24, an observation was conducted of Room #B14, where Resident #50 resided. During the observation, a glove was discovered lying on the floor beside the trash can in the room. A large piece of clear plastic was lying underneath Resident #50's bed, along with multiple pieces of paper.
At approximately 10:55 AM on 04/09/24, the Housekeeping Manager in Training (HMIT) entered the room and acknowledged the gloves and trash in the floor.
b) Room #C26
At approximately 11:10 AM on 04/09/24, an observation was conducted of Room #C26. During the observation, a medical glove was discovered in the floor by the trash can along with plastic and other debris underneath Resident #46's bed. There was a trail of a brown substance running from Resident #46's bed, into the bathroom, ending on the toilet seat, of which the substance covered multiple places. Next to the toilet, toilet paper was found torn and scattered about the bathroom. The water in the shower was found to be running, and upon further observation, there were two plastic cups in the shower.
At approximately 11:17 AM on 04/09/24, the Director of Nursing (DON) acknowledged the trash, trail of brown substance, toilet paper in the bathroom floor, and plastic cups in the shower.
D) Room #D31
At approximately 11:27 AM on 04/09/24, an observation was conducted of Room #D31. During the observation, a medical glove was found on the floor next to Resident #58's bed. Upon further observation, two medical gloves were found next to a trash can beside Resident 36's bed. A bottle of lotion was in the floor underneath Resident #36's bed, along with another bottle of lotion lying on the floor, underneath the heating and cooling unit, next to Resident #36's bed.
The Business Office Manager (BOM) acknowledged the gloves and bottles on the floor in the room at approximately 11:32 AM on 04/09/24.
Upon further observation of Room D31, multiple small black oval shaped grains were found on the floor of Resident #36's wardrobe.
At approximately 12:25 PM on 04/09/24 the Director of Nursing (DON) and Maintenance Supervisor (MS) came to the room and observed the wardrobe. The DON was asked if the grains appeared to be mouse droppings, to which they stated, That looks like that's what it is. The MS acknowledged the small black grains in the wardrobe as well.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0692
(Tag F0692)
Could have caused harm · This affected multiple residents
Based on record review and staff interview the facility failed to provide accurate one (1) resident was provided to the extent possible acceptable parameters of nutrition. Resident identifier: #2. Fac...
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Based on record review and staff interview the facility failed to provide accurate one (1) resident was provided to the extent possible acceptable parameters of nutrition. Resident identifier: #2. Facility Census: #88
Findings included:
a) Resident #2
On 04/09/24 at 10:02 AM record review shows Resident #2 has had a significant weight loss in the last three (3) months and the last six (6) months.
Resident #2 had a medical diagnosis of: Eating disorder, feeding difficulties, and a recent diagnosis of Amyotrophic Lateral Sclerosis (ALS).
She was on a regular diet, regular texture, finger foods preferred, large portions at all meals. She requires feed assist from staff. She was on monthly weights.
According to documented weights, Resident #2 weighed 166.4 pounds as of 03/22/24.
On 01/03/24 she weighed 182.2, reflecting a 8.67% weight loss in those three (3) months.
Resident #2 weighed 190.2 pounds on 10/30/22, reflecting a 12.1% weight loss in the six (6) months from 10/30/22 until 03/22/24.
A significant weight loss is identified as:
5% change in weight in 1 month (30 days)
7.5% change in weight in 3 months (90 days)
10% change in weight in 6 months (180 days)
During a interview with Registered Dietitian #104 on 04/10/24 at 01:55 PM she stated she documented her findings for meal intakes from the Facility Follow Up Question Report. When Registered Dietitian #104 and the surveyor went over the report together, Registered Dietitian #104 agreed there was insufficient documentation for her to accurately assess the meal intakes. When asked why this was not addressed with the Administrator, DON or other staff, she commented she did not know.
Documentation review of Nutritional Assessments and Nutrition Progress Notes by Register Dietitian #104, stated:
03/06/24 with good meal intakes, (approximately) 70% of most meals . Currently meal intakes are capable of meeting estimated needs .
03/12/24 . with good meal intakes, (approximately) 75% of most meals
03/29/24 . Resident has fair PO intake of roughly 25-75% of most meals .
04/5/24 .with good meal intakes, ~ (approximately) 70% of most meals .
A review of the Follow Up Questions Report provided for 03/09/24 through 04/08/24 shows there were ninety one (91) opportunities to document meal intakes of which there were fifteen (15) meal intakes documented.
Below is the details of the intake documentation provided on the Facility Follow Up Question Report.
03/09/24 - breakfast - no documentation
03/09/24 - lunch - no documentation
03/09/24 - dinner- no documentation
03/10/24- breakfast - no documentation
03/10/24- lunch - no documentation
03/10/24- dinner - no documentation
03/11/24- breakfast - no documentation
03/11/24- lunch - no documentation
03/11/24- dinner - no documentation
03/12/24- breakfast - no documentation
03/12/24- lunch - no documentation
03/12/24- dinner - no documentation
03/13/24- breakfast - no documentation
03/13/24- lunch - no documentation
03/13/24- dinner - no documentation
03/14/24- breakfast - 75% intake
03/14/24- lunch - no documentation
03/14/24- dinner - no documentation
03/15/24- breakfast - no documentation
03/15/24- lunch - no documentation
03/15/24- dinner - no documentation
03/16/24 - breakfast - 25% intake
03/16/24- lunch - no documentation
03/16/24- dinner - no documentation
03/17/24- breakfast -75% intake
03/17/24- lunch - 100% intake
03/17/24- dinner - no documentation
03/18/24 - breakfast - 50% intake
03/18/24- lunch - 75% intake
03/18/24- dinner - 50% intake
03/19/24 - breakfast - no documentation
03/19/24- lunch - no documentation
03/19/24- dinner - no documentation
03/20/24- breakfast - no documentation
03/20/24- lunch - no documentation
03/20/24- dinner - no documentation
03/21/24- breakfast - no documentation
03/21/24- lunch - no documentation
03/21/24- dinner - no documentation
03/22/24- breakfast - 10% intake
03/22/24- lunch - 50% intake
03/22/24- dinner - no documentation
03/23/24- breakfast - no documentation
03/23/24- lunch - no documentation
03/23/24- dinner - no documentation
03/24/24- breakfast - no documentation
03/24/24- lunch - no documentation
03/24/24- dinner - no documentation
03/25/24- breakfast - no documentation
03/25/24- lunch - no documentation
03/25/24- dinner - no documentation
03/261/24- breakfast - 50% intake
03/26/24- lunch - 50% intake
03/26/24- dinner - 50% intake
03/27/24- breakfast - no documentation
03/27/24- lunch - no documentation
03/27/24- dinner - no documentation
03/28/24- breakfast - no documentation
03/28/24- lunch - no documentation
03/28/24- dinner - no documentation
03/29/24- breakfast - no documentation
03/29/24- lunch - no documentation
03/29/24- dinner - no documentation
03/30/24- breakfast - no documentation
03/30/24- lunch - no documentation
03/30/24- dinner - no documentation
03/31/24- breakfast - 100% intake
03/31/24- lunch - 100% intake
03/31/24- dinner - no documentation
04/01/24- breakfast - no documentation
04/01/24- lunch - no documentation
04/01/24- dinner - no documentation
04/02/24- breakfast - no documentation
04/02/24- lunch - no documentation
04/02/24- dinner - no documentation
04/03/24- breakfast - no documentation
04/03/24- lunch - no documentation
04/03/24- dinner - no documentation
04/04/24- breakfast - no documentation
04/04/24- lunch - no documentation
04/04/24- dinner - no documentation
04/05/24- breakfast - no documentation
04/05/24- lunch - no documentation
04/05/24- dinner - no documentation
04/06/24- breakfast - no documentation
04/06/24- lunch - no documentation
04/06/24- dinner - no documentation
04/07/24- breakfast - no documentation
04/07/24- lunch - no documentation
04/07/24- dinner - no documentation
04/08/24- breakfast - 75% intake
04/08/24- lunch - not served as this time
04/08/24- dinner - not served at this time
The above information was confirmed with the DON on 04/10/24 at 01:32 PM. The DON agreed there was not enough documentation of accurately access Resident #2's meal intake for nutritional status assessments.
Dec 2023
6 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 F0657
(Tag F0657)
Could have caused harm · This affected 1 resident
Based on record review, observation and staff interview the facility failed to implement care plans for one (1) of three (3) Residents whose care plans were reviewed during the long-term care complain...
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Based on record review, observation and staff interview the facility failed to implement care plans for one (1) of three (3) Residents whose care plans were reviewed during the long-term care complaint survey process. Resident # 2's care plan was not implemented for placing a radio in closer reach on the left side. Resident identifier: #2. Facility census: 83.
Findings included:
a) Resident #2
A review of resident #2's care plan found the current care plan, updated on 10/22/23 read as follows:
Potential at risk for falls and actual falls: cognitive loss, lack of safety awareness, impaired mobility, history of falls
The goal read as follows: Residents will have no falls with major injury requiring hospitalization through the next review.
On 12/18/23 at 11:56 AM, an observation found Resident #2 sleeping in his room no radio was found in room within reach on left side of bed.
On 12/19/23 at 10:30 AM, the Director of Nursing was interviewed and asked where the radio was that is care planned to be placed close on the left side of the bed. She stated, the family had taken it home.
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
Respiratory Care
(Tag F0695)
Could have caused harm · This affected 1 resident
Based on observation, resident interview and staff interview, the facility failed to ensure respiratory care was provided according to professional standards of practice. These were random opportuniti...
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Based on observation, resident interview and staff interview, the facility failed to ensure respiratory care was provided according to professional standards of practice. These were random opportunities of discovery. Resident Identifier: #2, #76, #28 and #1. Facility Census: 83.
Findings Included:
a) Resident #2
On 12/19/23 at 9:24 AM, an observation was made of Resident #2's nebulizer mask laying on the nightstand without being in a respiratory bag.
On 12/19/23 at 9:25 AM, Licensed Practical Nurse (LPN) #13 was notified and confirmed the nebulizer mask was not stored correctly. LPN #13 stated, I will get a respiratory bag.
On 12/19/23 at 10:00 AM, the Director of Nursing (DON) and the Administrator were notified and confirmed the nebulizer mask should have been placed in a respiratory bag.
b) Resident #76
On 12/19/23 at 9:24 AM, an observation was made of Resident #2's nebulizer mask laying on the nightstand without being in a respiratory bag.
On 12/19/23 at 9:25 AM, Licensed Practical Nurse (LPN) #13 was notified and confirmed the nebulizer mask was not stored correctly. LPN #13 stated, I will get a respiratory bag.
On 12/19/23 at 10:00 AM, the Director of Nursing (DON) and the Administrator were notified and confirmed the nebulizer mask should have been placed in a respiratory bag.
c) Resident #28
On 12/19/23 at 9:30 AM, an observation was made of Resident #28's nasal cannula laying directly on the floor.
On 12/19/23 at 9:35 AM, LPN #13 was notified and confirmed the nasal cannula should not be laying directly on the floor. LPN #13 stated, I'll go get a new cannula.
On 12/19/23 at 10:00 AM, the DON and the Administrator were notified and confirmed the nasal cannula should not be laying in the floor.
d) Resident #1
On 12/19/23 at 9:53 AM, an observation was made of Resident #1's nebulizer mask laying on the night stand without being in a respiratory mask.
On 12/19/23 at 9:54 AM, Registered Nurse (RN) #47 was notified and confirmed the nebulizer mask was not stored correctly. RN #47 stated, I will get this taken care of.
On 12/19/23 at 10:00 AM, the DON and the Administrator were notified and confirmed the nebulizer mask should have been placed in a respiratory bag.
No further information was obtained during the survey process.
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
Pharmacy Services
(Tag F0755)
Could have caused harm · This affected 1 resident
.
Based on observation, record review and staff interview the facility failed to establish a system that determines drug records are in order and an account of all controlled drugs is maintained and ...
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.
Based on observation, record review and staff interview the facility failed to establish a system that determines drug records are in order and an account of all controlled drugs is maintained and periodically reconciled. The facility had controlled substances that had been removed from the medication card and was then taped back into the medication card on two separate medication carts. Also for Resident # 27 his tramadol, a controlled substance was signed out on the Controlled Substance log but was not documented as given on the Medication Administration Record (MAR). These failed practices have the potential to affect more than a limited number of residents. Resident Identifier: #27, #36 and # 75. Facility Census: 83.
Findings Included:
a) Medication cart for the A hall and D hall.
An observation of the medication cart utilized for the A and D hall of the facility with Licensed Practical Nurse (LPN) # 13 on 12/19/23 at 10:41 am, found Resident # 36 had four (4) lorazepam .5 milligram tablets left in her medication card. As LPN #13 pulled it out of the controlled substance out of the locked compartment on the medication cart she stated, Oh one of these has been taped back in. I did not do that. Observation of the card found one (1) of the four (4) remaining pills had been removed from the card and a pill had been replaced and a piece of tape was placed over the back of the card to keep the pill in place.
LPN #13 took the medication and the controlled substance log to the Director of Nursing and advised her what had happened. The DON stated, We need to waste that pill. That's what she should have done to start with.
b) Medication Cart on Mary's Garden
An observation of the medication cart utilized for Mary's Garden with LPN #1 on 12/19/23 at 10:50 am found, Resident #75 had 25 clonazepam .5 (milligram) mg tablets left in his medication card. When LPN #1 removed the card from the controlled substance compartment on the medication cart to show the surveyor she said, Oh there is one taped in. Pill number eight (8) had been removed from the card and a pill had been placed back in the card and a piece of tape had been placed on the medication card to keep it in place. LPN #1 stated, I did not notice that before, I did not do that,
LPN #1 took the card to the DON who stated they would waste the pill. The DON was asked if it was an acceptable practice to tape a pill in a controlled substances medication card. She confirmed it was not an acceptable standard of practice and should not be done.
c) Resident #27
A review of Resident #27's medical record on 12/19/23 at 12:00 PM found a physician order for tramadol 50 milligram (MG) give one tablet by mouth every 12 hours as needed for pain.
A review of the controlled substance log for the tramadol found on the following dates and times Resident #27 had a tramadol signed out on the controlled substance log but it was not documented as administered on the medication administration record:
-- 12/09/23 at 10:00 am,
-- 12/14/23 at 12:00 am, and
-- 12/19/23 at 10:18 am.
An interview with the Director of Nursing (DON) at approximately 1:30 PM on 12/19/23 confirmed the above findings. She indicated, I saw that, and I am working on a plan to correct it.
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
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
Based on observation, resident interview and staff interview, the facility failed to maintain appropriate infection control standards for the disposal of soiled linens in Rooms #D38 and #D32, the stor...
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Based on observation, resident interview and staff interview, the facility failed to maintain appropriate infection control standards for the disposal of soiled linens in Rooms #D38 and #D32, the storage of a wash basin in Room #C26, the storage of a urinal in Room #C25, and in Room #D31 the storage of a used bed pan. These were random opportunities for discovery. Facility Census: 83.
Findings Included:
a) Room D38
On 09/19/23 at 9:30 AM, an observation was made of soiled linen in Room #D38 which was in two (2) clear plastic bags left open and untied sitting in floor of the room by the bathroom. Resident #76 stated, Those are from when they cleaned us up.
On 09/19/23 at 9:35 AM, Licensed Practical Nurse (LPN) #13 was notified and confirmed the soiled linen bags should have been tied up and removed from the room.
On 09/19/23 at 10:15 AM, the Director of Nursing (DON) was notified and confirmed the soiled linen bags should have been tied up and removed from the room. The DON stated, they know better than this .we will get it cleaned up.
b) Room D32
On 09/19/23 at 9:45 AM, an observation was made of soiled linen in Room D32 which was in two (2) plastic bags sitting on the floor of the room by the door.
On 09/19/23 at 9:50 AM, LPN #13 was notified and confirmed the soiled linen bags should have been removed from the room.
On 09/19/23 at 10:15 AM, the Director of Nursing (DON) was notified and confirmed the soiled linen bags should have been tied up and removed from the room. The DON stated, they know better than this .we will get it cleaned up.
c) Room C26
On 09/19/23 at 9:53 AM, a tour of Room C26 was completed. During the tour, a used wash basin was laying on the floor behind the commode in the bathroom.
On 09/19/23 at 9:55 AM, Registered Nurse (RN) #47 was notified and removed the used wash basin from the bathroom.
On 09/19/23 at 10:15 AM, the Director of Nursing (DON) was notified and confirmed the wash basin was not stored properly. The DON stated, we will get this taken care of.
d) Room C25
On 09/19/23 at 9:58 AM, a tour of Room #C25 was completed. During the tour, a dirty urinal with a dried brown substance was hanging on the safety rail in the bathroom.
On 09/19/23 at 10:01 AM, RN #47 was notified and removed the dirty urinal from the bathroom.
On 09/19/23 at 10:15 AM, the Director of Nursing (DON) was notified and confirmed the dirty urinal should have been disposed of. The DON stated, The resident was sent to the hospital with blood in his urine .that's what the dried brown substance is.
e) Room #D31
On 09/19/23 at 10:23 AM, a tour of Room #D31 was completed. An observation of a used bed pan laying in the floor behind the commode was made.
On 09/19/23 at 10:25 AM, RN #20 was notified and confirmed the bed pan was not stored correctly. RN #20 stated, We will get this cleaned up right away.
On 09/19/23 at 10:30 AM, the DON and Administrator were notified and confirmed the bed pan was not stored correctly and would be removed right away.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, the facility failed to provide a safe, clean, and homelike environment for Room #D32 w...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, the facility failed to provide a safe, clean, and homelike environment for Room #D32 which had trash and food laying on the floor, Room #D37 was noted with two (2) dirty and stained nightstands and a soiled blanket with a dry, brown substance on the bed in room [ROOM NUMBER]. The facility's sit to stand lifts were also observed dirty. These were random opportunities of discovery. Facility census: 83.
Findings included:
a) Room #D32
On 12/19/23 at 9:20 AM, an observation was made in Room #D32. The observation found trash and food lying on the floor under the beds and in the entire room.
On 12/19/23 at 9:22 AM, Registered Nurse (RN) #20 stated, We will get this cleaned up right away.
On 12/19/23 at 9:50 AM, the Director of Nursing (DON) was notified of the findings. The DON stated, We will get this taken care of right away.
b) Room #D37
On 12/19/23 at 9:27 AM, an observation was made in Room D37. The observation found two (2) nightstands which were dirty and stained.
On 12/19/23 at 9:30 AM, Licensed Practical Nurse (LPN) #13 was notified and confirmed the nightstands were dirty and stained.
On 12/19/23 at 9:50 AM, the Director of Nursing (DON) was notified of the findings. The DON stated, we will get this taken care of right away.
c) Room #D40
On 12/19/23 at 9:40 AM, an observation was made in Room #D40. The observation found a soiled blanket with a dry, brown substance on the bed covering the resident.
On 12/19/27 at 9:35 AM, Licensed Practical Nurse (LPN) #13 confirmed the blanket was soiled with a dry, brown substance. LPN# 13 stated, I'll get her a clean blanket.
On 12/19/23 at 9:50 AM, the DON was notified and stated, The resident should always have clean linen.
No further information was obtained during the survey process.
d) Sit to Stand Lifts
On 12/19/2023 at 9:40 AM three (3) of the facility sit-to-stand lifts were observed to be soiled with dirt and debris on the platform where residents would place their feet when being assisted to stand. During an interview with the Nursing Home Administrator (NHA) and the Director of Nursing (DON), the NHA stated she believed it was the responsibility of the nursing staff or housekeeping to clean the units. She further stated that she thought it was a weekly schedule to clean them and or when needed. The DON agreed at this time.
On 12/19/2023 at 10:15 AM, the DON provided their Infection Control Policies and Procedures. The intent of these policies and procedures were to prevent infectious spread from items or environment to patients and/staff. They were also to ensure reusable medical equipment was cleaned and disinfected properly. The policy further denotes in the practice standards under 5.3, multi-function equipment must be cleaned/ disinfected between residents. 5.4 states if an item will be stored after cleaning, bag and/or label to indicate ready for next use.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected multiple residents
Based on record review and staff interview the facility failed to administer medications within the physician ordered time frames. Resident # 2, Resident # 27 and Resident #46 had medications administ...
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Based on record review and staff interview the facility failed to administer medications within the physician ordered time frames. Resident # 2, Resident # 27 and Resident #46 had medications administered late on multiple occasions during the month of 12/2023. This was true for three (3) of three (3) residents reviewed for medication administration during a complaint survey. Resident Identifiers: #2, #27, and #46. Facility Census: 83.
Findings Included:
a) Resident #27
A review of Resident #27's medication administration audit report for the month of 12/2023 found on the following occasions Resident #27 medication was administered more than one (1) and one (1) half hour past the scheduled time of administration:
-- Insulin Sliding Scale was scheduled for 11:30 am on 12/03/23 and was not administered until 4:32 PM this was five (5) hours and two (2) minutes late.
-- cyanocobalamin tablet was scheduled to be administered at 10:00 AM on 12/06/23 and was not administered until 12:08 PM which was two (2) hours and eight (8) minutes late.
-- Duloxetine HCI oral capsule was scheduled to be administered at 10:00 AM on 12/06/23 and was not administered until 12:08 PM which was two (2) hours and eight (8) minutes late.
-- Diltiazem HCI ER Beads was scheduled to be administered at 10:00 AM on 12/06/23 and was not administered until 12:08 PM which was two (2) hours and eight (8) minutes late.
-- Torsemide Oral Tablet was scheduled to be administered at 10:00 AM on 12/06/23 and was not administered until 12:08 PM which was two (2) hours and eight (8) minutes late.
-- Isosorbide Mononitrate was scheduled to be administered at 10:00 AM on 12/06/23 and was not administered until 12:08 PM which was two (2) hours and eight (8) minutes late.
-- Protonix Oral Tablet was scheduled to be administered at 10:00 AM on 12/06/23 and was not administered until 12:08 PM which was two (2) hours and eight (8) minutes late.
-- Warfarin Sodium was scheduled to be administered at 10:00 AM on 12/06/23 and was not administered until 12:08 PM which was two (2) hours and eight (8) minutes late.
-- Neurontin was scheduled to be administered at 10:00 AM on 12/06/23 and was not administered until 12:08 PM which was two (2) hours and eight (8) minutes late.
-- Calcitriol was scheduled to be administered at 10:00 AM on 12/06/23 and was not administered until 12:08 PM which was two (2) hours and eight (8) minutes late.
-- Neuriva Plus was scheduled to be administered at 10:00 AM on 12/06/23 and was not administered until 12:08 PM which was two (2) hours and eight (8) minutes late.
-- Clonidine HCI was scheduled to be administered at 10:00 AM on 12/06/23 and was not administered until 12:08 PM which was two (2) hours and eight (8) minutes late.
-- Warfarin Sodium was scheduled to be administered at 10:00 AM on 12/08/23 and was not administered until 11:40 AM which was one (1) hour and 40 minutes late.
-- Protonix Oral Tablet was scheduled to be administered at 10:00 AM on 12/08/23 and was not administered until 11:43 AM which was one (1) hour and 43 minutes late.
-- Isosorbide Tablet was scheduled to be administered at 10:00 AM on 12/08/23 and was not administered until 11:43 AM which was one (1) hour and 43 minutes late.
-- Clonidine was scheduled to be administered at 10:00 AM on 12/08/23 and was not administered until 11:42 AM which was one (1) hour and 42 minutes late.
-- Neuriva was scheduled to be administered at 10:00 AM on 12/08/23 and was not administered until 11:43 AM which was one (1) hour and 43 minutes late.
-- Calcitriol was scheduled to be administered at 10:00 AM on 12/08/23 and was not administered until 11:41 AM which was one (1) hour and 41 minutes late.
-- Torsemide was scheduled to be administered at 10:00 AM on 12/08/23 and was not administered until 11:44 AM which was one (1) hour and 44 minutes late.
-- Diltiazem was scheduled to be administered at 10:00 AM on 12/08/23 and was not administered until 11:42 AM which was one (1) hour and 42 minutes late.
-- Duloxetine was scheduled to be administered at 10:00 AM on 12/08/23 and was not administered until 11:43 AM which was one (1) hour and 43 minutes late.
-- Cyanocobalamin was scheduled to be administered at 10:00 AM on 12/08/23 and was not administered until 11:42 AM which was one (1) hour and 42 minutes late.
-- Gabapentin was scheduled to be administered at 10:00 AM on 12/08/23 and was not administered until 11:41 AM which was one (1) hour and 41 minutes late.
An interview with the Director of Nursing at approximately 1:30 PM on 12/19/23 confirmed the above findings. She stated, I just got two (2) new med carts and I am hiring some more nurses to break up the med pass.
b) Resident #2
On 12/19/23 at 1:00 PM, a record review of the Medication Administration Audit Report from 12/01/23 through 12/18/23 was completed for Resident #2. The review found the following medications were administered late and the physician's orders were not followed:
The physician's orders dated for 12/01/23 at 10:00 PM were not administered as ordered.
--Brimonidine Tartrate 0.15% was administered at 12:44 AM which is 2 hours and 44 minutes late
--Melatonin 5mg was administered at 12:44 AM which is 2 hours and 44 minutes late
--Tylenol 650mg was administered at 12:44 AM which is 2 hours and 44 minutes late
--Levoxyl 50mcg was administered at 12:44 AM which is 2 hours and 44 minutes late
--Symbicort 160-4.5mcg was administered at 12:44 AM which is 2 hours and 44 minutes late
--Valporic Acid 500mg was administered at 12:44 AM which is 2 hours and 44 minutes late
--Docusate Sodium 100mg was administered at 12:44 AM which is 2 hours and 44 minutes late
--Latanoprost Solution 0.005% was administered at 12:44 AM which is 2 hours and 44 minutes late
--Cosopt Opthlamic Solution 2-0.5% was administered at 12:44 AM which is 2 hours and 44 minutes late
The physician's orders dated for 12/02/23 at 9:00 PM were not administered as ordered.
--Rhopressa Opthalmic Solution 0.02% was administered at 12:32 AM which is 3 hours and 32 minutes late
--Eliquis 5mg was administered at 12:32 AM which is 3 hours and 32 minutes late
--Buspar 5mg was administered at 12:32 AM which is 3 hours and 32 minutes late
The physician's orders dated for 12/02/23 at 10:00 PM were not administered as ordered.
--Brimonidine Tartrate 0.15% was administered at 12:32 AM which is 2 hours and 32 minutes late
--Melatonin 5mg was administered at 12:32 AM which is 2 hours and 32 minutes late
--Tylenol 650mg was administered at 12:32 AM which is 2 hours and 32 minutes late
--Levoxyl 50mcg was administered at 12:32 AM which is 2 hours and 32 minutes late
--Symbicort 160-4.5mcg was administered at 12:32 AM which is 2 hours and 32 minutes late
--Valporic Acid 500mg was administered at 12:32 AM which is 2 hours and 32 minutes late
--Docusate Sodium 100mg was administered at 12:32 AM which is 2 hours and 32 minutes late
--Latanoprost Solution 0.005% was administered at 12:32 AM which is 2 hours and 32 minutes late
--Cosopt Opthlamic Solution 2-0.5% was administered at 12:32 AM which is 2 hours and 32 minutes late
The physician's orders dated for 12/03/23 at 9:00 PM were not administered as ordered.
--Rhopressa Opthalmic Solution 0.02% was administered at 12:32 AM which is 3 hours and 32 minutes late
--Eliquis 5mg was administered at 12:32 AM which is 3 hours and 32 minutes late
--Buspar 5mg was administered at 12:32 AM which is 3 hours and 32 minutes late
The physician's orders dated for 12/03/23 at 10:00 PM were not administered as ordered.
--Brimonidine Tartrate 0.15% was administered at 12:32 AM which is 2 hours and 32 minutes late
--Melatonin 5mg was administered at 12:32 AM which is 2 hours and 32 minutes late
--Tylenol 650mg was administered at 12:32 AM which is 2 hours and 32 minutes late
--Levoxyl 50mcg was administered at 12:32 AM which is 2 hours and 32 minutes late
--Symbicort 160-4.5mcg was administered at 12:32 AM which is 2 hours and 32 minutes late
--Valporic Acid 500mg was administered at 12:32 AM which is 2 hours and 32 minutes late
--Docusate Sodium 100mg was administered at 12:32 AM which is 2 hours and 32 minutes late
--Latanoprost Solution 0.005% was administered at 12:32 AM which is 2 hours and 32 minutes late
--Cosopt Opthlamic Solution 2-0.5% was administered at 12:32 AM which is 2 hours and 32 minutes late
The physician's orders dated for 12/04/23 at 9:00 PM were not administered as ordered.
--Rhopressa Opthalmic Solution 0.02% was administered at 12:48 AM which is 3 hours and 48 minutes late
--Eliquis 5mg was administered at 12:48 AM which is 3 hours and 48 minutes late
--Buspar 5mg was administered at 12:48 AM which is 3 hours and 48 minutes late
The physician's orders dated for 12/05/23 at 9:00 PM were not administered as ordered.
--Rhopressa Opthalmic Solution 0.02% was administered at 12:51 AM which is 3 hours and 51 minutes late
--Eliquis 5mg was administered at 12:51 AM which is 3 hours and 51 minutes late
--Buspar 5mg was administered at 12:51 AM which is 3 hours and 51 minutes late
The physician's orders dated for 12/06/23 at 9:00 PM were not administered as ordered.
--Rhopressa Opthalmic Solution 0.02% was administered at 11:37 PM which is 2 hours and 37 minutes late
--Eliquis 5mg was administered at 11:37 PM which is 2 hours and 37 minutes late
--Buspar 5mg was administered at 11:37 PM which is 2 hours and 37 minutes late
The physician's orders dated for 12/06/23 at 10:00 PM were not administered as ordered.
--Guaifenesin ER 600mg was administered at 11:37 PM which is 1 hour and 37 minutes late
--Doxycycline 100mg was administered at 11:37 PM which is 1 hour and 37 minutes late
--Brimonidine Tartrate 0.15% was administered at 11:37 PM which is 1 hour and 37 minutes late
--Melatonin 5mg was administered at 11:37 PM which is 1 hour and 37 minutes late
--Tylenol 650mg was administered at 11:37 PM which is 1 hour and 37 minutes late
--Levoxyl 50mcg was administered at 11:37 PM which is 1 hour and 37 minutes late
--Symbicort 160-4.5mcg was administered at 11:37 PM which is 1 hour and 37 minutes late
--Valporic Acid 500mg was administered at 11:37 PM which is 1 hour and 37 minutes late
--Docusate Sodium 100mg was administered at 11:37 PM which is 1 hour and 37 minutes late
--Latanoprost Solution 0.005% was administered at 11:37 PM which is 1 hour and 37 minutes late
--Cosopt Opthlamic Solution 2-0.5% was administered at 11:37 PM which is 1 hour and 37 minutes late
The physician's orders dated for 12/08/23 at 9:00 AM were not administered as ordered
--Buspar 5mg was administered at 12:27 PM which is 3 hours and 27 minutes late
--Eliquis 5mg was administered at 12:27 PM which is 3 hours and 27 minutes late
The physician's orders dated for 12/08/23 at 10:00 AM were not administered as ordered.
--Symbicort 160-4.5mcg was administered at 12:27 PM which is 2 hours and 27 minutes late
--GlycoLax 17 grams was administered at 12:27 PM which is 2 hours and 27 minutes late
--Amiodarone 200mg was administered at 12:27 PM which is 2 hours and 27 minutes late
--Docusate Sodium 100mg was administered at 12:27 PM which is 2 hours and 27 minutes late
--Valporic Acid 500mg was administered at 12:27 PM which is 2 hours and 27 minutes late
--Cosopt Opthlamic Solution 2-0.5% was administered at 12:27 PM which is 2 hours and 27 minutes late
--Brimonidine Tartrate Solution 0.15% was administered at 12:27 PM which is 2 hours and 27 minutes late
--Doxycycline 100mg was administered at 12:27 PM which is 2 hours and 27 minutes late
--Lexapro 5mg was administered at 12:27 PM which is 2 hours and 27 minutes late
--Abilify 20mg was administered at 12:27 PM which is 2 hours and 27 minutes late
The physician's orders dated for 12/09/23 at 9:00 PM were not administered as ordered.
--Rhopressa Opthalmic Solution 0.02% was administered at 10:54 PM which is 1 hour and 54 minutes late
--Eliquis 5mg was administered at 10:54 PM which is 1 hour and 54 minutes late
--Buspar 5mg was administered at 10:54 PM which is 1 hour and 54 minutes late
The physician's orders dated for 12/10/23 at 2:00 PM were not administered as ordered.
--Tylenol 650mg was administered at 4:58 PM which is 2 hours and 58 minutes late
--Lasix 20mg was administered at 4:58 PM which is 2 hours and 58 minutes late
The physician's orders dated for 12/11/23 at 2:00 PM were not administered as ordered.
--Tylenol 650mg was administered at 3:51 PM which is 1 hour and 51 minutes late
--Lasix 20mg was administered at 3:51 PM which is 1 hour and 51 minutes late
The physician's order dated for 12/12/23 at 9:00 PM was not administered as ordered.
--Rhopressa Opthalmic Solution 0.02% was administered at 10:41 PM which is 1 hour and 41 minutes late
The physician's orders dated for 12/14/23 at 9:00 AM were not administered as ordered.
--Buspar 5mg was administered at 11:09 AM which is 2 hours and 9 minutes late
--Eliquis 5mg was administered at 11:10 AM which is 2 hours and 10 miniutes late
The physician's orders dated for 12/16/23 at 10:00 PM were not administered as ordered.
--Levoxyl 50mcg was administered at 2:33 AM which is 4 hours and 33 minutes late
--Symbicort 160-4.5mcg was administered at 2:33 AM which is 4 hours and 33 minutes late
--Melatonin 5mg was administered at 2:33 AM which is 4 hours and 33 minutes late
--Valporic Acid 500mg was administered at 2:33 AM which is 4 hours and 33 minutes late
--Latanoprost Solution 0.005% was administered at 2:33 AM which is 4 hours and 33 minutes late
--Cosopt Opthalmic Solution 2-0.5% was administered at 2:33 AM which is 4 hours and 33 minutes late
The physician's orders dated for 12/18/23 at 9:00 PM were not administered as ordered.
--Eliquis 5mg was administered at 10:56 PM which is 1 hour and 56 minutes late
--Buspar 5mg was administered at 10:56 PM which is 1 hour and 56 minutes late
--Rhopressa Opthalmic Solution 0.02% was administered at 10:57 PM which is 1 hour and 57 minutes late
On 12/19/23 at 1:30 PM, the Director of Nursing (DON) was notified and confirmed the physician's orders were not followed as written.
C) Resident #46
The physician's orders dated for 12/01/23 at 8:00 AM were not given as ordered:
--Buspirone HCL 5mg given at 10:16am which is 2 hours and 16 minutes late
--Insulin Detemir 100 unit/mil given at 10:16am which is 2 hours and 16 minutes late
The physician ' s orders dated for 12/03/23 at 6:00pm were not given as ordered:
--Hydrocodone-Acetaminophen 5-325MG was given at 8:04 which is 2 hours and 4 minutes late
The physician ordered dated 12/08/23 at 12:00 PM were not given as ordered:
--Hydralazine HCL 50 MG was given at 2:50 OM which is 2 hours 50 minutes late
The physician ' s orders dated for 12/16/23 at 12:00 PM were not given as ordered:
--Hydralazine HCL 50 MG was given at 2:28 PM which is 2 hours and 28 minutes late
The physician ' s orders dated for 12/01/23 at 8:00 PM were not given as ordered:
--Gabapentin 400mg was given at 10:20pm which is 2 hours and 20 minutes late
--Hydralazine HCL 50 MG was given at 10:20 PM which is 2 hours and 20 minutes late
--Warfarin Sodium 4 MG was given at 10;20 PM which is 2 hours and 20 minutes late
--Furosemide 40 MG was given at 10:19pm which is 2 hours and 19 minutes late
--Melatonin 5 MG was given at 10:20PM which is 2 hours and 20 minutes late
--Zoloft 100 MG was given at 10:20 PM which is 2 hours and 20 minutes late
--Calvitriol 0.25 was given at !0:29 PM which is 2 hours and 29 minutes late
--FiberCon 625 MG was given at 10:29 PM which is 2 hours and 29 minutes late
The physician ' s orders dated 12/02/23 at 8:00 PM were not given as ordered:
--Zoloft 100 MG was given at 4:07 AM which us 8 hours and 7 minutes late
--Melatonin 5 MG was given at 4:07 AM which us 8 hours and 7 minutes late
--FiberCon 625 MG was given at 4:07 AM which us 8 hours and 7 minutes late
--Hydralazine 50 MG was given at 4:07 AM which us 8 hours and 7 minutes late
--Calcitriol 0.25 MG was given at 4:07 AM which us 8 hours and 7 minutes late
--Furosemide 40 MG was given at 4:07 AM which us 8 hours and 7 minutes late
--Warfarin Sodium 4 MG was given at 4:07 AM which us 8 hours and 7 minutes late
--Gabapentin 400 MG was given at 4:07 AM which us 8 hours and 7 minutes late
--Insulin Detemir 100 UNIT/ML was given at 4:07 AM which us 8 hours and 7 minutes late
--Norco 5-325 MG was given at 4:07 AM which us 8 hours and 7 minutes late
The physician's orders dated 12/16/23 at 8:00 PM were not given as ordered:
--Gabapentin 400 MG was given at 10:05 pm which is 2 hours and 5 minutes late.
--Insulin Detemir 100 UNIT/ML was given at 10:05 pm which is 2 hours and 5 minutes late.
--Hydralazine 50 MG was given at 10:05 pm which is 2 hours and 5 minutes late.
--FiberCon 625 MG was given at 10:05 pm which is 2 hours and 5 minutes late.
--Furosemide 40 MG was given at 10:05 pm which is 2 hours and 5 minutes late.
--Warfarin Sodium 4 MG was given at 10:06 pm which is 2 hours and 6 minutes late.
--Calcitriol 0.25 MG was given at 10:05 pm which is 2 hours and 5 minutes late.
--Melatonin 5 MG was given at 10:06 pm which is 2 hours and 6 minutes late.
On 12/19/23 at 1:00 PM, the Director of Nursing (DON) was notified and confirmed the medication was not administered as ordered.
Sept 2023
3 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 F0657
(Tag F0657)
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 revise a care plan for Resident #15 regarding lift status. ...
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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 revise a care plan for Resident #15 regarding lift status. This was true for one (1) of five (5) residents reviewed during the survey process. Resident Identifiers: Resident #15. Facility Census: 83.
Findings Included:
a) Resident #15
On 09/19/23 at 11:00 AM, a record review was completed for Resident #15. The review found a lift assessment dated [DATE] indicating the staff should use a gait belt while transferring the resident instead of a mechanical lift. The care plan was reviewed and the new lift status had not been revised to use the gait belt for transfers.
On 09/19/23 at 1:00 PM, the Director of Nursing (DON) confirmed the care plan had not been revised. The DON stated, I take full responsibility .I didn't update the care plan but I did do the lift assessment.
No further information was obtained during the survey process.
.
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
Safe Environment
(Tag F0921)
Could have caused harm · This affected 1 resident
.
Based on observation and staff interview, the facility failed to maintain a safe, functional, sanitary, and comfortable environement for resident #53 and resident #74. This was a random opportunity ...
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.
Based on observation and staff interview, the facility failed to maintain a safe, functional, sanitary, and comfortable environement for resident #53 and resident #74. This was a random opportunity for discovery. Facility census is 83.
Findings include:
a) On 09/18/23 at approximately 2:35 p.m., observed some drywall repair work to the outer wall to the right of the window that was unsanded and unpainted in resident room D-38.
b) On 09/18/23 at approximatley 2:37 p.m., observed that the cove base has separated from the base of the wall and the lower section of wall located behind the head of bed B appears to have some type damage located in Resident Room D-38.
c) On 09/18/23 at approximately 2:55 p.m., observed that the empty bed space in room D-40 appears to have damage on the lower section of wall .
d) On 09/19/23 at approximately 10:53 a.m., observed the sink in Resident Room A6 the hand washing sink was loose from the wall and the support leg was leaning inwards.
e) Interview with Maintenance Assistant and the Director of Nursing verified these findings and findings were acknowledged by the Administrator upon on exit on 09/20/23 at 1:30 p.m.
.
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
.
Based on observation, record review, staff interview and random opportunities of discovery, the facility failed to maintain appropriate infection control standards for linen storage and disposal of ...
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.
Based on observation, record review, staff interview and random opportunities of discovery, the facility failed to maintain appropriate infection control standards for linen storage and disposal of dirty linen. These were random opportunities for discovery. Facility Census: 83.
a) B Hall Linen
On 09/19/23 at 1:23 PM, two (2) linen carts were observed on B Hall with the doors open and uncovered. Currently, there is one (1) COVID-19 positive resident residing on this hall. On 09/19/23 at 1:27 PM, two (2) dirty hand towels were observed laying on the floor of room B18.
On 09/19/23 at 1:26 PM, Licensed Practical Nurse (LPN) #22 confirmed the two (2) linen carts were not covered and the doors were open. LPN #22 also confirmed the dirty linen was laying on the floor in room B18. LPN #22 stated, Maintanence worked on those carts Friday (09/15/23), I thought they fixed them. LPN #22 stated, okay in reference to the dirty linen laying on the floor in room B18.
On 09/19/23 at 1:31 PM, the Administrator was notified and confirmed the linen cart doors should be shut and dirty linen should not be laying on the floor. We will get this taken care of right away.
b) D Hall Linen
On 09/19/23 at 1:27 PM, one (1) linen cart was observed on the D Hall with doors open, a drawer pulled out and uncovered. Currently, there are five (5) positive COVID-19 residents residing on this hall. On 09/19/23 at 1:29 PM, LPN #42 confirmed the linen cart doors were open, the drawer was pulled out and and the linen was uncovered.
On 09/19/23 at 1:31 PM, the Administrator was notified and confirmed the linen cart doors should be shut, the drawer should not be pulled out, and the linen should be covered. We will get this taken care of right away.
c) Facility Policy
The facility policy entitled, Linen Handling, with a revision date of 05/01/23, was reviewed and states the following:
--1.1 Keep clean linen covered. (Typed as written.)
--7.4 Soiled linen should be bagged or directly placed in covered container at the location where removing linen. (Typed as written.)
No further information was obtained during the survey process.
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Apr 2023
4 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Notification of Changes
(Tag F0580)
Could have caused harm · This affected 1 resident
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Based on record review and staff interview, the facility failed to ensure the resident's responsible party was notified when the resident experienced a significant weight loss. This was true for one...
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Based on record review and staff interview, the facility failed to ensure the resident's responsible party was notified when the resident experienced a significant weight loss. This was true for one (1) of three (3) residents reviewed. Resident identifier: #1. Facility census: 87.
Findings included:
a) Resident #1
On 2/23/23 the Resident's weight was 189.0 pounds. On 04/06/23 the Resident's weight was recorded as 166.6 pounds.
A capacity statement dated 08/10/20 found the resident lacked capacity to make medical decisions. On 02/27/23 a second capacity was provided by the facility physician noting the resident continued to lack capacity to make medical decisions.
Before admission to this facility, the resident had appointed family members as medical powers of attorneys on 09/25/18.
Review of the electronic medical record found an entry from the Registered Dietician, dated 4/10/2023 Weight Change
Note: WEIGHT WARNING:
Value: 166.6
Vital Date: 2023-04-06 19:38:00.0
-7.5% change [ 10.9% , 20.4 ]
Resident triggering for of -10.9% (-20.4 lbs.) x 6 weeks. CBW (current body weight) 166 lbs. (75.5 kgs.) BMI (Body Mass Index) 26.1 (just above normal-appropriate for age). Wt. gain/loss trend since admit. 8/26/22 admit wt. (weight) 171 lbs. Reg. (regular) dys.(dysphagia) adv. (advanced) with ground meats diet order eating with extensive assistance or total dependence on staff with meals with excellent intakes of 75-100% of meals per adls (activities of daily living) on 14-day review. Order for furosemide with potential for fluctuations in wt.
Rec (record) for wkly.(weekly) weights to monitor for further wt. loss before nutrition interventions at this time
At 1:10 PM on 04/17/23, the assistant director of nursing (ADON) was unable to find verification the medical power of attorney was notified of the Resident's significant weight loss.
The weight loss and failure to notify the responsible party of the weight loss was discussed with the administrator and the director of nursing at 1:58 PM on 04/17/23.
At the close of the survey no further information was provided.
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CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
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Based on policy review, record review, and staff interview, the facility failed to complete neurological examinations (Neuro Checks) per facility policy and professional standards of care after Resi...
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Based on policy review, record review, and staff interview, the facility failed to complete neurological examinations (Neuro Checks) per facility policy and professional standards of care after Resident #1 experienced a fall. This was true for one (1) of three (3) residents reviewed for the care area of falls. Resident identifier: #1. Facility census: 87.
Findings included:
Facility Policy:
Review of the facility policy, entitled, Neurological Evaluation, revised on 06/01/21 found:
Neurological evaluation will be performed as indicated or ordered. When a patient sustains an injury to the head or face and/or has an unwitnessed fall, neurological evaluation will be performed:
Every 15 minutes for two hours, then
Every 30 minutes for two hours, then
Every 60 minutes for four hours, then
Every eight (8) hours until at least 72 hours has elapsed
a) Resident #1
On 02/23/23, the resident was observed on the floor in his room lying on his back beside the bed. The fall was unwitnessed. Review of the Neurological Evaluation Flow Sheet, found neuro checks were started at 9:15 AM on 02/23/23.
The eight (8) hour neuro checks were not recorded on:
02/24/23 at 1:00 AM, 9:00 AM, and 5:00 PM.
02/25/23 at 1:00 AM, 9:00 AM, 5:00 PM, 1:00 AM, and 9:00 AM.
At 1:58 PM on 04/17/23, the Director of Nursing (DON) confirmed the neuro checks were not recorded on the above dates and times and were not obtained per facility policy.
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
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Based on observation, record review and staff interview, the facility failed to ensure a resident with known falls had devices in place to prevent accidents. This was true for one (1) of three (3) r...
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Based on observation, record review and staff interview, the facility failed to ensure a resident with known falls had devices in place to prevent accidents. This was true for one (1) of three (3) residents reviewed for the care area of falls. Resident identifier: #1. Facility census: 87.
Findings included:
a) Resident #1
Review of the medical record found the following recorded falls:
On 11/28/22, the Resident was found lying in the floor beside his bed.
On 12/20/22, the Resident was found lying in the floor of his room in front of his reclining chair.
On 02/23/23, the Resident was observed on the floor of his room lying on his back beside the bed.
On 03/03/23, the Resident was noted to be lying on the floor mat at the left side of the bed.
Review of the current care plan found the following focus:
Resident is at risk for falls: cognitive loss, lack of safety awareness, impaired mobility.
The goal associated with the focus:
Resident will have no falls with major injury requiring hospitalization through next review.
Interventions included:
Bed in low position
Defined perimeter mattress overlay
Fall mat to left bedside while Resident is in bed
Nightstand to be out of the way in case resident rolls out of bed again.
When up in his geri-chair, ensure that the lift sling is removed and not left under him.
When resident is in bed or bed-side chair place personal items within reach
Will place radio in closer reach on left side.
Observation of the Resident's bed with the Director Of Nursing (DON) at 1:58 PM on 04/17/23 found no perimeter mattress overlay was on the Resident's bed. The DON reviewed the care plan and said she would make sure the overlay was put on the bed.
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CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0921)
Could have caused harm · This affected 1 resident
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Based on observation and staff interview, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents. The headboard of Resident #1's bed was broken. This ...
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Based on observation and staff interview, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents. The headboard of Resident #1's bed was broken. This was a random opportunity for discovery. Resident identifier: #1. Facility census: 87.
Findings included:
a) Resident #1
At 8:55 AM on 04/17/23, the Resident was observed in his bed. A nursing assistant (NA) had just finished feeding the Resident his breakfast.
Observation found the left side of the headboard was loose from the bed frame, The headboard was leaning towards the floor.
NA #35 verified the headboard was not securely attached to the bed frame. She stated, I think the bolt is stripped or something. NA #35 said she would immediately tell the maintenance man.
At 2:00 PM on 04/17/23, the above observation was discussed with the administrator.
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Mar 2023
14 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
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Based on medical record review, policy review and staff interview the facility failed to notify the resident's representative in a timely manner when Resident #77's was transferred to the hospital. ...
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Based on medical record review, policy review and staff interview the facility failed to notify the resident's representative in a timely manner when Resident #77's was transferred to the hospital. This was true for one (1) of three (3) residents reviewed for hospitalizations. Resident Identifier: Resident #77. Facility census: 87.
Findings Included:
a) Resident #77
A review of a facility policy titled Change in Condition: Notification of with a revision date of 06/01/21 read as follows.
POLICY
A Center must immediately inform the resident/patient (hereinafter patient), consult with the patient's physician and notify, consistent with his/her authority, the patient's Health Care Decision Maker (HCDM), where there is:
.A decision to transfer or discharge the patient from the Center
During a record review on 03/15/23 at 9:18 AM Resident # 77's medical record revealed a Hospital transfer form on 07/13/22. The Resident Representative section was completed with the representative's name and telephone number. A question stated, Notified of transfer? The facility responded with, No.
During an interview on 03/15/23 at 9:26 AM the Administrator acknowledged the Hospital Transfer form was coded no for the resident representative being notified of the transfer on 07/13/22.
No other information was provided by the end of the survey.
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CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Transfer Requirements
(Tag F0622)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
b) Resident #87
Review of Resident #87's medical records showed a note written on 02/16/23 by the nurse practitioner stating ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
b) Resident #87
Review of Resident #87's medical records showed a note written on 02/16/23 by the nurse practitioner stating the resident was transferred to the emergency room on [DATE] for suicidal ideation with a plan.
The resident's nurse's progress notes contained no mention of the resident's transfer to the emergency department. Additionally, the medical records contained no documentation that necessary information was provided to the receiving hospital to ensure a safe and effective transition of care.
During an interview on 03/15/23 at 12:21 PM, the Administrator confirmed a Hospital Transfer Form, which would have conveyed the necessary information to the receiving hospital, was not completed when the resident was transferred to the emergency room on [DATE].
No further information was provided through the completion of the survey process.
Based on record reviews and staff interviews the facility failed to ensure the required information was conveyed to the receiving providers, to ensure a safe and effective transition of care. This was discovered for two (2) of two (2) residents reviewed for the area of hospitalizations during the Long Term Care Survey Process. Resident identifiers: #59 and #87. Facility census: 87.
Findings included:
a) Resident #59
On 03/15/23 a medical record review revealed no transfer information was conveyed to the hospital on [DATE] for Resident #59 to ensure a safe and effective transition of care.
The transfer information provided must include a minimum of the following:
- Contact information of the practitioner responsible for the care of the resident.
- Resident representative information including contact information
- Advance Directive information
- All special instructions or precautions for ongoing care, as appropriate.
- Comprehensive care plan goals.
During an interview on 03/15/23 at 11:00 AM, with the Nursing Home Administer, verified there was no discharge paperwork provided for the hospitalization on 12/21/22 for Resident #59.
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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 and staff interview, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice. The facility failed to obtain l...
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Based on record review and staff interview, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice. The facility failed to obtain laboratory testing as ordered for one (1) of five (5) residents reviewed for the care area of unnecessary medications. Resident identifier: #13. Facility census: 87.
Findings included:
a) Resident #13
Review of Resident #13's physician's orders showed an order written on 10/10/22 for thyroid stimulating hormone (TSH) laboratory testing every six (6) months, in December and June. The resident had a diagnosis of hypothyroidism and was receiving the medication Levothyroxine as a thyroid replacement. Results for TSH testing in December could not be located in the resident's electronic records.
During an interview on 03/15/23 at 3:11 PM, the Director of Nursing (DON) confirmed Resident #13 did not have TSH testing in December as ordered by the physician.
No further information was provided through the completion of the survey process.
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CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0698
(Tag F0698)
Could have caused harm · This affected 1 resident
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Based on record review and staff interview the facility failed to provide an ongoing assessment and oversight for Resident #57 after hemodialysis treatments, that included monitoring the resident's ...
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Based on record review and staff interview the facility failed to provide an ongoing assessment and oversight for Resident #57 after hemodialysis treatments, that included monitoring the resident's condition for complications. Shared communication between the nursing home and the dialysis facility was not properly implemented. This failed practice was true for one (1) of one (1) resident reviewed for dialysis services with the potential to affect only a limited number of residents. Resident identifier: #57. Facility census: 87.
Findings included:
a) Resident #57
Record Review showed an order for Resident to attend hemodialysis at a local Dialysis center every Monday, Wednesday, Friday with time of departure to be 5:45 AM transported by local Ambulance service.
On 03/13/23 at 2:40 PM, Record review showed no documentation to indicate if the Resident was out of the facility for Hemodialysis services. The Director of Nursing (DON) was asked if the Resident was out to the dialysis center? The DON stated, Yes she should be it is Wednesday. Did they not enter a note? They should have. The DON was then asked if the Resident had returned yet? The DON replied, I am not sure I will have to check.
On 03/15/23 at 2:50 PM Registered Nurse (RN) #24 came into the room and stated [Resident #57 first and last name] is back from dialysis, they wanted me to let you know. RN #24 was unsure of the time when the resident returned.
Record review of the facility's policy titled Dialysis: Hemodialysis (HD) Provided by a Certified Dialysis Center, revised on 06/01/21, showed: After receiving dialysis, facility staff must provide monitoring and documentation of: the Resident's vital signs, vascular access site to observe for bleeding or other complications; and monitor for post complication symptoms including dizziness, nausea, vomiting, fatigue, and hypotension.
Record review showed the facility uses a hemodialysis communication record form to coordinate the care between the dialysis center and the facility. Each Resident has a designated binder that is sent with them to the Hemodialysis center containing this form. Section #1 is to be completed by the facility nurse prior to the Resident leaving for hemodialysis. Section #2 is to be completed by the Hemodialysis facility following hemodialysis treatment, and then accompanies the Resident back to the nursing home after hemodialysis treatment. Section #3 is to be completed by facility nurse when the resident gets back to the facility from hemodialysis treatment. Section #3's required information included: vascular access site complications, vital signs, post hemodialysis complication symptoms, and new orders.
Record review of the Resident's hemodialysis Communication Records for February 2023 and March 2023 showed Section #3 was not completed by facility staff upon Resident #57's return from hemodialysis treatment for the following dates: 02/15/23, 02/17/23, 02/20/23, 02/22/23, 02/24/23, 02/27/23, 03/01/23, 03/03/23, 03/06/23, 03/13/23, 03/15/23.
On 03/16/23 at 11:08 AM, the Director of Nursing (DON) confirmed that when a Resident returned to the facility from the dialysis center, a licensed nurse is to review the hemodialysis Communication Record, evaluate the Resident, and complete the post-hemodialysis treatment on Sections #3. The DON verified the post dialysis assessments were not completed on the hemodialysis communication record form, and staff were not properly documenting when the Resident was leaving and returning to the facility.
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CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0809
(Tag F0809)
Could have caused harm · This affected 1 resident
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Based on observation, policy review, Resident Council meeting and staff interview the facility failed to provide Residents with evening snacks. This had the potential to affect a limited number of r...
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Based on observation, policy review, Resident Council meeting and staff interview the facility failed to provide Residents with evening snacks. This had the potential to affect a limited number of residents receiving snacks from the nourishment room and the Memory Unit kitchen. Facility Census: 87
Findings Included:
a) Policy
A review of a facility policy titled Snacks with a revision date of 09/17 read as follows.
Snacks and beverages will be provided as identified in the individual plans of care. Bedtime (a.k.a. HS) snacks will be provided for all residents. Additional snacks and beverages will be available upon request for all residents who want to eat at non-traditional times.
.4. The dining Services Department will assemble and deliver to each unit the individually planned snacks and bulk snack items to be offered at bedtime.
5. The Dining Service Department provides a listing of the current diet orders and snacks for each resident to each care area.
6. Nursing Services is responsible for delivering the individual snacks to the identified residents and the offering evening snacks to all other residents
b) Memory Unit kitchen
During the initial tour of the Memory Unit kitchen on 03/13/23 at 1:57 PM with Dementia Program Director (DPD) observation revealed a standard items snack list. The following items were not available.
-tea bags
-cereal
-ice cream
-coffee
-coffee filters
-liquid eggs, or eggs
-no bread for the sandwiches
The DPD stated the coffee pot is broken and has never been replaced by the facility. I purchased a Bun coffee pot but they said we could not use it due to a burn hazard so I took it home. The staff buy the snacks for residents because we can never get what we need.
On 03/13/23 at 2:34 PM, the Administrator stated I bring over coffee every morning.
On 03/13/23 at 5:11 PM, the Administrator provided an updated standard snacks list , and stated we added more to the list of the resident preferences. We will be bringing over coffee every two hours also.
c) Resident Council
During a resident council meeting held on 03/14/23 at 2:04 PM, the group as a whole was asked the following question Do you receive snacks at bedtime or when you request them?
Confidential interviews with the Resident group found the following concerns related to evening snacks:
-You have to go to the front desk and ask for the snacks, they do not go room to room asking everyone.
- The ones that can't leave there room on their own are SOL, they do not get a snack.
-We never get a snack before bed.
-Sometimes it's a long time before breakfast.
-I have not seen any snacks, did not know they even had snacks I could ask for.
During an interview on 03/14/23 at 3:00 PM, the Director of Nursing stated I will inservice my staff immediately and get this issue addressed.
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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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b) Memory Unit
During the initial tour of the Memory Unit kitchen on 03/13/23 at 1:57 PM, with the Dementia Program Director (DPD) observation revealed the ice machine was leaking water onto the flo...
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b) Memory Unit
During the initial tour of the Memory Unit kitchen on 03/13/23 at 1:57 PM, with the Dementia Program Director (DPD) observation revealed the ice machine was leaking water onto the floor and under the refrigerator next to the ice machine. The ice machine water drain did not have a one inch gap and was touching the floor drain allowing for the potential for contaminants to enter the line and travel to the ice machine.
The stove top had dried up food and the aluminum foil was torn around the burners. The outside of the refrigerator had residue built up.
Immediately the DPD acknowledged the need for a cleaner environment. DPD stated we are not sure who is supposed to clean it, the housekeeping, the kitchen or the nursing staff, but the nursing staff do not have time to clean the kitchen daily.
During an interview on 03/13/23 at 3:45 PM, the Administrator stated the Memory Unit kitchen issues have been addressed and a cleaning schedule is in place.
Based on observations and staff interviews, the facility failed to maintain the facility kitchens in a safe and sanitary manner in accordance with professional standards of practice. During the main kitchen tour it was discovered the freezer floor needed to be cleaned, the wall entering the Dish Room was in poor repair and the kitchen on the memory unit needed a deep cleaning. This had the potential to affect a limited number of residents. Facility census: 87.
Findings included:
a) Main kitchen tour
During the main kitchen tour on 03/14/23 at 11:42 AM, it was discovered the floor to the walk-in freezer had a dark substance on the floor, in the back corners. Also the wall to the Dish Room had, missing corner molding, baseboard, and a hole in the wall.
An interview with the Dietary Manager (DM) on 03/14/23 at 11:55 AM, verified the floor to the walk-in freezer needed to be cleaned and the wall to the Dish Room needed to be repaired.
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CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Medical Records
(Tag F0842)
Could have caused harm · This affected 1 resident
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Based on record reviews and staff interviews the facility failed to ensure complete and accurate medical records. The facility failed to ensure the Physician Orders for Scope of Treatment (POST) for...
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Based on record reviews and staff interviews the facility failed to ensure complete and accurate medical records. The facility failed to ensure the Physician Orders for Scope of Treatment (POST) forms were completed per directions specified by the [NAME] Virginia Center for End-of-Life Care. This was true for three (3) of 18 residents reviewed for the area of Advance Directives during the Long-Term Care Survey Process. Resident Identifiers: #13, #59. Facility Census: 87.
Findings included:
a) Resident #13
A medical record review for Resident #13 on 03/14/23, revealed the POST had only a verbal consent witnessed by two (2) persons on 07/08/22 and no signature had been obtained by the Medical Power of Attorney (MPOA).
In an interview with the Licensed Social Worker (LSW) on 03/14/23 at 12:09 PM, she verified there was no signature obtained from the Medical Power of attorney (MPOA) for the POST completed on 07/08/22.
b) Resident #59
A medical record review for Resident #59 on 03/14/23, revealed the POST had only a verbal consent witnessed by two (2) persons on 07/21/21 and no signature had been obtained by the Medical Power of Attorney (MPOA).
An interview with the Licensed Social Worker (LSW) on 03/14/23 at 12:09 PM, verified there was no signature obtained from the Medical Power of attorney (MPOA) for the POST completed on 07/21/21.
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CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0883
(Tag F0883)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on record review and staff interview, the facility failed to offer influenza and pneumococcal immunizations to residents...
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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 offer influenza and pneumococcal immunizations to residents as appropriate. This deficient practice had the potential to affect two (2) of five (5) residents reviewed for the care area of immunizations. Resident identifiers: #69, #8. Facility census: 87.
Findings included:
a) Policy review
The facility's policy titled Immunizations: Influenza/Pneumococcal with effective date 12/0/1/06 stated upon admission residents or health care decision makers were to be asked if the resident had ever received pneumovax, and/or annual influenza vaccine.
Pneumococcal vaccination was to be encouraged for all residents who had never received the vaccine, for those who have unknown status of vaccination, and those over age [AGE] who were vaccinated five (5) or more years previously and were aged less than 65 at the time of vaccination.
Influenza vaccination was to be offered in the fall of each year.
b) Resident #69
Review of Resident #69's medical records showed the resident did not receive an influenza vaccination in the fall of 2022. The records contained no documentation that the resident was offered an influenza vaccination in 2022.
Additionally, Resident #69's medical records showed the resident had received a vaccination against pneumococcal disease, Prevnar 13, before admission to the facility. There was no documentation the resident was offered the next recommended pneumococcal vaccination in the series after admission to the facility in 2021.
On 03/14/23 at 10:00 AM, the Infection Preventionist was asked if Resident #69 was offered an influenza vaccination in fall 2022 or the recommended pneumococcal vaccination.
On 03/14/23 at 3:30 PM, the Infection Preventionist presented a Pneumococcal Vaccine Informed Consent and an Influenza Vaccine Informed Consent dated 03/14/23. The resident's representative gave verbal consent for both vaccinations.
During an interview on 03/15/23 at 12:57 PM, the Infection Preventionist confirmed there was no documentation Resident #69 was offered an influenza vaccination in 2022 or was offered a pneumococcal vaccine before surveyor intervention.
No further information was provided through the completion of the survey.
c) Resident #8
Review of Resident #8's medical records showed no indication the resident had received vaccination against pneumococcal disease. There was no indication the resident had been offered pneumococcal vaccination.
On 03/14/23 at 10:00 AM, the Infection Preventionist was asked if Resident #8 was offered pneumococcal vaccination.
On 03/14/23 at 3:30 PM, the Infection Preventionist presented a Pneumococcal Vaccine Informed Consent dated 03/14/23. The resident's representative gave verbal consent for the vaccination.
During an interview on 03/15/23 at 12:57 PM, the Infection Preventionist confirmed there was no documentation Resident #8 was offered 2022 or was offered pneumococcal vaccine before surveyor intervention.
No further information was provided through the completion of the survey.
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CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0887
(Tag F0887)
Could have caused harm · This affected 1 resident
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Based on record review and staff interview, the facility failed to document consent and refusal of COVID-19 vaccinations. This deficient practice had the potential to affect two (2) of five (5) resi...
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Based on record review and staff interview, the facility failed to document consent and refusal of COVID-19 vaccinations. This deficient practice had the potential to affect two (2) of five (5) residents reviewed for the care area of immunizations. Resident identifiers: #77, #33. Facility census: 87.
Findings included:
a) Policy review
The facility's policy titled COVID-19 Vaccination with effective date 12/14/20 and review date 11/15/22 stated resident COVID-19 vaccination history would be obtained upon admission. Based on the resident's COVID-19 vaccination history, vaccination would be offered. Additionally, a Patient Informed Consent or Declination COVID-19 form was to be used.
b) Resident #77
Review of Resident #77's medical records showed the resident had received a COVID-19 booster vaccination on 05/05/22. No COVID-19 vaccination consent form was located in the resident's medical records.
During an interview on 03/15/23 at 9:19 AM, Unit Manager (UM) #19 stated she was unable to locate a consent form for Resident #77's COVID-19 vaccination on 05/05/22. UM #19 stated she spoke to the resident's representative on 03/14/23, who stated she would have given consent for the vaccination. This was documented on a Patient Informed Consent or Declination COVID-19 form dated 03/14/23.
No further information was provided through the completion of the survey process.
c) Resident #33
Review of Resident #33's medical records stated the resident had received primary COVID-19 vaccination prior to admission but had refused COVID-19 booster vaccination upon admission to the facility. The resident had signed a Patient Informed Consent or Declination COVID-19 Vaccine form on 01/10/23. The form had areas to check to indicate that consent for the vaccination was given or to indicate consent for the vaccination was not given. However, neither of these areas were checked to indicate whether Resident #33 had given or refused consent for COVID-19 booster vaccination.
During an interview on 03/15/23 at 11:01 AM, the Infection Preventionist confirmed Resident #33's Patient Informed Consent or Declination COVID-19 Vaccine form had not been completed to indicate whether or not the resident had given consent for additional COVID-19 vaccinations. The Infection Preventionist stated the resident had refused COVID-19 booster vaccination.
No further information was provided through the completion of the survey process.
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CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0582
(Tag F0582)
Could have caused harm · This affected multiple residents
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Based on observation and staff interview, the facility failed to correctly inform and explain to beneficiaries the Centers for Medicare & Medicaid Services (CMS) Form #10055-Skilled Nursing Facility...
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Based on observation and staff interview, the facility failed to correctly inform and explain to beneficiaries the Centers for Medicare & Medicaid Services (CMS) Form #10055-Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN) when medicare services were ending for three (3) of three (3) residents reviewed for beneficiary notification. Resident identifiers: #59, #41, and #31. Facility census: 87.
Findings included:
a) Beneficiary Notification
The facility provided a list of Medicare beneficiaries who were discharged from Medicare covered Part A services with benefits days remaining in the past 6 months.
Three (3) residents, Resident's #59, #41, and #31 were chosen from the list for review.
All 3 residents were provided with the CMS form 10055-a Skilled Nursing Facility Advance Beneficiary notice of non-coverage (SNFABN.)
It is important to note that the CMS-10055, is only issued if the beneficiary intends to continue services and the skilled nursing facility believes the services may not be covered under Medicare. It is the facility's responsibility to inform the beneficiary about potential non-coverage and the option to continue services with the beneficiary accepting financial liability for those services.
All 3 residents/responsible parties checked option #1, which directs: I want the care listed above. I want Medicare to be billed for an official decision on payment, which will be sent to me on a Medicare Summary Notice (MSN). I understand that if Medicare doesn't pay, I'm responsible for paying, but I can appeal to Medicare by following the directions on the MSN.
Resident #59 was informed that beginning 11/18/22 inpatient skilled services would be terminated. You may have to pay out of pocket for this care if you do not have other insurance that may cover these costs. The reason was, You only need assistance or supportive care. You do not require daily skilled care by a professional nurse or therapist. Medicare will not pay for your stay at this center unless you require daily skilled care. The estimated cost to continue receiving daily skilled care was listed as $466.00 per day.
Option #1 was checked but neither the resident or the responsible party had signed the CMS-10055. According to additional information accompanying form 10055, the business office manager called the responsible party by telephone and the responsible party agreed to Option #1.
Resident #31 was informed that beginning on 11/19/2022 inpatient skilled services would be terminated. You may have to pay out of pocket for this care if you do not have other insurance that may cover these costs. The reason Medicare may not pay was listed as, You only need assistance or supportive care. You do not require daily skilled care by a professional nurse or therapist. Medicare will not pay for your stay at this center unless you require daily skilled care. The estimated cost to continue receiving daily skilled care is $466.00 per day. Option #1 was checked and this form was signed by the resident.
Resident #41 was informed that beginning on 11/24/22 skilled services would be terminated. You may have to pay out of pocket for this care if you do not have other insurance that may cover these costs. The reason Medicare may not pay was listed as: You only need assistance or supportive care. You do not require daily skilled care by a professional nurse or therapist. Medicare will not pay for your stay at this center unless you require daily skilled care. The estimated cost of this skilled care is 509.00 per day. Option #1 was checked and this form was signed by the resident's responsible party.
On 03/15/23 at 10:45 AM, the business office manager (BOM) #77 reviewed CMS form 10055 for all three (3) residents. BOM #77 confirmed she was responsible to notify families and residents when residents were being discharged from Medicare services. She stated she is the facility staff person who takes of issuing CMS 10055. She said, oh that was just a mistake. I should have never checked option #1 because neither the resident/responsible party wanted to continue with skilled care services they would have to pay for. She said, I don't know why I did that when I know better. BOM #77 confirmed that by checking option #1 skilled services would continue for all three (3) residents at the daily rate specified on the form. If Medicare did not pay for services the residents would be responsible to pay the out of pocket daily rate.
The above issues were discussed with the administrator at 11:00 AM on 03/15/23. No further information was provided prior to the end of the survey.
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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** .
b) Memory Unit
A review of the facility policy titled Sanitation with an effective date of 05/01/18 read as follows.
.Furnitu...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
b) Memory Unit
A review of the facility policy titled Sanitation with an effective date of 05/01/18 read as follows.
.Furniture, floors, ceilings, walls and fixtures will be clean, sanitary and in good repair
During the initial interview on 03/13/23 at 1:10 PM, Resident #3 stated look at these walls; they are bare and need to be painted and on that wall the wallpaper is torn and peeling off. It's sad here, the walls are depressing. Observation found the walls had scuff marks with paint chipping. The blinds were in poor condition and the wallpaper was torn.
During an interview 03/13/23 01:18 PM, the Dementia Program Director (DPD) stated room [ROOM NUMBER] does need some repairs, I put a work order in last year and it did not get it done.
During the initial tour on 03/13/23 of the Memory Unit revealed repairs needed in the following rooms:
-room [ROOM NUMBER] The paint is chip off the walls and the window blinds are in poor condition.
-room [ROOM NUMBER] The wallpaper is peeling and in poor condition.
-room [ROOM NUMBER] The wallpaper is peeling and in poor condition.
-room [ROOM NUMBER] The walls have scuff marks and the paint is chipping. The wall around the HVAC unit is cracked and there is a gap between the wall and the HVAC unit. There is a crack in the wall from the window to the ceiling.
-The shower room flooring was in poor repair. There were several holes in the walls in the shower stall.
During an interview on 03/13/23 at 1:46 PM, the Dementia Program Director (DPD) acknowledged the shower room and the need for repairs. At 1:53 PM, the DPD acknowledged the above rooms needed some repairs, mainly wallpaper and paint.
During an interview on 03/14/23 at 11:45 PM, the DPN stated room [ROOM NUMBER] needs some major work and I put in a work order.
Based on observation, staff interview and policy review the facility failed to provide housekeeping and maintenance services necessary to maintain a sanitary, well-kept resident care area. Resident rooms were absent of clean bed linens, and personalization items that promoted a home-like environment. These failed practices were a random opportunity for discovery and had the potential to affect more than a limited number of residents. Facility census: 87.
Findings included:
a) Skilled Long Term Care Unit
Room #B9:
On 03/13/23 at 12:00 PM observation was made of Resident #50 laying on a blue mattress with no sheets covering mattress. Resident #50 was asked where the sheets were? Resident #50 replied, I don't know. Licensed Practical Nurse (LPN) #64 was asked why sheets were not on the Resident's bed? She stated, I don't know, I'll get the aides to put some on there. A light brown/yellow substance was spilled in the floor and at A bed and had ran across the floor under B bed. The bed control for the Resident residing in B bed was laying in the floor in the brown/yellow liquid substance. Housekeeping manager #112 was called into room at 12:05 PM and stated, Yea I'll get that cleaned up, we clean rooms every day but I can't bring the cleaning cart until the drink trays leave the floor.
Room #B15:
On 03/13/23 at 12:12 PM observation was made of several dark brown quarter size spots of a cake like substance, smashed flat on floor leading from doorway of room B15 to Bed A. The dirty floor was verified by Certified Nurse Aide (CNA) #62 at 12:13 PM. CNA #62 stated It's probably a fudge round she [Resident residing in room B15-A] carries a snack cake around all the time and eats them. At 12:19 PM on 03/13/23, observation was made of environmental staff #113 scrapping the cake like substance of the floor with a long-handled scrapping tool.
Room B13A:
On 03/13/23 at 12:28 PM observation was made of a dark brown dried liquid substance trail that started at the doorway of Room B13 leading into the resident room and bed A. The substance was sticky to the touch of a shoe. Housekeeping manager #112 verified the dirty floor at 12:30PM, and stated, Looks like spilled coffee or pop, or maybe when they took the trash bag out it leaked on the floor. I will get that mopped up.
Room #D28:
On 03/14/23 at 8:45 AM, observation was made Resident #149's foot board with the veneer sticker covering pealing away from the wood in huge sections. LPN #60 verified the condition of the footboard at 8:47 AM and stated, Yea that looks bad. At 11:28 AM on 03/14/23, the Administrator was present in room and stated, I don't like that, we will get that taken care of. Looks bad.
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CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Grievances
(Tag F0585)
Could have caused harm · This affected multiple residents
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Based on observation, policy review, resident interview, and staff interview the facility failed to make grievances forms accessible to all residents and resident representatives. This had the poten...
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Based on observation, policy review, resident interview, and staff interview the facility failed to make grievances forms accessible to all residents and resident representatives. This had the potential to affect more than a limited number of residents living in the Memory Unit. Facility census: 87.
Finding Included:
A review of the facility policy titled Grievance/Concern-Resident/Family with an effective date of 03/01/02 read as follows.
.Purpose
-To ensure that any resident or resident representative has the right to express a grievance/concern without fear of interference, coercion, discrimination or reprisal in any form.
a) Grievances
During the initial tour of facility on 03/13/23, observation found the Grievance forms were in a box on a wall beside the nurses station not accessible for the residents or resident representatives and not at wheelchair level for resident accessibility.
During an interview on 03/14/23 at 3:14 PM, Dementia Program Director acknowledged the grievance forms need to be accessible to all residents and their representatives.
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CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Transfer Notice
(Tag F0623)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
d) Resident #87
Review of Resident #87's medical records showed a note written on 02/16/23 by the nurse practitioner stating ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
d) Resident #87
Review of Resident #87's medical records showed a note written on 02/16/23 by the nurse practitioner stating the resident was transferred to the emergency room on [DATE] for suicidal ideation with a plan. The resident did not return to the facility.
During an interview on 03/15/23 at 10:54 AM, the Administrator stated the ombudsman had not been notified of Resident #87's transfer to the hospital on [DATE].
No further information was provided through the completion of the survey process.
Based on record reviews and staff interviews the facility failed to provide Notices of Transfer to the State Ombudsman. This was discovered for three (3) of three (3) residents reviewed for hospitalizations during the Long-Term Care Survey Process. Residents #59, #77 and #87 were transferred to acute care hospitals, and no Notices of Transfer were provided to the State Ombudsman. Resident identifiers: #59, #77 and #87. Facility census: 87.
Findings included:
a) Policy
A review of a facility policy titled Discharge and Transfer with a revision date of 11/15/22 reads as follows.
.Written notice must also be provided to the Ombudsman or other required state agency using the NOID or state specific discharge form
b) Resident #59
A medical record review on 03/15/23 for Resident #59, revealed the resident was discharged to the hospital on [DATE] and no Notice of Transfer was sent to the State Ombudsman.
An interview with the Nursing Home Administrator (NHA) on 03/15/23 at 10:52 AM, reported there was no Notice of Transfer sent to the State Ombudsman for the hospitalization on 01/30/23 for Resident #59.
c) Resident #77
During a record review on 03/15/23 at 9:18 AM Resident # 77 medical record review revealed Resident #77 was transferred to a local hospital on [DATE] with a Hospital transfer form dated 07/13/22.
The record did not reflect the Notice of Transfer was sent to the Ombudsman.
During an interview on 03/15/23 10:52 AM, the facility Administrator acknowledged the facility failed to notified the Ombudsman of the transfer.
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CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0888
(Tag F0888)
Could have caused harm · This affected multiple residents
.
Based on record review and staff interview, the facility failed to track COVID-19 vaccination status for eight (8) of 149 facility employees. This deficient practice was identified during the infect...
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Based on record review and staff interview, the facility failed to track COVID-19 vaccination status for eight (8) of 149 facility employees. This deficient practice was identified during the infection control facility task and had the potential to affect more than a limited number of residents. Facility census: 87.
Findings included:
a) Staff vaccination tracking
A spreadsheet of COVID-19 vaccination status for facility employees was provided by the administrator on 03/14/23 at 10:43 AM. On this spreadsheet, eight (8) employees were indicated to be unvaccinated, without delay or exemptions. These employees were as follows: Licensed Practical Nurse (LPN) #21, LPN #63, CNA (Certified Nursing Assistant) student #61, LPN #86, Bookkeeper #82, Housekeeper #114, Dietary Aid #104, and Laundry Worker #115.
The Infection Preventionist subsequently provided documentation that all eight (8) employees were fully vaccinated against COVID-19. During an interview on 03/15/23 at 10:33 AM, the Infection Preventionist stated the spreadsheet was obtained from the corporate office and confirmed the spreadsheet was incorrect regarding these employees' COVID-19 vaccination statuses.
No further information was provided through the completion of the survey process.
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Jan 2022
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
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Based on observation and staff interview, the facility failed to ensure the residents environment was safe, clean, comfortable, and home-like. The floors were stained and dirty, wallpaper was torn, ...
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Based on observation and staff interview, the facility failed to ensure the residents environment was safe, clean, comfortable, and home-like. The floors were stained and dirty, wallpaper was torn, door facing was loose, walls were scuffed and dirty, a sheet and privacy curtain were stained. This was a random opportunity for discovery. Facility census: 83.
Findings included:
a) Room B -15
On 01/18/22 at 11:41 AM, a large pool of red liquid was dried on the floor beside the A - bed. A dark brown stain was observed on the bottom sheet of the A bed. The wall around the doorway leading out into the hallway and the wall opposite the foot of the bed were marred and scuffed with black marks. In addition, yellow and brown liquids were splashed on the wall and door facing leading into the hallway.
Employee #49 the admission director was present and observed the above issues.
On 01/24/22 at 9:17 AM, the administrator toured the room with the surveyor. A very large dried area of what appeared to be coffee was spilled on the floor around the sink. A straw paper and a piece of paper had absorbed the liquid and was stuck to the floor. The floor was also stained with red dried liquid. The walls remained scuffed and a liquid substance was splattered to the wall beside the door leading out of the room.
b) B 17
01/18/22 11:53 AM, observation found a sheet of paper taped to the faucet saying the sink was out of order. The right metal door facing, on the inside of the door, was dangling loose and hanging sideways from the wall. It was attached at the top only. These observations were witnessed by nursing assistant (NA) #21.
On 01/24/22 at 9:17 AM, the administrator toured the room with the surveyor. The sink and the door facing had been repaired.
On 01/24/22 at 9:31 AM, observation found the bedside curtain beside the A bed was soiled with red and brown stains along the bottom edge. This observation was confirmed with Registered Nurse (RN) #46.
c) B 18
On 01/18/22 at 11:55 AM, observation revealed the walls of the room were scuffed with black marks. The wallpaper above the heater was torn from the wall.
Employee #49 was present during the observations.
On 01/24/22 at 9:17 AM, the administrator toured the room with the surveyor. The walls remained scuffed and the wallpaper was torn around the heater.
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CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Free from Abuse/Neglect
(Tag F0600)
Could have caused harm · This affected 1 resident
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Based on record review and staff interview, the facility failed to ensure an alleged allegation of neglect voiced by the resident was reported to the proper State authorities. This was a random oppo...
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Based on record review and staff interview, the facility failed to ensure an alleged allegation of neglect voiced by the resident was reported to the proper State authorities. This was a random opportunity for discovery. Resident identifier: #57. Facility census: 83.
Findings included:
a) Resident #57
During review of the Event Summary Reports for Resident #57 it was discovered that on 08/15/21 at 4:30 PM, the resident reported the following:
Resident states staff took him to the bathroom at 3:00 PM and dropped him. Resident has been on precautions for Respiratory virus RSV (Respiratory Syncytial Virus.) X-ray was ordered of the left knee by MD which revealed no injury. Resident monitored for any new changes.
Review of the nursing notes for 08/15/21, found no mention of the incident.
On 01/24/22 at 12:09 PM, the administrator was asked if she had any information regarding investigation / reporting of the incident on 08/15/21?
On 01/24/22 at 12:53, the administrator confirmed she was unable to find any evidence the incident was reported to the proper state authorities or investigated. She stated the facility was reporting it now.
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CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Abuse Prevention Policies
(Tag F0607)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** c) Resident #2
During the initial screening process on 01/18/22 at approximately 12:30 PM, Resident #2 stated the staff on night...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** c) Resident #2
During the initial screening process on 01/18/22 at approximately 12:30 PM, Resident #2 stated the staff on night shift is mean to me and pick on me. A staff member [name] is putting bruises on my stomach.
The resident was admitted to the dementia unit on 12/01/20. The most recent Minimum Data Set (MDS) dated [DATE] recorded the resident's Brief Interview for Mental Status (BIMS) score of 15, the highest score obtainable.
On 01/18/22 at 1:55 PM, a review of the reportables as well as the grievances and concerns from July, 2021 through January, 2022 was completed. The review found no allegations of any type of abuse reported to the staff.
On 01/19/22 at 2:07 PM, The Director of the dementia unit (Director) #53 acknowledged the resident feels a night shift worker [name] is being mean and putting bruises on her stomach. The Director #53 stated there is no one on the staff on any shift with the [name]. The Director #53 also stated she gets insulin injections and those can cause bruising to the stomach. The Director #53 stated the resident is delusional and heard voices coming from the vents at the personal care home, sees a man in her room at night, hears laughing from the ceiling as well as loud static when in her room alone with no TV or radio on. The Director #53 states the resident brings small written notes on pieces of scrap paper regarding her anxiety and anger. The Director #53 was aware of the allegation regarding abuse for an unknown amount of time. The Director #53 did not tell the Administrator or Social Worker (SW) # 80 about the allegations. The Director #53 stated with the resident's history of delusions and paranoia, there was no further investigation completed. Therefore, the facility policy entitled Abuse Prohibition was not followed.
After reviewing the Care Plan on 01/19/22, there was no focus topic found regarding any behaviors regarding delusions, paranoia or the resident making false allegations towards staff. There was no goals or interventions regarding the above behaviors listed as well.
Prior to Surveyor intervention, there was no report or investigation of the allegation made by Resident #2 completed.
On 01/19/22 at 2:59 PM, the Administrator was notified of the alleged allegation of abuse by Resident #2. The Administrator was unaware of any allegation of abuse made by the resident. The Administrator stated I'll have Social Worker (SW) #80 investigate it and report it right now.
On 01/19/22 at 3:10 PM, the Administrator and SW #80 spoke with the resident. The Administrator stated the resident did say someone on night shift was picking on her and it was [name]. The resident told the Administrator, It hurts when they poke my scar on my stomach. The Administrator asked the resident what was used to hurt her stomach; and the resident replied a needle. The Administrator verified a staff member by the [name] did not work in the facility.
On 01/19/22 at 3:30 PM, the Administrator stated after the SW and I interviewed the resident we don't feel this is appropriate to report.
There was no further information obtained during the survey process.
Based on record review, staff interview, resident interview, and policy review, the facility failed to implement their policy for abuse prohibition regarding reporting and investigating allegations of abuse/neglect when two (2) of two (2) residents alleged they were abused/neglected. Resident identifiers: #57 and #2. Facility census: 83.
Findings included:
a) Policy
Review of the facility policy entitled Abuse Prohibition, revised 04/09/21 found the following:
7. Immediately upon receiving information concerning a report of suspected or alleged abuse, mistreatment, or neglect, the CED (Center Executive Director) or designee will perform the following.
7.3 Report allegations to the appropriate state and local authority(s) involving neglect, exploitation or mistreatment (including injuries of unknown source), suspected criminal activity, and misappropriation of patient property not later than two (2) hours after the allegation is made if the event results in serious bodily injury. Serious bodily injury is reportable. Only an investigation can rule out abuse, neglect, or mistreatment.
7.4 Report allegations involving neglect, exploitation or mistreatment (including injuries of unknown source), suspected criminal activity, and misappropriation of patient property within 24 hours if the event does not result in serious bodily injury .
7.7 Initiate an investigation within 24 hours of an allegation of abuse that focuses on:
7.7.1 whether abuse or neglect occurred and to what extent;
7.7.2 clinical examination for signs of injuries, if indicated;
7.7.3 causative factors; and
7.7.4 interventions to prevent further injury
7.8 The investigation will be thoroughly documented within RMS. Ensure that documentation of witnessed interviews is included .
b) Resident #57
During review of the Event Summary Reports for Resident #57 it was discovered that on 08/15/21 at 4:30 PM, the resident reported the following:
Resident states staff took him to the bathroom at 3:00 PM and dropped him. Resident has been on precautions for Respiratory virus RSV. X-ray was ordered of the left knee by MD which revealed no injury. Resident monitored for any new changes.
Review of the nursing notes for 08/15/21, found no mention of the incident.
On 01/24/22 at 12:09 PM, the administrator was asked if she had any information regarding the incident on 08/15/21?
On 01/24/22 at 12:53, the administrator confirmed she was unable to find any evidence the incident was reported or investigated. She stated the facility was reporting it now.
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, staff interview, resident interview, and policy review, the facility failed to report alleged allegations of abuse/neglect to the proper State authorities for one (1) of two ...
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Based on record review, staff interview, resident interview, and policy review, the facility failed to report alleged allegations of abuse/neglect to the proper State authorities for one (1) of two (2) residents reviewed for the care area of abuse/neglect. Resident identifiers: #57. Facility census: 83.
Findings included:
a) Policy for Abuse Prohibition
Review of the facility policy entitled Abuse Prohibition, revised 04/09/21 found the following:
7. Immediately upon receiving information concerning a report of suspected or alleged abuse, mistreatment, or neglect, the CED or designee will perform the following.
7.3 Report allegations to the appropriate state and local authority(s) involving neglect, exploitation or mistreatment (including injuries of unknown source), suspected criminal activity, and misappropriation of patient property not later than two (2) hours after the allegation is made if the event results in serious bodily injury. Serious bodily injury is reportable. Only an investigation can rule out abuse, neglect, or mistreatment.
7.4 Report allegations involving neglect, exploitation or mistreatment (including injuries of unknown source), suspected criminal activity, and misappropriation of patient property within 24 hours if the event does not result in serious bodily injury .
b) Resident #57
During review of the Event Summary Reports for Resident #57 it was discovered that on 08/15/21 at 4:30 PM, the resident reported the following:
Resident states staff took him to the bathroom at 3:00 PM and dropped him. Resident has been on precautions for Respiratory virus RSV. X-ray was ordered of the left knee by MD which revealed no injury. Resident monitored for any new changes.
Review of the nursing notes for 08/15/21, found no mention of the incident.
On 01/24/22 at 12:09 PM, the administrator was asked if she had any information regarding the incident on 08/15/21?
On 01/24/22 at 12:53, the administrator confirmed she was unable to find any evidence the incident was reported or investigated. She stated the facility was reporting it now.
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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
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
b) Resident #2
During the initial screening process on 01/18/22 at approximately 12:30 PM, Resident #2 stated the staff on nig...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
b) Resident #2
During the initial screening process on 01/18/22 at approximately 12:30 PM, Resident #2 stated the staff on night shift is mean to me and pick on me. A staff member [name] is putting bruises on my stomach.
The resident was admitted to the dementia unit on 12/01/20. The most recent Minimum Data Set (MDS) dated [DATE] recorded the resident's Brief Interview for Mental Status (BIMS) score of 15, the highest score obtainable.
On 01/18/22 at 1:55 PM, a review of the reportables as well as the grievances and concerns from July, 2021 through January, 2022 was completed. The review found no allegations of any type of abuse reported to the staff.
On 01/19/22 at 2:07 PM, The Director of the dementia unit (Director) #53 acknowledged the resident feels a night shift worker [name] is being mean and putting bruises on her stomach. The Director #53 stated there is no one on the staff on any shift with the [name]. The Director #53 also stated she gets insulin injections and those can cause bruising to the stomach. The Director #53 stated the resident is delusional and heard voices coming from the vents at the personal care home, sees a man in her room at night, hears laughing from the ceiling as well as loud static when in her room alone with no TV or radio on. The Director #53 states the the resident brings the small written notes on pieces of scrap paper regarding her anxiety and anger. The Director #53 was aware of the allegation regarding abuse for an unknown amount of time. The Director did not tell the Administrator or Social Worker (SW) # 80 about the allegations. The Director #53 stated with the resident's history of delusions and paranoia, there was no further investigation completed. Therefore, the facility policy entitled Abuse Prohibition was not followed.
After reviewing the Care Plan on 01/19/22, there was no focus topic found regarding any behaviors regarding delusions, paranoia or the resident making false allegations towards staff. There was no goals or interventions regarding the above behaviors listed as well.
Prior to Surveyor intervention, there was no report or investigation of the allegation made by the Resident #2 completed.
On 01/19/22 at 2:59 PM, the Administrator was notified of the alleged allegation of abuse by Resident #2. The Administrator was unaware of any allegation of abuse made by the resident. The Administrator stated I'll have SW #80 investigate it and report it right now.
On 01/19/22 at 3:10 PM, the Administrator and SW #80 spoke with the resident. The Administrator stated the resident did say someone on night shift was picking on her and it was [name]. The resident told the Administrator it hurts when they poke my scar on my stomach. The Administrator asked the resident was was used to hurt her stomach; and the resident replied a needle.
On 01/19/22 at 3:30 PM, the Administrator stated after the SW and I interviewed the resident we don't feel this is appropriate to report.
There was no further information obtained during the survey process.
Based on record review, staff interview, resident interview, and policy review, the facility failed to investigate alleged allegations from two (2) of two (2) residents reviewed for abuse when the
residents alleged they were abused and or neglected by staff. Resident identifiers: #57 and #2. Facility census: 83.
Findings included:
a) Facility policy for Abuse Prohibition , revised 04/09/21
Review of the policy found the following related to investigation of allegations involving neglect and abuse:
7.7 Initiate an investigation within 24 hours of an allegation of abuse that focuses on:
7.7.1 whether abuse or neglect occurred and to what extent;
7.7.2 clinical examination for signs of injuries, if indicated;
7.7.3 causative factors; and
7.7.4 interventions to prevent further injury
7.8 The investigation will be thoroughly documented within RMS. Ensure that documentation of witnessed interviews is included .
b) Resident #57
During review of the Event Summary Reports for Resident #57 it was discovered that on 08/15/21 at 4:30 PM, the resident reported the following:
Resident states staff took him to the bathroom at 3:00 PM and dropped him. Resident has been on precautions for Respiratory virus RSV. X-ray was ordered of the left knee by MD which revealed no injury. Resident monitored for any new changes.
Review of the nursing notes for 08/15/21, found no mention of the incident.
On 01/24/22 at 12:09 PM, the administrator was asked if she had any information regarding the incident on 08/15/21?
On 01/24/22 at 12:53, the administrator confirmed she was unable to find any evidence the incident was reported or investigated. She stated the facility was reporting it now.
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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 a notice of transfer to the State Ombudsman...
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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 a notice of transfer to the State Ombudsman. This was discovered for one (1) of one (1) resident reviewed for the care area of hospitalizations during the Long Term Care Survey Process (LTCSP). Resident #189 was transferred to the hospital and no notification was sent to the State Ombudsman. Resident identifier: #189. Facility census: 83.
Findings included:
a) Resident #189
A medical record review on 01/24/22, revealed Resident #189 was transferred to the hospital on [DATE]. There was no evidence the State Ombudsman received a notice of transfer for the hospitalization on 11/18/21 for this resident.
In an interview with the Administrator on 01/24/22 at 11:26 AM, reported she was unable to locate any notification sent to the State Ombudsman for the hospital transfer on 11/18/21 for Resident #189.
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CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0679
(Tag F0679)
Could have caused harm · This affected 1 resident
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Based on record review, observation, resident interview, and staff interview the facility failed to implement an ongoing activity program designed to meet the interests of and support the well-being...
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Based on record review, observation, resident interview, and staff interview the facility failed to implement an ongoing activity program designed to meet the interests of and support the well-being of residents. This has to potential to affect a limited number of Residents residing on Mary's Garden a locked memory care unit. Resident identifiers: #76. Facility census 83.
Findings include:
a) Resident #76
During an Interview with Resident #76 on 01/18/22 at 11:55 AM, She stated that there are not many activities to participate in on this unit. She stated that we just sit around most of the time.
Resident #76's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/23/21 noted the resident had a score of Brief Interview for Mental Status (BIMS) of 12. A BIMS score of 12 indicates that the resident is considered to be mildly impaired cognitively.
An observation on 01/18/22 at 1:47 PM found, Residents on Mary's Garden just sitting around the unit with no activities being provided.
A Second observation on 01/18/21 at 2:52 PM revealed, no activities being provided.
On 01/19/22 at 8:44 AM during an interview with the Dementia Program Director (E#53), she stated that they don't have a permanent activities person at this time. She continued to say that the nurse aides try to feel-in as much as possible to complete activities. She stated that when no-one is here to do activities, the staff try to do something with the Residents. When this surveyor ask about a unit activities calendar, E#53 stated that the unit don't have a regular schedule / calendar. She stated that the unit has a daily flow calendar that they just use month to month.
An observation on 01/20/22 at 10:00 AM on Mary's Garden, no activities programming was being completed.
During an interview on 01/20/22 at 10:48 AM with the facility Activities Director (AD) stated that the Mary's Garden activities assistant quit. The AD stated that she tries to help when she can. The AD acknowledged that the flow calendar was not being followed at this time.
An observation on 01/24/22 at 10:38 AM found Residents just sitting around the activities room with no activities programming being performed.
On 01/24/22 at 11:16 AM During an Interview with the Administrator she verified the Memory unit has a daily flow calendar they are supposed to be following. She stated that If the staff are not following the flow chart, it is not correct.
No further information was given prior to the end of the survey.
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CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0688
(Tag F0688)
Could have caused harm · This affected 1 resident
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Based on observation, staff interview and record review the facility failed to ensure a resident with limited range of motion (ROM) received appropriate treatment and services to increase range of m...
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Based on observation, staff interview and record review the facility failed to ensure a resident with limited range of motion (ROM) received appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion. This was true for one (1) of two (2) residents reviewed for ROM. Resident identifier #15. Facility census 83.
Findings included:
a) Resident #15
On 01/18/22 at 2:30 PM, observation found the resident has contractures to her right hand and is not wearing any devices to address the contractures. It was immediately confirmed with Licensed Practical Nurse (LPN) #43 that the resident was not wearing her palm protector but the resdient has an order for a palm protector. After looking for the palm protector the LPN could not locate it in the residents' room.
Review of the medical record found a Physicians order for, Resident to wear palm protector on right hand 5 hours per day She has a history of quadriplegia and traumatic brain injury with contractures and aphasia.
On 1/19/22 at 2:55 PM, observation found the resident continues to have no palm protector on. This was again confirmed with LPN #43.
Review of the Treatment Administration Record (TAR) for January up through 1/19/22, found documentation the palm protector was in place daily.
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CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Tube Feeding
(Tag F0693)
Could have caused harm · This affected 1 resident
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Based on record review and staff interview, the facility failed to follow the physician's orders for checking the resident's enteral gastrostomy feeding tube prior to water flushes. This was true fo...
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Based on record review and staff interview, the facility failed to follow the physician's orders for checking the resident's enteral gastrostomy feeding tube prior to water flushes. This was true for one (1) of three (3) residents reviewed for the care area of tube feeding. Resident identifier: #46. Facility census: 83.
Findings included:
a) Resident #46
Record review found the resident receives bolus enteral tube feedings and also receives a regular meal tray.
On 11/16/21 an order was written for:
Flush 250 ml water every 4 hours, via PEG tube, every 4 hours provide a total of 1500 ml (milliliters) water/day
On 12/31/21 an order was written for:
Placement and Tube Length is 34 CM every shift Check tube for proper placement prior to each feeding, flush, or medication administration by measuring the length of the tube.
Review of the Medication Administration Record (MAR) with the Director of Nursing (DON) at 01/19/22 at 10:00 AM confirmed the following:
The facility flushed the PEG tube with provided 250 ml's of water at 12:00 AM, 4:00 AM, 8:00 AM 12:00 PM, 4:00 PM and 8:00 PM.
The second order to check the placement of the tube prior to the flushes was only written to be completed on three occasions during the 24 hour period. Once on day shift, once on evening shift and once on the night shift; a total of 3 occasions in the 24 hour time period.
On 01/19/22 at 10:00 AM the Director of Nursing (DON) confirmed the order needed to be clarified as water flushes occur six (6) times a day, but the facility on documents checking the placement of the feeding tube three times a day. The physician's order directs nursing staff to check the tube for proper placement with every flush.
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CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
Could have caused harm · This affected 1 resident
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b) Resident #49
On 01/18/22 at 11:30 AM, an oxygen concentrator with connected oxygen tubing and a humidity bottle was found in Resident #49's room with the date of 01/04/22. Licensed Practical Nurs...
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b) Resident #49
On 01/18/22 at 11:30 AM, an oxygen concentrator with connected oxygen tubing and a humidity bottle was found in Resident #49's room with the date of 01/04/22. Licensed Practical Nurse (LPN) #55 verified the date on the oxygen tubing and humidity bottle was 01/04/22. LPN #55 stated it only needs changed every 30 days.
The resident has a physician's order for oxygen at 2 (two) L/min (liters per minute) via nasal cannula as needed for shortness of breath dated 01/04/22. [Typed as written.]
After a review of the facility policy entitled Respiratory Equipment/Supply Cleaning/Disinfecting on 01/18/22 states oxygen delivery devices and oxygen humidifiers are to be changed every seven (7) days and as needed for soiling.
On 01/18/22 the Director of the dementia unit #53 was notified at 11:50 AM of the outdated respiratory supplies. LPN #55 disposed of respiratory equipment in the trash.
On 01/18/22 at approximately 1:00 PM, the Administrator was notified of the outdated respiratory supplies.
No further information was obtained during the survey process.
Based on observation, medical record review, and staff interview, the facility failed to ensure respiratory care was provided according to professional standards of practice. This failed practice had the potential to affect two (2) of two (2) residents reviewed for the care area of respiratory care. Resident identifiers: #5, #49. Facility census: 83.
Findings included:
a) Resident #5
During an observation on 01/18/22 at 2:04 PM, Resident #5 was noted to be using supplemental oxygen therapy, three (3) liters by nasal cannula. Review of Resident #5's physician's orders did not show an order for supplemental oxygen therapy.
During an additional observation on 01/19/22 at 8:43 AM, Resident #5 was noted to be continuing to use supplemental oxygen therapy, three (3) liters by nasal cannula.
During an interview on 01/19/22 at 2:26 PM, the Director of Nursing (DON) confirmed Resident #5 did not have an order for oxygen. The DON stated the resident had been admitted to the facility with supplemental oxygen and she would obtain an order from the physician for the oxygen.
No further information was provided through the completion of the survey.
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CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0698
(Tag F0698)
Could have caused harm · This affected 1 resident
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Based on observation, medical record review, and staff interview, the facility failed to ensure residents who require dialysis received services consistent with professional standards of practice. T...
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Based on observation, medical record review, and staff interview, the facility failed to ensure residents who require dialysis received services consistent with professional standards of practice. This failed practice had the potential to affect one (1) of one (1) residents reviewed for the care area of dialysis. Resident identifier: #54. Facility census: 83.
Findings included:
a) Resident #54
Resident #54 received dialysis treatments through a Permacath dialysis catheter in his chest.
Review of the resident's medical records showed on order written 12/07/21 to Check Smooth clamps at the bedside and on patient wheelchair (if applicable). Having smooth clamps available for a resident with a permacath dialysis catheter is a safety precaution. The clamps can be applied to prevent bleeding from the catheter or air entering the catheter if the catheter becomes damaged.
During the resident's initial interview on 01/18/21 at 1:24 PM, no smooth clamps were observed at Resident #54's bedside. The resident had no knowledge of the clamps.
On 01/19/22 at 11:22 AM, Registered Nurse (RN) #28 was asked to locate smooth clamps at Resident #54's bedside. RN #28 looked in the drawers of the resident's bedside stand and in the wardrobe. No smooth clamps could be located.
On 01/19/22 at 11:32 AM, RN #46 stated he had smooth clamps in the treatment cart and would make sure they were put at the resident's bedside as ordered by the physician.
Resident #54's Hemodialysis Communication Records for 01/19/22, 01/17/22, and 01/14/22 were reviewed. The Hemodialysis Communication Records have a section to be completed by the facility's nurse before the dialysis treatment, a section to be completed by the dialysis facility after the treatment was completed, and a section to be completed by the facility's nurse after the resident returns to the facility from the dialysis treatment. On the dates reviewed, none of the sections to be completed by facility's nurse after the dialysis treatment had been completed. The information to be documented were the access (dialysis catheter) site condition, vital signs, post-hemodialysis complications, and new orders from the dialysis center.
On 01/20/22 at 10:13 AM, the Director of Nursing confirmed Resident #54's Hemodialysis Communication Records had not been completed on 01/19/22, 01/17/22, and 01/14/22.
No further information was provided through the completion of the survey.
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CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Medical Records
(Tag F0842)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on medical record review and staff interview the facility failed to ensure medical records were complete and accurate. T...
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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 medical records were complete and accurate. This was true for one (1) of 24 sample residents reviewed during the Long Term Care Survey Process (LTCSP). Resident #58's Physician Orders for Scope of Treatment (POST) was completed incorrectly. Resident identifier: #58 Facility census: 83
Findings included:
a) Resident #58
During the medical record review on 01/19/22, revealed the POST form for Resident #58 had the wrong first name of [NAME] instead of [NAME].
In an interview with the Social Worker on 01/19/22 at 3:45 PM, verified the name on the POST was incorrect with the wrong resident name.
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CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0578
(Tag F0578)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on record review and staff interview the facility failed to ensure [NAME] Virginia Physician Orders for Scope of Treatme...
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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 [NAME] Virginia Physician Orders for Scope of Treatment (POST) forms were completed correctly for ten (10) of twenty-four (24) residents in the long-term care survey sample. Resident identifier #15, #27, #82, #39, #58, #43, #2,
#34, #50, and #84. Facility Census 83
Findings included:
a) Resident #15
Record review of the POST form found the resident is do not resuscitate (DNR), comfort measures, intravenous fluids for a trial period of no longer than 14 days and feeding tube long term. On [DATE], the resident's MPOA (medical power of attorney) verbally completed the POST form, witnessed by two nurses. As of [DATE], it was mandatory that the POST be signed by the MPOA.
On [DATE] at 11:05 AM, an interview with Social Worker #80, confirmed the POST needed to be signed by the MPOA. SW #80 said she will contact the MPOA to have her come in to sign the POST.
b) Resident #27
Record review found a POST form dated [DATE]. The POST form directed no CPR (cardiopulmonary resuscitation) - Do not attempt resuscitation with selective treatments and no artificial nutrition.
An interview with the Social Worker (SW) #80 and admission Director (AD) #49 on [DATE] at 11:10 AM confirmed a verbal agreement was obtained from the resident for the POST form. In addition, SW #80 and AD #49 confirmed the resident has capacity to sign her own POST form. SW #80, states she doesn't know why the POST was completed in this manner.
On [DATE] at 12:36 PM record review shows the following progress note: Social Service Note: SW met with pt (patient) to discuss her POST form. Pt completed a new POST form with DNR, Selective Treatment, and no artificial nutrition. Pt signed POST form and it was placed in the physician's book for signature.
c) Resident #82
Record review found a POST form completed on [DATE]. The POST form directed DNR (Do not resuscitate), limited additional interventions with IV fluids for a trial period of no longer than 14 days.
The resident's POST form was completed via verbal consent by his MPOA and witnessed by two nurses.
On [DATE] at 11:00 AM, SW #80 confirmed the POST form required a signature from the MPOA.
Record review shows on [DATE] at 12:58 PM, Social Service Note: SW spoke with pt's son regarding POST form. Son to come in on Sunday to complete a new POST form. SW leaving the form in an envelope with son's name on it at the receptionist desk.
d) Resident #39
A medical record review on [DATE] for Resident #39 revealed the POST form dated [DATE] was not completed correctly. The POST form did not have the required signature from the Resident Representative, only a verbal consent.
In an interview on [DATE] at 3:45 PM, the Social Worker verified the POST for Resident #39 did not contain the required signature of the Resident Representative.
e) Resident #58
A medical record review on [DATE] for Resident #58 revealed the POST form dated [DATE] was not completed correctly. The POST form did not have the mandatory signature from the Resident Representative, only a verbal consent.
In an interview on [DATE] at 3:45 PM, the Social Worker verified the POST for Resident #58 did not contain the mandatory signature of the Resident Representative.
f) Resident #43
Record review found a POST form completed on [DATE]. Verbal consent was obtained from the Resident's responsible party to complete the POST form.
At the time of completion, Section D of the POST form noted, Signature of Patient/Resident, Parent of Minor, or Guardian/MPOA (Medical power of attorney) Representative/Surrogate is mandatory.
The directions for completing the POST form in 2019 required, The patient or representative/surrogate and physician/APRN must sign the form in this section.
These signatures are mandatory. A form lacking these signatures is NOT valid
(Taken from the 2016 Edition of completing the POST form.)
On [DATE] at 3:46 PM, an interview with the Social Worker #80 confirmed the POST form required the signature of the Resident's responsible party.
On [DATE] at 3:49 PM, the completion of the POST form was discussed with the administrator. No further information was provided at the close of the survey on [DATE].
g) Resident #2
On [DATE] at 12:50 PM, the [NAME] Virginia Physician Orders for Scope of Treatment (POST) was reviewed. The POST form showed a verbal consent obtained from the Medical Power of Attorney (MPOA) was witnessed by two (2) nurses on [DATE]. The signature line of the POST form is mandatory for the patient, resident, parent of minor, guardian, MPOA representative/surrogate to sign and date. This signature line on the POST form has not been signed or dated by the MPOA.
On [DATE] at 3:43 PM, Social Worker (SW) #80 verified the POST form had not been signed by the MPOA and was incorrect.
h) Resident #34
On [DATE] at 12:55 PM, the POST form was reviewed. The POST form was signed by the MPOA. However, the signature was not dated by the MPOA.
On [DATE] at 3:43 PM, SW #80 verified the MPOA had not dated the POST form when it was signed and this was incorrect.
No further information was received throughout the survey.
i) Resident #50
Record review on [DATE], revealed section for Patient Information, Section C - (Medically Assisted Nutrition) trial IV trial period checked with no longer than _______ left blank and Section D (Health care provider) was not completed with a physician name, phone number, a mandatory physician signature and date on Resident #50's active Physician Order for Scope of Treatment Form (POST Form).
During an interview on [DATE] at 3:40 PM with the Social Worker Director, she confirmed Resident #50's POST form patient information was incomplete and Section D was not valid without physician information and signature.
j) Resident #84
Record review on [DATE], of the POST form revealed: Section A (Cardiopulmonary Resuscitation) checked for Attempt Resuscitation - Section B Check One (Medical Intervention) this section was completed Comfort Measures and Limited interventions. Section D (Patient/Resident, Guardian/ MPOA Representative) was not completed with a Signature on Resident #50's active Physician Order for Scope of Treatment Form (POST Form).
During an interview on [DATE] at 3:40 PM with the Social Worker Director, she confirmed Resident #84's POST form was inaccurate with two interventions completed, and section D was incomplete without a Resident representatives signature.
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CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected multiple residents
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e) Resident #5
Review of Resident #5's medical records showed an order written on 11/11/21 for Lasix (furosemide) 40 mg twice a day for congestive heart failure (CHF). Lasix is a diuretic that can ...
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e) Resident #5
Review of Resident #5's medical records showed an order written on 11/11/21 for Lasix (furosemide) 40 mg twice a day for congestive heart failure (CHF). Lasix is a diuretic that can cause serious side-effects such as dehydration and electrolyte imbalance.
Review of Resident #5's comprehensive care plan showed there was no focus related to diuretic use.
During an interview on 01/19/22 at 3:00 PM, the Director of Nursing (DON) confirmed Resident #5's comprehensive care plan did not have a focus related to diuretic use. The DON stated diuretic use should be addressed on the care plan.
No additional information was provided through the completion of the survey process.
Based on observation, record review and staff interview, the facility failed to ensure a person-centered comprehensive care plan was developed and/or implemented to address Resident #34's behaviors, oxygen therapy for Resident #49, wandering for Resident #43, monitoring oral intake for Resident #46, and Resident #5's diuretic use. This was true for five (5) of 24 residents reviewed for the care area of developing and implementing comprehensive care plans. Resident Identifiers: #34, #49, #43, #46 and #5. Facility Census: 83.
Findings Included:
a) Resident #34
On 01/18/22 at 2:47 PM, a record review notes Resident #34 had multiple resident to resident altercations on 01/11/22, 10/22/21, 10/09/21 and 09/25/21. The behaviors listed were yelling at other residents when close to Resident #34's room, yelling at residents in the common areas and physical altercations.
A Psychiatric Service follows Resident #34 due to the diagnoses of Adjustment Disorder with other symptoms, Major Depressive disorder, recurrent episode, unspecified, Major neurocognitive disorder probably due to vascular dementia with behavioral disturbances and Vascular dementia with behavioral disturbances listed on the consultation notes. The appointments listed with these services are 01/05/22, 12/18/21, 12/13/21, 12/08/21, 12/07/21, 11/24/21 and 11/11/21.
After reviewing the Care Plan on 01/19/22, there is no focus topic on the care plan regarding behavioral disturbances, verbal outbursts or physical altercations. There is no indication on the care plan the resident is followed by Psychiatric Services. There are no interventions or goals listed on the care plan regarding any behaviors.
On 01/19/22 at 12:22 PM, an interview with Director of the dementia unit regarding Resident #34's behavior. The Director stated we just had a care plan meeting and discussed it as a team. I haven't been able to reach the Power of Attorney and I haven't updated the care plan with the increased behaviors. The Director also stated, I didn't realize it didn't have any behaviors listed.
On 01/19/22 at approximately 2:00 PM, the Administrator was notified the care plan did not include any types of behaviors exhibited by the resident.
No further information was obtained during the survey process.
b) Resident #49
On 01/18/22 at 11:30 AM, an oxygen concentrator with tubing and a humidity bottle was observed in Resident #49's room.
After a record review on 01/18/22, the resident does have a physician's order for oxygen at 2 (two) L/min (liters per minute) via nasal cannula as needed for shortness of breath dated 01/04/22. [Typed as written.]
A review of the care plan was completed on 01/18/22 and does not list oxygen therapy as an intervention under the focus area of resident exhibits or is at risk for respiratory complications r/t (related to) seasonal allergies. [Typed as written.] This focus area was created on 04/03/19 with no update of the oxygen therapy ordered on 01/04/22.
On 01/19/22 at approximately 2:00 PM, the Administrator was notified regarding the care plan.
No further information was obtained during the survey process.
c) Resident #43
Review of the Resident's progress notes found the following entries:
11/19/2021 at 11:47 AM Assessment Late Entry: Note: Since the last evaluation there has been no change in behavior symptoms. Resident wanders constantly into others rooms. Takes other resident belongings. none noted Non-pharmacological intervention(s) attempted in the last 30 days: Redirection when wandering into other rooms, activities encouraged, snacks offered. There has been no increases in doses or new initiated psychotherapeutic/antipsychotic meds in the past 30 days
11/24/21 at 4:23 PM, .This RN was notified by CNA staff that another resident struck the resident with his cane, hitting the right forearm. Residents were immediately separated and the victim was assessed once safety was assured .
12/08/21 Resident was observed by CNA (certified nursing assistant) being led out of the room of another resident. This resident was visibly upset verbalized feelings of frustration at resident's intrusion into her room. (Name of the other resident) was not seen harming this resident in any way and verbalized that she just lead her out of the room.
12/10/2021 at 9:07 AM, Care Plan Evaluation Note: IDT (interdisciplinary team) note for resident on 12-8-21 wandered into second resident room and second resident became upset and shook this resident's shoulders. Staff member redirected wandering resident out of room. No injury to resident with social service to research day programs to aid in wandering behaviors.
12/13/2021 at 12:29 PM, General Note: While in the hallway, a CNA brought to my attention, bruising noted to this resident's bottom lip. Also a noted discoloration to the inside area of her bottom lip. Resident also had notable scratch marks to the right side of her neck. This resident walked away towards the hallway where her room is. Another resident, #99583265, was sitting in the hallway and had a bottle of body wash or shampoo on his lap. He then raised it to hit this resident as she was walking by. This nurse and CNA intervened, preventing this resident from being struck by resident #99583265 at this time. Resident #99583265 stated I will hit her whenever I want to hit her! The CNA attempted to take this resident towards her room for lunch, and this nurse walked between the two residents. Resident #99583265 then raised the bottle and attempted to strike this resident again as she walked by. Resident #99583265 instead struck this nurse on the arm with the bottle. This resident was safely escorted to her room by the CNA.
An incident report was completed on 12/13/21 at 10:00 AM.
Resident was observed to have a bruise to her lower lip and swelling to her L (left) eyelid, scratches to rt (right) side of throat Resident was assessed for other undocumented injuries, with no other issues observed.
The root cause/conclusion: Resident wanders into other resident rooms and resident on 12/12/21 seen throwing things at resident.
The incident was reported to the proper State authorities on 12/13/21.
The allegation of neglect/abuse was unsubstantiated. A summary was attached to the complaint:
(Name of Resident) lacks capacity due to her schizophrenia and is unable to communicate where/how she received these injuries. (Name of Resident) is care planned for wandering in and out of other patient's room. The facility is concerned that she may have been injured by another resident as a result of entering another resident's room, but the facility is unable to prove this. New interventions have been added to her care plan to help deter her from entering other resident rooms. Her spouse was contacted and he brought in a photo album of their family for her to look at, the facility purchased crafts that her spouse suggested for (Name of Resident) to do, a tambourine and pop it bracelet were also given to resident, and the facility is going to introduce (Name of Resident) to more activities on Mary's Garden as well. (Mary's Garden is the dementia care unit at the facility - the Resident does not reside on this unit.)
12/30/2021 13:52
Social Service
Note: Referral made to a tele-med Psychiatric Services for possible medication recommendations/interventions. Staff report in the past that pt was given IM Ativan at the hospital and was able to have meaningful conversation and interact with her family. She is unable to do that at this time.
On 1/6/2022 at 10:28 AM,
Social Service
Note: 2nd referral made to a tele-med Psychiatric Services for possible medication recommendations/interventions. Staff report in the past that pt (patient) was given IM Ativan at the hospital and was able to have meaningful conversation and interact with her family. She is unable to do that at this time.
Review of the current current care plan found a focus:
Resident wanders into other resident's rooms. She sometimes takes things that aren't hers, including food off of her roommates tray and food from other resident's rooms.
The goal associated with the problem was:
Resident will have decreased episodes of taking things that belong to her and wandering into other resident's rooms. (Typed as written)
New interventions added after the injury included:
Spouse to being in family photo album for (name of Resident ) to look at.
Stop signs placed in doorways of rooms that resident gravitates towards.
Research into day programs to aid in providing distraction during the day.
Reintroduce activities that she enjoyed in the past.
Interventions prior to the injury included:
Activities director will provide some one on one time to keep resident occupied when wandering.
Attempt to engage resident in activities that she might enjoy, such as working with her hands.
Re-direct resident from wandering into other resident's rooms and taking things that don't belong to her.
On 01/19/22 at 11:58 AM, the dementia program director, employee #53 said the Resident has never been over to Mary's Garden for any activities.
On 01/19/22 at 12:00 PM the activity logs were reviewed with the Activity Director.
Review of the activity logs from January 2022 found the resident was coded as actively being involved in exercise/physical activity/walking daily.
During the month the following activities were recorded:
-Seven episodes of manicure/aromatherapy/massage painting nails/salon spa.
-Six episodes of movie/TV that were coded as independent activities.
-Daily relaxing/looking out window/resting/thinking, these activities were independent also.
-Daily activity of socializing/socials/talking on phone/visits/sending cards
-Daily snack and hydration
-The activity participation record contained a category for Music/concerts/live music/operas/playing/singing which the resident did not participate in for the month.
The log did not include any activities the resident could do with her hands.
The Resident walks independently daily and goes in and out of other resident rooms.
There was no evidence day programs were explored.
On 01/19/22 at 12:10 PM, the activity director said the Resident's attention span is short. I walk around with her and play music on my iPhone and she sings songs. She knows the words to gospel songs. The AD said she couldn't provide activities all day long because she has other residents to provide activities for.
01/19/22 at 12:54 PM, the resident was observed going in and out of other resident rooms on B hallway. Two (2) nursing assistants (NA #47 and NA #58) working on the resident's hallway were asked what they do with the resident to keep her from wandering into others rooms? NA #47 said we take her to her room for activities. The 2 NA's took the residents hands and walked with her to her room. The surveyor followed the NA's and the Resident to the Resident's room to view the the activities available in her room. A clock was setting on the residents night stand. NA #47 and #58 said they thought it was a clock radio. Neither staff member was able to get the radio to play. NA #47 said the resident had a photo album. Both NA's looked in the residents closet, drawers and night stand and said they couldn't find the album. They concluded the resident must have, carried it off somewhere. The tambourine could not be located in the room and neither knew anything about a pop-it bracelet. NA #47 said the resident had a CD player at one time and she thought her husband had brought in a folder containing her favorite CD's. NA #47 said the CD player came up missing a while back. She was unable to find any CD's.
On 01/19/22 at 2:17 PM, the administrator and activity director said the Resident does have a radio, picture book and tambourine in her room, the staff just didn't know where to look. The administrator was asked if the resident had a visit with the tele - med psychiatrist. The administrator said the resident had not had a visit yet.
On 01/20/22 at 11:20 AM, observation found the resident roaming in the hallway on her unit. The resident entered room B- 11. The resident looked around the room and exited.
On 01/20/22 at 11:50 AM, the resident entered B - 9. The Resident looked around the room and exited. The Resident then entered B - 10 and took what appeared to be a lunch cake laying on the over-the bed table. The Resident left the room with the snack. At the time the occupant of B - 10 was not in the room.
On 01/20/22 at 11:51 AM, observation found the clock radio was playing and the picture book was on the over-the bed table. The Resident had left her room.
On 01/24/22 at 11:20 AM, the resident entered B-11. The Resident walked around the room and didn't take anything from the room.
On 01/24/22 at 11:21 AM, the Resident entered A -1. The male resident in the bed bed began yelling and told the resident to get out of the room. The resident left the room.
On 01/24/22 at 11:22 AM, the Resident entered A-2. The female resident in the A bed yelled at this resident and said, get out, get out, and leave me alone. The Resident left the room. The surveyor entered Room A-2 to see if the resident was OK. This Resident said, I am sorry I yelled at her and was loud, I feel sorry for her, its not her fault but this is very frustrating. She is a nuisance, she picks up stuff and gets in my face. She makes ugly faces at me and you never know what she is going to do.
It happens all the time.
On 01/24/22 at 11:32 AM, the resident picked up a juice glass from the nurses station and began drinking what appeared to be water.
The resident was not redirected when wandering as directed by the care plan based on the above observations.
The above information was discussed with the administrator at 12:40 PM on 01/24/22. No further information was provided.
d) Resident #46
Record review found the resident receives bolus enteral tube feedings and also receives a regular meal tray. The Resident receives bolus tube feedings at nights and receives 3 regular meal trays during the day - breakfast, lunch, and supper.
Review of the current care plan found a focus:
Resident is a nutritional concern r/t (related to): mechanically altered diet, PEG (percutaneous endoscopic gastrostomy) tube, pressure injury, BMI (Body Mass Index)> 25 with significant weight loss trend, and dx (diagnosis) /PMH (past medical history) including:
aphasia, CVA (cerebrovascular accident), dysphagia, weakness, HTN (Hypertension), PEG tube, HLD (hypersensitivity lung disease), that may impact nutritional status.
Revision on: 11/17/2021
The goal associated with the focus was:
Goal for resident to tolerate PO (by mouth) diet /enteral nutrition to maintain weight and support skin healing through next period of review.
Created on: 09/15/2021
Interventions included:
Monitor intake at all meals, offer alternate choices as needed, alert dietitian and physician to any decline in intake.
Review of the residents intake by mouth for the last 20 days found the following days when meal consumption was not recorded and the resident was not coded as refusing meals:
-01/01/22, no percentage was recorded for the evening meal.
-01/02/22, no percentage was recorded for the evening meal.
-01/05/22, a percentage of 50% was recorded at 12:31 PM.
-01/06/22, only one entry for 100% of a meal at 8:51 PM was recorded.
-01/10/22 only 2 entries were made on this date, one (1) at 12:08 PM for 75% of a meal consumed and one (1) at 12:08 PM for 100% of a meal consumed.
-01/11/22 no percentage for the evening meal
-01/15/22 only 1 meal percentage recorded at 2:11 PM.
-01/16/22 only two (2) percentages recorded: one at 1:38 PM for 50% of a meal consumed and and one (1) at 1:39 PM for 75% of the meal consumed
-01/17/22 only 2 meal percentages were documented.
On 01/19/22 at 10:07 AM, the Director of Nursing (DON) confirmed the resident receives 3 meals a day and each day should include the percentage of meals consumed for breakfast, lunch and supper (three (3) entries a day.) The DON verified the care plan was not followed.
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CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
g) On 01/18/22 at 11:15 AM upon initial interview the resident stated she has had trouble getting the Nurse Practioner or Phys...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
g) On 01/18/22 at 11:15 AM upon initial interview the resident stated she has had trouble getting the Nurse Practioner or Physician to see her about her finger that hurts and her ears feel clogged. She states she has informed several nurses about this.
On 01/18/22 at 11:20 AM, per staff interview with Licensed Practical Nurse # 43 she stated she had not heard anything concerning these issues but she will discuss them with the Physician. Upon review of medical records there is no previous documentation of her sore finger or any problems with her ears.
Per medical record review on 01/18/22 4:30 PM, there are new orders for the following: Keflex 500 milligrams, 1 capsule three times per day for 10 days for cellulitis to the right index finger. Debrox 6.5% 4 drops to both ears 4 times a day for 5 days. On day 6 lightly flush both ears with warm tap water, do not force.
f) Resident #50
On 01/19/22 at 8:34 AM Resident #50 was resting in a low bed.
A review of the facility fall log on 01/19/22 revealed, Resident #50 had a witnessed fall on 12/27/21 at 5:00 PM. Further Review found Neurological checks (Neuro's) were initiated.
Subsequent review of Resident #50's Neurological Evaluation flow Sheet from the fall on 12/27/21 found they were not completed as ordered. The section for every eight (8) hours was not completed for 12/30/21 at 10:00 AM and 6:00 PM.
During an interview on 01/20/22 at 1:30 PM with the DON and Administrator they acknowledged the Neuro checks were not completed for resident #50's fall on 12/27/21.
e) Resident #5
Review of Resident #5's medical records revealed an order written on 12/07/21 for laboratory testing consisting of a fasting lipid panel and HgbA1c to be performed with the next laboratory draw. No results were located in the resident's medical records.
During an interview on 01/19/22 at 12:12 PM, the Director of Nursing (DON) stated the laboratory testing for Resident #5 ordered on 12/07/21 was never done. The DON stated the physician was being notified.
No further information was provided through the completion of the survey.
Based on record review, staff interview, resident interview, and observation the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for six (6) of twenty-four residents reviewed in the long-term care survey sample. For Resident #57 the facility did not recognize a skin condition change and staff did not know how to access Hospice agency progress notes. For Residents #68, #81, and #5 the facility did not obtain laboratory values as ordered by the physician. For Resident #27 the facility did not assess a change in condition. For Resident #50 the facility did not complete neuro checks after an unwitnessed fall. Resident identifiers: #57, #68, #81, #5, #27, and #50. Facility census: 83.
Findings included:
a) Resident #57 (observation of skin injury)
Observation of the resident on 01/18/22 at 12:28 PM, found he was in bed with his feet sticking out from under the covers. A scab was noted to the left great toe.
A skin assessment dated [DATE] at 12:36 PM noted the resident had no skin injuries or wounds.
On 01/24/22 at 9:33 AM, the Registered Nurse (RN) #28 in charge of treatments was asked about the area. RN #28 said, I think maybe Hospice saw that. RN #28 was asked if she could get the Hospice records to see what was charted. RN #28 said the Hospice notes are on the cloud and I don't know how to get them. (According to the residents care plan Hospice services began on 12/01/21.)
On 01/24/22 at 9:30 AM, Registered Nurse (RN) #46 observed the area and said he didn't know anything about the area, it was new to him and he didn't have any treatment orders.
On 01/24/22 at 10:06 AM, the above information was discussed with the administrator.
On 01/24/22 at 11:33 AM, RN #28 said she wrote an order just to keep an eye on the area and she though it would be all right when the scab fell off.
b) Resident #57 (Hospice notes)
Observation of the resident on 01/18/22 at 12:28 PM, found he was in bed with his feet sticking out from under the covers. A scab was noted to the left great toe.
A skin assessment dated [DATE] at 12:36 PM, noted the resident had no skin injuries or wounds.
On 01/24/22 at 9:33 AM, the Registered Nurse (RN) #28 in charge of treatments was asked about the area. RN #28 said, I think maybe Hospice saw that. RN #28 was asked if she could get the Hospice records to see what was charted. RN #28 said the Hospice notes are on the cloud and I don't know how to get them. (According to the residents care plan Hospice services began on 12/01/21.)
On 01/24/22 at 9:37 AM, Registered Nurse (RN) #28 said he did not know how to access any Hospice notes, they were on the cloud. (RN #28 was the resident's nurse.)
On 01/24/22 at 9:37 AM, the infection control Registered Nurse (RN) #94 said she did not know how to access the notes.
On 01/24/22 at 9:38 AM, RN #37 (who completes the Minimum Data Sets) said she did not know how to access information on the cloud.
On 01/24/22 at 9:42 AM, the Social Worker (SW) #80 said she had just been trained to access the notes. SW #80 tried to get into the notes but said she was going to have to contact Hospice to get her password changed. SW #80 was asked to provide copies of the nursing notes once she entered the system.
On 01/24/22 at 10:06 AM, the above situation was discussed with the administrator.
At the close of the survey on 01/24/22 at 3:45 PM, no Hospice notes had been provided.
c) Resident #68
On 12/10/21 the physician ordered a fasting lipid panel to be obtained on the next lab drawl day.
On 01/19/22 at 1:50 AM, the DON confirmed the lab had not been obtained.
On 01/24/22 at 12:16 PM, the above situation was discussed with the administrator. No further information was provided at the close of the survey.
d) Resident #81
On 01/20/22 at 2:10 PM, a record review for Resident #81 indicated a Depakote level (laboratory test) was ordered for 12/24/21 by the physician on 11/24/21. Licensed Practical Nurse (LPN) #15 verified the laboratory test (lab) was not completed on 12/24/21 and the laboratory requisition was in the lab book under the December tab. LPN #15 stated if a lab gets missed we usually move it to the next lab day which is on Friday 01/21/22. At this time, LPN #15 moved the lab requisition to 01/21/22 in the lab book.
On 01/20/22 at 2:25 PM, the Director of the dementia unit was notified the laboratory test was not completed.
On 01/20/22 at 2:30 PM, the Administrator was notified and verified the laboratory test was not completed.
On 01/24/22 at 10:30 AM, LPN #55 verified the Depakote level had not been drawn on 01/21/22. LPN #55 stated the results might be on the long-term side .sometimes we don't get them back right away.
On 01/24/22 at 10:45 AM, Registered Nurse #94 was notified the Depakote level was not completed as ordered. RN #94 stated she will follow-up with the physician in regards to the laboratory test not being done.
On 01/24/22 at 11:00 AM, RN #94 contacted the physician and received a new order to change the laboratory test to the next lab day on 01/26/22. The Medical Power of Attorney (MPOA) was notified of the missed laboratory test and the test would be completed on 01/26/22.
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CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected multiple residents
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Based on observation and interview the facility failed to ensure the resident environment over which it had control was as free from accident hazards as possible. This was a random opportunity for d...
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Based on observation and interview the facility failed to ensure the resident environment over which it had control was as free from accident hazards as possible. This was a random opportunity for discovery of staff smoking in non-designated areas and a medication cart and medication room unlocked and unattended. Also, the facility failed to provide adequate supervision for resident #43 identified as likely to be involved in an altercation due to wandering behaviors. Resident Identifier #43. Facility census 83.
a) Non-designated smoking area
An observation on 01/19/22 at 8:50 AM nurse aide #89 was smoking a cigarette right outside Mary's Garden door on the Resident's porch. There was no fire extinguisher available or a metal container with a self-closing cover for proper cigarette disposal.
On 01/19/22 at 08:54 AM during an interview with the Dementia Program Director #53 she stated that staff have been smoking out on the Resident porch, since she started as the Program director. She stated that if there is no snow on the ground the staff go around the corner out of sight from the Residents.
During a second interview with E#53 on 01/19/22 at 9:02 AM, she stated that staff should not be smoking on the Residents porch. She stated that she spoke to staff and told them to go off the porch to smoke.
On 01/20/22 at 1:21 PM during an Interview with the Administrator, she verified that staff are not supposed to smoke on the resident porch in Mary's Garden or any other Resident areas. She stated that there is a designated smoking area for staff.
b) Medication Cart and Medication Room
On 01/19/22 at 9:13 AM, during observation of the dementia unit, Licensed Practical Nurse (LPN) #15 was with a resident in the lounge area across from the nurses' station. The medication room is located behind the nurses' station. The medication room door was unlocked and open. The medication cart was also unlocked.
On 01/19/22 at 9:16 AM, a maintenance man walked into the medication room with equipment, laid the equipment down and exited the medication room. LPN #15 was having a conversation with a resident and did not realize the maintenance man had entered and exited the medication room.
On 01/19/22 at 9:19 AM, LPN #15 returned to the nurses' station and the medication room door remained open and the medication cart remained unlocked.
After Surveyor intervention, LPN #15 locked the medication cart and closed the medication room door which automatically locks when closed. LPN #15 stated you made me nervous I always lock the cart and med room.
A review of the facility policy entitled Medication Administration: General states to maintain security of cart and keys at all times. [Typed as written.]
On 01/19/22 at 9:22 AM, the Director of the dementia unit #53 was notified of the unlocked medication room and medication cart.
On 01/19/22 at 9:28 AM, the Administrator was notified of the unlocked medication room and medication cart.
No further information was obtained during the survey process.
c) Resident #43
Review of the Resident's progress notes found the following entries:
11/19/2021 at 11:47 AM Assessment Late Entry: Note: Since the last evaluation there has been no change in behavior symptoms. Resident wanders constantly into others rooms. Takes other resident belongings. none noted Non-pharmacological intervention(s) attempted in the last 30 days: Redirection when wandering into other rooms, activities encouraged, snacks offered. There has been no increases in doses or new initiated psychotherapeutic/antipsychotic meds in the past 30 days
11/24/21 at 4:23 PM, .This RN was notified by CNA staff that another resident struck the resident with his cane, hitting the right forearm. Residents were immediately separated and the victim was assessed once safety was assured .
12/08/21 Resident was observed by CNA (certified nursing assistant) being led out of the room of another resident. This resident was visibly upset verbalized feelings of frustration at resident's intrusion into her room. (Name of the other resident) was not seen harming this resident in any way and verbalized that she just lead her out of the room.
12/10/2021 at 9:07 AM, Care Plan Evaluation Note: IDT (interdisciplinary team) note for resident on 12-8-21 wandered into second resident room and second resident became upset and shook this resident's shoulders. Staff member redirected wandering resident out of room. No injury to resident with social service to research day programs to aid in wandering behaviors.
12/13/2021 at 12:29 PM, General Note: While in the hallway, a CNA brought to my attention, bruising noted to this resident's bottom lip. Also a noted discoloration to the inside area of her bottom lip. Resident also had notable scratch marks to the right side of her neck. This resident walked away towards the hallway where her room is. Another resident, #99583265, was sitting in the hallway and had a bottle of body wash or shampoo on his lap. He then raised it to hit this resident as she was walking by. This nurse and CNA intervened, preventing this resident from being struck by resident #99583265 at this time. Resident #99583265 stated I will hit her whenever I want to hit her! The CNA attempted to take this resident towards her room for lunch, and this nurse walked between the two residents. Resident #99583265 then raised the bottle and attempted to strike this resident again as she walked by. Resident #99583265 instead struck this nurse on the arm with the bottle. This resident was safely escorted to her room by the CNA.
An incident report was completed on 12/13/21 at 10:00 AM.
Resident was observed to have a bruise to her lower lip and swelling to her L (left) eyelid, scratches to rt (right) side of throat Resident was assessed for other undocumented injuries, with no other issues observed.
The root cause/conclusion: Resident wanders into other resident rooms and resident on 12/12/21 seen throwing things at resident.
The incident was reported to the proper State authorities on 12/13/21.
The allegation of neglect/abuse was unsubstantiated. A summary was attached to the complaint:
(Name of Resident) lacks capacity due to her schizophrenia and is unable to communicate where/how she received these injuries. (Name of Resident) is care planned for wandering in and out of other patient's room. The facility is concerned that she may have been injured by another resident as a result of entering another resident's room, but the facility is unable to prove this. New interventions have been added to her care plan to help deter her from entering other resident rooms. Her spouse was contacted and he brought in a photo album of their family for her to look at, the facility purchased crafts that her spouse suggested for (Name of Resident) to do, a tambourine and pop it bracelet were also given to resident, and the facility is going to introduce (Name of Resident) to more activities on Mary's Garden as well. (Mary's Garden is the dementia care unit at the facility - the Resident does not reside on this unit.)
12/30/2021 13:52
Social Service
Note: Referral made to a tele-med Psychiatric Services for possible medication recommendations/interventions. Staff report in the past that pt was given IM Ativan at the hospital and was able to have meaningful conversation and interact with her family. She is unable to do that at this time.
On 1/6/2022 at 10:28 AM,
Social Service
Note: 2nd referral made to a tele-med Psychiatric Services for possible medication recommendations/interventions. Staff report in the past that pt (patient) was given IM Ativan at the hospital and was able to have meaningful conversation and interact with her family. She is unable to do that at this time.
Review of the current current care plan found a focus:
Resident wanders into other resident's rooms. She sometimes takes things that aren't hers, including food off of her roommates tray and food from other resident's rooms.
The goal associated with the problem was:
Resident will have decreased episodes of taking things that belong to her and wandering into other resident's rooms. (Typed as written)
New interventions added after the injury included:
Spouse to being in family photo album for (name of Resident ) to look at.
Stop signs placed in doorways of rooms that resident gravitates towards.
Research into day programs to aid in providing distraction during the day.
Reintroduce activities that she enjoyed in the past.
Prior interventions included:
Activities director will provide some one on one time to keep resident occupied when wandering.
Attempt to engage resident in activities that she might enjoy, such as working with her hands.
Re-direct resident from wandering into other resident's rooms and taking things that don't belong to her.
On 01/19/22 at 11:58 AM, the dementia program director, employee #53 said the Resident has never been over to Mary's Garden for any activities.
On 01/19/22 at 12:00 PM the activity logs were reviewed with the Activity Director.
Review of the activity logs from January 2022 found the resident was coded as actively being involved in exercise/physical activity/walking daily.
During the month the following activities were recorded:
-Seven episodes of manicure/aromatherapy/massage painting nails/salon spa.
-Six episodes of movie/TV that were coded as independent activities.
-Daily relaxing/looking out window/resting/thinking, these activities were independent also.
-Daily activity of socializing/socials/talking on phone/visits/sending cards
-Daily snack and hydration
-The activity participation record contained a category for Music/concerts/live music/operas/playing/singing which the resident did not participate in for the month.
The log did not include any activities the resident could do with her hands.
The Resident walks daily independently and goes in and out of other resident rooms.
On 01/19/22 at 12:10 PM, the activity director said the Resident's attention span is short. I walk around with her and play music on my iPhone and she sings songs. She knows the words to gospel songs. The AD said she couldn't provide activities all day long because she has other residents to provide activities for.
01/19/22 at 12:54 PM, the resident was observed going in and out of other resident rooms on B hallway. Two (2) nursing assistants (NA #47 and NA #58) working on the resident's hallway were asked what they do with the resident to keep her from wandering into others rooms? NA #47 said we take her to her room for activities. The 2 NA's took the residents hands and walked with her to her room. The surveyor followed the NA's and the Resident to the Resident's room to view the the activities available in her room. A clock was setting on the residents night stand. NA #47 and #58 said they thought it was a clock radio. Neither staff member was able to get the radio to play. NA #47 said the resident had a photo album. Both NA's looked in the residents closet, drawers and night stand and said they couldn't find the album. They concluded the resident must have, carried it off somewhere. The tambourine could not be located in the room and neither knew anything about a pop-it bracelet. NA #47 said the resident had a CD player at one time and she thought her husband had brought in a folder containing her favorite CD's. NA #47 said the CD player came up missing a while back. She was unable to find any CD's.
On 01/19/22 at 2:17 PM, the administrator and activity director said the Resident does have a radio, picture book and tambourine in her room, the staff just didn't know where to look. The administrator was asked if the resident had a visit with the tele - med psychiatrist. The administrator said the resident had not had a visit yet.
On 01/20/22 at 11:20 AM, observation found the resident roaming in the hallway on her unit. The resident entered room B- 11. The resident looked around the room and exited.
On 01/20/22 at 11:50 AM, the resident entered B - 9. The Resident looked around the room and exited. The Resident then entered B - 10 and took what appeared to be a lunch cake laying on the over-the bed table. The Resident left the room with the snack. At the time the occupant of B - 10 was not in the room.
On 01/20/22 at 11:51 AM, observation found the clock radio was playing and the picture book was on the over-the bed table. The Resident had left her room.
On 01/24/22 at 11:20 AM, the resident entered B-11. The Resident walked around the room and didn't take anything from the room.
On 01/24/22 at 11:21 AM, the Resident entered A -1. The male resident in the bed bed began yelling and told the resident to get out of the room. The resident left the room.
On 01/24/22 at 11:22 AM, the Resident entered A-2. The female resident in the A bed yelled at this resident and said, get out, get out, and leave me alone. The Resident left the room. The surveyor entered Room A-2 to see if the resident was OK. This Resident said, I am sorry I yelled at her and was loud, I feel sorry for her, its not her fault but this is very frustrating. She is a nuisance, she picks up stuff and gets in my face. She makes ugly faces at me and you never know what she is going to do.
It happens all the time.
On 01/24/22 at 11:32 AM, the resident picked up a juice glass from the nurses station and began drinking what appeared to be water.
On 01/24/22 at 11:34 AM, the Resident entered room B -11. NA #47 entered the room and took the Resident out of B-11.
The above information including the physical abuse to this resident by other residents occurring on 11/24/21 and 12/13/21 was discussed with the administrator at 12:40 PM on 01/24/22. In addition, during the survey process numerous observations found the resident continued to wander in and out of other resident rooms. Facility staff did not redirect the resident. These observations were discussed with the administrator. The observations of other residents yelling at this resident during the survey process were discussed. The facility was aware or should have been aware the resident's continued behavior of entering other resident rooms, taking their personal belongings, places her at risk of injury from other residents.
No further information was provided during the survey process.
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CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Drug Regimen Review
(Tag F0756)
Could have caused harm · This affected multiple residents
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Based on record review and interview, the facility failed to provide evidence the attending physician reviewed and addressed the monthly medication reviews completed by the pharmacist. This was true...
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Based on record review and interview, the facility failed to provide evidence the attending physician reviewed and addressed the monthly medication reviews completed by the pharmacist. This was true for four (4) of five (5) residents reviewed for unnecessary medications during the Long Term Care Survey Process (LTCSP). Resident identifiers: #58, #39, #77, and #5. Facility census: 83.
Findings included:
a) Resident #58
A medical record review on 01/20/22 for Resident #58, revealed a pharmacy recommendation
on 06/28/21 for Trazodone 50 milligrams (mg) at bedtime to be considered for a gradual dose reduction. There was no signature or date to verify the recommendation was addressed by the attending physician.
On 01/20/22 at 11:30, the Director of Nursing (DON) verified they were unable to find any evidence the attending physician addressed the recommendation for Resident #58.
b) Resident #39
During a medical record review on 01/20/22 for Resident #39, revealed a pharmacy recommendation
on 05/06/21 for Seroquel 50 mg at 8:00 AM and 100 mg at bedtime to be considered for a gradual dose reduction. There was no signature or date to verify the recommendation was addressed by the attending physician.
In an interview with the Director of Nursing (DON) on 01/20/22 at 10:35 AM, the DON verified they were unable to find any evidence the attending physician addressed the recommendation for Resident #39.
c) Resident #77
Review of the consultant pharmacist monthly report found the pharmacist reviewed the residents medication and recommended the following on 09/27/21:
Resident has two orders for PRN (as needed) antipsychotics
Zyprexia tablet 5 mg (Olanzapine) give 1 tablet every 12 hours as needed (PRN) for 14 days
Olanzapine solution reconstituted 10 mg inject 5 mg intramuscularly every 24 hours as needed (PRN)for agitation.
Please consider discontinuing both PRN orders, consider optimizing individualized nonpharmacological interventions in an effort to decrease the frequency of antipsychotic use.
The pharmacist also stated if this therapy is to continue, it is recommended that
a) the prescriber document an assessment of risk versus benefit, indicating that it continues to be a valid therapeutic intervention for this individual,
b) the record contains documentation of specific target behaviors(s), desired outcome(s) and the effectiveness of individualized nonpharmacological interventions (e.g., cognitive behavioral therapy); and
c) the facility interdisciplinary team ensures ongoing monitoring for effectiveness and potential adverse consequences (e.g., orthostasis, uncontrollable movements). PRN antipsychotic orders should include a stop date of no greater than 14 days.
The physician has never signed this recommendation or made any comments.
The order for Zyprexia (by mouth) was discontinued on 09/30/21.
On 10/26/21 the pharmacist again told the physician the resident has a PRN order for an antipsychotic, which has been in place for greater that 14 days without a stop date. Olanzapine Solution Reconstituted 10 mg, inject 5 mg intramuscularly every 24 hours as needed for agitation since 09/16/21. CMS (Centers for Medicare/Medicaid Services) requires that PRN orders for antipsychotic drugs be limited to 14 days.
The physician did not sign the recommendation until 12/02/21. The medication was finally discontinued on 12/02/21.
At 10:35 AM on 01/20/22, the Director of Nursing confirmed she could find no evidence the physician addressed the pharmacists recommendation for 09/27/21. The order for PRN antitipsychotic of Olanzapine Solution Reconstituted remained an active active order for over 14 days. (Written on 09/16/21, discontinued on 12/02/21.) The failure of the physician to answer the pharmacists recommendations allowed a PRN antipsychotic medication to exceed 14 days.
On 01/24/22 at 12:17 PM, the above recommendations were discussed with the administrator. No further evidence was presented by the close of the survey on 01/24/22 at 3:45 PM.
d) Resident #5
Resident #5 had resided in the facility since September 2021.
Review of Resident #5's medical records showed the pharmacist had performed monthly medication reviews and had made recommendations on 09/30/21 and 10/26/21. Only the pharmacist's consultation report with recommendations on 10/26/21 was able to be located in the resident's medical records.
On 01/20/22 at 10:35 AM, the Director of Nursing (DON) presented three (3) pharmacy consultation reports with recommendations dated 09/30/21. The DON also presented an additional pharmacy consultation report with recommendations on 10/26/21. None of these reports had the physician's response or signature or the signature of the Director of Nursing. The DON stated the consultation reports had been reviewed and signed by the physician, but she was unable to locate the signed copies.
No further information was provided through the completion of the survey.
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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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The facility failed to ensure medications were stored, labeled and kept in proper temperature controls in accordance with the accepted professional standards of practice. These were random opportuni...
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The facility failed to ensure medications were stored, labeled and kept in proper temperature controls in accordance with the accepted professional standards of practice. These were random opportunities for discovery. Resident Identifiers: #2, #49, #45 and #36. Facility Census: 83.
Findings Included:
a) Medication cart
On 01/19/22 at 8:40 AM, the inspection of the medication cart found medication not dated after opening. The medication not dated were three (3) insulin pens labeled for Resident #2, Resident #49 and Resident #45. In addition, one (1) Spriva Handihaler was labeled for Resident #36 and not dated as well.
On 01/19/22 at 8:50 AM, Licensed Practical Nurse (LPN) #15 verifed the medication was not dated upon opening.
On 01/19/22 at 9:22 AM, the Director of the dementia unit #53 was notified of the undated medication found on the medication cart.
On 01/19/22 at 9:28 AM, the Administrator was notified of the undated medication found on the medication cart.
No further information was obtained during the survey process.
b) Medication Refrigerator
On 01/19/22 at 8:55 AM, two incomplete temperature logs hanging on the medication refrigerator were observed. The first temperature log was entitled Temperature Log For Medication/Vaccine Refrigerator. The second temperature log was entitled Food and Nutrition Services Refrigerator/Freezer Temperature Log. LPN #15 verified neither log was complete in recording the temperatures for the days in the month of January, 2022. LPN #15 stated I think restorative (nursing) is to complete those.
According to the facility policy entitled Medication and Vaccine Refrigerator/Freezer temperatures, the refrigerators and freezers temperatures are to be checked and recorded twice daily on the Medication/Vaccine Refrigerator Temperature Log or Medication/Vaccine Freezer Temperature Log. There is no indication on the policy which staff members are responsible for checking and recording the temperatures.
The incomplete temperature log entitled Temperature Log For Medication/Vaccine Refrigerators is missing the following temperatures and the times the temperatures were checked:
--01/01/22 evening
--01/03/22 morning
--01/04/22 morning and evening
--01/05/22 morning and evening
--01/06/21 morning
--01/07/21 evening
--01/08/22 morning and evening
--01/09/22 morning and evening
--01/10/22 morning and evening
--01/11/22 morning
--01/12/22 morning and evening
--01/13/22 morning and evening
--01/14/22 morning and evening
--01/15/22 morning and evening
The incomplete temperature log entitled Food and Nutrition Services Refrigerator/Freezer Temperature Log is missing the following temperatures and the times the temperatures were checked:
--01/16/22 morning and evening
--01/17/22 morning
--01/18/22 evening
On 01/19/22 at 9:22 AM, the Director of the dementia unit #53 was notified of the temperature logs being incomplete.
On 01/19/22 at 9:28 AM, the Administrator was notified of the temperature logs being incomplete.
No further information was obtained during the survey process.
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CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safe...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety.
PS - DR
a) Kitchen DR
b) LT resident room refrigerators did not temperature logs or thermometers
FACILITY
FTAGDIR
Based on observation and staff interview the facility failed to complete Resident refrigerator temperatures in accordance with professional standards for food service safety related to storage.
01/19/22 09:20 AM no temp log or thermometer
01/20/22 09:53 AM interview with [NAME] S verified there were no refrig temp log or thermometers on the resident refrig in rooms
108
112
107
b) Personal Refrigerators
On 01/19/22 at 9:20 AM an observation of Mary's Garden found, three (3) Residents personal refrigerators in rooms [ROOM NUMBER] with no temperature logs.
On 01/20/22 at 9:53 AM during an interview with the Dementia Program Director (E#53), she verified there was no temperature logs on personal refrigerator in rooms [ROOM NUMBER]. E #53 stated that temperatures were not being completed at this time.
Based on observations and staff interviews the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety. During the kitchen tour it was discovered the floor of the walk-in cooler, drip pan, and a shelving unit were dirty. Also food was not dated after opening and temperatures were not being monitored on resident's private refrigerators. These failed practices had the potential to affect all residents receiving nourishment from the kitchen and food safety storage for resident's private refrigerators. Facility census: 83
Findings included:
a) Kitchen tour
During the kitchen tour on 01/18/22 at 11:25 AM, it was discovered the floor of the walk-in cooler was heavily soiled, the stove had a dirty drip pan and a shelving unit had stock pots stored rim down on dirty shelving. Also a storage bin containing elbow macaroni was not dated after opening.
In an interview with the Administrator on 01/18/22 at 11:45 AM, verified the walk-in cooler, drip pan, and the shelving unit needed to be cleaned. Also the macaroni was not dated after opening.
The facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety.
PS - DR
a) Kitchen DR
b) LT resident room refrigerators did not temperature logs or thermometers
FACILITY
Kitchen
F 812 The facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety. During the kitchen tour it was discovered the drip pan, the floor of the walk-in cooler were dirty. The stock pots were stored on dirty shelving.
01/18/22 at 11:25 AM completed kitchen tour
Walk-in cooler/freezer were being temped daily with no missing data
Walk-in cooler had a dirty floor and ice build up in the corner
Drip pan was dirty
pasta opened and not dated
shelving unit under prep table had stock pots stored rim down on a dirty shelving.
Storage bin for elbow mac was not dated
DM enrolled in program and food handlers
Food temps of noon meal
meatballs 182
fish 178
Mashed potatoes 180
potato tots 180
Meals being served in resident rooms due to outbreak
gloves and hairnets being used properly
appropriate hand hygiene being used
The dietary asst verified the undated food, the dirty shelves, and the mac bin that was not dated.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected multiple residents
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Based on observation, staff interview and record review, the facility failed to maintain appropriate infection control standards during medication administration for Resident #48 dropped pill, faile...
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Based on observation, staff interview and record review, the facility failed to maintain appropriate infection control standards during medication administration for Resident #48 dropped pill, failed to perform hand hygiene between Resident #48 and Resident #24, not placing barriers between inhalers and nasal spray for Resident #45 and #40 and popping pills into bare hands during preparation of the medication for Resident #40 and #82 This was true for five (5) of five (5) residents who were observed during medication administration. Resident Identifiers: #48, #24, #38, #40 and #82. Facility Census: 83.
Findings Included:
a) Resident #48
On 01/19/22 at 8:25 AM, Licensed Practical Nurse (LPN) #15 was observed during medication administration. LPN #15 dropped a pill on the medication cart. LPN #15 picked up the pill with a gloved hand and placed the pill into the medication cup.
On 01/19/22 at approximately 8:40 AM, LPN verified the pill was dropped on the medication cart and placed in the medication cup.
On 01/19/22 at 9:22 AM, the Director of the dementia unit was notified of the infection control issues during the medication administration.
On 01/19/22 at 9:28 AM, the Administrator was notified of the infection control issues during the medication administration.
No further information was obtained during the survey process.
b) Resident #24
On 01/19/22 at 8:30 AM, LPN #15 did not perform hand hygiene between Resident #48 and Resident #24 during medication administration.
On 01/19/22 at approximately 8:40 AM, LPN #15 verified hand hygiene was not performed between Resident #48 and Resident #24 prior to administering medication.
On 01/19/22 at 9:22 AM, the Director of the dementia unit was notified of the infection control issues during the medication administration.
On 01/19/22 at 9:28 AM, the Administrator was notified of the infection control issues during the medication administration.
No further information was obtained during the survey process.
c) Resident #38
On 01/19/22 at approximately 8:40 AM, LPN #15 placed two (2) inhalers on the bedside table for Resident #38. LPN #15 did not use a barrier before placing the two (2) inhalers on the bedside table.
On 01/19/22 at 8:45 AM, LPN #15 verified a barrier was not used when the inhalers were placed on the bedside table.
On 01/19/22 at 9:22 AM, the Director of the dementia unit was notified of the infection control issues during the medication administration.
On 01/19/22 at 9:28 AM, the Administrator was notified of the infection control issues during the medication administration.
No further information was obtained during the survey process.
b) Medication Administration - A and D hallways
On 01/19/22 at 8:39 AM, medication administration by Licensed Practical Nurse (LPN) #43 to Resident #40 was observed. Resident #40 was ordered the following oral medications to be administered in the morning: metoprolol, torsemide, creon, potassium, vascepa, and lisinopril. These oral medications came in a blister pack, with each pill packaged in a separate compartment to allow the tablets to be popped out of the compartment into a medicine cup. However, LPN #43 popped the medications into her bare hand to put them into the medicine cup.
Additionally, Resident #40 had an order for Flonase nasal spray. LPN #43 removed the Flonase bottle from the box and laid the bottle on top of the medication cart before taking it into the resident's room. While the resident's oral medications were being administered, LPN #43 placed the Flonase directly onto the resident's bedside table without using a barrier. After administration, LPN #43 took the Flonase bottle out of the room and placed it directly on the top of the medication cart before placing the bottle back in the box and returning it to the medication cart drawer.
On 01/19/22 at 8:50 AM, medication administration by Licensed Practical Nurse (LPN) #43 to Resident #82 was observed. Resident #82 was ordered the following oral medications to be administered in the morning: metoprolol, magnesium, rytery, folic acid, loratadine, and Seroquel. These oral medications came in a blister pack, with each pill packaged in a separate compartment to allow the tablets to be popped out of the compartment into a medicine cup. However, LPN #43 popped the medications into her bare hand to put them into the medicine cup.
Additionally, Resident #82 had an order for Flonase nasal spray. LPN #43 removed the Flonase bottle from the box and laid the bottle on top of the medication cart before taking it into the resident's room. While the resident's oral medications were being administered, LPN #43 placed the Flonase directly onto the resident's bedside table without using a barrier. After administration, LPN #43 took the Flonase bottle out of the room and placed it back in the box and returned it to the medication cart drawer.
On 01/19/22 at 9:06 AM, LPN #43 was informed that placing the medication bottles directly on the resident's bedside table without a barrier, such as a paper towel, could transfer infectious agents from the bedside table to the medication cart. LPN #43 was also informed that medication tablets should not be touched with bare hands. LPN #43 stated she understood.
The facility's Medication Administration Policy with effective date 01/01/04 and revision date 06/02/21 stated, When using a blister pack, pop medications through foil or paper backing into a medication cup.
During an interview on 01/19/22 at 9:15 AM, the Director of Nursing confirmed nurses were taught to not touch medication tablets with their bare hands and were taught to use a barrier when placing items on residents' bedside table that were to be returned to the cart.
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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
- "What changes have you made since the serious inspection findings?"
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • 42% turnover. Below West Virginia's 48% average. Good staff retention means consistent care.
Concerns
- • Multiple safety concerns identified: 1 life-threatening violation(s), $72,205 in fines. Review inspection reports carefully.
- • 79 deficiencies on record, including 1 critical (life-threatening) violation. These warrant careful review before choosing this facility.
- • $72,205 in fines. Extremely high, among the most fined facilities in West Virginia. Major compliance failures.
- • Grade F (18/100). Below average facility with significant concerns.
Bottom line: Trust Score of 18/100 indicates significant concerns. Thoroughly evaluate alternatives.
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About This Facility
What is Marmet Center's CMS Rating?
CMS assigns MARMET CENTER an overall rating of 1 out of 5 stars, which is considered much below average nationally. Within West Virginia, this rating places the facility higher than 0% of the state's 100 nursing homes. A rating at this level reflects concerns identified through health inspections, staffing assessments, or quality measures that families should carefully consider.
How is Marmet Center Staffed?
CMS rates MARMET CENTER's staffing level at 1 out of 5 stars, which is much below average compared to other nursing homes. Staff turnover is 42%, compared to the West Virginia average of 46%. This relatively stable workforce can support continuity of care. RN turnover specifically is 70%, which is notably high. RNs provide skilled clinical oversight, so turnover in this role can affect medical care quality.
What Have Inspectors Found at Marmet Center?
State health inspectors documented 79 deficiencies at MARMET CENTER during 2022 to 2025. These included: 1 Immediate Jeopardy (the most serious level, indicating potential for serious harm or death) and 78 with potential for harm. Immediate Jeopardy findings are rare and represent the most serious regulatory concerns. They require immediate corrective action.
Who Owns and Operates Marmet Center?
MARMET 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 GENESIS HEALTHCARE, a chain that manages multiple nursing homes. With 90 certified beds and approximately 84 residents (about 93% occupancy), it is a smaller facility located in MARMET, West Virginia.
How Does Marmet Center Compare to Other West Virginia Nursing Homes?
Compared to the 100 nursing homes in West Virginia, MARMET CENTER's overall rating (1 stars) is below the state average of 2.7, staff turnover (42%) is near the state average of 46%, and health inspection rating (2 stars) is below the national benchmark.
What Should Families Ask When Visiting Marmet Center?
Based on this facility's data, families visiting should ask: "What changes have been made since the serious inspection findings, and how are you preventing similar issues?" "Can you walk me through typical staffing levels on day, evening, and night shifts?" "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" These questions are particularly relevant given the facility's Immediate Jeopardy citations and the below-average staffing rating.
Is Marmet Center Safe?
Based on CMS inspection data, MARMET CENTER has documented safety concerns. Inspectors have issued 1 Immediate Jeopardy citation (the most serious violation level indicating risk of serious injury or death). The facility has a 1-star overall rating and ranks #100 of 100 nursing homes in West Virginia. Families considering this facility should ask detailed questions about what corrective actions have been taken since these incidents.
Do Nurses at Marmet Center Stick Around?
MARMET CENTER has a staff turnover rate of 42%, 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 Marmet Center Ever Fined?
MARMET CENTER has been fined $72,205 across 1 penalty action. This is above the West Virginia average of $33,801. Fines in this range indicate compliance issues significant enough for CMS to impose meaningful financial consequences. Common causes include delayed correction of deficiencies, repeat violations, or care failures affecting resident safety. Families should ask facility leadership what changes have been made since these penalties.
Is Marmet Center on Any Federal Watch List?
MARMET 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.