CARE HAVEN CENTER
For profit - Corporation
68 Beds
GENESIS HEALTHCARE
Data: November 2025
Trust Grade
70/100
#20 of 122 in WV
Photo by Care Haven Center
Photo by Care Haven Center
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1 / 9 photos
Last Inspection: September 2024
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
Care Haven Center in Martinsburg, West Virginia, has a Trust Grade of B, indicating it is a good choice for families, though there may be some concerns to consider. It ranks #20 out of 122 nursing homes in the state, placing it in the top half of facilities, and is the best option out of two in Berkeley County. Unfortunately, the facility is experiencing a worsening trend, with the number of issues increasing from 10 in 2023 to 12 in 2024. Staffing is a weak point, rated 2 out of 5 stars, with a 52% turnover rate that is average for West Virginia, and there were times when no registered nurse was present for at least eight hours a day, which could potentially affect resident care. On a positive note, the center has not incurred any fines, indicating compliance with regulations, and has better RN coverage than 78% of state facilities. However, specific incidents included residents waiting excessively for assistance, with one reporting up to three hours for help, and the lack of a certified infection preventionist, which raises concerns about infection control practices. Overall, while Care Haven Center has strengths in areas like RN coverage and no fines, families should weigh these against the staffing challenges and specific incidents that may impact care quality.
- Trust Score
- B
- In West Virginia
- #20/122
- Safety Record
- Low Risk
- Inspections
- Getting Worse
- Staff Stability ⚠ Watch
- 52% turnover. Above average. Higher turnover means staff may not know residents' routines.
- Penalties ✓ Good
- No fines on record. Clean compliance history, better than most West Virginia facilities.
- Skilled Nurses ○ Average
- Each resident gets 40 minutes of Registered Nurse (RN) attention daily — about average for West Virginia. RNs are the most trained staff who monitor for health changes.
- Violations ⚠ Watch
- 52 deficiencies on record. Higher than average. Multiple issues found across inspections.
70/100
Top 16%
No red flags
10 → 12 violations
★★★★☆
4.0
Overall Rating
★★☆☆☆
2.0
Staff Levels
★★★★☆
4.0
Care Quality
★★★★☆
4.0
Inspection Score
↔
Stable
2023: 10 issues
2024: 12 issues
The Good
-
4-Star Quality Measures · Strong clinical quality outcomes
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
Facility shows strength in quality measures, fire safety.
The Bad
Staff Turnover: 52%
Near West Virginia avg (46%)
Higher turnover may affect care consistency
Chain: GENESIS HEALTHCARE
Part of a multi-facility chain
Ask about local staffing decisions and management
The Ugly 52 deficiencies on record
Sept 2024
12 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Resident Rights
(Tag F0550)
Could have caused harm · This affected 1 resident
Based on observation, and staff interview the facility failed to treat each resident with respect and dignity regarding meal service. This was a random opportunity for discovery. Resident identifier: ...
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Based on observation, and staff interview the facility failed to treat each resident with respect and dignity regarding meal service. This was a random opportunity for discovery. Resident identifier: #119. Facility census: 64.
Findings included:
b) Resident #119
An observation on 09/03/24 at 2:26 PM of Resident #119 lying in bed with her noon meal tray sitting on bed side table not opened.
During a second observation of the meal service on 09/03/24 at 2:43 PM revealed Nurse Aide (NA) #12 was standing over Resident #119 feeding her in bed.
During an interview on 09/03/24 at 2:45 PM the Director of Nursing confirmed NA #12 was standing over Resident #119 feeding her at this time. The DON corrected NA #12 at this time.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0582
(Tag F0582)
Could have caused harm · This affected 1 resident
Based on record review and staff interview, the facility failed to provide the required Skilled Nursing Facility Advanced Beneficiary Notice of Non-Coverage (SNF ABN) form to one (1) of three (3) resi...
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Based on record review and staff interview, the facility failed to provide the required Skilled Nursing Facility Advanced Beneficiary Notice of Non-Coverage (SNF ABN) form to one (1) of three (3) residents reviewed for the facility's beneficiary protection notification practice during an annual survey. This failure placed the resident at risk of not being informed of her rights prior to the end of Medicare Part A covered services. Resident identifier: #25. Facility census: 64.
Findings included:
a) Resident #25
On 09/06/24 at 8:36 AM, a review was completed regarding the beneficiary protection notification liability notices given for Resident #25 who remained at the facility following her last covered day of Medicare Part A services:
Resident #25 began Medicare Part A skilled services on 08/15/24. The last covered day of Part A service was 08/28/24. Notice of Medicare Non-Coverage (NOMNC) was signed and dated on 06/26/24. No SNF ABN form was provided.
Review of Form Instructions Skilled Nursing Facility Advanced Beneficiary Notice on Non-coverage (SNF ABN) Form CMS-10055 (2018) denoted Medicare requires Skilled Nursing Facilities to issue the SNF ABN to Medicare beneficiaries prior to providing care that Medicare usually covers, but may not pay for because the care is:
- not medically reasonable and necessary; or
- considered custodial.
On 09/06/24 at 9:45 AM, Clinical Reimbursement Coordinator #58 acknowledged the facility failed to provide SNF ABN form to Resident #25 to her last covered day of Medicare Part A skilled services.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0583
(Tag F0583)
Could have caused harm · This affected 1 resident
Based on record review and staff interview, the facility failed to protect the personal privacy and confidentiality of residents ' medical records. This was true for two (2) residents as a random oppo...
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Based on record review and staff interview, the facility failed to protect the personal privacy and confidentiality of residents ' medical records. This was true for two (2) residents as a random opportunity for discovery. Resident identifiers: #47 and #59. Facility census: 64.
Findings included:
a) At 2:30 PM on 9/4/24, the surveyor discovered that pharmacist medication regimen review paperwork dated 8/28/24 (entitled PharMerica Recommendation maintain current dose Citalopram .pdf) containing Resident #59's name and medication information was scanned into Resident #47's medical record. Further record review revealed that the same document had been scanned into resident #59's record. The two residents' respective medication reviews were included on a single printed sheet, and medical records did not redact the name before the document was scanned in.
On 09/04/24 at 2:50 PM, the surveyor informed the Director of Nursing (DON) who reviewed the record and confirmed that the record, as present, contained the combined personal health information of Resident #47 and #59.
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 and staff interview, the facility failed to report alleged violation related to, neglect, or abuse, and report the results of all investigation to the proper authorities within ...
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Based on record review and staff interview, the facility failed to report alleged violation related to, neglect, or abuse, and report the results of all investigation to the proper authorities within prescribe time-frames. This was a random opportunity for discovery. Resident identifier: #8. Facility census: 64.
Findings include:
a) Resident #8
An investigation of a Facility Reported Incident of abuse that accrued on 03/23/24 revealed that the Incident was not reported to appropriate agencies until 04/05/24.
Continued record review found multiple statements from Registered Nurses #47 and #39 and Nurse aide #13 stating they witnessed Nurse Aide # 74 clap her hands and yell at Resident #8 on 03/23/24.
During an interview with the Administrator and Director of Nursing on 09/05/24 at 2:32 PM they verified the incident on 03/23/24 for Resident #8 was not reported within prescribe time-frames. It was also verified that all employees at the facility were mandatory reporters.
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
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to develop and implement a comprehensive person-centered care pl...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to develop and implement a comprehensive person-centered care plan for Resident #15 that was trauma-informed and would allow Resident #15 to attain or maintain his highest practicable physical, mental, and psychosocial well-being. This was true for one (1) of three (3) residents reviewed for the diagnosis of Post Traumatic Stress Disorder (PTSD). Resident identifier: #15. Facility census: 64.
Findings included:
a) Resident #15
A record review, completed on 09/04/24 at 2:52 PM, revealed Resident #15 was admitted to the facility on [DATE] with a PTSD diagnosis. Review of Resident #15's Care Plan revealed the following:
Focus: [Resident #15] has the potential to exhibit signs or symptoms of anxiety or depression r/t (related to) a dx (diagnosis) of Post Traumatic Stress Disorder.
Goal: [Resident #15] will be free of signs or symptoms of depression or anxiety throughout next review.
Interventions:
-Provide a calm, quiet, well-lit environment
-Explain all care, including procedures (one step at a time), and the reason for performing the care before initiating.
-Social Service visits to provide support, as needed and/or requested by resident/patient
During an interview on 09/05/24 at 2:00 PM, Social Worker #62 reported she did not know the reason for Resident's PTSD diagnosis. Social Worker #62 reported she recognized she did not have possible PTSD triggers care planned or appropriate staff interventions.
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 staff interview and medical record review the facility failed to ensure Resident #92 received assistance with meals. This was true for one (1) of (1) residents reviewed for nutrition. Residen...
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Based on staff interview and medical record review the facility failed to ensure Resident #92 received assistance with meals. This was true for one (1) of (1) residents reviewed for nutrition. Resident identifier #119. Facility census: 64.
Findings included:
a) Resident #119
An observation on 09/03/24 at 2:26 PM the lunch tray was sitting in front of resident, she was not eating, no assistance was offered.
An bservation of the meal service on 09/04/24 at 1:24 PM revealed a tray set up in front of Resident #119 with food spillage all over her. She was trying to drink her sherbet. She had her phone receiver laying in the middle of her tray.
During an interview with the Director of Nursing (DON) on 09/04/24 at 1:28 PM she verified Resident #119 was an assist with meals. At this time the DON went to get Resident #119 assistance.
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 medical record review, observation, and staff interview, the facility failed to ensure one (1) residents received treatment and care in accordance with professional standards of practice. Res...
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Based on medical record review, observation, and staff interview, the facility failed to ensure one (1) residents received treatment and care in accordance with professional standards of practice. Resident identifier: #30. Facility census: 64.
Findings included:
a) Resident #30
A record review on 09/05/24 at approximately 8:00 AM, revealed nurses documenting Blood pressure (BP) being taken in the right arm.
Further record review revealed the resident had a Physician order which stated, Do not take B/P in the right arm, with an order date of 08/14/24.
Continued record review on 09/05/24 shows resident having orders
- Dialysis port location: right upper chest.
- Monitor hemodialysis catheter site 2 lumens, right upper chest for signs and symptoms infection, edema, bleeding, and upon return from dialysis. Notify primary care physician and dialysis unit if there are signs and symptoms of infection. If catheter site is bleeding apply pressure for 15 minutes and notify MD/physician if bleeding does not stop, every shift and as needed. Do Not Change End Caps.
On 09/05/24 at 9:52 AM a call was placed to Resident #30's dialysis center revealed the order for no BP in right arm did not come from the dialysis center or Neurologist. There is no reason to not take B/P in right arm from them. It was stated that mapping, or shunt / fistula placement has not taken place yet.
On 09/05/24 at 10:32 AM, The Director of Nursing stated that the order was put in place just for precautions and would not hurt him if the B/P was taken in the right arm. The (DON) also stated, The orders and care plan should have been followed to not take a B/P in the left arm.
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 staff interview and medical record review the facility failed to ensure Resident #92 received assistance with meals. This was true for one (1) of (1) residents reviewed for nutrition. Residen...
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Based on staff interview and medical record review the facility failed to ensure Resident #92 received assistance with meals. This was true for one (1) of (1) residents reviewed for nutrition. Resident identifier #119. Facility census: 64.
Findings included:
a) Resident #119
An observation on 09/03/24 at 2:26 PM the lunch tray was sitting in front of resident, she was not eating, no assistance was offered.
An bservation of the meal service on 09/04/24 at 1:24 PM revealed a tray set up in front of Resident #119 with food spillage all over her. She was trying to drink her sherbet. She had her phone receiver laying in the middle of her tray.
During an interview with the Director of Nursing (DON) on 09/04/24 at 1:28 PM she verified Resident #119 was an assist with meals. At this time the DON went to get Resident #119 assistance.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0805
(Tag F0805)
Could have caused harm · This affected 1 resident
Based on medical record review and staff interview the facility failed to ensure one (1) of one (1) residents reviewed for nutrition received the correct therapeutic diet. Resident #119. Facility cens...
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Based on medical record review and staff interview the facility failed to ensure one (1) of one (1) residents reviewed for nutrition received the correct therapeutic diet. Resident #119. Facility census: 64.
Findings included:
a) Resident #119
A record review on 09/04/24 at 11:45 AM found, two (2) conflicting orders for a diet:
--2 gm Sodium (2g Na) diet, Dysphagia Advanced texture, Standard Thin Liquids consistency diet. Order date 09/02/24.
--2 gm Sodium (2g Na) diet, Regular Texture, Standard Thin Liquids consistency
diet. Order date 8/26/2024.
An interview 09/04/24 at 1:28 PM the Director of Nursing (DON) verified Resident #119 had two (2) different diet orders on her active chart. The DON stated that they should have discontinued the regular texture diet out of the active orders.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Medical Records
(Tag F0842)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to maintain accurate records on two (2) out of 22 sampled reside...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to maintain accurate records on two (2) out of 22 sampled residents in the Long-Term Care Survey Process. Resident identifiers: #64 and #119. Facility census: 64.
Findings included:
a) Resident #64
A record review, completed on 09/05/24 at 7:30 PM, revealed resident had been hospitalized on [DATE] and had not returned to the facility.
There was also a nurse practitioner (NP) note, dated on 6/25/2024 at 10:52 PM, that listed the date of service (date of NP visit at the facility) as 06/25/24. Details of the note were, She is seen resting to bed with no grimaces or s/s (signs and symptoms of) pain. She was recommended hospice by oncology however declined. Labs and meds reviewed. She continues rehab for weakness. This shift increased weakness reported with general declines. The note indicated the NP had spent 46 minutes total meeting with resident and reviewing resident's chart.
During an interview, on 09/06/24 at 10:05 AM, the Director of Nursing (DON) reported there was an error with the date of service listed in the chart. The DON further explained it was a telehealth vist that was made on 06/19/24 prior to Resident #64 going to the hospital.
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 F0809
(Tag F0809)
Could have caused harm · This affected multiple residents
Based on observations, record review, resident interview, and staff interview, the facility failed to maintain regularly scheduled mealtimes. This had the potential to affect all residents that get th...
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Based on observations, record review, resident interview, and staff interview, the facility failed to maintain regularly scheduled mealtimes. This had the potential to affect all residents that get their nutrition from the kitchen. Facility census: 64.
Findings Included:
a) Dining Observation
An observation on 09/03/24 at 12:30 PM revealed the lunch meal had not been served. 16 residents were in the dining room waiting for their meal.
A review of the posted mealtimes found that the lunch meal was scheduled to start at 12:15 PM daily.
An interview with Nurse Aide #29 on 09/03/24 at 12:44 PM revealed the lunch meal was late most days.
During an interview, on 09/03/24 at 12:56 PM, Certified Dietary Manager (CDM) verified the noon meal was not served on time. She stated breakfast was late so they could not start on time for the lunch meal.
Continued observation on 09/03/24 found drinks were not served until 1:05 PM, upon inquiry by the surveyor.
Observation continued to find the first tray was served in the dining room at 1:20 PM.
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 and staff interview the facility failed to serve food in accordance with professional standards for food serve safety. This had the ability to effect more than a limited number of...
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Based on observation and staff interview the facility failed to serve food in accordance with professional standards for food serve safety. This had the ability to effect more than a limited number of residents. Facility census: 64.
Findings included:
a) Initial Kitchen Tour
During the initial kitchen tour on 09/03/24 at 1:20 PM an observation of tray service found the Dietary Manager (DM) dipping food with gloved hands, touching and opening hamburger buns, touching serving scoops, the plate warming cart, the counter, bowls, bowl rack, and the environment around the service area.
Continued observation found The DM using the plate lifter to get the plates from the warmer and when not in use, suction the plate lifter to the countertop.
During an interview at 09/03/24 1:35 PM the DM stated that she only cleans the top counter after breakfast, lunch and dinner. The DM confirmed that suctioning the plate lifter to the countertop could cause germs to be spread. She also verified that she was touching the surrounding environment and the resident's hamburger buns without changing her gloves.
Mar 2023
10 deficiencies
CONCERN
(D)
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 and staff interview, the facility failed to treat one (1) of the 21 sampled residents in the long-term ca...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on observation and staff interview, the facility failed to treat one (1) of the 21 sampled residents in the long-term care survey process with dignity and respect. The facility failed to honor Resident #46's right to a dignified existence prior to beginning an activity in a public area. Resident Identifier: #46. Facility Census: 67.
Findings included:
a) Resident #46
Observation on 02/21/23 at 2:18 PM, revealed multiple residents in the dining room being greeted by activity staff. As residents entered the dining room, [NAME] Gras beads were being placed around their necks in preparation for the [NAME] Gras party that was scheduled at 2:30 PM. Further observation found Resident #46 sitting in the dining room with what appeared to be flaking skin covering the top part of Resident #46's maroon long-sleeved shirt. The white particles were in the front of the maroon long-sleeved shirt from shoulder to shoulder and easy visible to any passerby. Staff had already greeted resident and had placed [NAME] Gras beads around his neck.
During an interview, on 02/21/23 at 2:24 PM, the RN #38 stated, It's probably dandruff. We have noticed a history of it flaking. She then removed Resident #49 from activity to address the dignity concern. Resident was changed into a gray t-shirt and returned to the activity room to participate in the activity.
.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0552
(Tag F0552)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on medical record review and staff interview, the facility failed to honor Resident #56's right to direct her own medica...
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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 honor Resident #56's right to direct her own medical care. This was true for one (1) of nine (9) residents reviewed for Advance Directives. Resident identifier #56. Facility census: 66.
Findings included:
a) Resident #56
A medical record review for Resident #54 revealed, the Maryland Medical Order for Life-Sustaining Treatment (MOLST) completed [DATE]. The life sustaining decision for Resuscitation (CPR) was indicated with full interventions, completed by Resident #56.
A continued review revealed, Resident #56's Physician Determination of Capacity found, she had continued to demonstrated Capacity to make medical decisions on [DATE].
Subsequent review discovered, Resident #56's Physician Determination of Capacity completed [DATE], found she demonstrated Incapacity to make medical decisions, with the expected duration of incapacity to be short term.
Following medical record review found a Physician Orders for Scope of Treatment (POST) form completed per directions specified by the [NAME] Virginia Center for End-of-Life Care in conjunction with the [NAME] Virginia Health Care Decisions Act (16-30-1). The form Indicated No CPR with selective treatment signed by the Health Care Surrogate, completed [DATE].
During an interview on [DATE] at approximately 9:45 AM the Social Worker confirmand Resident #56's Life-Sustaining Treatment was changed by her HCS.
During an interview on [DATE] at 9:52 AM the Director of Nursing verified a Physician Orders for Scope of Treatment (POST) form completed per directions specified by the [NAME] Virginia Center for End-of-Life Care should have been completed upon admission.
No further information was provided, prior to the end of the Long-Term Survey Process on [DATE] at 11:30 AM.
.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0583
(Tag F0583)
Could have caused harm · This affected 1 resident
.
Based on record review and staff interview, the facility failed to honor Resident #16's privacy when taking a skin and wound assessment picture . This was a random opportunity for discovery. Residen...
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.
Based on record review and staff interview, the facility failed to honor Resident #16's privacy when taking a skin and wound assessment picture . This was a random opportunity for discovery. Resident identifier: #16. Facility census: 67.
Findings included:
a) Resident #16
Record review, completed on 02/21/23 at 2:36 PM, found the following:
-Skin & Wound Assessment Picture for a Deep Tissue Injury of the right heel, taken in the day room area of the facility with what appeared to be another resident and that resident's visitor in the room. This picture was scanned into Resident #16's electronic medical record and was dated 01/18/23 at 11:30 AM.
During an interview on 02/27/23 at 3:15 PM, the Director of Nursing (DON) confirmed the picture had been taken in a public area of the building [in the day room by the nurses station] with what appeared to be a resident and a resident's visitor present. The DON acknowledged this practice failed to honor Resident #16's privacy.
.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Grievances
(Tag F0585)
Could have caused harm · This affected 1 resident
.
Based on interview and record review the facility failed to follow up on a grievance regarding lost dentures. This is true for one (1) of two (2) reviewed for dental care during the Long-Term Care S...
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.
Based on interview and record review the facility failed to follow up on a grievance regarding lost dentures. This is true for one (1) of two (2) reviewed for dental care during the Long-Term Care Survey Process (LTCSP). Resident identifiers: #56. Facility census: 66.
Findings Included:
a) Resident #56
On 02/22/23 at 11:08 AM during an interview Resident #56's Health Care Surrogate (HCS) stated that he reported her dentures missing about three weeks ago to the facility. He stated that he asks about the dentures every time he visits, and the staff states that they are looking for the dentures.
A review of the facility concerns, and grievance log found no issue for Resident #56's lost dentures.
During an interview on 02/28/23 at 3:47 PM the Social Worker (SW) stated that she had heard about Resident #56's missing dentures. She continued to say that she though they had found them.
During an interview with the SW and Director of Nursing on 02/28/23 at approximately 4:11 PM the SW stated that Resident #56 has lost her dentures multiple times, and they have found them within a day or so, without doing a grievance form.
During an interview on 02/28/23 at 4:28 PM the SW stated that she contacted Resident #56's HCS. She verified that he had reported the dentures missing about a month ago.
.
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
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on record review and staff interview, the facility failed to provide care and services in accordance with acceptable sta...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on record review and staff interview, the facility failed to provide care and services in accordance with acceptable standards of practice. This was true for one (1) out of 21 residents sampled during the annual recertification survey. Resident identifier: #45. Facility Census: 67.
Findings included:
a) Resident #45
A record review, completed on [DATE] at 7:15 PM, revealed the following discrepancy:
--The code status listed on the profile page of the electronic medical record stated: DNR - Comfort Measures
--The Physician order, dated [DATE], stated: DNR/Comfort Measures
--The Physician Orders for Scope of Treatment (POST) form, signed [DATE], stated CPR, Full Treatments, and Feeding Tube.
Additionally, the following documentation incorrectly listed Resident #45's code status:
--Family Nurse Practitioner Encounter note, dated [DATE], listed code status as DNR - Comfort Measures
--SBAR [situation, background, assessment and recommendation] Communication Form and Progress Note, dated [DATE], listed code status as DNR - Comfort Measures
--Family Nurse Practitioner Encounter note, dated [DATE], listed code status as DNR - Comfort Measures
--SBAR Communication Form and Progress Note, dated [DATE], listed code status as DNR - Comfort Measures
--Family Nurse Practitioner Encounter note, dated [DATE], listed code status as DNR - Comfort Measures
--Family Nurse Practitioner Encounter note, dated [DATE], listed code status as DNR - Comfort Measures
During an interview on [DATE] at 8:24 AM, the Acting Interim Administrator / Director of Nursing (DON) agreed the facility had failed to change Resident #45's code status to CPR, Full Treatments, and Feeding Tube following the completion of the [DATE] POST form.
.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Dental Services
(Tag F0791)
Could have caused harm · This affected 1 resident
.
Based on interview and record review the facility failed to provide prompt dental treatment for lost dentures. This is true for one (1) of two (2) reviewed for dental care during the Long-Term Care ...
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Based on interview and record review the facility failed to provide prompt dental treatment for lost dentures. This is true for one (1) of two (2) reviewed for dental care during the Long-Term Care Survey Process (LTCSP). Resident identifiers: #56. Facility census: 66.
Findings Included:
a) Resident #56
On 02/22/23 at 11:08 AM during an interview Resident #56's Health Care Surrogate (HCS) stated that he reported her dentures missing about three weeks ago to the facility. He stated that he asks about the dentures every time he visits. The staff states that they are looking for the dentures.
A review of the facility concerns, and grievance log found no issue for Resident #56's lost dentures.
During an interview on 02/28/23 at 3:47 PM the Social Worker (SW) stated that she had heard about Resident #56's missing dentures. She continued to say that she though they had found them.
During an interview with the SW and Director of Nursing on 02/28/23 at approximately 4:11 PM the SW stated that Resident #56 has lost her dentures multiple times, and they have found them within a day or so, without doing a grievance form.
During an interview on 02/28/23 at 4:28 PM the SW stated that she contacted Resident #56's HCS. She verified that he had reported the dentures missing about a month ago.
.
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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Based on record review and staff interview, the facility failed to address resident preference and potential for future discharge within resident care plans. This was true for Residents #55, #46, an...
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Based on record review and staff interview, the facility failed to address resident preference and potential for future discharge within resident care plans. This was true for Residents #55, #46, and #12. The facility also failed to develop a care plan for non-pharmacological interventions for pain. This was true for Residents #164 and #42. The facility's failure to ensure accurate comprehensive care plans was true for five (5) of 21 sampled residents in the long-term care survey process. Resident identifiers: #55, #46, #12, #164, and #42. Facility census: 67.
a) Resident #12
A record review, completed on 02/27/23 at 9:04 PM, revealed the care plan did not address Resident #12's preference and potential for future discharge.
During an interview on 02/28/23 at 8:34 AM, the Acting Interim Director / Director of Nursing (DON) acknowledged the care plan was lacking resident's potential for discharge. The the Acting Interim Director / DON stated she would need to follow-up with the facility's Social Worker to determine why it had not been included.
b) Resident #46
A record review, completed on 02/27/23 at 9:13 PM, revealed the care plan did not address Resident #46's preference and potential for future discharge.
During an interview on 02/28/23 at 8:34 AM, the Acting Interim Director / Director of Nursing (DON) acknowledged the care plan was lacking resident's potential for discharge. The the Acting Interim Director / DON stated she would need to follow-up with the facility's Social Worker to determine why it had not been included.
c) Resident #55
A record review, completed on 02/27/23 at 8:53 PM, revealed the care plan did not address Resident #55's preference and potential for future discharge.
During an interview on 02/28/23 at 8:34 AM, the Acting Interim Director / Director of Nursing (DON) acknowledged the care plan was lacking resident's potential for discharge. The the Acting Interim Director / DON stated she would need to follow-up with the facility's Social Worker to determine why it had not been included.
d) Resident #164
On 02/21/23 at 3:19 PM during an interview with Resident #164, She stated that she had a broken hip and arm. She stated that she feels that they make her wait for her pain medication.
A record review revealed a physician order for Resident #164:
--Oxycodone HCl tablet 5 MG Controlled Drug, give one (1) tablet by mouth every four (4) hours as needed for moderate to severe pain.
--Tylenol Extra Strength Oral Tablet 500 MG (Acetaminophen)
Give one (1) tablet by mouth every six (6) hours as needed for mild pain.
A review of Resident #56's Care Plan found no non-pharmacological treatments for pain:
Focus:
--Resident #146 exhibits or is at risk for alterations in comfort related to surgical-post-operation pain, and right femur
Goal:
--Resident #164 will achieve acceptable level of pain control through next review.
Interventions:
--Evaluate pain characteristics: quality, severity, location, precipitating/relieving factors.
--Utilize pain scale 0-10.
--Advise her to request pain medication before pain becomes severe.
--Medicate her as ordered for pain and monitor for effectiveness and monitor for side effects such as nausea and vomiting, constipation, headache, dizziness, lightheadedness, drowsiness, weakness or lack of energy, severe itching, report to physician as indicated.
--Monitor frequency of episodes of breakthrough pain to determine the need for pain med adjustment.
--Medicate 30-45 mins prior to treatment or therapy.
--Complete pain assessment per protocol
--Assist her to a position of comfort, utilizing pillows and appropriate positioning devices.
--Manage Pain by providing ice packs or cold compresses to applicable area
During an interview on 2/28/23 9:34 AM the Director of Nursing, verified the care plan did not have no non-pharmacological treatments for pain.
e) Resident (R) #42
Review of the medical record revealed R#42 has ongoing pain issues and receives Gabapentin 100 milligrams (mg) at bedtime and Xtampza (an abuse deterrent Oxycodone) 9 mg twice a day for chronic pain. In addition, she frequently receives Acetaminophen and or Oxycodone for pain. The current care plan identifies the resident's alterations in comfort related to acute pain and neuropathic pain but lacks resident specific non-pharmacological interventions to utilize for pain relief.
During an interview on 02/28/23 at 12:30 PM, Registered Nurse (RN) #38 agreed the care plan lacks resident specific non-pharmacological interventions to assist R#42 with pain relief.
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CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0697
(Tag F0697)
Could have caused harm · This affected multiple residents
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Based on observation, interview and record review, the facility failed to ensure that a resident received the treatment and care in accordance with professional standards of practice regarding param...
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Based on observation, interview and record review, the facility failed to ensure that a resident received the treatment and care in accordance with professional standards of practice regarding parameters for pain medications. This was true for four (4) of four (4) residents reviewed for pain. Resident identifiers: #28, #164, #56, #42. Facility census: 66.
Findings included:
a) Resident #28
Medical record review for Resident # 28 found a physician's order:
--Acetaminophen Extra Strength Tablet 500 MG (Acetaminophen)
Give two (2) tablets by mouth every six (6) hours as needed for mild pain, with a start date 04/07/22.
A continued review of Medication Administration Record (MAR) revealed:
--02/20/23 at 7:41 PM pain level 7 -Acetaminophen tablet given.
--02/24/23 at 5:00 PM pain level 4 -Acetaminophen tablet given.
--02/26/23 at 5:40 PM pain level 4 -Acetaminophen tablet given.
During an interview on 2/28/23 9:34 AM the Director of Nursing, verified Resident #28 had no physician prescribed parameters for pain medications. She stated that pain medications should be given for pain levels 1-3 mild pain 4-7 moderate pain and 8-10 severe pain.
b) Resident #56
An observation on 02/21/23 at 3:30 PM on initial tour Resident #56 was screaming, crying, and displaying restless movement.
Medical record review for Resident #56 found a physician's orders:
--Acetaminophen Extra Strength Tablet 500 MG (Acetaminophen)
Give two (2) tablets by mouth every six (6) hours as needed for mild pain, with a start date 04/07/22.
--Oxycodone HCl tablet 5 MG Controlled Drug, give one (1) tablet by mouth every four (4) hours as needed for moderate pain. Start date 02/22/23.
--Oxycodone HCl tablet 5 MG Controlled Drug, give two (2) tablets by mouth every four (4) hours as needed for moderate pain. Start date 02/22/23.
--Roxicodone (Oxycodone HCl) tablet 5 MG Controlled Drug, give one (1) tablet by mouth every four (4) hours as needed for moderate pain. Start date 12/20/22.
--Roxicodone (Oxycodone HCl) tablet 5 MG Controlled Drug, give two (2) tablets by mouth every four (4) hours as needed for Severe pain. Start date 12/20/22.
A continued review of Medication Administration Record (MAR) revealed:
--02/01/23 at 1:10 AM pain level 5 -Roxicodone one (1) tablet given.
--02/01/23 at 8:04 PM pain level 8-Roxicodone one (1) tablet given.
--02/03/23 at 6:11 PM pain level 10-Roxicodone two (2) tablet given.
--02/04/23 at 10:08 AM pain level 7-Roxicodone one (1) tablet given.
--02/06/23 at 3:27 AM pain level 9-Roxicodone two (2) tablet given.
--02/06/23 at 1:38 PM pain level 8-Roxicodone one (1) tablet given.
--02/06/23 at 7:02 PM pain level 6-Roxicodone one (1) tablet given.
--02/07/23 at 8:27 AM pain level 7-Roxicodone two (2) tablet given.
--02/07/23 at 8:10 PM pain level 8-Roxicodone two (2) tablet given.
--02/08/23 at 2:00 AM pain level 8-Roxicodone two (2) tablet given.
--02/08/23 at 8:36 PM pain level 8-Roxicodone two (2) tablet given.
--02/09/23 at 9:00 PM pain level 8-Roxicodone two (2) tablet given.
--02/10/23 at 2:10 AM pain level 8-Roxicodone two (2) tablet given.
--02/11/23 at 1:15 AM pain level 8-Roxicodone one (1) tablet given.
--02/12/23 at 3:02 PM pain level 5-Roxicodone two (2) tablet given.
--02/13/23 at 10:00 AM pain level 10-Roxicodone two (2) tablet given.
--02/13/23 at 11:56 PM pain level 8-Roxicodone two (2) tablet given.
--02/14/23 at 8:53 PM pain level 7-Roxicodone two (2) tablet given.
--02/14/23 at 7:57 PM pain level 8-Roxicodone one (1) tablet given.
--02/15/23 at 12:24 AM pain level 7-Roxicodone two (2) tablet given.
--02/15/23 at 9:33 AM pain level 7-Roxicodone one (1) tablet given.
--02/16/23 at 9:45 AM pain level 3-Roxicodone one (1) tablet given.
--02/16/23 at 6:00 PM pain level 8-Roxicodone two (2) tablet given.
--02/17/23 at 2:11 AM pain level 8-Roxicodone two (2) tablet given.
--02/18/23 at 10:30 PM pain level 8-Roxicodone two (2) tablet given.
--02/19/23 at 7:00 PM pain level 8-Roxicodone two (2) tablet given.
--02/20/23 at 12:40 PM pain level 8-Roxicodone two (2) tablet given.
--02/20/23 at 7:41 PM pain level 7 -Acetaminophen tablet given.
--02/21/23 at 12:27 AM pain level 5-Roxicodone one (1) tablet given.
--02/21/23 at 10:03 AM pain level 8-Roxicodone one (1) tablet given.
--02/24/23 at 5:00 PM pain level 4 -Acetaminophen tablet given.
--02/26/23 at 5:40 PM pain level 4 -Acetaminophen tablet given.
During an interview on 2/28/23 9:34 AM the Director of Nursing, verified Resident #56 had no physician prescribed parameters for pain medications. She stated that pain medications should be given for pain levels 1-3 mild pain 4-7 moderate pain and 8-10 severe pain.
c) Resident #164
On 02/21/23 at 3:19 PM during an interview with Resident #164, She stated that she had a broken hip and arm. She stated that she feels that they make her wait for her pain medication.
A record review revealed a physician order for Resident #164:
--Oxycodone HCl tablet 5 MG Controlled Drug, give one (1) tablet by mouth every four (4) hours as needed for moderate to severe pain.
--Tylenol Extra Strength Oral Tablet 500 MG (Acetaminophen)
Give one (1) tablet by mouth every six (6) hours as needed for mild pain.
During an interview on 2/28/23 9:34 AM the Director of Nursing, verified Resident #56 had no physician prescribed parameters for pain medications. She stated that pain medications should be given for pain levels 1-3 mild pain 4-7 moderate pain and 8-10 severe pain.
d) Resident (R) #42
Review of the medical record revealed R#42 receives Gabapentin 100 milligrams (mg) at bedtime and Xtampza 9 mg twice a day for chronic pain. In addition she has physician orders for as needed pain medications without defined parameters for administration. The orders include Acetaminophen 500 milligrams (mg) two tablets (1000 mg) every six hours for mild to moderate pain and Oxycodone hydrochloride five mg every eight hours for moderate to severe pain.
The medication administration record (MAR) for the month of February 2023 notes the resident was given Acetaminophen 1000 mg on 02/03/23 for a pain level of 10 of 10, 02/08/23 for a pain level of 6 of 10, 02/24/23 for a pain level of 9 of 10, 02/26/23 for a pain level of 10 of 10 and 02/27/23 for a pain level of 4 of 10. R#42 received Oxycodone 5 mg for reported pain levels of 5 to 10 out of 10 on the following dates in February 2023: 5, 6, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 21, 22 23, 24, 25, 26, 27 and 28.
During an interview on 02/28/23 at 12:30 PM, Registered Nurse (RN) #38 confirmed the physician orders lacked specific parameters for the nurses to follow when administering the as needed pain medications to R#42.
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CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Medical Records
(Tag F0842)
Could have caused harm · This affected multiple residents
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Based on record review and staff interview, the facility failed to maintain an accurate medical record for four (4) of nine (9) sampled residents reviewed in the Long-Term Care Survey process. Resid...
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Based on record review and staff interview, the facility failed to maintain an accurate medical record for four (4) of nine (9) sampled residents reviewed in the Long-Term Care Survey process. Resident identifiers: #16, #34, #55, and #45. Facility census: 67.
Findings included:
a) Resident #16
A brief record review, completed on 02/21/23 at 7:29 PM, identified resident had a Physician Orders for Scope of Treatment (POST) form on file. The facility had obtained verbal consent from Resident #16's Health Care Surrogate (HCS) on 01/26/22. The facility failed to follow-up with the HCS to obtain an original signature.
The 2021 POST Form Guidance instructs, If the incapacitated patient's MPOA representative or Health Care Surrogate is unavailable at the time of form completion, this section can be signed by two witnesses for verbal confirmation of agreement from the patient's MPOA representative or health care surrogate. The form should be signed at the earliest available opportunity.
During an interview on 02/28/23 at 8:30 AM, the Acting Interim Director / Director of Nursing (DON) acknowledged verbal consent had been accepted over a year ago and the facility had failed to obtain a written signature from the HCS.
b) Resident #34
A brief record review, completed on 02/21/23 at 8:11 PM, identified resident had a POST form on file. The facility had obtained verbal consent from Resident #34's Medical Power of Attorney (MPOA) on 10/27/20. The facility failed to follow-up with the MPOA to obtain an original signature.
During an interview on 02/28/23 at 8:30 AM, the Acting Interim Director / DON acknowledged verbal consent had been accepted over two (2) years ago and the facility had failed to obtain a written signature from the MPOA.
c) Resident #55
A brief record review, completed on 02/21/23 at 8:18 PM, identified resident had a POST form on file. The facility had obtained verbal consent from Resident #55's HCS on 12/03/22. The facility failed to follow-up with HCS to obtain original signature.
During an interview on 02/28/23 8:30 AM, the Acting Interim Director / DON acknowledged verbal consent had been accepted over two (2) months ago and the facility failed to obtain a written signature from the HCS.
d) Resident #45
A brief record review, completed on 02/21/23 at 7:15 PM, revealed Resident #45's niece was listed as Guardian on the profile tab in the electronic medical record. There was no Legal Guardianship paperwork scanned into the electronic medical record.
On 02/27/23 at 4:15 PM, a review of the hard copy chart at nurses station revealed there was no copy of the Legal Guardianship paperwork on file. This was confirmed by the Acting Interim Administrator / DON.
During an interview on 02/27/23 at 4:42 PM, Business Office Manager #55 reported she had attended the Legal Guardianship court hearing and heard the judge verbally stated that Resident #45's niece was appointed as Legal Guardian. The Business Office Manager went on to state, I don't get those [referring to copies of the signed Legal Guardianship paperwork for residents]. They never send them to me.
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CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected multiple residents
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d) Dining Room Observation
On 02/22/23 at 11:55 PM, an observation was made of the dining room meal service. Some residents remained in the dining room following morning activity. Others were obser...
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d) Dining Room Observation
On 02/22/23 at 11:55 PM, an observation was made of the dining room meal service. Some residents remained in the dining room following morning activity. Others were observed self-propelling themselves into the dining room in their wheelchairs. Some were brought in by staff members who had pushed the residents from their rooms to the dining room. There were a total of 21 residents present for the dining room meal service. There was no opportunity given to residents for hand hygiene before the lunchtime meal was served.
During an interview on 02/22/23 at 12: 43 PM, CNA #6 stated she has worked at the facility for a little over a year. CNA #6 acknowledged hand hygiene is not performed in the dining room and added, Maybe they do it in their rooms before coming.
Based on observations, 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 including Covid-19 and infections with regards to Resident handwashing, Resident Covid -19 screening not completed accurately (Vital Signs) and storing a used bed pan on the bathroom floor. This has the potential to affect more than a limited number of residents in the facility. Resident identifiers: #28, #56 and #146. Facility census: 66.
Findings included:
a) Hallway meal pass
02/22/23 03:23 PM Interview with Interim Adm she stated that she will have a in-service.
An observation on 02/21/23 12:18 PM revealed, the Resident's on the B hall, did not receive hand hygiene prior to or during the noon meal tray pass.
During a second observation on 02/22/23 at 12:00 PM, no hand hygiene was provide to the residents on the A hall or the B hall prior to the noon meal
On 02/22/23 at 12:25 AM during an interview Nurse Aide (NA) #54 and Nurse Aide (NA) #74, NA verified no had hygiene was provided to Residents on A Hall or B Hall.
On 02/22/23 at 3:23 PM during an Interview the DON stated that she will have an in-service with all Nurse Aides.
b) Resident Covid -19 screening
1) A review of the facility's policy titled, Infection Control Policies and procedures. Revision date 10/12/22 revealed the following:
--Infection Surveillance: During an outbreak, the COVID-19 UDA screen will be completed each shift.
2) During an interview on 02/22/23 at 8:30 AM the Infection Preventionist revealed the facility was in COVID -19 outbreak.
3) Resident #28
A record review for Resident #28 revealed a Physician order for:
--Daily COVID Screen, everyday, shift.
Continued review of the Medication Administration Record found, Resident #28's Vital signs documented:
02/21/23 -Temperature 97.5, Pulse 68, Respirations 18, Oxygen Saturation 97.
02/22/23 -Temperature 97.5, Pulse 68, Respirations 18, Oxygen Saturation 97.
02/23/23 -Temperature 97.5, Pulse 68, Respirations 18, Oxygen Saturation 97.
02/24/23 -Temperature 97.5, Pulse 68, Respirations 18, Oxygen Saturation 97.
4) Resident #56
A record review for Resident #28 revealed a Physician order for:
--Daily COVID Screen, everyday shift.
Continued review of the Medication Administration Record found, Resident #56's Vital signs documented:
02/21/23 -Temperature 97.6, Pulse 78, Respirations 16, Oxygen Saturation 97.
02/22/23 -Temperature 97.6, Pulse 78, Respirations 16, Oxygen Saturation 97.
02/23/23 -Temperature 97.6, Pulse 78, Respirations 16, Oxygen Saturation 97.
02/24/23 -Temperature 97.6, Pulse 78, Respirations 16, Oxygen Saturation 97.
5) Resident #164
A record review for Resident #164 revealed a Physician order for:
--Vital Signs Short term / Skilled, daily.
Continued review of the Medication Administration Record found, Resident #164's Vital signs documented:
02/21/23 -Blood Pressure 114/72, Temperature 98.2, Pulse 74, Respirations 18, Oxygen Saturation 97.
02/22/23 -Blood Pressure 114/72, Temperature 98.2, Pulse 74, Respirations 18, Oxygen Saturation 97.
02/23/23 -Blood Pressure 114/72, Temperature 98.2, Pulse 74, Respirations 18, Oxygen Saturation 97.
02/24/23 -Blood Pressure 114/72, Temperature 98.2, Pulse 74, Respirations 18, Oxygen Saturation 97.
02/25/23 -Blood Pressure 114/72, Temperature 98.2, Pulse 74, Respirations 18, Oxygen Saturation 97.
02/26/23 -Blood Pressure 114/72, Temperature 98.2, Pulse 74, Respirations 18, Oxygen Saturation 97.
During an interview on 02/28/23 at 9:55 AM the DON verified Resident #28, Resident #56, and Resident #164's vitals are inaccurate and stated that vital signs would not be the exact same for consecutive days in a row.
c) Room B30
On 02/21/23 at 2:09 PM during the initial interview tour an observation of a dirty bed pan was laying on the floor of the bathroom in room B30.
During an interview on 02/21/23 at 2:12 with Registered Nurse #46 confirmed bed pans should not be stored on the floor. She removed the dirty bed pan at this time.
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Jan 2022
30 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0583
(Tag F0583)
Could have caused harm · This affected 1 resident
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Based on observation and interview, the facility failed to secure and keep confidential residents personal and medical information. The facility failed to safeguard private information that was plac...
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Based on observation and interview, the facility failed to secure and keep confidential residents personal and medical information. The facility failed to safeguard private information that was placed in a clear acrylic wall file holders located in the residents' hallway. These were random opportunities for discovery. Resident identifiers: #12 and 57. Facility census: 57.
Findings included:
a) Identifiable Patient Information Visible Outside the Director of Nursing's Office
On 01/03/22 at 6:00 AM, a random observation for discovery found an acrylic wall file holder mounted outside of the Director of Nursing's (DON) door. The file holder pocket had a Post-Fall Root Cause checklist form detailing information on Resident #12's fall throughout the night.
RN #42, during an interview on 01/03/22 at 6:10 AM, reported it was normal protocol for nighttime nursing staff to place fall reports in the acrylic wall file holder mounted outside the DON's office.
b) Identifiable Patient Information Visible Outside the Therapy Office
On 01/03/22 at 6:40 AM, a random observation for discovery found an acrylic wall file holder mounted outside of the therapy office. The file holder pocket had a Weight Variance report detailing weight loss for Resident #57.
RN #42, during an interview on 01/03/22 at 6:45 AM, reported it was normal protocol for staff to place such weight loss reports in the acrylic wall file holder mounted outside the therapy office.
c) Safeguarding and Storage of Health Information Records Policy
Review of the facility's Safeguarding and Storage of Health Information Records Policy, with a revision date of 02/10/20, found the following expectation noted as a means to protect all health information records from damage, loss destructions, or unauthorized use:
-Do not leave health information records unattended in public areas.
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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** .
Based on record review and interview, the facility failed to ensure appropriate information was communicated to the receiving ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on record review and interview, the facility failed to ensure appropriate information was communicated to the receiving hospital to ensure a safe and effective transition of care. This was true for one (1) of three (3) hospitalizations reviewed during the long-term care survey process. Resident identifier: 39. Facility census: 57.
Findings included:
a) Resident #39's Hospital Transfer on 11/06/21
A medical record review was completed on 01/05/22 at 9:00 AM. The record review revealed Resident #39 was transferred to the hospital on [DATE].
LPN #41 documented on 11/06/21, Pt [patient] transport arrived at facility to get resident. Resident told pt [patient] transport she was not feeling well and was shivering. Pt [patient] transport contacted dialysis center. Per dialysis center, resident was to be transported to [the name of the local hospital] emergency room]. Pt [patient] transport left with resident to [the name of the local hospital] emergency room. Will call for update.
The record did not reflect that a transfer form was completed by nursing staff and sent along with patient to the receiving facility. There was no evidence the facility had communicated contact information of the physician responsible for the care of the resident, resident representative information including contact information, advance directive information, any special instructions or precautions for ongoing care, or name and number of who to call at the facility should there be any questions.
During an interview on 01/10/22 at 10:49 AM, the Director of Nursing confirmed transfer/discharge paperwork was not completed.
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CONCERN
(D)
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, resident interview and staff interview, the facility failed to invite residents/family and/or responsi...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on record review, resident interview and staff interview, the facility failed to invite residents/family and/or responsible party to care plan meetings. This was true for two (2) of 24 sample residents Resident identifiers: #15 and #41. Facility census: 57.
Findings included:
a) Resident #15
On 01/03/22 at 10:51 AM was asked if she attended care plan meetings and Resident #15 stated that she does not know what I (Surveyor) am talking about. Resident #15 stated that she had not attended a care plan meeting nor had she been invited to a care plan meeting.
In an interview on 01/04/22 at 2:45 PM with the Activity Director who is responsible for care plan meetings stated that care plan meetings had not been conducted since 10/18/21.
In an interview with the Assistant Director of Nursing (ADON) on 01/05/22 at 7:22 AM regarding the care planning process, she stated she would review in the computer. The ADON stated that the only evidence of a care plan meeting with Resident #15 was Post admission Patient-Family Conference - V 3 dated 07/12/21. The only staff noted at this meeting was resident and recreation. No other disciplines were marked as in attendance. No other evidence was provided by the facility even with Minimum Data Set (MDS) dated [DATE] with a significant change MDS.
b) Resident #41
A review of the electronic medical record found no evidence of a care plan meeting or communication with the resident/family and/or responsible party.
In an interview with the Assistant Director of Nursing (ADON) on 01/05/22 at 7:22 AM regarding the care planning process, she stated she would review in the computer. The ADON stated that the only evidence of a care plan meeting with Resident #41 was Post admission Patient-Family Conference - V 3 dated 12/14/21. The only staff noted at this meeting was resident, recreation and rehab. No other disciplines were marked as in attendance. No other evidence was provided by the facility with Minimum Data Set (MDS) dated [DATE], 08/27/21, 05/27/21 and 01/16/21.
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CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0692
(Tag F0692)
Could have caused harm · This affected 1 resident
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Based on observation, record review, and staff interview the facility failed to provide residents with the appropriate therapeutic diets as required. This was true for two (2) of 24 sampled resident...
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Based on observation, record review, and staff interview the facility failed to provide residents with the appropriate therapeutic diets as required. This was true for two (2) of 24 sampled residents. These were random opportunities for discovery. Resident identifiers: #25 and 36. Facility census: 57
Findings included:
a) Resident #25
An interview, on 01/03/22 at 7:40 AM, Resident #25 stated, I am a diabetic and I am all hyped up on regular syrup cause they gave me regular today. Resident # 25 stated, I had to stop eating my breakfast and couldn't finish it because it is just too much sugar for a diabetic. Resident #25 stated usually the facility provides light syrup.
An observation, on 01/03/22 at 7:40 AM, revealed Resident #25's tray had regular syrup on the tray opened and poured on the remainder of French toast that was left on the tray. The tray card on Resident #25's tray stated ,Diet Condiments.
An interview with Nurse Aide (NA) #205, on 01/03/22 at 7:45 AM, stated that diet condiments should have been light syrup but that is the way it came out of the kitchen.
Review of Resident #25's medical record showed a physician order that stated, Regular Texture texture diet condiments. The care plan showed, Provide regular/liberalized diet with diet condiments as ordered.
b) Resident #36
During an interview, on 01/03/22 at 7:55 AM, Resident #36 stated, I am not suppose to have oatmeal but I am eating it anyway cause that is what they sent me to eat today.
An observation of Resident #36's tray, on 01/03/22 at 7:55 AM, revealed a half eaten bowl of oatmeal remained on the tray. The tray card on Resident #36's tray stated, NO OATMEAL.
An interview with Nurse Aide (NA) #38, on 01/03/22 at 8:00 AM, verified the food on tray was oatmeal and that Resident # 36 was not suppose to have it due to choking concerns. NA #38 stated usually Resident #36 gets cream of wheat for breakfast. NA #38 after interview did not remove oatmeal from tray and walked out of the room
Review of Resident #36's medical record showed a physician order that stated, Dysphasia Advanced texture, Thick Liquids-Nectar Like/thick consistency, Pureed meats only/ No oatmeal. The care plan stated, No oatmeal due to choking hazard.
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CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
Could have caused harm · This affected 1 resident
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Based on observation, record review and interview, the facility failed to provide necessary respiratory care and services. This was true for two (2) of seven (7) residents reviewed for respiratory s...
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Based on observation, record review and interview, the facility failed to provide necessary respiratory care and services. This was true for two (2) of seven (7) residents reviewed for respiratory services. Resident Identifiers: #28 and #30 Facility census: 57.
Findings Included:
a) Facility Policy
A policy review title with revision date 06/01/21 stated to verify order prior to oxygen administration and to date and store all respiratory masks in treatment bags when not in use.
b) Resident #28
During the initial tour on 01/03/22 at 8:08 AM, Resident #28 oxygen flow rate was at two and a half (2.5) liters/minute(l/m) via nasal cannula.
During an interview with Licensed Practical Nurse (LPN) #11 on 01/04/22 at 9:15 AM, verified Resident #28 oxygen flow rate was at two and half (2.5) l/m and the physician order was for 2.0 m/l.
A Physician Order dated 12/31/19 was Oxygen at two (2) liters/min via nasal cannula to keep sats at or above 90%.
c) Resident #30
During initial tour on 01/03/22 at 5:27 AM, Resident #30 Nebulizer treatment mask and tubing was hanging off residents bed railing.
On 01/03/22 at 5:40 AM LPN #207 acknowledged the Nebulizer treatment mask and tubing was not in the proper storage treatment bag.
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CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Staffing Information
(Tag F0732)
Could have caused harm · This affected 1 resident
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Based on observation and staff interview, the facility failed to post the daily nurse staffing in a prominent place readily accessible to residents and visitors. This was a random opportunity for di...
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Based on observation and staff interview, the facility failed to post the daily nurse staffing in a prominent place readily accessible to residents and visitors. This was a random opportunity for discovery. Facility census 57.
Findings included:
a) No Daily Nurse Staffing Posted
Review of the facility's Posting Staffing policy, with a revision date of 11/01/19, directed that in accordance with federal and state regulations, the facility would post the census, shift hours, number of staff, and total actual hours worked by licensed and unlicensed nursing staff who are directly responsible for patient care for each shift and on a daily basis.
Observation on 01/03/22 at 5:50 AM, did not find the daily nurse staffing posted in a prominent place readily accessible to residents and visitors. During an interview on 01/03/22 at 6:00 AM, RN #42 stated nurse staffing is supposed to be posted on the billboard outside the Director of Nursing's office. RN #42 confirmed there was no daily nurse staffing posted.
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CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0800
(Tag F0800)
Could have caused harm · This affected 1 resident
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Based on observation, food test tray and staff interview, the facility failed to provide each resident with foods within proper temperatures. This had the potential to affect a limited number of res...
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Based on observation, food test tray and staff interview, the facility failed to provide each resident with foods within proper temperatures. This had the potential to affect a limited number of residents who receive nutrients from the kitchen. Facility Census 57.
Findings included;
a) Food Temperatures
On 1/03/21 at 7:45 AM, observed breakfast food cart coming to A hall and witnessed food cart sitting for 35 minutes and at 8:20 AM, the last tray was left on food cart and Manager in training (MIT) #111 from Dietary came to take temperatures on tray.
-french toast casserole 101.9
-apple juice 58.6
MIT #111 stated, foods are not at proper temperature and removed tray from cart.
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CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Administration
(Tag F0835)
Could have caused harm · This affected 1 resident
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Based on facility documentation and staff interview the facility failed to provide an administration to effectively lead the facility. This had the potential to affect a limited number of residents ...
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Based on facility documentation and staff interview the facility failed to provide an administration to effectively lead the facility. This had the potential to affect a limited number of residents residing in the facility. Facility census 57 .
Findings included:
a) Administration
Facility documentation in the form of the 672 was provided to the survey team on 01/03/22 at 9:00 AM. The 672 information was incorrect as the numbers provided did not equal to the 57 census of Residents in the facility.
An interview with the Administrator and the Director of Nursing (DON), on 01/03/22 at 9:10 AM, confirmed something was wrong and the that numbers provided on the 672 was not correct and not match the 57 census.
A second 672 facility document was provided to the survey team on 01/03/22 at 10:00 AM. The second 672 was reviewed with numbers that matched the 57 census.
On 01/10/22 at 11:55 AM, a third 672 was provided to the survey team.
An interview with the DON, on 01/10/22 at 11:55PM, stated the urinary training programs numbers were changed from 49 on 01/03/21 to three (3) residents on the urinary training program as of 01/10/22. DON stated the second 672 was wrong when provided to the survey team but was caught to be wrong when the survey team asked for a list of residents who were on the urinary traning program.
An interview with Administrator, on 01/10/22 at 12:30 PM stated We are just trying to keep the facility a float. Administrator stated there is not enough staff in the facility, we have an all hands on deck philosophy and all the staff here are tired. Administrator stated there is nothing we can do about the short staffing. Administrator stated there are issues with the 672 so it is being fixed as the survey team questions the issues. Administrator stated that we talk about short staffing all the time and our hands are tied all we can do is go down the call list and hope someone comes in if we don't then we take whoever comes in to work that shift. Administrator stated all issues are ok because in ten (10) days, I am out of here headed to Iowa for a new job because money talks.
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CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Resident Rights
(Tag F0550)
Could have caused harm · This affected multiple residents
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e) Resident Council
On 01/04/22 at 2:34 PM, during the Resident Council meeting the Residents as a group stated,
No we don't have rights, what's our rights, we are in prison we don't go anywhere or...
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e) Resident Council
On 01/04/22 at 2:34 PM, during the Resident Council meeting the Residents as a group stated,
No we don't have rights, what's our rights, we are in prison we don't go anywhere or do anything.
During Resident Council meeting on 01/04/22 at 2:34 PM, as a group stated, Our rights in this facility are not respected, we are in prison here, we do not have rights.
During Resident Council meeting on 01/04/22 at 2:34 PM, as a group stated, We don't know where the information about our rights are located. We don't know how to find the information to let the state know about our care.
During Resident Council meeting on 01/04/22 at 2:34 PM, Resident #24 stated, The staff yell at me and don't listen to anything I say.
During Resident Council meeting on 01/04/22 at 2:34 PM, Resident #15 stated, they yell at you if you need a bed pan. They are usually short with you especially if you need something.
During Resident Council meeting on 01/04/22 at 2:34 PM, as a group stated, They are always rude and the staff does not treat us with dignity and respect.
Many observations made during the Long-Term Care Survey Process, the Resident Rights and contact information for the State Ombudsman and State Survey Agency were not posted for the accessibility for the residents.
c) Resident #54
On 01/04/22 at 12:23 PM, Resident #54 was observed to be standing in the doorway of her room looking up and down the hallway in an attempt to locate facility staff. Resident #54 flagged Surveyor down and pointed to her mouth and then to the food cart that was in the hallway and just past Resident #54's room. Surveyor questioned if resident was wanting her lunch tray. Resident #54 enthusiastically nodded her head in agreement. No staff members were in sight. Surveyor checked the food cart to determine there was one (1) unserved food tray still inside. The tray ticket on the unserved food tray listed Resident #54's name and confirmed it was hers. Surveyor then walked down towards the Assistant Director of Nursing's (ADON's) office and reported Resident #54 was waiting for her lunch tray. The ADON commented that it must have been an oversight and then directed another staff member to deliver the resident's meal. Surveyor observed Resident #54's roommate had eaten 1/2 of her grilled cheese sandwich, 1/2 of her tomato soup and 1/3 of her pears before Resident #54 was given her tray.
d) Resident #19
On 01/04/22 at 12:35 PM, Resident #19 reported that her first name posted outside of her room was spelled incorrectly noting that it had been that way since summer, and no one has bothered to fix it. Resident reported it was frustrating that the staff never cared to change it or apologize for the mistake.
A subsequent record review revealed that Resident #19 had transferred to the room, where her name posted outside was spelled incorrectly, in July 2021. On 01/05/22 at 10:20 AM, the Administrator acknowledged the fact that Resident #19's name being spelled incorrectly outside of her room for five (5) months was a dignity issue and stated he would have the error corrected immediately.
Based on observation, interview and record review, the facility failed to protect resident rights. The facility failed to: 1) provide privacy during incontinent care, 2) provide meals when roommates were served and 3) did not spell Resident's names correctly on door name plaque. These were random opportunities for discovery. The failed practice was true for four (4) of 24 sampled residents. Resident identifiers: #19, #22, #44, #54. Facility census: 57.
Findings included:
a) Resident #22
An observation of B-hallway, on 01/03/22 at 5:30 AM, revealed Nurse Aide (NA) #18 was providing incontinent care to Resident # 22. Resident #22's door was not closed to provide privacy and observation took place from the hallway. Resident was observed being rolled to the side of the bed with buttocks exposed to hallway.
An interview with NA #18, on 01/03/21 at 5:40 AM, stated incontinent care is never provided with the door shut as NA #18 was not taught to shut the door when patient care was to be provided.
b) Resident #44
On 01/03/22 at 5:00 AM found Resident #44 appeared to be sleeping on the right side. The sheet was off the bare lower extremities and a brief was visible covering the buttocks. The privacy curtain was not pulled. This resident was visible by anyone.
Again on 01/04/22 at 12:06 PM Resident #44 was observed lying on the right side and appeared to be asleep. The sheet was off the bare lower extremities and a brief was visible covering the buttocks. The privacy curtain was not pulled. This resident was visible by anyone. Physical Therapy (PT) staff #116 saw the resident was exposed and pulled the curtain and stated I will find someone to take care of this. Nursing Aide (NA) #203 entered the room and put pajama pants on the resident.
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CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0557
(Tag F0557)
Could have caused harm · This affected multiple residents
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Based on observation, interview and record review, the facility failed to treat residents with dignity and respect. The facility failed to: 1) provide privacy during incontinent care, 2) provide mea...
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Based on observation, interview and record review, the facility failed to treat residents with dignity and respect. The facility failed to: 1) provide privacy during incontinent care, 2) provide meals when roommates were served and 3) did not spell Resident's names correctly on door name plaque. These were random opportunities for discovery. The failed practice was true for four (4) of 24 sampled residents. Resident identifiers: #19, #22, #44, #54. Facility census: 57.
Findings included:
a) Resident #22
An observation of B-hallway, on 01/03/22 at 5:30 AM, revealed Nurse Aide (NA) #18 was providing incontinent care to Resident # 22. Resident #22's door was not closed to provide privacy and observation took place from the hallway. Resident was observed being rolled to the side of the bed with buttocks exposed to hallway.
An interview with NA #18, on 01/03/21 at 5:40 AM, stated incontinent care is never provided with the door shut as NA #18 was not taught to shut the door when patient care was to be provided.
b) Resident #44
On 01/03/22 at 5:00 AM found Resident #44 appeared to be sleeping on the right side. The sheet was off the bare lower extremities and a brief was visible covering the buttocks. The privacy curtain was not pulled. This resident was visible by anyone.
Again on 01/04/22 at 12:06 PM Resident #44 was observed lying on the right side and appeared to be asleep. The sheet was off the bare lower extremities and a brief was visible covering the buttocks. The privacy curtain was not pulled. This resident was visible by anyone. Physical Therapy (PT) staff #116 saw the resident was exposed and pulled the curtain and stated I will find someone to take care of this. Nursing Aide (NA) #203 entered the room and put pajama pants on the resident.
c) Resident #54
On 01/04/22 at 12:23 PM, Resident #54 was observed to be standing in the doorway of her room looking up and down the hallway in an attempt to locate facility staff. Resident #54 flagged Surveyor down and pointed to her mouth and then to the food cart that was in the hallway and just past Resident #54's room. Surveyor questioned if resident was wanting her lunch tray. Resident #54 enthusiastically nodded her head in agreement. No staff members were in sight. Surveyor checked the food cart to determine there was one (1) unserved food tray still inside. The tray ticket on the unserved food tray listed Resident #54's name and confirmed it was hers. Surveyor then walked down towards the Assistant Director of Nursing's (ADON's) office and reported Resident #54 was waiting for her lunch tray. The ADON commented that it must have been an oversight and then directed another staff member to deliver the resident's meal. Surveyor observed Resident #54's roommate had eaten 1/2 of her grilled cheese sandwich, 1/2 of her tomato soup and 1/3 of her pears before Resident #54 was given her tray.
d) Resident #19
On 01/04/22 at 12:35 PM, Resident #19 reported that her first name posted outside of her room was spelled incorrectly noting that it had been that way since summer, and no one has bothered to fix it. Resident reported it was frustrating that the staff never cared to change it or apologize for the mistake.
A subsequent record review revealed that Resident #19 had transferred to the room, where her name posted outside was spelled incorrectly, in July 2021. On 01/05/22 at 10:20 AM, the Administrator acknowledged the fact that Resident #19's name being spelled incorrectly outside of her room for five (5) months was a dignity issue and stated he would have the error corrected immediately.
e) Resident Council
On 01/04/22 at 2:34 PM, during the Resident Council meeting the Residents as a group stated,
No we don't have rights, what's our rights, we are in prison we don't go anywhere or do anything.
During Resident Council meeting on 01/04/22 at 2:34 PM, as a group stated, Our rights in this facility are not respected, we are in prison here, we do not have rights.
During Resident Council meeting on 01/04/22 at 2:34 PM, as a group stated, We don't know where the information about our rights are located. We don't know how to find the information to let the state know about our care.
During Resident Council meeting on 01/04/22 at 2:34 PM, Resident #24 stated, The staff yell at me and don't listen to anything I say.
During Resident Council meeting on 01/04/22 at 2:34 PM, Resident #15 stated, they yell at you if you need a bed pan. They are usually short with you especially if you need something.
During Resident Council meeting on 01/04/22 at 2:34 PM, as a group stated, They are always rude and the staff does not treat us with dignity and respect.
Many observations made during the Long-Term Care Survey Process, the Resident Rights and contact information for the State Ombudsman and State Survey Agency were not posted for the accessibility for the residents.
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CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0561
(Tag F0561)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on observation, resident interview and staff interview, the facility failed to wash a residents hair in an adequate time...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on observation, resident interview and staff interview, the facility failed to wash a residents hair in an adequate time frame, residents not being able to eat meals in the dining room or to have group activities. This was true for 8 of 24 sampled residents. Resident identifiers: 60, 9, 2, 15, 24, 19, 41 and 21. Facility census: 57
Findings included:
a) Resident #60
On 1/03/22 at 5:23 AM, interview with resident observed residents' hair to be extremely greasy and when asking resident #60 if she receives a shower or bed bath and resident #60 stated I get a bed bath per choice however, have not had my hair washed for a month and before that it was two (2) months. Resident Is being told that they are working short and hair can not be washed.
Interview with Assistant Director of Nursing (ADON)# 16 asking for shower sheets for the last six (6) months for resident #60. shower sheets were produced from ADON # 16 and ADON # 16 stated, some shower sheets for resident are missing and I can not find them.
b) Dining room and Group Activities - Residents #9, 2, 15, 24, 19, 41 and 21
On 1/3/2022 at 8:30 AM, observed no breakfast meal being served in the Main Dining room. All meals were served to residents in their rooms.
On 1/4/2022 at 2:00 PM, during resident council meeting resident voiced that the dining room has not been back open since March 2021. Residents voiced that not being able to socialize with others during meals in the dining room was missed. No group activities have been scheduled since March 2021 as well. Only thing that there is to do is look out the windows or watch television.
An interview on 1/5/2022 at 9:50 AM, with Recreation Assistant # 24, today's activity, Cranium Crunches at 10:30 AM, and Table Talk at 11:15 AM, should be in the Main dining room, if the CNA are not short. I will have to find out if they short staff today.
During an interview, 01/05/2022 at 10:32 AM, with the Recreation Director (RD) #47 asked about activity calendar and no group activities seen RD stated 01/2021 was one on one visits only, 02/2021, 03/2021, 04/2021 we had room and doorway activities only. On 05/09/2021, we started group activities back, we stopped group activities again on 12/19/2021 until yesterday 01/042022 due to an outbreak. RD states, I just follow the direction of the administrator, the administrator tells me when I can have group activities. RD stated, I looked up the Center for Disease Control guidelines that I can follow with group settings and dining room for all meals but the administrator won't let me.
On 1/05/2022 at 10:40 AM, This surveyor asked the RD about the Facility Community Life During COVID-19 10/20/20 policy supplied by the Administrator on 01/05/2021, RD stated I have never seen the policy the Administrator follows. Administrators direction is when there are two (2) to three (3) nursing employees we can't have activities.
On 01/05/2022 at 10:41 AM, an interview with the Administrator stated We were in outbreak until yesterday 1/04/2022, we had 4 employees tested positive but they were on vacation and had not been in facility but, the county health then puts us in an outbreak. Administrator stated, we have had an outbreak (2) times since I have been at facility. I started around [DATE]
On 1/05/2022 at 11:15 AM, this surveyor asked why residents have not had group activities or having meals in the dining room. The Administrator stated They should have been doing group activities, the RD #47 should have been doing them. We can't get the residents back down to Dining room to eat, they don't want to come out of their rooms. This has not been an easy venture.
During the Interview on 01/05/22 at 12:15 PM, with RD #47 stated We have zoom meetings daily and that's when the Administrator tells activities when we can have activities and if group activities and meals can be served in the Dining room are all based on short staffing. When there are only two (2) or three (3) nursing staff we can not have group activities. There are plenty of activity staff to do group activities its just based on nursing staff for that day.
An interview on 01/05/22 at 12:33 PM, Physical Therapy Assistant #116, stated we started back to group therapy in the gym around the end of March 2021. Therapy have to follow the guidelines during outbreaks, we are contracted staff. During the stand up morning meetings Administration let us know when we are in outbreaks. We follow the contract guidelines, not the facility guidelines unless the Administrator makes us. We know the residents love the activities, it is a pleasure to socialize with others. They beg to come to therapy because of socialization. Staffing is a huge issue, we can help residents get ready for therapy, we can get the residents ready that are total care we just can't use the hoyer lift. They love the social aspect of the activities and dining together.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0563
(Tag F0563)
Could have caused harm · This affected multiple residents
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Based on interview and record review, the facility failed to announce in a timely manner that the facility was opened to visitation and there was no need for appointments to be scheduled for visitat...
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Based on interview and record review, the facility failed to announce in a timely manner that the facility was opened to visitation and there was no need for appointments to be scheduled for visitation. This had the ability to affect all residents who may receive visitors. Resident identifiers: #9, #2, #15, #24, #19, #14, #21. Facility census: 57.
Findings included:
a) Visitation
On 01/04/22 at 2:34 PM, during the Resident Council meeting Residents as a group stated, was not informed when the facility opened to the public and visitors in November. We never knew when they can come, they never tell us anything.
An interview with the Administrator on 01/05/22 at 10:41 AM, stated we inform the families by email about visitation. The residents just hear it from us.
Resident Council meeting notes dated 11/18/21, showed no communication about updated visitation guidelines.
On 11/12/21 the Centers for Medicare and Medicaid Services (CMS) offered new visitation guidance for visitation in nursing homes directing that visitation should be allowed for all residents at all times. (Memorandum QSO-20-14-NH)
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CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0565
(Tag F0565)
Could have caused harm · This affected multiple residents
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Based on observation, interview and record review, the facility failed to consider the voiced concerns of residents in resident council as grievances. The facility failed to act promptly to investig...
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Based on observation, interview and record review, the facility failed to consider the voiced concerns of residents in resident council as grievances. The facility failed to act promptly to investigate resident grievances concerning issues of resident care. This had the potential to affect an unlimited amount of residents living in the facility. Resident Identifiers: # 9, #2, #15, #24, #19, #14, #21, #28, and #51. Facility census: 57.
Findings included:
a) Grievances
During Initial Tour of facility on 01/03/22, observed that the Grievance forms and book were on the outside of social services door not at wheelchair level for resident accessibility.
Many observations made during the Long-Term Care Survey Process, the Resident Rights and contact information for the State Ombudsman and State Survey Agency contact information not were not posted for the accessibility for the residents.
Resident Council Meeting held on 01/08/21 and 01/10/21, the following concerns were voiced:
-Food is cold, hot plates have not been used recently.
-Would like to have food choices back.
-Knives are missing in the morning with breakfast trays. Please provide knives in order to butter toast.
-Call lights are taking a long time to answer between 30 minutes to an hour.
Resident Council Meeting held on 08/26/21 the following concerns were voiced:
-Would like to have box in room for trash bags
-Nursing Staff talking on their phones.
Resident Council Meeting held on 09/23/21, the following concerns were voiced:
-Menus changing without notice
- Clothes taking a while to get come back from laundry
-Call lights taking a long time to answer, some sides/nurses will answer the light turn it off and will not meet the needs
-Ombudsman noticed call light on the floor, not within reach and staff are on their phones in residents room
Resident Council Meeting held on 10/28/21, the following concerns were voiced:
-Would like a menu change(a new one in December). Need to order silverware, plastic ware is to hard to eat with.
Resident Council Meeting held on 11/18/21, the following concerns were voiced:
-Need more staff
During the Resident Council meeting on 01/04/22 at 2:34 PM, the residents as a group were asked: Do you know how to file a grievance? Only one person knew how to file a grievance; the other residents as a group stated, no.
Another question asked during the Resident Council Meeting held on 01/04/22 at 2:34 PM, Does the facility consider the views of the resident group and act promptly upon grievances and recommendations? The residents as a group stated, No nothing ever changes. They don't listen to us. It's like a prison here, will you bail us out?
During Resident Council meeting held on 01/04/22 at 2:34 PM, Resident #15 stated, a Certified Nurses Assistant (CNA) grabbed my arm and bruised it, they have pictures and never had anything done to her, she still works and comes in my room.
During the Resident Council meeting held on 01/04/22 at 2:34 PM, the question was asked: Does the grievance official respond to the resident concerns? Residents as a group stated, Activities and the administrator are supposed to take care of it , but they don't. We tell them things all the time and nothing ever gets done.
An interview on 01/03/22 at 8:08 AM, with Resident #28 stated, The CNA's take awhile to answer the call light, sometimes 3 hours, I sit for a long time on a bed pan.
An interview on 01/03/22 at 8:19 AM, Resident # 51 stated, it depends on staff shortage, sometimes it takes them 1-2 hours to answer the call light.
On 01/03/22 at 8:56 AM, an interview with Resident #24 stated, sometimes it takes them three (3) hours to answer a call light, I have been laying in my own poop, I have told the nurses before but nothing gets done. I have to lay for a long period of time in the same position and I have bed sores. Some aide helps, the Nurses Aides that was on this morning, she doesn't ask me want I want She just comes in turns off the light and leaves. She doesn't ever listen to me. She is awful,I told (name of the recreation director) her a month ago about that aide and (name of activities assistant). I don't like him and I don't do activities if he's involved.
On 01/04/22 at 12:50 PM, an interview with Resident #24 stated that, I turned my call light on at 10:00 AM needing changed, 10:10 AM the Doctor came in with someone else. At 10:15 a guy in a suit came in asked me what I needed, I said aide to change me and I asked who he was and stated I'm from (facility company name). 10:25 AM an aide came in and asked what I needed and left, 10:45 AM another aide came in and asked what I needed and left. At 11:05 my aide came in and changed me. I always turn my light back on when someone leaves, I know how they are, they turn it off and never return. I talk to the nurses all the time about the call lights and they tell me my call light wasn't on. And I know they turn it off. This surveyor asked her to turn her light on, went to the hallway the light above the door and the room light at the nurses station was operating Resident #24 stated, I know it works, they just don't answer it.
An interview on 01/05/22 at 9:30 AM, Resident #51 stated, the building has a massive problem in staffing. Resident #51 also stated that, sometimes you have to wait a long time when you push your call light for assistance. Resident #51 stated that not too long ago she had to wait almost four (4) hours to go to the bathroom because there was only one (1) aid and she needs assistance to go to the bathroom so she does not fall.
When asking the administrator for the grievance log on 01/04/22 at 10:15 AM, the administrator stated the grievance book is lost and I can't find it.
During interview on 01/05/22 at 12:30 PM, the Recreation Director #47 stated Resident #24 spoke to me about the (Activity Assistant's name). (The Administrator's name) and I spoke to him in his office. I did a grievance and (the Administrator's name) wrote on it. At this time no further information was provided.
During interview on 01/05/22 at 12:30 PM, the Recreation Director #47 stated the therapy department has helped with a few grievances.
During an interview on 01/05/22 at 12:33, the (Physical Therapy Assistant) PTA #116 stated we have filed a few grievances, I will bring you a copy of them. I don't know what happens after I give them to (the Administrator's name).
On 01/04/22 at 4:04 PM an interview with Resident #50's Medical Power of Attorney (MPOA) stated the call lights were not being answered for a couple hours, my mother calls me and then I called the facility to get her the help she needs. And when I call no one answers the phone and when they do answer they tell me they are short staffed,and apologize to me and tell me they will take care of it. My mother never complains but when she calls me that's when I know it's bad. My mother has never had an Urinary Tract Infection (UTI) till she came here and now she has all kinds. Mother had been having symptoms of a UTI and I wanted her sent out and finally on Christmas they sent her out and now she is on IV antibiotics. I called all the time and no one answered the phone they needed to carry a phone with them. I have spoken to the Director of Nursing and the Administrator but nothing ever gets done. I am so glad you guys are here. Hopefully you can get something done.
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CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0574
(Tag F0574)
Could have caused harm · This affected multiple residents
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Based on observation and interview, the facility failed to make accessible the ombudsman and the State Survey Agency contact information for Residents. This had the potential to affect more than a l...
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Based on observation and interview, the facility failed to make accessible the ombudsman and the State Survey Agency contact information for Residents. This had the potential to affect more than a limited number of residents. Resident identifiers: #9, #2, #15, #24, #19, #41, and #21. Facility census: 57.
Findings included:
a) Notifications
During Initial Tour of facility on 01/03/22, observed that the Grievance forms and book were on the outside of social services door not at wheelchair level for resident accessibility.
Many observations made during the Long-Term Care Survey Process, the Resident Rights and contact information for the State Ombudsman and State Survey Agency contact information not were not posted for the accessibility for the residents.
On 01/04/22 at 2:34 PM, during the Resident Council meeting the Residents as a group stated we don't know how to let the state know about our care we did not know we could let anyone know.
On 01/05/22 at 10:41 PM, the Administrator acknowledged there was no contact information for the Ombudsman or the State Survey Agency posted in the facility.
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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 four (4) of 24 residents reviewed during the long-te...
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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 four (4) of 24 residents reviewed during the long-term care survey process had advance directives and Physician Orders for Scope of Treatment (POST) forms completed correctly per state law. Resident identifiers: #53, #30, #24, #51. Facility census: 57.
a) Resident #53
On 01/03/22 at 9:45 AM, a record review was completed with the following results noted:
-Resident #53 was admitted to the facility on [DATE] with capacity to make medical decisions.
-A Physician Orders for Scope of Treatment (POST) form was completed on 12/2/21 signifying Resident #53 desired to be a Full Code; and to receive Full Treatment.
-There was no evidence Resident #53 had ever been offered the opportunity to appoint a Medical Power of Attorney (MPOA).
-A Physician Determination of Capacity, dated 12/05/21, reflected Resident #53 had lost capacity to make her own medical decisions.
-There was no legal decision maker identified in Resident #53's record.
On 01/04/22 at 11:20 AM, RN #34 confirmed Resident #53 lost decision-making capacity on 12/05/21. RN #34 also confirmed there was no MPOA on chart nor a Health Care Surrogate (HCS) on the chart. RN #34 verbalized there was no evidence a legal decision maker was identified for staff to report any change in condition or new orders to.
On 01/04/22 at 11:23 AM, the Assistant Director of Nursing (ADON) confirmed there was no Medical Power of Attorney (MPOA) or Health Care Surrogate (HCS) scanned into the electronic medical record. The ADON suggested Surveyor check with the Activities Director who had been filling in as needed during the absence of any social worker in the building.
On 01/04/22 at 11:27 AM, the Activities Director reported to her knowledge there is no advance directive / legal decision maker in existence for Resident #53. The Activities Director went on to say that Resident #53's son stated in a care plan meeting in early November 2021 that he was unsure if his mother ever completed MPOA paperwork. He was going to look through her belongings and get back to the Activities Director. The Activities Director stated she never heard back from the son. A record review demonstrated no evidence Resident #53 was ever offered the opportunity to appoint a MPOA while at the facility. The Activities Director stated she has attempted to reach Adult Protective Services by phone since resident's son is frequently unavailable, but has not received a call back. There was no documentation in resident's medical record that such a telephone call was made.
During an interview on 01/05/22 at 9:59 AM, the Administrator acknowledged Resident #53 did not have a legal medical decision maker in place, that the facility did have a policy stating if the resident was determined to be incapable of making health care decisions for medical treatment that a substitute decision maker would be identified in accordance with state law, and stated the facility would speak to the attending physician to begin the process of appointing a Health Care Surrogate (HCS).
b) Resident #30
On 01/03/22 at 12:20 PM, a record review was completed with the following results noted:
-Patient information on Resident #30's POST form was not filled out properly. Patient Information did not include resident's social security number or gender status.
-Section E on Resident #30's POST Form was not filled out properly. Patient or Patient Representative/Surrogate/Guardian was not completed.
-Section F Signature Healthcare Provider on Resident #30's POST Form was not filled out properly. It did not include the physician's printed name or phone number.
-The patient's full name was not on page 2 and lacked information on which staff completed the POST form.
During an interview on 01/04/22 at 4:30 PM, the Director of Nursing stated the POST form should have everything filled out and The doctor should be printing his name and adding his phone number if he doesn't do it, we should do it. They need a lot of work, lots of blank spaces. I will be looking into all of them.
c) Resident #24
On 01/03/22 at 12:33 PM, a record review was completed with the following results noted:
-Patient information on Resident #24's POST form was not filled out properly. Patient Information did not include resident's social security number or gender status.
-Section E on Resident #24's POST Form was not filled out properly. Patient or Patient Representative/Surrogate/Guardian was not completed.
-Section F Signature Healthcare Provider on Resident #24's POST Form was not filled out properly. It did not include the physician's printed name or phone number.
During an interview on 01/04/22 at 4:30 PM, the Director of Nursing stated the POST form should have everything filled out and The doctor should be printing his name and adding his phone number if he doesn't do it, we should do it. They need a lot of work, lots of blank spaces. I will be looking into all of them.
d) Resident #51
On 01/03/22 at 12:30 PM, a record review was completed with the following results noted:
-Patient information on Resident #51's POST form was not filled out properly. Patient Information did not include resident's social security number.
-Section F Signature Healthcare Provider on Resident #24's POST Form was not filled out properly. It did not include the physician's printed name or phone number.
During an interview on 01/04/22 at 4:30 PM, the Director of Nursing stated the POST form should have everything filled out and The doctor should be printing his name and adding his phone number if he doesn't do it, we should do it. They need a lot of work, lots of blank spaces. I will be looking into all of them.
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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** .
Based on observation and staff interview, the facility failed to provide a safe, clean, comfortable, and homelike environment,...
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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, comfortable, and homelike environment, homelike environment. Walls were not in good repair for three (3) of 35 resident rooms. The facility also failed to identify and resolve missing personal property in a timely fashion for one (1) of the 24 sampled residents during the long-term care survey process. The resident had gone without corrective glasses for approximately one (1) month prior to Surveyor intervention. Room Identifiers: B32-B, B34-A, B35-B. Resident Identifier: #53. Facility census: 57.
Findings included:
a) Room B32-B
Upon entering Room B32-B, on 01/03/22 at 7:45 AM, an immediate observation found two (2) patches of plaster behind Resident #29's bed. On the wall to the right of Resident #29's bed were two (2) additional patches of plaster.
Resident #29 remarked the patches had been there since his admission and no one had ever communicated to him a plan to paint the walls. Resident #29 remarked that he was most upset by the approximately five (5) brown spots on ceiling ranging from dime-sized to quarter-sized noting when he is lying in bed he would stare at the brown spots and [NAME] what caused them. Resident #29 stated the spots have the appearance of body fluids/waste from a bed pan liner being changed. Resident #29 described visually seeing aides go to the foot of his roommate's bed and stand at the end of the privacy curtain and shake the bedpan when taking the filled bed pan liner out and placing a new one in. Resident #29 described hearing a popping sound at such times.
b) Room B34-A
Upon entering Room B34-A, on 01/03/22 8:20 AM, an immediate observation found two (2) patches of plaster on the wall which were directly under the wall-mounted television in the room. Room B34-A was an admission observation unit bed which denoted Resident #211 was being quarantined. As a result, watching television was one of the only things Resident #211 enjoyed doing for recreation. This meant staring at the patched wall any time Resident #211 was watching television. Resident #211 reported recently being admitted to the facility and the two (2) white patches being on the wall when he was admitted .
c) Room B35-B
Upon entering room B35-B, on 01/03/22 10:00 AM, an immediate observation found 11 patches of plaster on the wall under the wall-mounted television; three (3) patches of plaster to the left of the over bed light; 4 patches of plaster to the right of the over the bed light. Room B35-B was also an admission observation unit bed which denoted Resident #212 was being quarantined and also had the television as one of the only sources of recreation available to her.
d) Interview with Director of Maintenance
During an interview, on 01/04/22 at 9:50 AM, the Director of Maintenance acknowledged the walls in the three (3) identified rooms should be painted to provide a more home-like environment for the residents. The Director of Maintenance reported he was the only employee in the maintenance department. Prior to his hire, the Director of Maintenance reported the facility had gone approximately four (4) months without a maintenance employee. Reportedly, during that time, the facility had maintenance staff from sister facilities visit on an as needed basis. The Director of Maintenance stated he would add the identified rooms to his to-do list and apologized that his schedule had not afforded an opportunity to address concerns like painting resident rooms up until now.
e) Resident #53 Missing Glasses
On 01/03/22 at 12:26 PM, Resident #53 reported to Surveyor that she had glasses missing. Resident #53 described the glasses as having titanium frames and blended lenses. Resident #53 went on to say, I can't see to read or watch television without them and they have been missing for a while. Staff has attempted to locate them but have been unsuccessful.
On 01/05/22 at 8:30 AM, the Administrator communicated that there were no missing personal property reports filed.
On 01/05/22 at 8:40 AM, Central Supply Clerk #45 confirmed she was aware of the fact Resident #53 was missing glasses. Central Supply Clerk #45 reported staff had looked for them and found two (2) pair of glasses not associated with any other resident. She went on to report that when shown the glasses, Resident #53 stated neither of the two (2) pair of glasses belonged to her. Central Supply Clerk #45 reported resident had been out to the hospital recently and commented perhaps the glasses never returned with her from the hospital.
On 01/05/22 at 9:17 AM, an electronic record review demonstrated:
-Resident #53 sent out to the hospital 11/26/21 and returned to the facility on [DATE].
-A recreation evaluation, dated on 01/04/22 at 5:40 PM, noted Resident #53 pursued independent leisure opportunities with the preferred independent interests being socializing, watching TV, reading, playing games at a frequency of daily. It was also noted that Resident #53 had the following needs for special adaptation in order to participate in desired engagement opportunities: glasses for vision loss.
The Administrator reported, during an interview on 01/05/22 at 9:35 AM, there were several ways staff could address missing personal property for administration to know something is missing. The administrator noted staff could complete the formal grievance form or simply provide a handwritten statement to Administration. The Administrator reported staff failed to report the missing glasses which did not afford any sort of follow-up once a search could not locate the glasses. The Administrator assured Surveyor he was in the process of reinstituting the correct procedures to be followed in order to prevent such an issue in the future. The Administrator also stated that in the years' time he had been at the facility, I've been cleaning up a battle zone. When asked to produce a copy of the facility policy regarding lost items, the Administrator stated, I will have to look for it. The policy was not produced prior to Surveyor exit from the building on 01/11/22 at 1:45 PM.
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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, resident interview, staff interview and family interview, the facility failed to consider the voiced concerns of residents in resident council as grievances. The facility did n...
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Based on observation, resident interview, staff interview and family interview, the facility failed to consider the voiced concerns of residents in resident council as grievances. The facility did not make accessible grievances forms and failed to act promptly to investigate resident grievances concerning issues of resident care. This had the potential to an unlimited amount of residents living in the facility. Resident Identifiers: #9, #2, #15, #24, #19, #14, #21, #28 and #51. Facility census: 57.
Finding Included:
a) Grievances
During Initial Tour of facility on 01/03/22, observed that the Grievance forms and book were on the outside of social services door not at wheelchair level for resident accessibility.
Many observations made during the Long-Term Care Survey Process, the Resident Rights and contact information for the State Ombudsman and State Survey Agency contact information not were not posted for the accessibility for the residents.
Resident Council Meeting held on 01/08/21 and 01/10/21, the following concerns were voiced:
-Food is cold, hot plates have not been used recently.
-Would like to have food choices back.
-Knives are missing in the morning with breakfast trays. Please provide knives in order to butter toast.
-Call lights are taking a long time to answer between 30 minutes to an hour.
Resident Council Meeting held on 08/26/21 the following concerns were voiced:
-Would like to have box in room for trash bags
-Nursing Staff talking on their phones.
Resident Council Meeting held on 09/23/21, the following concerns were voiced:
-Menus changing without notice
- Clothes taking a while to get come back from laundry
-Call lights taking a long time to answer, some sides/nurses will answer the light turn it off and will not meet the needs
-Ombudsman noticed call light on the floor, not within reach and staff are on their phones in residents room
Resident Council Meeting held on 10/28/21, the following concerns were voiced:
-Would like a menu change(a new one in December). Need to order silverware, plastic ware is to hard to eat with.
Resident Council Meeting held on 11/18/21, the following concerns were voiced:
-Need more staff
During the Resident Council meeting on 01/04/22 at 2:34 PM, the residents as a group were asked: Do you know how to file a grievance? Only one person knew how to file a grievance; the other residents as a group stated, no.
Another question asked during the Resident Council Meeting held on 01/04/22 at 2:34 PM, Does the facility consider the views of the resident group and act promptly upon grievances and recommendations? The residents as a group stated, No nothing ever changes. They don't listen to us. It's like a prison here, will you bail us out?
During Resident Council meeting held on 01/04/22 at 2:34 PM, Resident #15 stated, a Certified Nurses Assistant (CNA) grabbed my arm and bruised it, they have pictures and never had anything done to her, she still works and comes in my room.
During the Resident Council meeting held on 01/04/22 at 2:34 PM, the question was asked: Does the grievance official respond to the resident concerns? Residents as a group stated, Activities and the administrator are supposed to take care of it, but they don't. We tell them things all the time and nothing ever gets done.
An interview on 01/03/22 at 8:08 AM, with Resident #28 stated, The CNA's take awhile to answer the call light, sometimes 3 hours, I sit for a long time on a bed pan.
An interview on 01/03/22 at 8:19 AM, Resident # 51 stated, it depends on staff shortage, sometimes it takes them 1-2 hours to answer the call light.
On 01/03/22 at 8:56 AM, an interview with Resident #24 stated, sometimes it takes them three (3) hours to answer a call light, I have been laying in my own poop, I have told the nurses before but nothing gets done. I have to lay for a long period of time in the same position and I have bed sores. Some aide helps, the Nurses Aides that was on this morning, she doesn't ask me want I want She just comes in turns off the light and leaves. She doesn't ever listen to me. She is awful,I told (name of the recreation director) her a month ago about that aide and (name of activities assistant). I don't like him and I don't do activities if he's involved.
On 01/04/22 at 12:50 PM, an interview with Resident #24 stated that, I turned my call light on at 10:00 AM needing changed, 10:10 AM the Doctor came in with someone else. At 10:15 a guy in a suit came in asked me what I needed, I said aide to change me and I asked who he was and stated I'm from (facility company name). 10:25 AM an aide came in and asked what I needed and left, 10:45 AM another aide came in and asked what I needed and left. At 11:05 my aide came in and changed me. I always turn my light back on when someone leaves, I know how they are, they turn it off and never return. I talk to the nurses all the time about the call lights and they tell me my call light wasn't on. And I know they turn it off. This surveyor asked her to turn her light on, went to the hallway the light above the door and the room light at the nurses station was operating Resident #24 stated, I know it works, they just don't answer it.
An interview on 01/05/22 at 9:30 AM, Resident #51 stated, the building has a massive problem in staffing. Resident #51 also stated that, sometimes you have to wait a long time when you push your call light for assistance. Resident #51 stated that not too long ago she had to wait almost four (4) hours to go to the bathroom because there was only one (1) aid and she needs assistance to go to the bathroom so she does not fall.
When asking the administrator for the grievance log on 01/04/22 at 10:15 AM, the administrator stated the grievance book is lost and I can't find it.
During interview on 01/05/22 at 12:30 PM, the Recreation Director #47 stated Resident #24 spoke to me about the (Activity Assistant's name). (The Administrator's name) and I spoke to him in his office. I did a grievance and (the Administrator's name) wrote on it. At this time no further information was provided.
During interview on 01/05/22 at 12:30 PM, the Recreation Director #47 stated the therapy department has helped with a few grievances.
During an interview on 01/05/22 at 12:33, the (Physical Therapy Assistant) PTA #116 stated we have filed a few grievances, I will bring you a copy of them. I don't know what happens after I give them to (the Administrator's name).
On 01/04/22 at 4:04 PM an interview with Resident #50's Medical Power of Attorney (MPOA) stated the call lights were not being answered for a couple hours, my mother calls me and then I called the facility to get her the help she needs. And when I call no one answers the phone and when they do answer they tell me they are short staffed,and apologize to me and tell me they will take care of it. My mother never complains but when she calls me that's when I know it's bad. My mother has never had an Urinary Tract Infection (UTI) till she came here and now she has all kinds. Mother had been having symptoms of a UTI and I wanted her sent out and finally on Christmas they sent her out and now she is on IV antibiotics. I called all the time and no one answered the phone they needed to carry a phone with them. I have spoken to the Director of Nursing and the Administrator but nothing ever gets done. I am so glad you guys are here. Hopefully you can get something done.
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CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected multiple residents
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b) Resident #42
On 1/3/22 at 10:00 AM, when doing observations seen resident #42 with a laceration on top of head. When asking resident #42 what happen to cause the laceration resident #42 stated, I...
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b) Resident #42
On 1/3/22 at 10:00 AM, when doing observations seen resident #42 with a laceration on top of head. When asking resident #42 what happen to cause the laceration resident #42 stated, I fell out of my chair and landed head first and had to go to the hospital to have stitches, this happened two weeks ago from today.
Nursing note from unwittenessed fall on 12/21/2021 3:35 AM, CIC Situation: The Change In Condition/s reported on this CIC Evaluation are/were: Bleeding (other than GI) Falls
Nursing observations, evaluation, and recommendations are:Resident called out for help when CNA found resident on the floor. CNA just in room when completed rounds. Resident was found laying on right side (lying on right arm), head laying on base of bed tray table. Blood on table base and floor. 911 notified and transported resident to BMC for emergency care. While waiting for EMS to arrive, VS and neuro checks were initiated. Pressure applied to right side of head to slow bleeding. Resident reports no other injuries, (just head)
On 1/5/22 at 11:50 AM, when looking at reportable's did not see a reportable completed for resident #42 related to fall with laceration and treatment outside of the facility.
On 1/5/22 at 12:15 PM, interview with the Administrator asking if a reportable was completed for resident #42 concerning the fall that occurred 12/21/2021. Administrator stated, oh yes, on that one we decided that we did not need to do a reportable since we knew how it happened.
Based on record review, resident council minutes, policy review, and staff interview, the facility failed to ensure that all alleged violations involving neglect were reported, not later than 24 hours of the event that caused the allegation, to appropriate state agencies as required. The facility also failed to ensure a resident fall resulting in a serious bodily injury was reported. This failed practice had the potential to affect more than a limited number of residents. These were random opportunities for discovery and a deficient practice identified during the long-term care survey process. Resident identifier: #42. Facility census: 57.
a) Resident Complaints of Neglect During Resident Council Meetings
A review of the Resident Council minutes from January 2021 through November 2021 found the following resident complaints:
-During a resident council meeting on 01/10/21, it was noted, Call lights are taking a long time to answer between 30 minutes and an hour.
-During a resident council meeting on 09/23/21, it was noted, Call lights are taken a long time to answer. Some aides/nurses will answer the light, turn it off, and not meet needs.
-During a resident council meeting on 11/18/21, it was noted the residents felt the facility need more staff to meet their needs.
Review of the facility's Grievance/Concern policy, with a revision date of 02/13/17, identified a resident's right to file grievances orally (meaning spoken) or in writing. The policy further stated upon receipt of a grievance/concern, the Grievance/Concern Form would be initiated by the staff member receiving the concern and documented on the Grievance/Concern Log.
During an interview on 01/10/22 at 10:30 AM, the Director of Nursing (DON) agreed that the concerns mentioned in resident council should have been considered spoken grievances/concerns and that staff should have completed a review of the grievance in a timely manner. Additionally, the DON answered that the spoken grievances/concerns should have been considered allegations of neglect and should have been reported according to state guidelines.
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CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Investigate Abuse
(Tag F0610)
Could have caused harm · This affected multiple residents
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Based on record review and staff interview, the facility failed to complete thorough investigations of multiple resident allegations of neglect, maintain documentation that alleged violations were t...
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Based on record review and staff interview, the facility failed to complete thorough investigations of multiple resident allegations of neglect, maintain documentation that alleged violations were thoroughly investigated, and report the results to Adult Protective Services and the State Survey Agency, within five (5) working days of the incidents in accordance with State law.
Findings included:
a) Review of 12/13/21 Reportable Alleging Call Light Not Being Answered in a Timely Manner
Review of a 12/13/21 reportable, which alleged Resident #47 reported her call light was not answered in a timely manner, demonstrated that an immediate fax reporting of the allegation was sent on 12/14/21 to the long-term care Ombudsman and to the Office of Health Facilities and Licensure (OHFLAC) office. There was no evidence the facility reported the results of a thorough investigation into the allegation to Adult Protective Services and OHFLAC, within five (5) working days of the incident in accordance with State law.
During an interview, on 01/05/22 at 11:50 AM, the Administrator reported the facility had no evidence it could produce to demonstrate an investigation had been completed or that a five (5) day follow-up report had been shared with APS or the State Survey Agency.
b) Resident Complaints of Neglect During Resident Council Meetings
A review of the Resident Council minutes from January 2021 through November 2021 found the following resident complaints:
-During a resident council meeting on 01/10/21, it was noted, Call lights are taking a long time to answer between 30 minutes and an hour.
-During a resident council meeting on 09/23/21, it was noted, Call lights are taken a long time to answer. Some aides/nurses will answer the light, turn it off, and not meet needs.
-During a resident council meeting on 11/18/21, it was noted the residents felt the facility need more staff to meet their needs.
The DON was unable to provide evidence that the staffing concerns noted in the January, September, and November 2021 resident council meetings had been addressed in a meaningful way.
The January 2021 Nursing Departmental Response Form noted, Call light audit performed. Response time was within 2 minutes. However, the DON was unable to produce the alleged call light audit form from January 2021 for Surveyor to review.
The September 2021 Nursing Departmental Response Form noted, Call light monitoring tool and Education provided to staff. However, the DON was unable to produce the alleged call light monitoring tool or any evidence of staff education in the month of September 2021.
There was no Nursing Departmental Response Form completed following the November 2021 resident council meeting.
Review of the facility's Grievance/Concern policy, with a revision date of 02/13/17, identified a resident's right to file grievances orally (meaning spoken) or in writing. The policy further stated upon receipt of a grievance/concern, the Grievance/Concern Form would be initiated by the staff member receiving the concern and documented on the Grievance/Concern Log.
During an interview on 01/10/22 at 10:30 AM, the Director of Nursing (DON) agreed that the concerns mentioned in resident council should have been considered spoken grievances/concerns and that staff should have completed a review of the grievance in a timely manner. Additionally, the DON answered that the spoken grievances/concerns should have been considered allegations of neglect and should have been reported and thoroughly investigated according to state guidelines.
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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** Based on medical record review and staff interview, the facility failed to provide evidence a resident/resident's representative...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to provide evidence a resident/resident's representative was provided a written Notice of Transfer for an acute hospital transfer. The facility also failed to provide evidence that a copy of the Notice of Transfer was sent to the Ombudsman. This was true for three (3) out three (3) hospital transfers reviewed during the long-term care process. This had the potential to affect all residents being transferred or discharged . Resident identifiers: #39, and #53. Facility census: 57.
Findings included:
a) Resident #39's Hospital Transfer on 11/06/21
A medical record review was completed on 01/05/22 at 9:00 AM. The record review revealed Resident #39 was transferred to the hospital on [DATE]. The record did not reflect the resident/resident's representative was provided a Notice of Transfer, nor did the record reflect the Notice of Transfer was sent to the Ombudsman.
During an interview with the Director of Nursing (DON) on 01/05/22 at 1:40 PM, the DON reported the Notice of Transfer was not provided to resident upon transfer. Additionally, the DON reported the Ombudsman was not provided a copy of the Notice of Transfer.
b) Resident #39's Hospital Transfer on 12/27/21
A medical record review was completed on 01/05/22 at 9:00 AM. The record review revealed Resident #39 was transferred to the hospital on [DATE]. The record did not reflect the resident/resident's representative was provided a Notice of Transfer, nor did the record reflect the Notice of Transfer was sent to the Ombudsman.
During an interview with the Director of Nursing (DON) on 01/05/22 at 1:40 PM, the DON reported the Notice of Transfer was not provided to resident upon transfer. Additionally, the DON reported the Ombudsman was not provided a copy of the Notice of Transfer.
c) Resident #53's Hospital Transfer on 11/26/21
A medical record review was completed on 01/05/22 at 9:17 AM. The record review revealed Resident #53 was transferred to the hospital on [DATE]. The record did not reflect the resident/resident's representative was provided a Notice of Transfer, nor did the record reflect the Notice of Transfer was sent to the Ombudsman.
During an interview with the Director of Nursing (DON) on 01/05/22 at 1:55 PM, the DON reported the Notice of Transfer was not provided to resident upon transfer. Additionally, the DON reported the Ombudsman was not provided a copy of the Notice of Transfer.
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CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0625
(Tag F0625)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on medical record review and staff interview, the facility failed to provide evidence a Bed Hold Notice was given to res...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on medical record review and staff interview, the facility failed to provide evidence a Bed Hold Notice was given to residents/resident representatives when transferred to the hospital. This was true for three (3) out three (3) hospital transfers reviewed during the long-term care process. This had the potential to affect all residents being transferred or discharged . Resident identifiers: #39, #53. Facility census: 57.
Findings included:
a) Resident #39's Hospital Transfer on 11/06/21
A medical record review was completed on 01/05/22 at 9:00 AM. The record revealed Resident #39 was transferred to the hospital on [DATE]. The record did not reflect the resident/resident's representative was provided a Bed Hold Notice.
During an interview with the Director of Nursing (DON), on 01/05/22 at 1:40 PM, the DON reported the Bed Hold Notice was not provided to resident upon transfer.
b) Resident #39's Hospital Transfer on 12/27/21
A medical record review was completed on 01/05/22 at 9:00 AM. The record revealed Resident #39 was transferred to the hospital on [DATE]. The record did not reflect the resident/resident's representative was provided a Bed Hold Notice.
During an interview with the Director of Nursing (DON), on 01/05/22 at 1:40 PM, the DON reported the Bed Hold Notice was not provided to resident upon transfer.
c) Resident #53's Hospital Transfer on 11/26/21
A medical record review was completed on 01/05/22 at 9:17 AM. The record revealed Resident #53 was transferred to the hospital on [DATE]. The record did not reflect the resident/resident's representative was provided a Bed Hold Notice.
During an interview with the Director of Nursing (DON), on 01/05/22 at 1:55 PM, the DON reported the Bed Hold Notice was not provided to resident upon transfer.
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CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0679
(Tag F0679)
Could have caused harm · This affected multiple residents
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Based on observation, record review, staff interview and resident interview, the facility failed to implement an ongoing resident centered activities program designed to meet the interest of and sup...
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Based on observation, record review, staff interview and resident interview, the facility failed to implement an ongoing resident centered activities program designed to meet the interest of and support the physical, mental and psychosocial well-being of each resident. This practice was found true for eight (8) of 24 Residents. The failed practice had the potential to affect an unlimited number of residents. Resident Identifiers: #9, #2, #15, #24, #19, #41, #21, #51 Facility Census: 57
Findings Included:
a) Group Activities
On 01/03/22, no group activities took place during the Long-Term Care Survey Process.
A review of the monthly activity calendars showed no group activities for the following months:
January 2021
February 2021
March 2021
April 2021
December 19, 2021 to January 4, 2022
During an interview on 01/05/22 at 10:32 AM, with the Recreation Director (RD) #47 stated, 01/21 was 1:1 room visits only, 02/21, 03/21, 04/21 we had room and doorway activities. On 05/09/21, we started group activities back, we stopped group activities again on 12/19/21 till yesterday 01/04/22 due to an outbreak.
The RD #47 on 01/05/22 at 10:32 AM stated, I just follow the direction of (Administrator's name), he tells me when I can have group two (2)-three (3) employees we can't have activities.
On 01/05/22 at 10:41 AM, an interview with the Administrator stated, We were in outbreak till yesterday, we had 4 employees tested positive but they were on vacation but the county puts us in outbreaks. We have had an outbreak two (2) times since I have been here. I started around 01/25/21
On 01/05/22 at 10:41 AM, this surveyor asked why the residents have not been having group activities or having meals in the dining room. The Administrator stated, They should have been doing group activities, that (Recreation Director's name) should have been doing them. We can't get them back down here to eat, they don't want to come out of their room. This has not been an easy adventure.
During the Interview on 01/05/22 at 12:30 PM, with RD #47 stated, We have zoom meetings daily and that's when (the Administrator's name) tells us when we can have activities and if there is an outbreak or short staff. When there are only two (2)-three (3) staff we can not have group activities. I have plenty of staff it's the staff on the floor.
An interview on 01/05/22 at 12:33 PM Physical Therapy Assistant #116, stated, we started back to group therapy in the gym around the end of March. We have to follow the guidelines doing outbreaks, we are contracted. During the stand up morning meeting they let us know when we are in outbreaks. We follow the contract guidelines, not the facility unless the Administrator makes us. We know the residents love the activities, it is a pleasure to socialize with others. They beg to come to therapy because of socialization. Staffing is a huge issue, we can help them get ready for therapy, we can get the residents ready that are total care we can't use the hoyer lift. They love the social aspect of the activities and dining together.
An interview with Recreation Assistant # 24, stated, today's activity, Cranium Crunches at 10:30 AM, and Table Talk at 11:15 AM the activities should be in the Main dining room, if the Certified Nurses Aide (CNA) are not short and they know. I will have to find out if they short staff today.
On 01/04/22 at 2:34 PM, during the Resident Council meeting, the Resident as a group stated, there are not enough activities. We never have any group activities, we like Bingo and we never play it anymore. I come down here and look out the window and watch the traffic go by. I watch TV a lot, there is nothing to do.
An interview on 01/03/22 at 8:19 AM, Resident # 51 stated, there are no activities I read and color in my room, my family and friends bring me things to do.
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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** .
d) Resident #41
On 1/10/22 at 8:49 AM, during observation on A Hall observed resident #41 in bed with bloody sheets and wraps ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
d) Resident #41
On 1/10/22 at 8:49 AM, during observation on A Hall observed resident #41 in bed with bloody sheets and wraps on both lower legs that were also bloody.
At 8:53 AM, this surveyor asked Infection Perfectionist (IP) #7 to come to Resident #41's room and look at his legs. IP #7 stated they should not be like that and went to get treatment cart.
Assistant Director of Nursing (ADON) #16 came in Resident #41's room at 8:58 AM, and looked at Resident #41's legs and was taking off blood bandages with a date of 01/08/22 and ADON #16 stated treatments are supposed to be done daily.
On 01/10/22 at 11:20 AM, this surveyor requested from ADON #16 to have a copy of Resident #41's treatment sheet (TAR) for January 2022. Orders on TAR was:
--Cleanse right lower leg with NS pat dry applies Xeroform and [NAME] with kerlex qday until resolve every day Active 12/13/21 07:00
--Cleanse left lower leg with NS pat dry apply Xeroform and wrap with Kerlex qday until resolve every day shift - Other Active 12/13/2021 07:00
Observation of days of treatment and on 1/09/22 was shown treatment was completed.
Interview with ADON #16 on 1/10/22 at 11:25 AM, this surveyor showed ADON #16 the TAR that was produced and showed the treatment was completed on 1/09/22 which dressing on residents legs both had 1/08/22. ADON #16 stated, there is a problem with that information on TAR with the date of January 9, 2022.
Based on observation, record review and staff interview the facility failed to provide medication within the parameters as ordered and failed to provide medication when ordered by the physician. The facility failed to show evidence of a neurological evaluation after an unwitnessed fall with head injury. This was true for four (4) of 24 sampled residents. Resident identifiers: 25, 41, 42, 29. Facility census: 57.
Findings included:
a) Resident #25
Review of Resident #25's medical record showed a physician order that stated, Oxycodone HCl Tablet 5 MG *Controlled Drug-Give 5 mg by mouth every 8 hours as needed for severe pain (8-10). The Mediation Administration Record (MAR) was reviewed for December 2021. The following dates showed Oxycodone was provided outside the parameters of the physician order.
12/01/2021 at 12:40 AM- Pain level 7
12/01/2021 at 10:15 AM- Pain level 0
12/02/2021 at 7:50 AM - Pain level 7
12/02/2021 at 4:10 PM- Pain level of 5
12/04/2021 at 4:35 AM - Pain level of 5
12/04/2021 at 2:06 PM- Pain level of 7
12/05/2021 at 12:49 AM - Pain level of 6
12/05/2021 at 11:22 AM- Pain level of 6
12/05/2021 at 7:10 PM- Pain level of 0
12/07/2021 at 8:31 AM- Pain level of 7
12/08/2021 at 4:59 PM-Pain level of 0
12/15/2021 at 10:09 AM- Pain level of 7
12/17/2021 at 2:31 PM - Pain level of 1
12/20/2021 at 7:54 AM- Pain level of 0
12/21/2021 at 6:45 AM- Pain level of 7
12/22/2021 at 12:41 AM- Pain level of 7
12/22/2021 at 9:04 AM- Pain level of 0
12/24/2021 at 5:51 PM- Pain level of 0
12/27/2021 at 2:57 AM- Pain level of 6
12/27/2021 at 1:20 PM- Pain level of 7
12/28/2021 at 10:57 AM- Pain level of 4
12/29/2021 at 5:00 AM- Pain level of 6
12/29/2021 at 4:40 PM- Pain level of 0
12/30/2021 at 10:25 AM- Pain level of 7
An interview with the Director of Nursing (DON), on 01/04/22 at 4:00 PM, confirmed physician order was not followed. DON stated that she would educate immediately.
An additional review of Resident #25's medical record showed the MAR for January 2022. The Mediation Administration Record was reviewed for [DATE]. The following dates showed Oxycodone was provided outside the parameters of the physician order.
01/06/2022 at 6:17 AM- Pain level of 7
01/06/2022 at 2:15 PM- Pain level of 0
01/07/2022 at 9:27 AM- Pain level of 5
01/11/2022 at 8:41 AM- Pain level of 7
b) Resident #42
Review of Resident #42's medical record showed a progress note dated for 12/21/2021 that stated, While waiting for EMS to arrive, Neuro checks were initiated. Pressure applied to right side of head to slow bleeding.
An interview with Assistant Director of Nursing (ADON), on 01/05/22 at 10:30 AM, stated there was no Neurological Evaluation Flow Sheet documentation available for the date of 12/21/21.
A record review of the facility's policy titled, Neurological Evaluation with revised date of 06/01/21 stated, a Neurological evaluation will be performed when a Resident sustained a head injury or an unwitnessed fall.
c) Resident #29
A record review was completed on 01/10/22 at 8:45 AM. The record review found the following physician's order dated 10/20/21, Insulin Lispro Solution 100 UNIT/ML - inject 5 unit subcutaneously [by injection] before meals for Diabetes. Hold if BS [blood sugar] < 150.
A review of the Medication Administration Records (MARS) for October 2021, November 2021, and December 2021 revealed the following dates the medication was administered outside of physician order parameters:
-On 10/29/21, Resident #29's blood sugar was documented as being 112. The MARS reflects that insulin was given subcutaneously in the right arm at 6:33 AM.
-On 11/04/21, Resident #29's blood sugar was documented as being 133. The MARS reflects that insulin was given subcutaneously in the right arm at 6:30 AM.
-On 11/07/21, Resident #29's blood sugar was documented as being 120. The MARS reflects that insulin was given subcutaneously in the left arm at 6:30 AM.
-On 12/09/21, Resident #29's blood sugar was documented as being 92. The MARS reflects that insulin was given subcutaneously in an area of the body marked as other at 11:30 AM.
-On 12/13/21, Resident #29's blood sugar was documented as being 107. The MARS reflects that insulin was given subcutaneously in the abdomen at 11:30 AM.
-On 12/14/21, Resident #29's blood sugar was documented as being 131. The MARS reflects that insulin was given subcutaneously in the abdomen at 11:30 AM.
-On 12/21/21, Resident #29's blood sugar was documented as being 127. The MARS reflects that insulin was given subcutaneously in the abdomen at 6:30 AM.
The Director of Nursing, during an interview on 01/10/21 at 11:35 AM, confirmed there were seven (7) times since Resident 29's admission to the facility on [DATE] that insulin was administered by nursing staff when it should not have been.
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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 staff interview, the facility failed to ensure the environment was free from three (3) accident hazards over which it had control. These were random opportunities for discov...
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Based on observation and staff interview, the facility failed to ensure the environment was free from three (3) accident hazards over which it had control. These were random opportunities for discovery. Resident identifier: 39. Facility census: 57.
a) Shower Room
On 01/03/22 at 5:20 AM, a random opportunity for discovery found the facility's shower room door propped open with a three-ring binder. Upon entering the shower room, Surveyor observed a bottle of Peroxide Multi-Surface Cleaner & Disinfectant unattended on the counter. The guidance on the bottle instructed the disinfectant had a three-minute dwell time, to keep out of reach of children, and to seek immediate first aid if sprayed in the eyes or ingested. Further precautionary statements such as Hazards to humans and domestic animals, Causes eye irritation, and Do not drink were also displayed on the bottle.
RN #42 acknowledged during an interview, on 01/03/22 at 5:30 AM, the shower door was propped open and stated there should never be a time that staff leave a bottle of multi-surface cleaner and disinfectant unattended. RN #42 reported that all staff are trained to know that all chemicals need to be locked up at all times.
b) Central Supply
On 01/03/22 at 5:45 AM, a random opportunity for discovery found the facility's central supply office unlocked. Upon entering the central supply office, Surveyor observed a self-retracting utility knife/box cutter laying on the desk and accessible to anyone who may enter the room.
CNA #18 acknowledged during an interview, on 01/03/22 at 5:55 AM, the central supply door was unlocked and that there was a self-retracting utility knife/box cutter laying on the desk and accessible to anyone who may enter the room. CNA #18 stated the door is usually locked at night and it may have been unlocked because we've been so short staffed. CNA #18 went on to explain it's easier for a CNA to get the supplies needed if they did not have to go in search of the nurse with the key.
c) Resident #39
An observation of the Nurses Station, on 01/03/22 at 6:00 AM, showed Resident #39's prescription of Orajel three (3) times medicated tube laid on the counter top of the nurses station right above the desk area and was assessable to both Residents or Visitors. The medication warning stated, in case of overdose contact poison control center right away.
An interview with Registered Nurse #42, on 01/03/22 at 6:05 AM, revealed Resident #39 had been discharged and the medication should not have been left at the nurses station or on top within reach of visitors or residents but placed in the discard bin.
Review of Resident #39's medical record showed a MDS dated for 12/27/21. The 12/27/21 MDS verified Resident #39 was discharged on 12/27/21. The medication at the nurses station was found seven (7) days after Resident #39's discharge date .
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0809
(Tag F0809)
Could have caused harm · This affected multiple residents
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Based on observation, staff interview and Resident interviews the facility failed to provide Residents with evening snacks. This is true for seven (7) of 24 sampled Residents. Resident identifiers #...
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Based on observation, staff interview and Resident interviews the facility failed to provide Residents with evening snacks. This is true for seven (7) of 24 sampled Residents. Resident identifiers #9, #2, 15, #24, #19, #41 and #21. Facility Census 57.
Findings Included:
a) Snacks - Residents #9, #2, 15, #24, #19, #41 and #21
Observation on 1/3/22 at 5:15 AM, upon entrance observed a tub of snacks by nurses' station from the evening before still sitting in water with snack labels of Residents who were to receive them. Snacks found:
-8 Supplements
-1 Pudding
-1 chocolate milk
-6 Peanut Butter and Jelly Sandwiches
On 01/04/22 at 2:34 PM, during the Resident Council meeting the Residents as a group stated they do not receive snacks at night time. If someone refuses their snacks you will get one. There is no food in the nourishment room or in the refrigerator and the kitchen is closed at night.
Staff interview on 1/4/22 at 3:57 PM, with Dietary [NAME] #115 when asked who stocks the nourishment room pantry refrigerator and Dietary [NAME] #115 stated it depends on who is scheduled. Everyone has done it. When asked if every Resident receives an evening snack, Dietary [NAME] #115 stated, No, only the ones who have snack labels prepared by Kitchen Staff.
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CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected multiple residents
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Based on observation and staff interview the facility failed to label and date foods in the kitchen and
the pantry refrigerators. This had the potential to affect more than a limited number of resid...
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Based on observation and staff interview the facility failed to label and date foods in the kitchen and
the pantry refrigerators. This had the potential to affect more than a limited number of residents who receive nutrients from the kitchen and pantry. Facility Census 57.
Findings included;
a) Kitchen and Pantry Refrigerators
On 1/03/22 at 5:43 AM, intial tour of kitchen with Manger in training (MIT) #111 found in the reach in refrigerator;
-12 cups of applesauce not dated
-14 cups of vanilla pudding not dated
-6 1/2 gallons of apple juice not dated
-6 1/2 gallon of orange juice not dated
-3 gallon container of ice tea with no date
Reach in refrigerator
-1 30 oz jar of mayonaise not dated
-1 8oz jar of garlic seasoning not dated
At 6:10 AM, inital tour of Pantry and Refrigerator with MIT #111 found;
-two (2) bowls of potato soup not dated
-one (1) Wendy's Chili no date or no name
-one (1) Wendy;s chicken sandwich no date or no name
-one (1) Arbys drink no date or name
-one (1) bag of wrapped candy no date or name
-two (2) yogurts with no date or name
Expired items;
-one (1) chinese bowl with no name
-one (1) container of blueberries no name
-one (1) bag of hardboiled eggs no name
-one (1) small vanilla ice cream no name all items in bag with date of 10/06/21
One meal tray sitting out on microwave with date on tray ticket from lunch on 1/01/22 was completely untouched.
MIT #111 stated, all food items not dated, with no names or outdated should have not been in kitchen or pantry refrigerators and should have been removed. Should have not had the opportunity to be served to a resident. MIT #111 removed all items found deficient immediately.
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CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0868
(Tag F0868)
Could have caused harm · This affected multiple residents
Based on facility documentation and staff interview, the facility failed to hold Quality Assessment and Assurance (QAA) Committee Meetings on a quarterly basis as required. This had the potential to a...
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Based on facility documentation and staff interview, the facility failed to hold Quality Assessment and Assurance (QAA) Committee Meetings on a quarterly basis as required. This had the potential to affect more than unlimited number of residents. Facility census: 57.
Findings included:
a) QAA Quarterly Meetings
An interview with Administrator, on 01/05/21 at 2:30 PM, stated, here is the QAA stuff requested, you will find it deficient.
The facility documentation review of the QAA Committee sign in sheets, on 01/05/22 at 2:46 PM, revealed the QAA Committee had one (1) sign in sheet for the entire year of 2021 and was dated for 05/27/21.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0725
(Tag F0725)
Could have caused harm · This affected most or all residents
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Based on interview, record review, observation, the facility failed to ensure sufficient qualified nursing staff were available at all times to provide nursing and related services to meet the resid...
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Based on interview, record review, observation, the facility failed to ensure sufficient qualified nursing staff were available at all times to provide nursing and related services to meet the residents' needs safely and in a manner that promoted resident rights, physical, mental and psychosocial well-being. Facility census: 57.
Findings included:
a) Citations
During the facility's long-term care survey relevant citations included:
-See F550
-See F583
-See F584
-See F585
-See F609
-See F610
-See F622
-See F657
-See F684
-See F689
-See F692
-See F695
-See F727
-See F882
b) Resident Interviews
During an interview on 01/03/22 at 8:19 AM, Resident # 51 stated it depends on staff shortage, sometimes it takes them 1-2 hours to answer the call light.
During an interview on 01/03/22 at 8:56 AM, Resident #24 stated, Sometimes it takes them 3 hours to answer a call light and I have been laying in my own poop. I have told the nurses before but nothing gets done. I have to lay for a long period of time in the same position and I have bed sores. Some aide helps, the Nurses Aides that was on this morning, she doesn't ask me want I want. She just comes in turns off the light and leaves or changes me and leaves. She doesn't listen to me. She is awful, I told [name of the recreation director] her a month ago about the aide. I don't get anything to drink on the night shift. During the day it's better but after that we get nothing. Resident #24 stated her hair had not been washed for four (4) weeks.
During an interview on 01/04/22 at 12:50 PM, Resident #24 stated, I turned my call light on at 10:00 AM needing changed, at 10:10 AM the Doctor came in with someone else. At 10:15 AM a guy in a suit came and asked me what I needed. I said an aide to change me, and I asked who he was. He stated he was from (facility company name). At 10:25 AM an aide came in and asked what I needed and left without assisting me. At 10:45 AM another aide came in and asked what I needed and left without assisting me. At 11:05 AM my aide came in and changed me. She is on light duty and not supposed to do it herself, but she had been waiting for someone to help her finally when she was almost finished another aide came in, but she said she was not going to let me lay in that mess any longer. I always turn my light back on when someone leaves, I know how they are, they turn it off and never return. I talk to the nurses all the time about the call light, and they tell me my call light wasn't on. And I know they turn it off. Surveyor asked her to turn her light on and went to the hallway and the light above the door was operating and also at the nurses' station was working. She stated, I know it works; they just don't answer it.
During an interview on 01/05/21 at 9:30AM, Resident #51 stated the building has a massive problem in staffing. Resident #51 stated that sometimes you have to wait a long time when you push your call light for assistance. Resident #51 stated that not too long ago she had to wait almost 4 hours to go to the bathroom because there was only one (1) aide working and she needs assistance to go to the bathroom so she does not fall.
During a resident council meeting on 01/04/22 at 2:34 PM, all seven (7) residents in attendance reported they do not get the help and care they need without waiting a long time (with waits sometimes lasting for hours and staff sometimes turning the call light off and walking away without providing assistance or coming back.) Residents also reported they do not get scheduled showers because there is not enough staff.
c) Resident Representative Interviews
Anonymous Resident Representative Interview #1 was conducted on 01/04/21 at 10:00 AM. The Resident Representative reported the facility had been understaffed for quite some time. The Resident Representative stated the facility cannot call staff in because they are so burnt out that they will not agree to come in on days they are not scheduled to work. Additionally, the Resident Representative stated she and her family have found it necessary to intervene on their loved one's behalf when their loved one's call light has gone unanswered for extended periods of time. The family developed a system where their loved one turns the call light on and if not answered within 15 minutes, the resident calls an outside family member to intervene. At that time, the outside family member resorts to calling the facility in an attempt to request staff address their loved one's call light and meet their loved one's care needs. Should the phone go unanswered, the outside family member has resorted to driving to the facility and intervening on their loved one's behalf to ensure their care needs are met. The Resident Representative stated the Administrator and the Director of Nursing are aware of extended wait times and family interventions, but have done nothing to address the concerns.
Anonymous Resident Representative Interview #2 was conducted on 01/04/22 at 4:04 PM. The Resident Representative stated the call lights were not being answered for a couple hours. The Resident Representative has called the facility in an attempt to get her loved one the help they require and has been told by staff they are short staffed and apologize. Resident Representative stated her loved one never complains but when they do call me, that's when I know it's bad. The Resident Representative stated her loved one has never had an UTI until coming here and now has had several UTIs. The Resident Representative stated, I have spoken to the Director of Nursing and the Administrator, but nothing ever gets done. I am so glad you guys are here. Hopefully you can get something done.
d) Staff Interviews
Anonymous RN Interview #1 revealed the RN felt the facility did not have enough staff available to make sure care was provided without residents having to wait for extended periods of time. The RN reported she had met earlier in the day with a resident who was in tears because the resident had needed to wait over an hour for their call light to be answered. The RN stated she frequently needs to meet with residents who are emotionally upset with the call light wait times and the lack of available staff. The RN stated the Administrator and the Director of Nursing have been made aware of the resident concerns about resident wait times but have done nothing to address the issue. The RN stated the facility is losing nursing staff as a result of Administration's apathy.
During an interview on 01/05/22 at 2:37PM, LPN #11 stated, The number one reason this facility is poor is because of Management and Staffing. LPN #11 went on to report:
-Residents stay in soiled briefs for hours because most of the time there are only one (1) or two (2) aides working.
-There is not enough staff to help assist residents with eating.
- If the DON is called due to staffing concerns, she reportedly either says handle it or hangs up on staff.
- LPN #11 is not allowed to discipline anyone. The aides like to all go outside at one time, but her hands are tied, and she cannot discipline anyone.
- Nursing management will not come out of office to help anyone. LPN #11 remarked, It's so frustrating.
- A week ago, the facility had one (1) aide on evening shift and LPN #11 asked if she could stay on and work as an Aide after her shift ended. LPN #11 reported she was told NO.
- When asked if she knew which residents are on a toileting program, LPN #11 stated she did not, and the aides would not know either.
- There are two (2) nurses that allegedly run all the new nurses off so they can get the overtime pay.
LPN #11 reported she was separating herself from employment at the facility because, It's totally abuse, and I can't put my license on the line.
During an interview on 01/3/22 at 6:23 AM, Temporary CNA #18 stated she works four (4) days a week usually four (4) night shifts. Temporary CNA #18 reported she was told she would work alongside another licensed CNA. Since she started, she has an entire hall all by herself.
During an interview on 01/05/22 at 9:34 AM, LPN #54 stated:
-Certain nurses sign off meds and then pass them, describing the practice like pre-pouring.
-Nurses and Aides are constantly on their cell phones while in resident rooms. LPN #54 is not allowed to discipline staff. When brought to her attention, the DON allegedly stated, We don't have enough staff the way it is.
-Residents sit in dirty briefs for hours due to lack of staff.
-Several times as LPN #54 has passed by the facility to get to her home, she has witnessed the majority of direct care staff outside together on a break leaving the residents in the building unattended.
LPN #54 indicated she was separating herself from employment and stated, I cannot do this anymore. I feel so bad for my residents, but I just cannot do it.
Later in the morning, at 10:30 AM, LPN #54 was in tears as she reported that the DON and Assistant Director of Nursing (ADON) wanted her to sign a neuro check fraudulently. LPN #54 stated, If they would not get me for abandonment, I would walk out of this facility right now. I am so upset.
During an interview on 01/04/22 at 9:10 AM, NA #56 stated, Last Sunday and Monday there were two CNAs for over 60 residents. No management came in to assist on the floor on Sunday or Monday. The RNs and LPNs don't help, they just complain we don't get our work done. Last week there was 1 aide in the evening, and she is pregnant and I stayed to help her. I am on light duty, but I still helped her. I have to help lift these people up in bed, I can't have these people choking trying to eat. I have told HR and still nothing gets done.
During an interview on 01/05/22 at 12:33 PM, Physical Therapist Assistant #116, stated we started back to group therapy in the gym around the end of March and They beg to come to therapy because of socialization. Staffing is a huge issue, we can help them get ready for therapy, but we cannot get the residents ready that are total care and we cannot use the hoyer lift.
During an interview on 01/10/22 at 8:48 AM, LPN #41 stated, There is a staff shortage. I have worked with only one aide in the building. The residents have laid soiled and wet due to no staff or little staff. The DON has told me she does not get paid to work the floor and her hours do not count towards the resident care. I have trouble getting all my stuff done. I usually have to stay over due to it all. Call offs are a big issue, and they don't mandate the CNAs but the nurses are mandated to work 16 hours.
During an interview on 01/10/22 at 8:57 AM, RN #34 stated, I am only part time. Christmas day there were 2 nurses and 1 aide to the whole building. The call lights go off forever because we are busy and cannot get to them. The residents lay wet and soiled for long periods of time because when it takes 2 people and 1 is busy, they have to wait. The call offs are ridiculous. They never reprimand them when they call off, it just gets swept under the rug. I usually have to work 16-hour shifts, because the facility can't find anyone to work.
During an interview on 01/20/22 at 9:17 AM, Recreation Assistant # 24 stated the day's activities (Cranium Crunches at 10:30 AM, and Table Talk at 11:15 AM) should be in the main dining room, if the CNAs are not short and they know about the activities. I will have to find out if they are short staffed today.
During an interview on 01/05/22 at 12:26 PM, the Administrator stated, We have an issue with staffing we have tried to discuss but there is nothing we can do about it.
During a subsequent interview with the Administrator, on 01/10/22 at 12:30 PM, the Administrator reported, We are just trying to keep the facility afloat. There is not enough staff in the facility, we have an all-hands-on deck philosophy, and all the staff here are tired. The Administrator again stated there is nothing that can be done about it. The Administrator replied, We talk about short staffing all the time and our hands are tied. All we can do is go down the call list and hope someone comes in.
e) Resident Council Minutes
A review of the Resident Council minutes from January 2021 through November 2021 found the following resident complaints:
-During a resident council meeting on 01/10/21, it was noted, Call lights are taking a long time to answer between 30 minutes and an hour.
-During a resident council meeting on 09/23/21, it was noted, Call lights are taken a long time to answer. Some aides/nurses will answer the light, turn it off, and not meet needs.
-During a resident council meeting on 11/18/21, it was noted the residents felt the facility need more staff to meet their needs.
The facility failed to meaningfully address the resident council concerns about extended wait times for call bells to be answered. The facility was unable to provide evidence of a thorough investigation including statements from the residents making the allegations, statements from any other residents regarding the care they had received during the same time frames reported, statements from the staff working at the time of the incidents, or statements from the staff who had knowledge or involvement in the incident. The Administrator also failed to provide evidence the facility investigated the staffing level in the facility at the time of the incident to ensure adequate staff was deployed to meet the resident's needs.
f) Review of the facility assessment and Record Review
The facility assessment (used to determine resources necessary to care for facility residents), documented a bed capacity of 68 with an average daily census of 61. The facility's staffing plan outlined the following staffing would be necessary to ensure sufficient staff to meet the needs of the residents at any given time:
Days
-1 RN
-2 LPNs
Evenings
-1 RN
-1 LPN
Nights
-1 RN
1 LPN
Necessary Certified Nurse Assistant (CNA) direct care hours were determined to be 2.27 hours per resident day (HPRD) which is slightly above the state minimum requirement of 2.25.
Review of the Daily Time Detail by Department on weekends revealed the following dates where nurse staffing did NOT follow the facility's staffing plan detailed in their facility assessment:
-12/03/21 Night Shift had one (1) LPN working. There was no RN on duty.
-12/04/21 Night Shift had one (1) RN working. There was no LPN on duty.
-12/05/21 Night Shift had one (1) RN working. There was no LPN on duty.
-12/11/21 Night Shift had one (1) LPN working. There was no RN on duty.
-12/12/21 Night Shift had one (1) LPN working. There was no RN on duty.
-12/18/21 Night Shift had one (1) RN working. There was no LPN on duty.
-12/19/21 Night Shift had one (1) RN working. There was no LPN on duty.
-12/24/21 Night Shift had one (1) LPN working. There was no RN on duty.
-12/25/21 Night Shift had one (1) RN working. There was no LPN on duty.
-12/31/21 Night Shift had one (1) RN working. There was no LPN on duty.
-01/01/22 Afternoon Shift had one (1) RN working. There was no LPN on duty.
-01/01/22 Night Shift had one (1) LPN working. There was no RN on duty.
-01/02/22 Night Shift had one (1) RN working. There was no LPN on duty.
Review of the Daily Time Detail by Department demonstrated the following days where CNA direct care hours per resident day were below the state minimum of 2.25 hours.
-2.10 hours per resident day on 12/01/21.
-1.97 hours per resident day on 12/02/21.
-2.16 hours per resident day on 12/03/21.
-1.37 hours per resident day on 12/04/21.
-1.47 hours per resident day on 12/05/21.
-1.99 hours per resident day on 12/06/21.
-2.06 hours per resident day on 12/07/21.
-1.93 hours per resident day on 12/11/21.
-1.97 hours per resident day on 12/12/21.
-1.65 hours per resident day on 12/16/21.
-1.75 hours per resident day on 12/18/21.
-1.69 hours per resident day on 12/19/21.
-2.04 hours per resident day on 12/23/21.
-2.16 hours per resident day on 12/25/21.
-1.80 hours per resident day on 12/26/21.
-1.50 hours per resident day on 12/27/21.
-1.93 hours per resident day on 12/28/21.
-1.79 hours per resident day on 12/31/21.
-1.28 hours per resident day on 01/01/22.
-1.20 hours per resident day on 01/02/22.
-1.82 hours per resident day on 01/09/22.
-1.42 hours per resident day on 01/10/22.
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CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0727
(Tag F0727)
Could have caused harm · This affected most or all residents
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Based on record review and interview, the facility failed to ensure a Registered Nurse (RN) was present at the facility for at least eight (8) consecutive hours a day, seven (7) days a week. There w...
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Based on record review and interview, the facility failed to ensure a Registered Nurse (RN) was present at the facility for at least eight (8) consecutive hours a day, seven (7) days a week. There were six (6) identified dates the facility had 0.00 hours of RN coverage. This had the potential to affect all residents at the facility. Facility census: 57.
Findings included:
a) RN coverage in December 2021
On 01/05/21 at 9:00 AM, a review of the staffing timesheets/schedules for RN coverage found four (4) occasions, occurring on weekends in December 2021, when RN coverage was not present in the facility.
Saturday, 12/11/21 - RN coverage was 0.00 hours. No RN coverage in the facility.
Sunday, 12/12/21 - RN overage was 0.00 hours. No RN coverage in the facility.
Friday, 12/24/21 - RN coverage was 0.00 hours. No RN coverage in the facility.
Sunday, 12/26/21 - RN coverage was 0.00 hours. No RN coverage in the facility.
On 01/05/22 at 3:00 PM, the Director of Nursing (DON) confirmed the facility timesheets for days in December 2022 did not reflect any RN coverage on the following four (4) dates: 12/11/21, 12/12/21, 12/24/21, and 12/26/21.
b) RN coverage in January 2022
On 01/10/22 at 3:10 PM, a review of staffing timesheets/schedules for RN coverge found two (2) additional occasions, occurring on weekends in January 2022, when RN coverage was not present in the facility.
Saturday, 01/08/22 - RN coverage was 0.00 hours. No RN coverage in the facility.
Sunday, 01/09/22 - RN coverage was 0.00 hours. No RN coverage in the facility.
On 01/10/22 at 10:43 AM, the DON confirmed the facility timesheets for days in January did not reflect any RN coverage on the following two (2) dates: 01/08/22 and 01/09/22.
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CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0882
(Tag F0882)
Could have caused harm · This affected most or all residents
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Based on facility documentation and staff interview the facility failed to provide an Infection Preventionist that had completed specialized training in infection prevention and control. The failed ...
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Based on facility documentation and staff interview the facility failed to provide an Infection Preventionist that had completed specialized training in infection prevention and control. The failed practice had the potential to affect all residents who reside in the facility. Facility census: 57.
Findings included:
a) Infection Prevention Certification
A review of facility documentation, on 01/05/22 at 3:50 PM, revealed a lack of evidence that verified staff had completed an Infection Prevention and Control specialized training in the facility.
An interview with the Infection Preventionist (IP), on 01/05/2022 at 4:00 PM, stated IP was not certified in infection prevention and control. IP stated the Director of Nursing (DON) and the Assistant Director of Nursing (ADON) were also not certified in infection prevention and control. IP stated there are no employees in the facility that have had any specialized training in infection prevention and control.
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Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated
K - Pattern
L - Widespread
Actual Harm
G - Isolated
H - Pattern
I - Widespread
Potential for Harm
D - Isolated
E - Pattern
F - Widespread
No Harm (Minor)
A - Isolated
B - Pattern
C - Widespread
Questions to Ask on Your Visit
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • No major safety red flags. No abuse findings, life-threatening violations, or SFF status.
- • No fines on record. Clean compliance history, better than most West Virginia facilities.
Concerns
- • 52 deficiencies on record. Higher than average. Multiple issues found across inspections.
Bottom line: Mixed indicators with Trust Score of 70/100. Visit in person and ask pointed questions.
✓ Report will be sent to your email
About This Facility
What is Care Haven Center's CMS Rating?
CMS assigns CARE HAVEN CENTER an overall rating of 4 out of 5 stars, which is considered above average nationally. Within West Virginia, this rating places the facility higher than 99% of the state's 100 nursing homes. This rating reflects solid performance across the metrics CMS uses to evaluate nursing home quality.
How is Care Haven Center Staffed?
CMS rates CARE HAVEN CENTER's staffing level at 2 out of 5 stars, which is below average compared to other nursing homes. Staff turnover is 52%, compared to the West Virginia average of 46%.
What Have Inspectors Found at Care Haven Center?
State health inspectors documented 52 deficiencies at CARE HAVEN CENTER during 2022 to 2024. These included: 52 with potential for harm. While no single deficiency reached the most serious levels, the total volume warrants attention from prospective families.
Who Owns and Operates Care Haven Center?
CARE HAVEN 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 68 certified beds and approximately 66 residents (about 97% occupancy), it is a smaller facility located in MARTINSBURG, West Virginia.
How Does Care Haven Center Compare to Other West Virginia Nursing Homes?
Compared to the 100 nursing homes in West Virginia, CARE HAVEN CENTER's overall rating (4 stars) is above the state average of 2.7, staff turnover (52%) is near the state average of 46%, and health inspection rating (4 stars) is above the national benchmark.
What Should Families Ask When Visiting Care Haven Center?
Based on this facility's data, families visiting should ask: "Can you walk me through typical staffing levels on day, evening, and night shifts?" "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" "Can I speak with family members of current residents about their experience?" These questions are particularly relevant given the below-average staffing rating.
Is Care Haven Center Safe?
Based on CMS inspection data, CARE HAVEN CENTER has a clean safety record: no substantiated abuse findings (meaning no confirmed cases of resident harm), no Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death), and is not on the Special Focus Facility watch list (a federal program monitoring the lowest-performing 1% of nursing homes). The facility has a 4-star overall rating and ranks #1 of 100 nursing homes in West Virginia. While no facility is perfect, families should still ask about staff-to-resident ratios and recent inspection results during their visit.
Do Nurses at Care Haven Center Stick Around?
CARE HAVEN CENTER has a staff turnover rate of 52%, which is 6 percentage points above the West Virginia average of 46%. Moderate turnover is common in nursing homes, but families should still ask about staff tenure and how the facility maintains care continuity when employees leave.
Was Care Haven Center Ever Fined?
CARE HAVEN CENTER has no federal fines on record. CMS issues fines when nursing homes fail to meet care standards or don't correct problems found during inspections. The absence of fines suggests the facility has either maintained compliance or corrected any issues before penalties were assessed. This is a positive indicator, though families should still review recent inspection reports for the full picture.
Is Care Haven Center on Any Federal Watch List?
CARE HAVEN 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.