MARTINSBURG HEALTHCARE CENTER
For profit - Corporation
120 Beds
COMMUNICARE HEALTH
Data: November 2025
Trust Grade
70/100
#31 of 122 in WV
Photo by Gruen Agency HCR - ManorCare
Photo by Gruen Agency HCR - ManorCare
Photo by Gruen Agency HCR - ManorCare
1 / 10 photos
Last Inspection: June 2025
Inspected within the last 6 months. Data reflects current conditions.
Overview
Martinsburg Healthcare Center has received a Trust Grade of B, indicating it is a good choice among nursing homes, offering solid care. It ranks #31 out of 122 facilities in West Virginia, placing it in the top half, and #2 out of 2 in Berkeley County, meaning there is only one other local option. The facility is showing an improving trend, with the number of issues decreasing from 27 in 2023 to 9 in 2025. Staffing is average, with a 43% turnover rate, slightly below the state average, and there are no fines on record, which is a positive sign. However, the facility has had several concerns, including failed inspections related to cleanliness in resident rooms and improper food storage practices, which could affect resident safety and health.
- Trust Score
- B
- In West Virginia
- #31/122
- Safety Record
- Low Risk
- Inspections
- Getting Better
- Staff Stability ○ Average
- 43% turnover. Near West Virginia's 48% average. Typical for the industry.
- 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
- 48 deficiencies on record. Higher than average. Multiple issues found across inspections.
70/100
Top 25%
No red flags
27 → 9 violations
★★★★☆
4.0
Overall Rating
★★★☆☆
3.0
Staff Levels
★★★★★
5.0
Care Quality
★★★☆☆
3.0
Inspection Score
↔
Stable
2023: 27 issues
2025: 9 issues
The Good
-
5-Star Quality Measures · Strong clinical quality outcomes
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
-
Staff turnover below average (43%)
5 points below West Virginia average of 48%
Facility shows strength in quality measures, fire safety.
The Bad
Staff Turnover: 43%
Near West Virginia avg (46%)
Typical for the industry
Chain: COMMUNICARE HEALTH
Part of a multi-facility chain
Ask about local staffing decisions and management
The Ugly 48 deficiencies on record
Jun 2025
9 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0552
(Tag F0552)
Could have caused harm · This affected 1 resident
Based on record review and staff interview, the facility failed to provide the resident or resident's representative of the risks and benefits of an anti-psychotic medication. This was found to be tru...
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Based on record review and staff interview, the facility failed to provide the resident or resident's representative of the risks and benefits of an anti-psychotic medication. This was found to be true for 1 (one) of six (6) residents reviewed. Resident identifier: #95. Facility census: 115.
Findings included:
a) Resident #95
Resident #95 had a diagnosis of depressive disorder on 05/10/24 and was prescribed Sertraline HCI tablet 50 mg on 05/10/24.
The facility failed to inform the resident's medical representative of the risks and benefits of the medication, other treatment options or alternatives. The resident did not have capacity to make her own medical decisions.
During the survey process, on 06/18/25 at 0:38 AM, the surveyor requested to see an informed consent for Sertraline. On 06/18/25 at 02:01 PM, the DON stated she was not able to locate the consent form. The DON did present a note from the medical record where the facility had tried to call the resident's representative, but the representative never returned the call.
On 06/24/25 at 2:02 PM, surveyor met with DON and NHA to re-verify lack of informed consent and reviewed the potential deficiency with them.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure that incontinence care was provided to dependent residents. ...
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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 that incontinence care was provided to dependent residents. Namely, dependent residents were not aided with toileting, cleaning themselves, and changing absorbent pads or briefs in a timely manner. This was true for one (1) of four (4) residents surveyed. Resident Identifiers: Resident identifier: #50. Facility Census: 116.
Findings Include:
a) Resident #50
Record review on 06/18/25 at approximately 10:00 AM revealed that Resident #50 does not have capacity. The record review revealed the following:
The facility had submitted an initial report of an allegation of neglect in the area of incontinence care for Resident #50 on 03/26/25 at 1:49 PM. The facility had submitted the five-day follow-up report on 03/28/25 at 1:53 PM. The report stated that the alleged perpetrator, Nursing Assistant (NA) #15 was suspended pending the completion of the investigation.
The five-day follow-up report stated that 'After thorough investigation, the allegation of incontinence care not provided timely has been unsubstantiated.'
Record review of the investigative notes revealed a phone statement obtained by the Director of Nursing (DON) from NA #15 stated: I worked on South Unit last pm. I had 150-156. The following residents are incontinent 150 A&B, 151 A, 152 A7B, 153 A7B, 155 A&B, 156 A&B will ring. I have always been told we do not do anything for him, he is independent and will use his urinal and will ring for anything else. My last rounds were started before 5:20 AM. At approximately 5:20, I started with the four rooms on stretch. I am 85% I started with them. It was around or not very long after that for I did not have to change many of my incontinent. [NAME] was dry, I changed 151 A, 152 A, B was dry, 153 A dry all night and B bed was changed. Both residents 153 A&B changed.I washed up 150 B and 150 B and NA #104 and I completed their baths. I did not have anyone to complete walking rounds with, but did write the reports with booth of their names on it. I left floor 6:36 AM. I wrote report with their names on it. I spoke with Registered Nurse (RN) #36 and NA #93 was standing there and I asked if they would make sure if NA #70 and NA #58 would get their report.
A written statement by NA #58 reviewed on 06/18/25 at approximately 10:11 AM, stated the following:
I went in to check my section. I went into [Room]. NA # 85 and NA #93 were in the middle of stripping Resident #50's bed. The sheets were soaked with brown ring from the middle of the sheets to almost the bottom.
Further review revealed written statements by NA #93 and NA #85:
NA #93 stated:
Around 6:40 me and NA #83 went into Resident #50's room to get him up for breakfast, when we pulled the blankets back, he was soaked, and shirt and sheets were wet. We went ahead and gave him a full head to toe bed bath. When we got done, we let his aide know. When I came out there was a report paper on the desk. When I opened it, it said he was changed and washed and dressed.
NA #85 stated the following:
Around 6:40 AM on 03/26/25 NA #93 and I were helping get residents up for breakfast. When we went to get Resident #50 up he was soaked up to his shirt and bed with bed with urine. We bathed him, and got him up and informed his aide of the situation. The night shift aide left a paper report stating he was changed and bathed already.
During an interview on 06/18/25 at approximately 1:15 PM, NA #58 confirmed that when she went into Resident #50's room on 03/26/25, she had observed a brown ring on Resident #50's sheets.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
Based on observation, interview and record review, the facility failed to ensure that a physician's order for oxygen administration was followed. This was a random opportunity for discovery. Resident ...
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Based on observation, interview and record review, the facility failed to ensure that a physician's order for oxygen administration was followed. This was a random opportunity for discovery. Resident Identifier: #6. Facility Census: 116.
Findings include:
a) Resident #6
During an observation on 06/16/25 at approximately 3:47 PM, the resident was observed asleep. The oxygen concentrator was noted to be set at three (3) liters per minute.
A review of Resident #6's medical record revealed that the resident was diagnosed with Acute and Chronic Respiratory failure with Hypoxia.
A review of Resident #6's care plan revealed a note that stated:
'Resident takes off O2 at times. Encourage the resident to allow the staff to replace the O2.
Date Initiated: 02/27/2025
During the survey period, there were no observations of the resident with her nasal cannula removed.
Physicians' orders prescribed Oxygen at two (2) liters per minute. Follow-up observations over the next few days revealed the following:
6/17/25 at 11:15 AM - Resident observed asleep with oxygen concentrator set at 3 liters per minute.
06/17/25 at 3:42 PM - Resident observed asleep with oxygen concentrator set at 3 liters per minute.
06/18/25 at 8:55 AM - Resident observed asleep with oxygen concentrator set at 2.5 liters per minute.
06/18/25 at 1:19 PM - Resident observed asleep with oxygen concentrator set at 2.5 liters per minute.
On 06/18/25 at 1:21 PM, Licensed Practical Nurse (LPN) #17 was notified of the incorrect oxygen dose. LPN #17 stated that she would check the physician's orders, and confirmed that the resident's prescribed oxygen delivery rate should be 2 liters per minute. LPN #17 adjusted the oxygen concentrator to deliver the prescribed dose and stated that she would monitor the concentrator to ensure it was not malfunctioning.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Pharmacy Services
(Tag F0755)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the consulting pharmacist failed to identify and notify the physician of pote...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the consulting pharmacist failed to identify and notify the physician of potential Adverse Drug Reactions (ADR's) related to the concurrent administration of opioids, benzodiazepines. Further, the pharmacist failed to identify that a medication had been prescribed to a resident with a documented allergy to it. Resident identifier: #6. Facility Census: 116.
Findings Include:
a) Resident #6
Record review on 06/16/25 at approximately 12:25 PM revealed that Resident #6 was an [AGE] year-old female. Resident #6 did not have capacity and a Brief Interview for Mental Status (BIMS) assessment on 05/07/25 revealed a BIMS of 02. The resident has been diagnosed with the following:
Acute and Chronic Respiratory Failure with Hypoxia.
Paroxysmal Atrial Fibrillation
Chronic Obstructive Pulmonary Disease
Alzheimer's Disease
Major Depressive Disorder
Atherosclerotic Heart Disease of Native Coronary Artery without angina pectoris
Following the record review, Resident #6 was observed at frequent intervals throughout the survey and the following was noted:
06/16/25 at 1:55 PM - Resident observed asleep
06/16/25 at 3:47 PM - Resident observed asleep
6/17/25 at 11:15 AM - Resident observed asleep
06/17/25 at 2:21 PM - Resident observed asleep
06/17/25 at 3:42 PM - Resident observed asleep
06/18/25 at 8:55 AM - Resident observed asleep
06/18/25 at 1:19 PM - Resident observed asleep
06/18/25 at 4:05 PM - Resident observed asleep
06/19/25 at 8:59 AM - resident observed awake and in Geri chair - very vocal, loud, and making unintelligible statements.
06/19/25 at 11:15 AM - resident observed asleep
06/24/25 at 2:32 PM - resident observed asleep
06/24/25 at 4:10 PM - resident observed asleep
06/25/25 at 9:15 AM - Resident observed asleep
06/25/25 at 11:21 AM - Resident observed asleep
06/25/25 at 1:49 PM - resident observed asleep
During an Interview with Registered Nurse (RN) #36 on 06/19/25 at approximately 10:30 AM, RN stated that Resident #6 usually preferred to sleep in her room for most of the day. RN #36 stated that the physician had prescribed Tramadol a few months back due to resident's behaviors. RN #36 further stated that resident's husband visits every evening, and that he would try to wake her up and talk to her.
Further record review on 06/16/25 at 2:10 PM revealed that the resident was prescribed the following medications:
Lorazepam Oral Tablet 1 MG (Lorazepam) Give one tablet every 8 hours as needed for anxiety.
Tramadol Tablet 50 MG *Controlled Drug* Give 1/2 tablet = 25 MG by mouth daily
Trazodone HCl Oral Tablet 50 MG (Trazodone HCl) - Give 50 mg by mouth at bedtime for Insomnia
Both lorazepam (a benzodiazepine) and tramadol (an opioid) are CNS depressants.
FDA guidance states that providers should take precautions when prescribing Tramadol (an opioid) and Lorazepam (a benzodiazepine), as concurrent use of these drug classes can result in excessive drowsiness, respiratory depression, overdose and death.
The guidance also stated that physicians should reserve concurrent use of prescribing of opioid analgesics with benzodiazepines or other CNS depressants for use in patients for whom alternative treatment options are inadequate.
.
Record review further revealed that Resident #6 had a documented allergy to Tramadol. The allergic reaction to Tramadol was documented as 'Hallucinations'.
During an interview with the Director of Nursing (DON) and Regional Clinical Nurse (RCN) #300 on 06/19/25 at 11:43 AM, they confirmed that no physicians note was available acknowledging the use of Tramadol even though the resident was allergic to it.
After a comprehensive review of the resident's medical record, it was observed that there were no nursing notes or other documentation related to the resident's sleep patterns during the day or her overall quality of life. Additionally, no documentation was provided showing that the drug-to-drug interactions and possible adverse reactions were considered. Further, none of the completed Monthly Monitoring Reports (MMRs) or Gradual Dose Reductions (GDRs) addressed the concurrent use of opioids and benzodiazepines.
During an interview on 06/25/25 at approximately 1:20 PM, Pharmacist #301 and RCN #300 attempted to explain the documentation provided. The pharmacist did not provide a reason for failing to identify and notify the physician about the potential adverse reactions associated with the concurrent use of benzodiazepines, and opioids.
RCN #300 noted that the physician had already put orders in place for monitoring the side effects of antianxiety medications, mood stabilizers, and antipsychotics. As a result, RCN #300 did not believe it was necessary to inform the physician about the potential dangerous adverse reactions of using these medications concurrently.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview the facility failed to monitor the expiration dates of medical supplies. Further, the facilit...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview the facility failed to monitor the expiration dates of medical supplies. Further, the facility failed to ensure that expired medical supplies were disposed of and not left accessible for use by staff for resident care. Facility Census: 116.
Findings Include:
a) North Medication Room
During an inspection of the North Medication Room on [DATE] at approximately 9:16 AM, accompanied by Licensed Practical Nurse (LPN) #17, the storage bins holding medical supplies revealed the following:
31 - BD 1 ML Syringes - expiration date [DATE]
7 - Insyte 24 GA x 0.75 in injection syringes - expiration date [DATE]
LPN #17 counted and confirmed the expiration dates on the syringes. LPN #17 further stated that she would notify the DON of the finding, and dispose of the expired syringes.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
Based on observation and staff interviews, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment a...
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Based on observation and staff interviews, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections with regards to the residents and unsanitary practices. This failed practice was a random opportunity of discovery. Facility Census: 117.
Findings included:
a) During a facility walk through on 06/16/25 at 3:34 PM, an opened box of tissues, an opened box of gloves and an opened package of wipes, was found on the middle shelf sitting on top of the clean linen of the linen cart in the South Hall.
On 06/17/25 at 9:56 AM, during a facility walk through, an opened box exam gloves, a small roll of clear garbage bags, and an opened package of wipes was found on top of the clean linen on the top shelf of the linen cart in the South Hall .
On 06/16/25 at 3:45 PM, in an interview with Licensed Practical Nurse (LPN) #107, she acknowledged the items on the linen cart and stated nothing should be on the linen cart with the clean linen and removed the package of wipes, box of gloves and tissues, immediately.
In an interview, on 06/17/25 at 10:05 AM with Nurses Aid (NA) #117, she acknowledged the items on the linen cart and immediately removed them.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected multiple residents
**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 fo...
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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 for residents in six (6) rooms. Room identifiers: #136, #143, #147, #149, #151, and #160. This was a random opportunity for discovery. Facility census: 117.
Findings included:
a) Upon survey entrance on 06/16/25 at 1:58PM, it was observed the following issues in Resident room numbers:
room [ROOM NUMBER]:
- wallpaper loose with air bubbles on the wall beside the bathroom door approximately 3 feet from the floor
- wallpaper loose with air bubbles on the window wall beside bed B, approximately 2 feet from the floor
- scuffs and black marks on the inside of the bathroom door
- A Large circular hole in the bathroom wall behind the toilet approximate size 6 inches wide
room [ROOM NUMBER]:
- scrapes and tears in the wallpaper on the wall next to the sink
- black scuff marks and loose trim inside bathroom door
- A Large circular hole in the bathroom wall behind the toilet approximate size 6 inches wide
room [ROOM NUMBER]:
- paint chips approximately 1/2inch wide in the wooden trim around the air conditioner/heating unit
room [ROOM NUMBER]:
- black scuff marks and scrapes on wall next to the bathroom door
- black scuff marks and scrapes on both sides of the bathroom door
- cracks in paint under the grab bar handle on the bathroom wall
room [ROOM NUMBER]:
- black scuff marks and scrapes across the bottom of the wall next to the bathroom door
- black scuff marks and scrapes inside on the bottom of the bathroom door
room [ROOM NUMBER]:
- wallpaper loose with air bubbles on the wall beside bathroom door approximately 3 feet high from the floor
- wallpaper loose with air bubbles inside Resident's room door to the right of bed A approximately 3 feet high from the floor
- A Large circular hole in the bathroom wall behind the toilet approximate size 6 inches wide
On 06/17/25 at 1:30 PM, during a walk through with the administrator regarding environment issues in room [ROOM NUMBER], #143, #147, #149, #151, and #160.
She acknowledged the environmental issues in these resident rooms and stated she will start a facility wide repair list for the maintenance department.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0628
(Tag F0628)
Could have caused harm · This affected multiple residents
Based on record review and staff interviews, the facility failed to perform an accurate discharge process for two (2) of 3 residents reviewed during the survey process for hospitalization. Resident id...
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Based on record review and staff interviews, the facility failed to perform an accurate discharge process for two (2) of 3 residents reviewed during the survey process for hospitalization. Resident identifiers: #30, and #279. Facility census: 115
Findings included:
a) Resident #30
Resident has capacity to make her own medical decision. The resident was on hospital leave from 03/23/25 until 03/26/25.
There was no documentation to support the ombudsman was notified of the transfer.
The facility was unable to provide a Bed Hold Notice for this hospital leave. This form was requested from the DON on 06/18/25 at 11:57 AM. On 06/18/25, late afternoon, the DON stated she was unable to find one.
On 06/24/25 at 2:05 PM, discussion was held with the DON and NHA about the transfer process for this hospitalization. At this time the surveyor asked if they had any additional information to provide. NHA stated no.
b) Resident #279
Resident #279 sustained a fall with injury in the facility on 02/24/25 and was transported to an acute care facility Emergency Department (ED) for evaluation. Resident did not return to the facility.
DON stated on 06/18/25 at 3:47 PM that she could not locate a bed hold notice.
On 06/24/25 at 2:05 PM, discussion was held with the DON and NHA about the transfer process for this hospitalization. At this time, the surveyor asked if they had any additional information to provide. NHA stated no.
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, interview and policy review the facility failed to properly store and serve food in accordance with professional standards for food service safety. This had the potential to affe...
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Based on observation, interview and policy review the facility failed to properly store and serve food in accordance with professional standards for food service safety. This had the potential to affect all residents in the facility. Facility census: 117.
Findings included:
a) On 06/16/25 11:35 AM, during the Initial Brief Tour of Kitchen, with Assistant Dietary Manager #182 acknowledged the following:
In the Freezer it was observed that a bag of frozen Hamburger patties were left opened and exposed.
On 06/17/25 at 1:00 PM a review facility policy labeled HCSG Policy 019, Food Storage: Cold Foods. Procedures, number 5 stated All foods will be stored wrapped or in covered containers, labeled and dated, and arranged in a manner to prevent cross contamination.
A bag of macaroni was observed left open and exposed in the pantry
On 06/17/25 at 1:00 PM a review facility policy labeled HCSG Policy 018, Food Storage: Dry Goods. Procedures, number 5 stated All packaged and canned food items will be kept cleam, dry, and properly sealed.
The temperature inside the kitchen refrigerator was 45 degrees verified by two different thermometers and witnessed by the Assistant Dietary Manager employee #182 .
During the initial brief kitchen walk through and interview with the Assistant Dietary Manager employee #182, she acknowledged the bag of open macaroni in the pantry, the box of frozen burgers left open and exposed in the freezer, and the fridge temperatures at 45 degrees and stated she would take care of them and would report the refrigerator temps to the Kitchen manager to have the refrigerator checked for repair.
In an interview on 06/16/25 at 1:10pm with the Dietary Manager (DM) #181, she stated she was aware of the previous mentioned issues in the pantry, freezer, and the temperature in the refrigerator.
Observations made on 06/17/25 at 12:015 PM while preparing resident food trays on the tray line, It was observed that Employee #175 walked over to the freezer, touched the freezer door stepped inside and took out a chocolate ice cream cup and then walked back to the tray line and began to prep resident food trays without changing gloves or washing her hands. At 12:20PM, she pulled the delivery cart up to the prep line and opened the cart doors in preparation to load resident trays and then began preparing resident food trays again without changing gloves or washing her hands.
In an interview with DM #181 on 06/17/25 at 12:20 PM, she acknowledged Employee #181 had not changed her gloves after leaving the tray line both times, touching the freezer door handle, then again touching the floor delivery cart and returning to tray prep without changing her gloves nor washing her hands.
Sept 2023
3 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on review of the concern/grievance forms, review of the facility documentation of reportable occurrences, and staff inte...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on review of the concern/grievance forms, review of the facility documentation of reportable occurrences, and staff interview, the facility failed to ensure that all alleged violations of abuse, were reported immediately, to all officials (including to the State Survey Agency and Adult Protective Services (APS), where state law provides for jurisdiction in long-term care facilities) in accordance with State law, through established procedures. This deficient practice was found true for two (2) of four (4) residents reviewed. An allegation of abuse, the staff had knowledge of, was not reported in a timely manner involving Residents #20 and #119. Resident identifiers: Residents #20 and #119. Facility census: 116.
Findings included:
a) Policy Review
A review of the Policy and Procedure, titled: WV Abuse, Neglect and Misappropriation, Policy #NS1018-03, approval date of 05/25/23, noted on page 15 of the policy, under 1. B., if the allegation did not cause serious bodily injury or abuse, the report must be made immediately, but not later than 24 hours after the discovery.
b) Concern/Grievance Review
A review of the facility grievance/concern file showed two (2) residents had complained of incontinence care not being provided in a timely manner involving Resident #20 and Resident #119. The grievance/concern was dated as received by facility staff on 07/03/23.
c) Reportable Occurrences Review
A review of the Reportable Occurrences maintained by the facility was reviewed and showed an allegation of Neglect, dated 07/03/23 for Resident #20 and Resident #119.
Further review of the reportable occurrence file showed the facility failed to notify all state agencies in accordance with state law and facility policy. The facility documentation showed the allegation of neglect for both Resident #20 and Resident #119 was not reported until 07/05/23 when the allegation was received on 07/03/23 at 6:30 AM.
d) Staff Interviews
An interview, with the Social Worker, on 09/19/23 at 11:50 AM, revealed the reporting of the allegations made by Resident #20 and Resident #119 had not been reported in accordance with the 24-hour window of reporting the allegation. The Social Worker confirmed the allegation should have been reported no later than 07/04/23.
An interview, with the Director of Nursing (DON), on 09/19/23 at 1:30 PM, verified after review of the reportable documentation, the facility failed to report the allegation in a timely manner. The DON confirmed the allegation was made known to the facility on [DATE] and was not reported until 07/05/23, which would not have met the requirements of reporting an allegation of abuse of neglect.
An interview, with the Administrator, on 09/19/23 at 4:30 PM, revealed there was no additional evidence to provide because the facility had failed to meet the reporting timeline on Resident #20 and Resident #119's reported allegation.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0692
(Tag F0692)
Could have caused harm · This affected 1 resident
.
Based on record review and staff interview the facility failed to notify the physician of a significant weight loss to evaluate and manage causes of the resident's nutritional risks and impaired nut...
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.
Based on record review and staff interview the facility failed to notify the physician of a significant weight loss to evaluate and manage causes of the resident's nutritional risks and impaired nutritional status. This is true for one (1) of three (3) residents reviewed for weight loss. Resident identifier: # 51. Facility census: 116.
Findings included:
a) Resident #51
On 09/19/23 during a complaint survey for weight loss and physician notification a record review for Resident #51 revealed a significant weight loss on 09/01/23.
Registered Dietician Notes:
9/1/2023 14:27 Weight Change Note
Note Text: WEIGHT WARNING:
Value: 180.8
-5.0% change over 30 day(s) [ 6.7%, 13.0]
-3.0% change over 30 day(s) [ 3.8%, 7.2]
-5.0% change [ 6.8% 13.2 ]
(Transcribed as Written)
9/18/2023 15:50 Weight Change Note
Note Text: WEIGHT WARNING:
Value: 179.2
-3.0% change over 30 day(s) [ 4.0%, 7.4]
-7.5% change [ 7.6%, 14.8]
-10.0% change [ 10.6%, 21.2]
(Transcribed as Written)
Continued Medical record review found no notification of the Physician for Resident #51's significant weight changes.
On 09/19/23 at approximately 1:54 PM during an interview the Director of Nursing verified the physician was not notified Resident #51's significant weight change.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected multiple residents
.
Based on observations 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...
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.
Based on observations and staff interview, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections with regards to resident handwashing. This practice had the potential to affect more than an isolated number of residents. Facility census: 116.
Findings included:
a) Meal tray pass
An observation during dining observation on 09/19/23, at 11:45 PM revealed the residents in the north dining room, did not receive hand hygiene prior to or during the lunch meal tray pass.
An observation on the 106 - 115 north hall on 09/19/23 at 12:15 PM found the residents were not offered to wash their hands prior to the lunch meal.
During an interview, on 09/19/23 at 12:22 PM, with Unit Manager (RN) #106 the Unit Manager verified no hand hygiene was completed prior to the meal service in the dining room or the halls. She stated they usually use hand wipes for the residents. She stated that they used to have hand wipes put on the trays.
Dining observation, on 09/19/23, at 12:45 PM, revealed the residents in the South dining room, did not receive hand hygiene prior to or during the lunch meal tray pass.
During an interview, on 09/19/23 at 12:48 PM, Nurse Aide (NA) #27 verified no hand hygiene was completed prior to the meal service in the dining room.
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May 2023
24 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
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Based on resident interview, record review, and staff interview, the facility failed to protect and promote the rights of Resident #50. The facility failed to issue Resident #50 an invitation to att...
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Based on resident interview, record review, and staff interview, the facility failed to protect and promote the rights of Resident #50. The facility failed to issue Resident #50 an invitation to attend two (2) appeals hearings regarding the discharge for nonpayment. This was a random opportunity for discovery. Resident identifier: #50. Facility census: 115.
Findings included:
a) Resident #50
During an interview on 05/23/23 at 8:11 AM, Resident #50 reported she had been given a discharge notice for nonpayment.
Record review, completed on 05/23/23 at 7:10 PM, identified the following details:
-A Physician Determination of Capacity, dated 04/21/21, which stated Resident #50 had capacity to make decisions.
-A Durable Power of Attorney (DPOA) on file listing resident's family member as DPOA. (A durable power of attorney is a legal document that gives another person the authority to make financial decisions for someone.)
-A Social Service Note, dated 02/17/23 at 9:03 AM, stated that the social worker had received notification from the Business Office Manager of a telephone hearing for the resident's appeal, regarding the notice of discharge for nonpayment, scheduled for 03/14/23 at 10:00 AM. There was no other information in the electronic medical record regarding this appeal hearing.
-A Social Service Note, dated 04/14/23 at 8:18 AM, stated that the Social Worker (SW) received a confirmation letter from Resident #50's family of the appeal hearing scheduled on 05/16/23 at 9:00 AM. The SW also documented the Business Office Manager confirmed the information to be accurate.
-A Social Service Note, dated 05/16/23 at 12:02 PM, stated that the telephone appeals hearing was held with the Business Office Manager, the SW, the DPOA, and the DPOA's granddaughter all present on the call. The SW also documented she was later approached by Resident #50 to inquire about the upcoming telephone hearing. Resident #50 was with the understanding that it was scheduled for 05/18/23.
During an interview on 05/24/23 at 8:13 AM, the SW confirmed Resident #50 had mental capacity. The SW reported she was not present for the 03/14/23 appeal hearing because she was off sick. The SW then stated that Resident #50 had not been present at the second appeal hearing on 05/16/23 because the facility had deferred to the resident's DPOA to participate on resident's behalf. No invitation was extended to Resident #50 to attend either hearing. The SW agreed the facility had failed to promote the rights of Resident #50 to participate in the two (2) appeal hearings.
During an interview on 05/24/23 at 10:40 AM, the Business Office Manager confirmed Resident #50 was not in attendance at the 03/14/23 appeals hearing. The Business Office Manager stated it was typically a social service function to identify if a resident should be in attendance at such meetings.
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CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Notification of Changes
(Tag F0580)
Could have caused harm · This affected 1 resident
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Based on policy review, record review, resident interview and staff interview, the facility failed to immediately inform a resident or the resident representative when there was a need to begin a ne...
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Based on policy review, record review, resident interview and staff interview, the facility failed to immediately inform a resident or the resident representative when there was a need to begin a new form of treatment or a change in care was required for two (2) or 32 residents reviewed. Resident #10's representative was not notified of a facility acquired pressure ulcer or the initiation of treatment for the pressure ulcer and Resident #30 was not notified of a change in a medical appointment. Resident identifiers: Resident #10 and Resident #30. Facility census: 115.
Findings included:
a) Policy Review
A review of the Policy for Notification of Change in Condition, titled Policy #NS1068-01, no date noted, showed under Circumstances requiring notification included but was not limited to, under item 3, Circumstances that require a need to alter treatment which may include a new treatment or discontinuation of a current treatment. Under the section Notifications, when a change in condition was noted, nursing staff would contact the resident and/or representative.
b) Resident #10
A record review for Resident #10, showed a skin condition assessment dated , 12/12/22, noting Resident #10 was identified as having a new pressure area on the right hip that improved from last assessment and the date the area was first observed was documented as 12/01/23. The pressure area was documented as being facility acquired.
A review of the physician's orders showed the start date of a treatment for the pressure ulcer on the right hip had an order date of 12/09/22 and an end date of 12/16/22. The order was obtained to treat R hip-unstagable ulcers cleanse area with wound cleanser and pat dry, apply Hydrogen to cover with dressing Monday, Wednesday and Friday and when necessary.
Further review of the medical record showed no evidence the resident's representative was notified of the unstagable pressure ulcer that was facility acquired or the treatment that was ordered to treat the pressure ulcer.
An interview with RN #133, on 05/24/23 at 9:12 AM, reviewed Resident #10's medical record and did not see any evidence the resident's representative had been notified of the pressure ulcer development or initiation of treatment. It was confirmed the resident did not have capacity and the representative did make decisions for the resident.
An interview with the Director of Nursing (DON), on 05/24/23 at 3:47 PM, confirmed after review, there was no evidence of the resident's representative being notified of the development and intimation of treatment of the right hip pressure ulcer. No additional information was provided at the time of exit.
b) Resident #30
During a Resident Council Meeting on 05/23/23 at 1:45 PM, Resident #30 reported the facility sometimes fails to keep residents informed of any changes in their scheduled appointments outside of the facility. Resident #30 went on to report he had a urology appointment scheduled on last Friday, 05/19/23, at 10:45 AM. Resident went on to report that he waited and waited and waited to be transported to the appointment. Resident reported it was a crazy day at the facility because there was a picnic scheduled for lunch. The Resident reported he eventually called the urologist office and was told that his appointment had been rescheduled to June 1st. Resident#30 reported being frustrated with the fact that he had not heard those details from the facility scheduler/transportation driver.
A brief record review, conducted on 05/23/23 at 3:40 PM, found the following details:
-Section C Cognitive Patterns of the Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD)) of 03/02/23, identified Resident #30 had a Brief Interview for Mental Status (BIMS) score of 15. The BIMS is a structured evaluation aimed at evaluating aspects of cognition in elderly patients. A score of 15 indicated Resident #30 was cognitively intact and had a high level of cognitive function.
-A Medication Administration Note, on 05/19/23 at 1:18 PM, stating the new urology appointment date had been scheduled for June 1st. This was the only note regarding the appointment being changed, and it was entered 2 1/2 hours after the original appointment time for 05/19/23 at 10:45 AM.
During an interview on 05/24/23 at 10:10 AM, the Scheduler/Transportation Driver #159 stated that to her recollection she would have informed Resident #30 of the rescheduled appointment. The Scheduler/Transportation Driver added that since Resident #30 was blind that he sometimes would confuse details of his appointment dates because he can't see the appointment cards. When questioned, the Scheduler/Transportation Driver reported she was not able to provide any evidence Resident #30 had been told about the rescheduled appointment.
During a meeting with Resident #30, on 05/24/23 at 2:35 PM, an observation found Resident #30 had a corkboard on the wall beside his bed. Hanging on the corkboard was the appointment card dated for May 19, 2023 at 10:45 AM. Resident #30 reported all appointment cards are posted on the corkboard as he receives them, and the nursing staff would defer to that appointment card if he ever had to question when his appointment was scheduled. Resident #30 added, Situations like thinking I am missing an appointment are very stressful. And it is not necessary.
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CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0582
(Tag F0582)
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 evidence the required Notification of Medicare Non-...
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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 evidence the required Notification of Medicare Non-Coverage (NOMNC) notice was issued in a timely fashion for one (1) of three (3) residents reviewed for beneficiary protection notification. This failure had the potential to place the resident at risk of not being informed of their rights prior to the end of Medicare Part A covered services. Resident identifier: #370. Facility census: 115.
Findings included:
a) Beneficiary Notice Review
On 05/23/23 at 11:00 AM, a review was completed regarding the beneficiary protection notification liability notice given for the following resident who was discharged home following her last covered day of Medicare Part A services:
-Resident #370's last covered day of Part A Services was on 01/02/23.
-Resident #370 was not issued a NOMNC.
-Resident #370 was discharged to home on [DATE].
The Form Instructions for the Notice of Medicare Non-Coverage (NOMNC) CMS-10123 state: The NOMNC must be delivered at least two (2) calendar days before Medicare covered services end . The instructions also state: A NOMNC must be delivered even if the beneficiary agrees with the termination of services.
Further record review found the following details:
-An admission Note, on 12/22/22 at 1:20 PM, which reflected Resident #370 was at the facility for a short-term skilled nursing facility stay for strength building. The resident's plan was to discharge to home once finishing the strength-building stay.
-A Social Service note, on 12/28/2022 at 11:10 AM, which stated, Patient has met the maximum potential with skilled services. Discharge has also been made at the request of the patient and/or her family. LCD [Last Covered Day] set for 1/2 - DC [Discharge] set for 1/3.
During an interview on 05/23/23 at 11:15 AM, the Director of Rehabilitation (rehab) DOR) #168 confirmed Resident #370's plan was to be discharged to home after therapy was completed. The DOR #168 stated the resident's last covered day of skilled care was on 01/02/23. Resident #370 had met the discharge goals.
During an interview on 05/23/23 at 12:05 PM, Social Worker #105 acknowledged the facility did not issue the NOMNC to Resident #370 prior to the last covered day of Medicare Part A skilled services, and stated it was the resident's choice to discharge to home and it had been considered a self-initiated discharge. Social Worker #105 acknowledged the social service note, dated 12/28/22 at 11:10 AM, specifically stated Resident #370 had met her maximum potential with skilled services and listed a last covered day of therapy. The Social Worker agreed the social service note could be interpreted to mean the resident felt her skilled therapy was ending and she had to choose to return home or choose to stay as a long-term care nursing home resident. Social Worker #105 agreed Resident #370's discharge was a planned discharge from the time she entered the facility on 12/22/22 and the Director of Rehab had reported Resident #370 had met her discharge goals. The Social Worker acknowledged it was the facility's responsibility to issue a NOMNC to a resident at least two calendar days before Medicare covered services are scheduled to end to respect a resident's right to appeal that decision.
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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 resident interview, record review, and staff interview, the facility failed to honor a resident's right to privacy and confidentiality for all aspects of care and services. This was a rando...
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Based on resident interview, record review, and staff interview, the facility failed to honor a resident's right to privacy and confidentiality for all aspects of care and services. This was a random opportunity for discovery. Resident identifier: #50. Facility census: 115
Findings included:
a) Resident #50
During an interview on 05/23/23 at 8:11 AM, Resident #50 reported being upset that the facility's Social Worker (SW) discussed private information about her finances and the fact that she was being discharged for nonpayment in front of her roommate.
A record review, completed on 05/23/23 at 7:02 PM, revealed the following:
- A Social Service Note, dated 4/25/2023 at 10:45 AM, which stated, This writer and Transportation Coordinator spoke with the patient at length regarding discharge planning. Patient reports that if she is unable to secure a HB (hospital bed), lift, and all other supplies/services necessary to ensure her discharge is safe, she states she will not be discharging . Patient's hearing date is 5/16 and she still won't make a decision as to where she's discharging.
- A Social Service Note, dated 04/25/2023 at 1:37 PM, which stated, Patient was transported to this writer's office in an obvious state of anger and quickly advised this writer that all discussions moving forward that pertain to her involuntary d/c [discharge] and discharge planning must take place in the SW [Social Work] office only. Patient pointed her finger at this writer while stating, 'I don't need to whole world to know my business.' Will honor.
During an interview on 05/24/23 at 8:39 AM, SW #105 recalled having the meeting in Resident #50's room on 04/25/23 at 10:45 AM. The SW reported Resident #50's door was not shut but that the privacy curtain had been pulled. SW #105 reported Resident #50's roommate was present and that her roommate has mental capacity to understand what had been discussed. The SW acknowledged the failure to request permission to discuss her current circumstances in her room or offer the option to meet someplace that would be more private. The SW agreed Resident #50 should have been afforded the right to privacy and confidentiality regarding her discharge for nonpayment.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on resident interview, observation and staff interview, the facility failed to maintain the walls of a resident's room a...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on resident interview, observation and staff interview, the facility failed to maintain the walls of a resident's room and keep a resident's wheel chair clean and odor free. These were random opportunity for discovery. Resident identifiers: #53 and room [ROOM NUMBER]. Facility census: 115.
Findings included:
a) Resident (R) #53
During an interview on 05/22/23 at 10:02 AM R#41 reported her roommate R#53 is frequently incontinent, her wheel chair smells of urine and is not cleaned regularly. R#41 pointed to the wheel chair in the hall and acknowledged it smells. An observation noted a strong odor of urine and multiple food crumbs in the seat and foot rest of the high back wheel chair.
At 11:03 AM on 05/23/23, Registered Nurse (RN) #10 and Central supply coordinator (CS) #138 confirmed R#53's wheel chair was full of food crumbs and smelled of urine. CS#138 removed the cushioned cover from the wheel chair and carried it to the laundry. After checking with the supervisor, laundry staff reported the cover could be put in wash machine and hung dry.
b) room [ROOM NUMBER]
An observation on 05/22/23 at 1:56 PM, revealed that under the sink the on the right side, the baseboard was peeling away and the wall was discolored in two (2) areas. Additionally, to the right side of the doorway, there was a section of the baseboard missing entirely. The missing section was approximately 12 - 16 in length. Both residents in the room reported, It's been this way for a while.
During an interview 05/24/23 at 10:21 AM, the Maintenance Director acknowledged the missing baseboard and the baseboard by the sink being in disrepair was not a homelike environment, stated housekeeping should have put in a work order for it to be corrected. The Maintenance Director then stated it would be addressed immediately.
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CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Abuse Prevention Policies
(Tag F0607)
Could have caused harm · This affected 1 resident
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Based on observation, staff interview, electronic medical record review and Operation Policy, the facility failed to follow written policy, thoroughly investigating and reporting to the proper agenc...
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Based on observation, staff interview, electronic medical record review and Operation Policy, the facility failed to follow written policy, thoroughly investigating and reporting to the proper agencies of an allegation of neglect. This has the potential to affect all residents that reside in the facility. Resident identifier: #4. Facility census: 115.
Findings Included:
A record review of the facility's policy titled, West Virginia Abuse, Neglect & Misappropriation, showed:
--Training
1) Provide education and training upon hire, annually and as needed for re-training to include not limited to:
a-Recognizing signs of abuse, neglect exploitation, and misappropriation of resident property, such as psychosocial and physical indicators (including injuries of unknown source)
--Reporting
1) The Executive Director / designee will report appropriate incidents to Office of Health Facilities Licensure and Certification (OHFLAC), Adult Protective Services (APS), the Regional Ombudsman, and other local authorities, including but not limited to local law enforcement (if appropriate), as required by the State.
a- If the events that cause allegation do not involve abuse and do not result in serious bodily injury, the self-report must be made immediately, but not later than 24 hours after discovery.
a) Resident #4
During a complaint survey on 05/23/23, the occurrence log revealed an incident on 05/18/23 for Resident #4:
-- 05/18/23 skin tear received during transfer (Resident stated that it happened when she was being moved/transferred from bed to chair. Her knee was bumped on the chair.)
Medical record review revealed a progress note on 5/18/2023 at 4:57 PM:
--Skin/Wound Note
Note Text: Trauma area to right knee noted today during morning rounds, Patient seen by the wound team, Area to knee is red with slight drainage noted no odor, Patient friend -------- has been informed of trauma to the right knee during transfer to Wheel chair, Physician ---- inform of trauma to right knee, Dressing with medihoney and to be changed every day, No pain or discomfort noted from patient, She is able to make needs known, Information has been care planned and area identified. (Transcribed as written)
Continued record review revealed, Resident #4 requires the use of hoyer lift, with two (2) person support.
On 05/24/23 at 3:55 PM the Director of Nursing (DON) stated that they are still investigating the incident, they only talked to the evening shift NA's. She verified that the incident was not reported to the appropriate agencies.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected 1 resident
Based on observation, staff interview, and operation policy the facility failed to report alleged violation related to, neglect, or abuse, and report the results of all investigation to the proper aut...
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Based on observation, staff interview, and operation policy 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 has the potential to affect all residents that reside in the facility. Facility census: 115.
Findings Include:
Record review of the facility's policy titled, West Virginia Abuse, Neglect & Misappropriation, showed:
--Training
1) Provide education and training upon hire, annually and as needed for re-training to include not limited to:
a-Recognizing signs of abuse, neglect exploitation, and misappropriation of resident property, such as psychosocial and physical indicators (including injuries of unknown source)
--Reporting
1) The Executive Director / designee will report appropriate incidents to OHFLAC, APS, the Regional Ombudsman, and other local authorities, including but not limited to local law enforcement (if appropriate), as required by the State.
a- If the events that cause allegation do not involve abuse and do not result in serious bodily injury, the self-report must be made immediately, but not later than 24 hours after discovery.
a) Resident #4
During a complaint survey on 05/23/23, the occurrence log revealed an incident on 05/18/23 for Resident #4:
-- 05/18/23 skin tear received during transfer (Resident stated that it happened when she was being moved / transferred from bed to chair. Her knee was bumped on the chair.)
Medical record review revealed a progress note on 5/18/2023 at 4:57 PM:
--Skin/Wound Note
Note Text: Trauma area to right knee noted today during morning rounds, Patient seen by the wound team, Area to knee is red with slight drainage noted no odor, Patient friend -------- has been informed of trauma to the right knee during transfer to Wheel chair, Physician ---- inform of trauma to right knee, Dressing with medihoney and to be changed every day, No pain or discomfort noted from patient, She is able to make needs known, Information has been care planned and area identified. (Transcribed as written)
Continued record review revealed, Resident #4 requires the use of hoyer lift, with two (2) person support.
On 05/24/23 at 3:55 PM the Director of Nursing (DON) stated that they are still investigating the incident, they only talked to the evening shift NA's. She verified that the incident was not reported to the appropriate agencies.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Investigate Abuse
(Tag F0610)
Could have caused harm · This affected 1 resident
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Based on observation, staff interview, and operation policy the facility failed to take actions to investigate an alleged violation related to, neglect and failed to take corrective actions followin...
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Based on observation, staff interview, and operation policy the facility failed to take actions to investigate an alleged violation related to, neglect and failed to take corrective actions following an investigation to re-educate staff after a resident injury. This has the potential to affect all residents that reside in the facility. Resident identifiers: #4, #13, #10. Facility census: 115.
Findings Included:
Record review of the facility's policy titled, West Virginia Abuse, Neglect & Misappropriation, showed:
--Training
1) Provide education and training upon hire, annually and as needed for re-training to include not limited to:
a-Recognizing signs of abuse, neglect exploitation, and misappropriation of resident property, such as psychosocial and physical indicators (including injuries of unknown source)
--Reporting
1) The Executive Director / designee will report appropriate incidents to OHFLAC, APS, the Regional Ombudsman, and other local authorities, including but not limited to local law enforcement (if appropriate), as required by the State.
a- If the events that cause allegation do not involve abuse and do not result in serious bodily injury, the self-report must be made immediately, but not later than 24 hours after discovery.
a) Resident #4
During a complaint survey on 05/23/23, the occurrence log revealed an incident on 05/18/23 for Resident #4:
-- 05/18/23 skin tear received during transfer (Resident stated that it happened when she was being moved / transferred from bed to chair. Her knee was bumped on the chair.)
Medical record review revealed a progress note on 5/18/2023 at 4:57 PM:
--Skin/Wound Note
Note Text: Trauma area to right knee noted today during morning rounds, Patient seen by the wound team, Area to knee is red with slight drainage noted no odor, Patient friend -------- has been informed of trauma to the right knee during transfer to Wheel chair, Physician ---- inform of trauma to right knee, Dressing with medihoney and to be changed every day, No pain or discomfort noted from patient, She is able to make needs known, Information has been care planned and area identified. (Transcribed as written)
Continued record review revealed, Resident #4 requires the use of hoyer lift, with two (2) person support.
On 05/24/23 at 3:55 PM the Director of Nursing (DON) stated that they are still investigating the incident, they only talked to the evening shift NA's. She verified that the incident was not reported to the appropriate agencies.
b) Resident #13
During a complaint survey on 05/23/23, the occurrence log revealed an incident on 11/03/22 for Resident #13.
Record review of the grievance form completed 11/03/22 revealed Resident #13 stated that her skin tear to her left lower shin was caused during transport due to improper seat belt restraint.
Continued record review of the Reportable from the incident on 11/03/22 revealed:
Resident has a skin tear to the lower left extremity. Patient states it was due to not being strapped in during transport to the pain clinic.
Resident #14's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/22/22 noted the resident had a score for Brief Interview for Mental Status (BIMS) of 15. A BIMS score of 15 indicates that the resident is cognitively intact and has capacity.
Review of the five 5-day follow-up revealed:
Reportable reviewed incident on 11/3/22 - Substantiated the skin tear happened during transport but found the allegation of improper seatbelt restraint inconclusive.
On 05/24/23 at 1:22 PM the Administrator stated there was no follow up re-education completed for the van driver after the incident.
c) Resident #10
A review of the policy and procedure, titled, [NAME] Virginia Abuse, Neglect and Misappropriation, policy NS 1018-03, no date, showed under Section V., Investigation of Incidents, items g. and h. noted by the fifth day, the alleged abuse investigation form would be completed and reviewed for completeness and accuracy. The investigation file would be kept in a confidential file and the file would be accessible for follow-up.
A review of the facility's reportable occurrences showed an allegation dated, 11/23/22, describing an incident alleging Resident #10 not receiving incontinence care in a timely manner on 11/23/23. Further review of the investigation, showed no evidence of a thorough investigation being conducted. The outcome of the investigation noted the allegation of incontinence care not provided had been unsubstantiated. The investigation provided by the facility, showed copies of Activities of Daily Living (ADLs) sheets which included Bed Mobility, Bladder Continence, Toilet use, Turning and Repositioning, Bowel Movements for the dates 11/10/23 through 11/23/23. There was no evidence of staff interviews being conducted with assigned staff for the date of the allegation or staff statements obtained. There was no evidence the resident's skin was assessed as part of the investigation. There was on evidence of a summary of the investigation maintained by the facility .
An interview with the Director of Nursing (DON), on 05/24/23 at 12:55 PM, revealed after researching the allegation, there was no evidence of a thorough investigation being conducted prior to making the determination the complaint allegation was not substantiated. Further interview at this time, with the DON, confirmed staff had been interviewed but the facility failed to keep a record of these interviews. The DON, agreed the investigation was not thorough and a summary was not maintained for review and should have been.
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CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Transfer Notice
(Tag F0623)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on medical record review and staff interview, the facility failed to provide evidence the long-term care Ombudsman was p...
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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 the long-term care Ombudsman was provided a copy of the written Notice of Transfer for two (2) acute hospital transfer/discharges for Resident #92. This was true for one (1) of two (2) residents reviewed for hospitalizations. Resident identifier: #92. Facility census: 115.
Findings included:
a) Resident #92
A medical record review was completed on 05/23/23 at 11:00 AM. There was no evidence the facility had provided a copy of the written Notice of Transfer/Discharge for Resident #92 to the long-term care Ombudsman for an acute hospital transfer/discharge on [DATE] or for another acute hospital transfer/discharge on [DATE].
In an interview on 05/24/23 at 11:11 AM, the Director of Nursing (DON) reported the facility could not produce evidence that the Ombudsman had been notified.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0625
(Tag F0625)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on medical record review and staff interview, the facility failed to notify the resident/resident representative of the ...
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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 notify the resident/resident representative of the facility bed hold when transferred. This was true for one (1) of two (2) residents reviewed for hospitalizations. Resident identifier: #92. Facility census: 115.
Findings included:
a) Resident #92
A medical record review was completed on 05/23/23 at 11:00 AM. There was no evidence the facility had provided a bed hold notice for an acute hospital transfer/discharge on [DATE].
In an interview on 05/24/23 at 11:11 AM, the Director of Nursing (DON) reported the facility had not provided a bed hold notice for the 05/10/23 discharge because the facility had initially thought it was discharging Resident #92 to the behavioral health treatment center as opposed to the resident having a short-term stay for stabilization purposes and then returning to their facility.
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CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
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Based on observation, policy review and staff interview, the facility failed to develop a comprehensive care plan for Aerosol droplet precautions. This was true for two (2) of thirty two (32) care p...
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Based on observation, policy review and staff interview, the facility failed to develop a comprehensive care plan for Aerosol droplet precautions. This was true for two (2) of thirty two (32) care plan records reviewed. Resident identifiers: #88 and #91. Facility Census: #115.
Findings included:
a) Resident #88
On 05/22/23 at 2:32 PM during the initial interview phase of the Long Term Care Survey Process it was noted that there was a transmission based precaution (TBP) donning/doffing station outside of Resident #88's room. There was however, no signage on the door to instruct what kind of precautions or what personal protective equipment (PPE) was needed. According to Licensed Practical Nurse (LPN) #4 the resident has nebulizer treatments ordered and the PPE is for treatments. The order states: Albuterol Sulfate inhalation Neulization Solution 2.5 MG/0.5 ML (Albuterol Sulfate) 1 vial inhale orally via nebulizer every 4 hours as needed for COPD. and DuoNeb Solution 0.5-2.5 (3) MG/3 ML (Ipratropium-Albuterol 1 application via mask every 6 hours as needed for COPD.
According to the Guidance for Aerosol Generating Procedures dated 02/03/22, An N95 mask, and full PPE must be worn with all aerosol generating procedures.close the door to the resident room before performing treatment. Keep door closed throughout treatment and for one hour post treatment if it is safe to do so .
On 05/23/23 at 12:35 PM during an interview with LPN #8 she states if a resident has a nebulizer treatment ordered and is in a semi private room, the only special procedure she would have to do would be to pull the curtain around the room mates bed. She would not have to wear any PPE unless the resident had a multidrug-resistant organism (MDRO) or COVID, she would not have to place any signs on the door reflecting that they are having a nebulizer treatment. It was explained to her that this was incorrect and the correct procedure was available with the Director of Nursing (DON).
According to the DON on 05/24/23 at 2:00 PM, there are Aerosol-Generating Procedure in Progress signs available which indicates what PPE is required to enter the room along with instructions to KEEP DOOR CLOSED DURING USE AND 1 HOUR POST TREATMENT (See nurse for time frames). The DON further confirmed there should be an order reading: Aerosol Droplet Precautions during nebulizer treatments: Please close door, pull privacy curtain, DON PPE during treatment, display Aerosol Droplet Precaution sign and remove once treatment is completed. Disinfect equipment and surrounding areas once treatment is completed.
There was no care plan developed for aerosol generating precautions and this was confirmed with the DON on 05/24/23 at 2:10 PM.
b) Resident #91
During a medical record review on 05/22/23, it was discovered the comprehensive care plan had not been developed for aerosol treatments or droplet precautions for Resident #91. Further investigation revealed an order as written: Albuterol Sulfate Nebulization Solution 1 vial inhale orally via nebulizer every 4 hours as needed for wheezing with a start date of 03/23/23.
In an interview with the Director of Nursing (DON) on 05/22/23 at 1:42 PM, verified the comprehensive care plan had not been developed for use of aerosol treatments or droplet precautions.
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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
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Based on observation, record review and staff interviews, the facility failed to revise care plans for two (2) of 32 resident's care plans during the Long Term Care Survey Process. Resident #3's had...
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Based on observation, record review and staff interviews, the facility failed to revise care plans for two (2) of 32 resident's care plans during the Long Term Care Survey Process. Resident #3's had not been revised for a nutritional intervention and Resident #421 had not been revised for hospice services. Resident identifiers: #3 and #42. Facility census: 115.
Findings included:
a) Resident #3
During a medical record review on 05/22/23 for Resident #3 revealed the care plan had not been revised for the nutritional intervention to add a double entree' portion with meals/per dialysis for protein with a start date of 01/23/23.
In an interview with the Director of Nursing (DON) on 05/24/23 at 9:37 AM, verified the care plan was not revised to include the order for double entree portions for meals with a start date of 01/23/23.
b) Resident #421
On 05/22/23 at 1:33 PM a record reviewed showed there was no order for hospice care while it was on the facility matrix as an active resident under hospice care.
Record review of the care plan and an interview on 05/23/23 at 1:51 PM with the DON confirmed that Resident #421 is currently under Hospice as of 05/09/23.
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CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
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Based on record review and staff interview, the facility failed to follow a physician's orders for weekly weights and the administration of pain medication for a Hospice resident was not followed. T...
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Based on record review and staff interview, the facility failed to follow a physician's orders for weekly weights and the administration of pain medication for a Hospice resident was not followed. These were random opportunities for discovery with the potential to affect a limited number of residents. Resident identifiers: #424 and #57. Facility census: 115.
Findings included:
a) Resident #424
On 05/24/23 at 04:08 PM, it was noted the facility did not follow physicians orders for administering pain medication for Resident #424.
The Physicians order with a revision date of 11/19/22 was for Oxycodone HCL tablet 5 mg give 1.5 tablet by mouth every 6 hours for pain.
For the review period of 11/01/22 through 12/31/22 there were nine (9) doses of Oxycodone not administered. Resident #424 was under Hospice care for end of life care during this time period.
Further record review of the Medication Administration Record (MAR) shows the following:
On 11/17/22 at 6:00 AM the medication was signed out of the narcotic count log by Registered Nurse #129 but not documented as being administered.
On 11/22/22 at 6:00 PM the medication was signed out of the narcotic count log by Licensed Practical Nurse (LPN) #103 but not documented as being administered.
On 11/25/22 at 6:00 AM the medication was signed out of the narcotic count log by LPN #191 but not documented as being administered.
On 11/28/22 at 12:00 Noon the medication was not documented as being administered and according to the DON there is no narcotic sign out sheet available for this date and time.
On 12/07/22 at 12:00 midnight the medication was signed out of the narcotic count log by RN #129 but not documented as being administered.
On 12/07/22 at 6:00 AM the medication was signed out of the narcotic count log by RN #129 but not documented as being administered.
On 12/13/22 at 6:00 AM the medication was signed out of the narcotic count log by LPN #141 but not documented as being administered.
On 12/27/22 at 12:00 midnight the medication was signed out of the narcotic count log by LPN #141 but not documented as being administered.
On 12/27/22 at 06:00 AM the medication was signed out of the narcotic count log by LPN #41 but not documented as being administered.
The above information was confirmed by the Director of Nursing on 05/24/23 at 3:50 PM.
b) Resident #57
Record review, completed on 05/22/23 at 3:28 PM, found the following details:
-Resident #57 had experienced significant weight loss in the last six (6) months. Resident had a 17.10% weight loss from December 2022 - May 2023.
-There was a physician order, dated 04/19/23, for weekly weights for four (4) weeks due to weight loss.
-There were only two (2) weekly weights, one (1) on 04/26/23 and one (1) on 05/02/23 recorded in the electronic medical record.
During an interview on 05/24/23 at 12:00 PM, the Assistant Director of Nursing (ADON) stated weights were always documented in the electronic medical record. The ADON went on to state that the physician order was not followed, and only two (2) of the four (4) weekly weights had been obtained.
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CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Pressure Ulcer Prevention
(Tag F0686)
Could have caused harm · This affected 1 resident
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Based on record review and staff interview, the facility failed to provide care and treatment, based on the comprehensive assessment of the resident, to ensure a resident received care, consistent w...
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Based on record review and staff interview, the facility failed to provide care and treatment, based on the comprehensive assessment of the resident, to ensure a resident received care, consistent with professional standards of practice, for pressure ulcer care. This was found true for one (1) of five (5) residents reviewed for pressure ulcer care. Resident #10 developed a facility acquired pressure ulcer, however, there were inconsistencies with the identification and time treatment was started to ensure monitoring of the healing process for the pressure ulcer. Resident Identifier: Resident identifier: #10. Facility census: 115.
Findings included:
a) Resident #10
An interview, with the Treatment Nurse, on 05/23/23 at 8:24 AM, revealed the facility's policy is to perform weekly measurements of a pressure ulcer. Additionally, the Treatment Nurse confirmed, when a pressure ulcer was identified, the date would be documented the pressure ulcer was identified and treatment initiated.
A record review for Resident #10, showed documentation of a skin assessment being completed on 12/12/22, indicating an unstageable wound located on the right throatier (hip) that was first observed on 12/01/22.
Further review, showed no evidence of documentation of the wound, including length, width, depth and stage with a description of the wound appearance for the initial observation on 12/01/22.
Weekly documentation of skin checks, dated 12/08/22, showed an incomplete assessment of the pressure ulcer identified on 12/01/22. There was no evidence the pressure ulcer was measured, with color of the wound noted, moisture, integrity or turgor, response to treatment or a summary of the assessment.
A review of the physician's orders, for Resident #10, showed an order dated 12/09/22, and discontinued on 12/12/22, for Right hip unstageable ulcer to be cleansed ;with wound cleanser and Hydrogel with a dressing Monday, Wednesday and Friday. There was no evidence a treatment was initiated after the ulcer was assessed on 12/01/22.
An interview, with the Director of Nursing (DON), on 05/24/23 at 3:00 PM, confirmed the skin assessment was dated 12/01/22 as identification of a new facility acquired pressure ulcer with treatment noted to begin on 12/9/22. The DON stated there were inconsistencies with documentation of the pressure ulcer and would further investigate to determine if additional information could be located.
An additional interview with the DON, on 05/24/22 at 3:47 PM, confirmed the care and treatment of Resident #10's pressure ulcer was not provided in accordance with standards of practice for pressure ulcer care and after further review, no additional evidence was located. The DON stated I have looked and there is nothing.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0730
(Tag F0730)
Could have caused harm · This affected 1 resident
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Based on employee record review and staff interview, the facility failed to ensure Employee #44 and #148 had completed the required annual 12 hours of in-services for dementia and abuse prevention. ...
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Based on employee record review and staff interview, the facility failed to ensure Employee #44 and #148 had completed the required annual 12 hours of in-services for dementia and abuse prevention. This deficient practice was found true for two (2) of five (5) employee records reviewed for staffing. Employee identifiers: #44 and #148. Facility Census: 115.
Findings included:
a) Required annual 12 hour in-services
During a review of employee records on 05/23/23, it was discovered employee Nurse Aide (NA) #44 and NA #148 had not completed addressing areas of the required annual in-services to include special resident needs, needs of residents with cognitive impairments, and abuse prevention.
In an interview with the Nursing Home Administrator (NHA) 05/24/23, verified NA #44 and #148 had not completed the required annual in-services to include dementia, cognitive impairments and abuse prevention.
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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 a review of staff postings and staff interview, the facility failed to display the required data on the daily Staff Postings. This was a random opportunity for discovery and affected a limi...
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Based on a review of staff postings and staff interview, the facility failed to display the required data on the daily Staff Postings. This was a random opportunity for discovery and affected a limited number of residents and visitors. Facility census: 115.
Findings included:
During a review of the staff postings on 05/23/23, it was discovered the daily staff postings for 05/01/23 to 05/22/23 had no daily census. The facility must post the following information on a daily basis:
1. Facility name.
2. The current date.
3. The total number .
4. Resident census.
In an interview with the Nursing Home Administrator (NHA) on 05/24/23 at 1:20 PM, verified the Staff Postings did not include the daily census.
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CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0883
(Tag F0883)
Could have caused harm · This affected 1 resident
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Based on medical record review and staff and interview, the facility failed to ensure each resident and/or representative is educated on the risks and benefits and given the opportunity to accept or...
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Based on medical record review and staff and interview, the facility failed to ensure each resident and/or representative is educated on the risks and benefits and given the opportunity to accept or decline the pneumonia vaccine prior to administration. This is true for one (1) of five (5) residents reviewed for immunizations. Resident identifier: #40 Facility census: 115.
Findings include:
a) Resident (R) #40
Review of the medical record on 05/22/23, found R#40 received the pneumococcal conjugate 20 (PCV20) vaccine on 09/05/22. The record lacks information related to education given to the resident on the risks and benefits of the vaccine and a consent to receive the PCV20 on 09/05/22.
During an interview on 05/22/23 at 3:35 PM, the Infection Preventionist/Registered Nurse #23 acknowledged the medical record lacked a consent for the PCV20 vaccine administered to R#40 on 09/05/22.
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CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0697
(Tag F0697)
Could have caused harm · This affected multiple residents
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Based on record review and staff interview, the facility failed to administer pain medication as ordered by the physician. This was true for one (1) of five (5) records reviewed for pain management....
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Based on record review and staff interview, the facility failed to administer pain medication as ordered by the physician. This was true for one (1) of five (5) records reviewed for pain management. This failed practice has the potential to affect a limited number of resdents. Resident identifier: #424 Facility census: #115.
Findings included:
a) Resident #424
On 05/24/23 at 4:08 PM, it was noted the facility did not follow physicians orders for administering pain medication for Resident #424.
The physicians order with a revision date of 11/19/22 was for Oxycodone HCL tablet 5 mg give 1.5 tablet by mouth every 6 hours for pain.
For the review period of 11/01/22 through 12/31/22 there were nine (9) doses of Oxycodone not administered. Resident #424 was under Hospice care for end of life care during this time period.
Further review of the Medication Administration Record (MAR) shows the following:
On 11/17/22 at 6:00 AM the medication was signed out of the narcotic count log by Registered Nurse #129 but not documented as being administered.
On 11/22/22 at 6:00 PM the medication was signed out of the narcotic count log by Licensed Practical Nurse (LPN) #103 but not documented as being administered.
On 11/25/22 at 6:00 AM the medication was signed out of the narcotic count log by LPN #191 but not documented as being administered.
On 11/28/22 at 12:00 Noon the medication was not documented as being administered and according to the Director of Nursing (DON) there is no narcotic sign out sheet available for this date and time.
On 12/07/22 at 12:00 midnight the medication was signed out of the narcotic count log by RN #129 but not documented as being administered.
On 12/07/22 at 6:00 AM the medication was signed out of the narcotic count log by RN #129 but not documented as being administered.
On 12/13/22 at 6:00 AM the medication was signed out of the narcotic count log by LPN #141 but not documented as being administered.
On 12/27/22 at 12:00 midnight the medication was signed out of the narcotic count log by LPN #141 but not documented as being administered.
On 12/27/22 at 6:00 AM the medication was signed out of the narcotic count log by LPN #41 but not documented as being administered.
The above information was confirmed by the DON on 05/24/23 at 3:50 PM.
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CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Drug Regimen Review
(Tag F0756)
Could have caused harm · This affected multiple residents
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Based on staff interview, medical record review, and policy review, the facility failed to ensure monthly medication regimen reviews (MRR) were completed by a pharmacist and the physician responded ...
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Based on staff interview, medical record review, and policy review, the facility failed to ensure monthly medication regimen reviews (MRR) were completed by a pharmacist and the physician responded to the pharmacy recommendations in a timely manner. This is true for four (4) of five (5) reviewed for unnecessary medications. Resident identifiers: #7, #34, #8, #22. Facility census: 115.
Findings include:
a) Policy
The facility policy titled Medication Regimen Review with a review date of 02/28/23, states non-urgent medication irregularities will be addressed with the attending physician no later than the next routine visit. The attending physician must document in the medical record the identified irregularity reviewed, any action taken to address rational for declining the recommendation.
b) Resident (R) #7
Review of the medical record on 05/23/23 revealed there were no MRR for October 2022, November 2022 and February 2023. In addition, the medical record lacks a physician response to the MRR dated 08/27/22. The MRR date 08/27/22 requests a gradual dose reduction for R#7's medications to treat depression and anxiety. Current medications include Trintellix (antidepressant) 20 milligrams (mg) daily, Ativan (antianxiety) 0.5 mg three (3) times a day and Buspar (antianxiety) 5 mg twice a day.
During an interview on 05/24/23 at 8:00 AM, the Director of Nursing (DON) reported the facility changed pharmacists and there were no monthly MRR completed for R#34 for October and November 2022. During a follow up interview on 05/24/23, the DON acknowledged she was unable to find the physician response for the MRR dated 08/27/22.
c) Resident (R) #34
A review of the medical record on 05/23/23 revealed there were no MRR's for October 2022, November 2022, December 2022, and February 2023. In addition, there is no physician response to the MRR completed on 04/29/23. The MRR dated 04/29/23 identifies a polypharmacy concern noting 26 active medication orders. The pharmacist requested the physician evaluate the following medications for possible discontinuation: Senokot S (laxative) one daily, Miralax (laxative) 17 grams daily, vitamin D3 5000 international units daily, Melatonin (alternative therapy sleep aide) 6 milligrams (mg) at bedtime which is being given with Trazadone (antidepressant they may help with sleep) 50 mg at bedtime. The pharmacist also noted the order for Singulair 10 mg daily for chronic obstructive pulmonary disease (COPD), stating this is not indicated for use in COPD. In addition, the pharmacist recommended the Lidocaine patch order be amended to state the patch is to be warn 12 hours daily and a notation should be made when the patch is removed. The Medication Administration Record (MAR) for May 2023 note the above medications are still active, the Singulair order is not corrected, and the Lidocaine patch order is not amended to include a sign off when the patch is removed after 12 hours.
During an interview on 05/24/23 at 8:00 AM, the Director of Nursing (DON) reported the facility changed pharmacists and there were no monthly MRR completed for R#34 for October 2022, November 2022, December 2022 and February 2023. The DON noted the MRR dated 04/29/23 is still in the physician's folder waiting to be reviewed. When asked how often he visits the facility, the DON stated he is in the building every Monday and Wednesday and every other Friday. The DON added she has been struggling with getting the physician to review the MRR and respond.
At 8:10 AM on 05/24/23, Registered Nurse #23 acknowledged R#34's MAR has not changed and the medication orders were not updated since the pharmacy recommendations were made on 04/29/23.
d) Resident #8
During a medical record review on 05/23/23, it was discovered the Pharmacist had not completed the MRR for 10/22 and 11/22. Also the MRR completed on 08/27/22 for a recommended dose reduction for Trazodone 50 milligrams (mg) had no response from the physician and or designee.
In an interview with the DON on 05/24/23 at 10:00 AM, verified she was unable to locate the MRR's for 10/22 and 11/22 and the Pharmacy MRR recommendation to review Trazodone on 08/27/22 had no response from the physician and or designee.
e) Resident #22
A record review, completed on 05/23/23 at 8:00 PM, revealed there were no medication regimen reviews on file for the months of October 2022, November 2022, and February 2023.
During an interview on 05/24/23 at 11:15 AM, the DON reported the facility could not provide evidence monthly mediation reviews were completed for October 2022 and November 2022 noting that was during the timeframe the facility was switching pharmacists. At that time, the DON stated she would have to check on the month of February 2023.
On 05/24/23 at 1:26 PM, the DON reported the facility could not produce evidence a monthly medication review had been completed by the pharmacist in February 2023.
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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 resident interviews during resident council, and staff interview, the facility failed to ensure a substantial/nourishing snack was provided as ordered and/or offered if of ordered between t...
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Based on resident interviews during resident council, and staff interview, the facility failed to ensure a substantial/nourishing snack was provided as ordered and/or offered if of ordered between the evening meal and breakfast. This had the ability to affect all residents who did not have a dietary order to receive an evening snack. Resident identifiers: #61, #30, #54, #36, and #9. Facility Census: 115.
Findings included:
a) Resident Council Meeting
During the resident council meeting on 05/23/23 at 1:00 PM, all residents in attendance stated the facility did not offer an evening snack to residents. They went on to say they would like an evening snack and felt the majority of facility residents would enjoy a bedtime snack. One (1) resident stated, They used to do that, but they don't do it anymore. Another resident reported being told by staff that the new ownership doesn't like to provide the snacks and the individual should probably have family bring them. When asked if all residents in the facility had ever been told they could request an evening snack, resident council members did not recall ever being told that was an option.
b) Record Review
A brief medical record review, completed on 05/23/23 at 8:05 PM, involved review of the resident council members' Brief Interview for Mental Status (BIMS) scores. The Brief Interview for Mental Status (BIMS) is a structured evaluation aimed at evaluating aspects of cognition in elderly patients. The three parts of the assessment look at patient attention, level of orientation, and the ability to recall information. A score ranging between 13-15 indicates a resident is cognitively intact and has a high level of cognitive function.
Five (5) out of the six (6) resident council members in attendance were cognitively intact as indicated by their BIMS score:
-Section C Cognitive Patterns of the Quarterly Minimum Data Set, with an assessment reference date of 03/17/23, identified Resident #61 had a Brief Interview for Mental Status score of 13.
-Section C Cognitive Patterns of the Quarterly Minimum Data Set, with an assessment reference date of 03/02/23, identified Resident #30 had a Brief Interview for Mental Status score of 15.
-Section C Cognitive Patterns of the Annual Minimum Data Set, with an assessment reference date of 04/11/23, identified Resident #54 had a Brief Interview for Mental Status score of 15.
-Section C Cognitive Patterns of the Quarterly Minimum Data Set, with an assessment reference date of 03/08/23, identified Resident #5 had a Brief Interview for Mental Status score of 15.
-Section C Cognitive Patterns of the Quarterly Minimum Data Set, with an assessment reference date of 04/25/23, identified Resident #9 had a Brief Interview for Mental Status score of 15.
c) Interview with Culinary Director
The aforementioned details were reviewed with the facility's Culinary Director on 03/24/23 at 3:30 PM. When asked to explain the facility's protocol for delivering evening snacks to the floor, the Culinary Director explained that all physician ordered snacks are taken to the floor at 8:00 PM and are labeled by resident. The Culinary Director also stated that any resident with a diagnosis of diabetes would have a snack like graham crackers that would be labeled with their name. When asked if residents without a physician order for a snack or a diagnosis for diabetes wanted an evening snack what the protocol would be, the Culinary Director stated the floor has a pantry where nursing staff could access snacks, upon request. The Culinary Director reported it was not facility protocol to ask each resident if he or she would like an evening snack, that it would be up to each individual resident to understand they needed to make the request.
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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 complete labeling and dates on refrigerator and freezer items in accordance with professional standards for food service safety relat...
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Based on observation and staff interview, the facility failed to complete labeling and dates on refrigerator and freezer items in accordance with professional standards for food service safety related to storage. This has the ability to affect all Residents that receive their nutrition from the kitchen and pantries. Facility census: 115.
Findings included:
Record review of the facility's policy titled, Food Storage with revision date 09/2017, showed that All food will be stored wrapped or covered containers, labeled, and dated, and arranged in a manner to prevent cross contamination.
a) Kitchen
During the initial kitchen tour on 05/22/23 at 9:15 AM, an observation found:
--Walk-in Freezer- pork Butcher Box, 2 hamburger patties, large package of hot dogs, chicken crumbles, were not labeled or dated.
Walk-in Freezer- Box of sausage patties, Chicken pieces and a pork roast, not closed, open to air.
During an interview on 05/22/23 at 9:22 AM, the Dietary Director confirmed the items were not labeled and stated that all food items should be labeled and dated.
b) Resident North Pantry's
--2 bowls of cereal, and a piece of cake, not labeled or dated.
--Two old brown boiled eggs in a bowl in the upper cabinet.
During an interview on 05/22/23 at 9:34 AM., Dietary Director confirmed the items were not labeled and stated that all food items should be labeled and dated.
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CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Garbage Disposal
(Tag F0814)
Could have caused harm · This affected multiple residents
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Based on observation and staff interview, the facility failed to store garbage and refuse in a proper manner. One (1) dumpster did not have a lid, the area was polluted with garbage and used medical...
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Based on observation and staff interview, the facility failed to store garbage and refuse in a proper manner. One (1) dumpster did not have a lid, the area was polluted with garbage and used medical supplies. This has the potential to affect all residents that reside in the facility. Facility census: 115.
Findings included:
a) Dumpster area
An observation on 05/24/23 found on the ground around the dumpster area was polluted with garbage, bags full of trash, and used medical supplies.
On 05/24/23 at 1:57 PM during an interview the Maintenance Director verified the garbage was not disposed of correctly. He stated that the lid to the dumpster has been gone for a while.
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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 a complete and accurate medical record for four (4) of thirty-two (32) records reviewed. Resident identifiers: #88, #421, ...
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Based on record review and staff interview, the facility failed to maintain a complete and accurate medical record for four (4) of thirty-two (32) records reviewed. Resident identifiers: #88, #421, #91 and #91. Facility census: 115.
Findings included:
a) Resident #88
On 05/22/23 at 2:32 PM it was noted that there was a transmission based precaution (TBP) donning/doffing station outside of Resident #88's room. There was however, no signage on the door to instruct what kind of precautions or Personal Protective Equipment (PPE) was needed.
According to Licensed Practical Nurse (LPN) #4 the resident had nebulizer treatments ordered and the PPE is for treatments. The order states: Albuterol Sulfate inhalation Neulization Solution 2.5 MG/0.5 ML (Albuterol Sulfate) 1 vial inhale orally via nebulizer every 4 hours as needed for COPD. and DuoNeb Solution 0.5-2.5 (3) MG/3 ML (Ipratropium-Albuterol 1 application via mask every 6 hours as needed for COPD.
According to the Director of Nursing (DON) on 05/24/23 at 2:00 PM, there should be an order reading: Aerosol Droplet Precautions during nebulizer treatments: Please close door, pull privacy curtain, DON PPE during treatment, display Aerosol Droplet Precaution sign and remove once treatment is completed. Disinfect equipment and surrounding areas once treatment is completed.
b) Resident #421
On 05/22/23 at 1:33 PM it was noted on the facility matrix Resident #421 was under Hospice services.
A record review shows there was no order for hospice care.
On 05/23/23 at 1:51 PM, it was confirmed with the DON that Resident #421 was on Hospice at this time and there should be a physicians order for Hospice.
c) Resident #91
During a medical record review on 05/23/23, it revealed there was an incomplete physician's orders for aerosol treatments, which did not include droplet precautions for Resident #91.
In an interview on 05/23/23 at 1:42 PM with the DON, verified the order was incomplete and did not include droplet precautions for aerosol treatments.
d) Resident #91 - Incorrect date for last covered day of skilled service
On 05/23/23 at 11:00 AM, a review was completed regarding the beneficiary protection notification liability notice given for the following resident who remained in the facility following the last covered day of Medicare Part A services:
-Resident #91's last covered day of Medicare Part A Services was on 04/06/23.
-Resident #91 was issued a Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNFABN) on 04/04/23 which listed her last covered day of Medicare Part A Services as 04/05/23.
The SNFABN read, Beginning on 04/05/23, you may have to pay out of pocket for this care if you do not have other insurance that may cover these costs.
During an interview, on 05/23/23 at 12:40 PM, the Social Worker #105 reported the 04/05/23 date was listed in error and the correct last covered date of Medicare Part A Services was 04/06/23.
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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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Based on observation, record review, staff interview and policy review, the facility failed to have signage on the door and/or a donning/doffing station available at the door of a resident's room de...
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Based on observation, record review, staff interview and policy review, the facility failed to have signage on the door and/or a donning/doffing station available at the door of a resident's room designated as a transmission-based precaution (TBP) room. Resident Identifiers: #88, #114, #111 and #101 Facility census: 115.
Findings included:
a) Policy review
According to the Guidance for Aerosol Generating Procedures dated 02/03/22, An N95 mask, and full PPE must be worn with all aerosol generating procedures.close the door to the resident room before performing treatment. Keep door closed throughout treatment and for one hour post treatment if it is safe to do so .
b) Resident #88
On 05/22/23 at 2:32 PM it was noted that there was a donning/doffing transmission based precaution (TBP) station outside of Resident #88's room. There were however, no signage on the door to instruct what kind of precautions or Personal Protective Equipment (PPE) was needed. According to Licensed Practical Nurse (LPN) #4 the resident has nebulizer treatments ordered and the PPE is for treatments. The order states: Albuterol Sulfate inhalation Nebulization Solution 2.5 MG/0.5 ML (Albuterol Sulfate) 1 vial inhale orally via nebulizer every 4 hours as needed for COPD. and DuoNeb Solution 0.5-2.5 (3) MG/3 ML (Ipratropium-Albuterol 1 application via mask every 6 hours as needed for COPD.
On 05/23/23 at 12:35 PM during an interview with LPN #8 stated that if a resident has a nebulizer treatment ordered and is in a semi private room, the only special procedure she would have to do would be to pull the curtain around the room mates bed. She would not have to wear any PPE unless the resident had a multidrug-resistant organism (MDRO) or COVID, she would not have to place any signs on the door reflecting that they are receiving a nebulizer treatment.
According to the DON on 05/24/23 at 2:00 PM, there were Aerosol-Generating Procedure in Progress signs available which indicates what PPE is required to enter the room along with instructions to KEEP DOOR CLOSED DURING USE AND 1 HOUR POST TREATMENT (See nurse for time frames). She also confirmed that such a sign should be on each door that has nebulizer treatments ordered.
c) Resident #114
On 05/22/23 at 2:40 PM it was noted that there was a donning/doffing TBP station outside of Resident #88's room. There were however, no signage on the door to instruct what kind of precautions or PPE were needed. According to LPN #4 the resident had nebulizer treatments ordered and the PPE was for treatments.
The order states: Albuterol Sulfate inhalation Nebulization Solution 2.5 MG/0.5 ML (Albuterol Sulfate) 1 inhalation inhale orally via nebulizer four times a day for COPD. There is also an order that reads Aerosol Droplet Precautions during nebulizer treatments: Please close door, pull privacy curtain, DON PPE during treatment, display Aerosol Droplet Precaution sign and remove once treatment is completed. Disinfect equipment and surrounding areas once treatment is completed. Four(4) times a day.
On 05/23/23 at 12:35 PM during an interview with LPN #8 she states if a resident has a nebulizer treatment ordered and is in a semi private room, the only special procedure she would have to do would be to pull the curtain around the room mates bed. She would not have to wear any PPE unless the resident had a multidrug-resistant organism (MDRO) or COVID, she would not have to place any signs on the door reflecting that they are having a nebulizer treatment.
According to the DON on 05/24/23 at 2:00 PM, there were Aerosol-Generating Procedure in Progress signs available which indicates what PPE is required to enter the room along with instructions to KEEP DOOR CLOSED DURING USE AND 1 HOUR POST TREATMENT (See nurse for time frames). She also confirmed that such a sign should be on each door that has nebulizer treatments ordered.
d) Resident #111
On 05/22/23 at 2:50 PM it was noted that there was a donning/doffing transmission based precaution station outside of Resident #88's room. There was however, no signage on the door to instruct what kind of precautions or PPE were needed. According to LPN #4 the resident had nebulizer treatments ordered and the PPE was for treatments. The order states: DuoNeb Solution 0.5-2.5 (3) MG/3 ML (Ipratropium-Albuterol 1 unit inhale orally via nebulizer every 4 hours as needed for COPD: cough. There is also an order that reads Aerosol Droplet Precautions during nebulizer treatments: Please close door, pull privacy curtain, DON PPE during treatment, display Aerosol Droplet Precaution sign and remove once treatment is completed. Disinfect equipment and surrounding areas once treatment is completed. Four times a day.
On 05/23/23 at 12:35 PM during an interview with LPN #8 stated that if a resident has a nebulizer treatment ordered and is in a semi private room, the only special procedure she would have to do would be to pull the curtain around the room mates bed. She would not have to wear any PPE unless the resident had a multidrug-resistant organism (MDRO) or COVID, she would not have to place any signs on the door reflecting that they are having a nebulizer treatment.
According to the DON on 05/24/23 at 2:00 PM, there were Aerosol-Generating Procedure in Progress signs available which indicates what PPE is required to enter the room along with instructions to KEEP DOOR CLOSED DURING USE AND 1 HOUR POST TREATMENT (See nurse for time frames). She also confirmed that such a sign should be on each door that had nebulizer treatments ordered.
e) Resident #101
An observation on 05/22/23 at 10:08 AM of Resident #101's room found an aerosol nebulizer machine with no signage on the door or personal protective supplies available.
A medical record review of Resident #101's Physician Orders revealed an order:
--Levalbuterol HCl Inhalation Nebulization Solution 0.63 MG/3 ML (Levalbuterol HCl)
One (1) vial inhale orally via nebulizer every 4 hours as needed for shortness of breath or wheezing.
During an interview on 05/22/23 at 12:55 PM the DON verified Resident 101's Nebulizer order and confirmed the EBP signage or PPE was not available in proximity. She stated that Resident #101 had moved rooms and the signage and PPE cart were not moved.
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Jun 2022
12 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Grievances
(Tag F0585)
Could have caused harm · This affected 1 resident
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Based on interview and record review the facility failed to making prompt efforts to resolve a grievance and to keep the resident notified of progress toward resolution. This is true for one (1) of ...
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Based on interview and record review the facility failed to making prompt efforts to resolve a grievance and to keep the resident notified of progress toward resolution. This is true for one (1) of four (4) reviewed for grievances during the Long-Term Care Survey Process (LTCSP). Resident identifiers: #19. Facility census: 111.
Findings included:
a) Resident #19
On 06/06/22 at 3:58 PM during an interview with Resident #19, she stated that her bible has been stolen/ missing for a week or more. Resident #19 stated that she reported the bible missing and nothing has been done about the item.
06/08/22 a record review of missing items /grievances revealed, no grievance form was filled out.
A medical record review of Resident #19's quarterly 3/18/22 Minimum Data Set (MDS), found the resident's brief interview for mental status was twelve (12). A BIMS score of 12 indicates that the resident is considered to be mildly impaired cognitively.
A continued medical record review for Resident #19 revealed a progress note dated 6/2/2022 at 4:15 PM:
--Activities Note
-Note Text: Patient was in the Activities Room this afternoon when she was confronted by #5890. #5890 had accused the patient of taking various items from the facility Bingo store. Patient responded by indicating she was searching for her Bible and then questioned #5890 if she had possession of it. #5890 became defensive and began to use foul language to which appeared to trigger the patient. This writer intervened and attempted to deescalate both patients with what seemed to be moderate success. N-UM consulted for needed assistance. Patient was then escorted down the hallway for interventional purposes and remained compliant. SW notified.
(Transcribed as written.)
During an interview with the Social Services #83 (SW) on 06/08/22 at 9:45 AM, she confirmed she was aware of the incident that occurred on 06/02/22 and the allegation of a missing bible. She stated that there was no grievance, follow-up or investigation conducted.
On 06/08/22 at 11:31 AM during an interview with the Director of Nursing (DON) she revealed that she was unaware of any missing bible for Resident #19.
During an interview on 06/08/22 at 1:17 PM, the DON verified that the facility was reporting the issue of the missing bible this date, after reviewing the documentation.
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CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Free from Abuse/Neglect
(Tag F0600)
Could have caused harm · This affected 1 resident
Based on observation, resident interview, family interview, record review and staff interview the facility failed to ensure residents were free from abuse in the form of mental anguish. The failed pra...
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Based on observation, resident interview, family interview, record review and staff interview the facility failed to ensure residents were free from abuse in the form of mental anguish. The failed practices were random opportunities for discovery. Resident identifiers: #62. Facility census: 111.
Findings included:
a) Resident #62
During an interview on 06/06/22 at 4:30 PM, Resident #62 stated that there was a problem with another Resident and the problem resulted in a resident to resident altercation on 06/02/22. Resident #62 stated the other resident aggressively claimed Resident #62 stole a Bible. Resident #62 stated the other resident, yelled at me saying you stole my Bible. Resident #62 stated that the door of room had been closed and the resident opened the door to Resident #62's room, walked right in and again began asking where was the Bible. Resident #62 stated she did not report to staff when the resident willfully entered room but stated all staff did after the resident to resident altercation was add an additional anxiety medication so now I am on two (2) anxiety medications over this. Resident #62 expressed feelings of fear and anxiousness that the other resident may come back to yell and falsely accuse again.
An observation on 06/06/22 at 4:30 PM, showed Resident #62 was tearful as resident to resident altercation was discussed.
Review of Resident #62's medical record showed two (2) progress notes related to the resident to resident alternation on 06/02/22. The two (2) notes were as followed:
--An activities note dated 06/02/22 stated, Patient returned from an afternoon activity and appeared to have observed #5699 in the Activities room. Patient soon became confrontational; advising #5699 that she cannot have anything from the Bingo store (located in the Activities room). #5699 had then informed the patient that she had been looking for her Bible and soon questioned if the patient had possession of it. Patient then responded by stating, I don't have your fu*king Bible! This writer intervened and attempted to deescalate both patients with what seemed to be moderate success. N-UM consulted for needed assistance. #5699 was then escorted down the hallway for interventional purposes and remained compliant. This writer then reminded the patient of the importance of being nice and respectful to her peers. Patient appeared to understand; however, elected to self-propel to #3751's room and soon became excessively tearful. Med Recs Director spoke with the patient and offered to relocate the patient back to her room to talk through her emotions in a more private setting. Patient was agreeable and consented. SW notified.
--A nurses note dated 06/02/22 stated, Patients sister came to the nurses station states patient is anxious from a verbal issue with another resident earlier, is tearful at times. I noted patient is on Buspar and Zoloft scheduled, will alert the physician about something prn for anxiety.
Further review of Resident #62's medical record showed Resident #62 had capacity with a Brief Interview for mental status (BIMS) of 12. The medical record showed a physician order with start date of 06/02/22 that stated, Hydroxyzine HCI Tablet Give 10 mg by mouth every 8 hours as needed for anxiety. The care plan stated, Patient is receiving antianxiety/hypnotic medication related to diagnosis of anxiousness with behaviors of yelling/screaming triggered by unwanted visitors (patients) entering/wandering into patient's room. Administer Hydroxyzine 10 mg po every 8 hours as needed. Monitor for side effects: sedation, dizziness, weakness, unsteadiness, headache. If noted contact MD. The Behavior Symptom flow sheet showed Resident #62 did not have any behaviors noted on a 30 day look back (05/15/22-06/13/22) except for the date of 06/02/22 when the resident to resident altercation occurred. There was no documentation of a nurse assessment of Resident #62 after the resident to resident altercation or prior to the call to doctor for additional anxiety medication.
During an interview on 06/09/22 at 10:09 AM, Social Service Worker (SSW) #83 stated that social services did not follow up or talk with Resident #62 after the resident to resident altercation. SSW #83 stated no incident report or investigation was conducted after the resident to resident altercation.
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CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Investigate Abuse
(Tag F0610)
Could have caused harm · This affected 1 resident
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Based on resident interview, observation, record review and staff interview facility failed to thoroughly investigate a resident to resident altercation to prevent and take corrective action as a re...
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Based on resident interview, observation, record review and staff interview facility failed to thoroughly investigate a resident to resident altercation to prevent and take corrective action as a result of the investigative findings. The failed practice was a random opportunity for discovery. Resident identifier: #62. Facility census 111.
Findings included:
Record review of the facility's policy titled, Compliance with Reporting Allegations of Abuse/Neglect/Exploitation , revised on 08/26/19, stated, The Center will investigate all allegations and incidents.
a) Resident #62
During an interview on 06/06/22 at 4:30 PM, Resident #62 stated that there was a problem with another Resident and the problem resulted in a resident to resident altercation on 06/02/22. Resident #62 stated the other Resident aggressively claimed Resident #62 stole a Bible. Resident #62 stated the other resident, yelled at me saying you stole my Bible. Resident #62 stated that the door of room once had been closed and the Resident opened the door to Resident #62's room, walked right in and again began asking where was the Bible. Resident #62 stated she did not report to staff when the resident willfully entered room but stated all staff did after the resident to resident altercation was add an additional anxiety medication so now I am on two (2) anxiety medications over this. Resident #62 expressed feelings of fear and anxiousness that the other resident may come back to yell and falsely accuse again.
An observation on 06/06/22 at 4:30 PM, showed Resident #62 was tearful as resident to resident altercation was discussed.
Review of Resident #62's medical record showed two (2) progress notes related to the resident to resident alternation on 06/02/22. The two (2) notes were as followed:
-An activities note dated 06/02/22 stated, Patient returned from an afternoon activity and appeared to have observed #5699 in the Activities room. Patient soon became confrontational; advising #5699 that she cannot have anything from the Bingo store (located in the Activities room). #5699 had then informed the patient that she had been looking for her Bible and soon questioned if the patient had possession of it. Patient then responded by stating, I don't have your fu*king Bible! This writer intervened and attempted to deescalate both patients with what seemed to be moderate success. N-UM consulted for needed assistance. #5699 was then escorted down the hallway for interventional purposes and remained compliant. This writer then reminded the patient of the importance of being nice and respectful to her peers. Patient appeared to understand; however, elected to self-propel to #3751's room and soon became excessively tearful. Med Recs Director spoke with the patient and offered to relocate the patient back to her room to talk through her emotions in a more private setting. Patient was agreeable and consented. SW notified.
- A nurses note dated 06/02/22 stated, Patients sister came to the nurses station states patient is anxious from a verbal issue with another resident earlier, is tearful at times. I noted patient is on Buspar and Zoloft scheduled, will alert the physician about something prn for anxiety.
Further review of Resident #62's medical record showed Resident #62 had capacity with a Brief Interview for mental status (BIMS) of 12. The medical record showed a physician order with start date of 06/02/22 that stated, Hydroxyzine HCI Tablet Give 10 mg by mouth every 8 hours as needed for anxiety. The care plan stated, Patient is receiving antiaxiety/hypnotic medication related to diagnosis of anxiousness with behaviors of yelling/screaming triggered by unwanted visitors (patients) entering/wandering into patient's room. Administer Hydroxyzine 10 mg po every 8 hours as needed. Monitor for side effects: sedation, dizziness, weakness, unsteadiness, headache. If noted contact MD. The Behavior Symptom flow sheet showed Resident #62 did not have any behaviors noted on a 30 day look back (05/15/22-06/13/22) except for the date of 06/02/22 when the resident to resident altercation occurred. There was no documentation of a nurse assessment of Resident #62's anxiety after the resident to resident altercation or prior to the call to doctor for additional anxiety medication.
During an interview on 06/09/22 at 10:09 AM, Social Service Worker (SSW) #83 stated that social services did not follow up or talk with Resident #62 after the resident to resident altercation. SSW #83 stated no incident report or investigation was conducted after the resident to resident altercation.
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CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Transfer Notice
(Tag F0623)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on medical record review and staff interview, the facility failed to provide evidence a resident/resident's representati...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on medical record review and staff interview, the facility failed to provide evidence a resident/resident's representative was provided a written Notice of Transfer for an acute hospital transfer. The facility also failed to provide evidence that a copy of the Notice of Transfer was sent to the Ombudsman. This was true for one (1) of four (4) residents reviewed for hospitalizations during the long-term care survey process. Resident identifier: #12. Facility census: 111.
Findings included:
a) Resident #12
An electronic medical record review was completed on 06/07/22 at 10:36 AM. Resident #12 was discharged to the hospital on [DATE]. There was no evidence a written Notice of Transfer/Discharge was provided to Resident #12's legal representative.
During an interview on 06/08/22 at 10:40 AM, the Assistant Director of Nursing (ADON) reported the facility was unable to provide evidence a Notice of Transfer Discharge was given to resident's legal representative. Additionally, the facility failed to produce evidence a copy of the Notice of Transfer/Discharge was sent to the Ombudsman.
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CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0625
(Tag F0625)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on medical record review and staff interview, the facility failed to provide evidence a resident/resident's representati...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on medical record review and staff interview, the facility failed to provide evidence a resident/resident's representative was provided a written Bed Hold Notice for a hospital transfer. This was true for one (1) of four (4) residents reviewed for hospitalizations during the long-term care survey process. Resident identifier: #12. Facility census: 111.
Findings included:
a) Resident #12
An electronic medical record review was completed on 06/07/22 at 10:36 AM. Resident #12 was discharged to the hospital on [DATE]. There was no evidence a written Bed Hold Notice was provided to Resident #12's legal representative.
During an interview on 06/08/22 at 10:40 AM, the Assistant Director of Nursing (ADON) reported the facility was unable to provide evidence a Bed Hold Notice was provided to Resident #12's legal representative.
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CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
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Based on record review, and staff interview, the facility failed to follow physician orders related to insulin. This was true for one (1) of six (6) residents reviewed for drug regimen review during...
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Based on record review, and staff interview, the facility failed to follow physician orders related to insulin. This was true for one (1) of six (6) residents reviewed for drug regimen review during the annual long-term care survey process. Resident identifier: #93. Facility census: 111.
Findings included:
a) Resident #93
A record review was completed on 06/06/22 at 5:43 PM. The record review demonstrated that Resident #93 had a diagnosis of diabetes mellitus and had three (3) different orders for administration of insulin to treat her disease.
A review of the Medication Administration Records (MARS) for revealed three different occasions the physician orders were not followed, and the MAR was left blank regarding the administration of insulin for Resident #93.
On 03/12/22 the physician order, Lantus SoloStar Solution Pen-injector 100 UNIT/ML (Insulin Glargine) Inject 18 unit subcutaneously two times a day for Diabetes Mellitus was not followed. There was no documentation on the MARS that the 8:00 PM dose was administered.
On 06/22/22 the physician order, NovoLOG FlexPen Solution Pen-injector 100 UNIT/ML (Insulin Aspart) Inject 6 unit subcutaneously before meals Diabetes Mellitus was not followed. There was no documentation on the MARS that the 11:30 AM dose was administered.
On 06/22/22 the physician order, NovoLOG FlexPen Solution Pen-injector 100 UNIT/ML (Insulin Aspart) Inject as per sliding scale: if 300 - 400 = 6 units; 401 - 999 = 8 units; subcutaneously before meals for Diabetes Mellitus was not followed. There was no documentation on the MARS to reflect a blood sugar had been taken or if any medication was administered for the 11:30 AM timeframe.
During an interview on 06/07/22 at 2:45 PM, the Assistant Director of Nursing (ADON) acknowledged the dates and times listed above were left blank on the MARs. The ADON reported that the MAR is used as a record to record all medications administered to a resident as well as the reason any medication was not administered if that would have been the case regarding the sliding fee scale insulin order. The ADON further stated all nurses are trained to document accurately in the MAR and leaving a blank in the MAR does not meet professional standards of practice.
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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, medical record review, and interview, the facility failed to deliver respiratory care services consistent with professional standards of practice. A physician's order for oxyge...
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Based on observation, medical record review, and interview, the facility failed to deliver respiratory care services consistent with professional standards of practice. A physician's order for oxygen was not followed. This was a random opportunity for discovery, during the Long-Term Care Survey Process (LTCSP). Resident Identifier: #70. Facility Census: 111.
Findings included:
a) Resident #70
An observation of Resident #70, on 06/06/22 at 4:03 PM, revealed the Resident was receiving oxygen at one (1) Liters via nasal cannula (an oxygen delivery device) from an oxygen concentrator.
A review of Resident #70's physician order, revealed the order Oxygen at two (2) Liters Per Minute (LPM), for shortness of breath.
A second observation of Resident #70, on 06/08/22 at 1:49 PM, revealed the Resident was receiving oxygen at one (1) Liters via nasal cannula from an oxygen concentrator.
An interview with Registered Nurse (RN) #133 on 06/08/22 at 1:55 PM, verified the Resident was receiving oxygen One (1) Liter Per Minute. RN #133 confirmand that Resident #70 was ordered oxygen at two (2) Liters via nasal cannula and verified the oxygen level was wrong. (RN) #133 changed Resident #70's oxygen to two (2) LPM on the concentrator at this time.
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CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0757
(Tag F0757)
Could have caused harm · This affected 1 resident
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Based on resident interview, observation, record review and staff interview the facility failed to assess for the indications required for the use an antianxiety medication and adequately monitor th...
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Based on resident interview, observation, record review and staff interview the facility failed to assess for the indications required for the use an antianxiety medication and adequately monitor the medication side effects. This was a random opportunity for discovery. Resident identifier: #62. Facility census: 111.
Findings included:
a) Resident #62
During an interview on 06/06/22 at 4:30 PM, Resident #62 stated that there was a problem with another Resident and the problem resulted in a resident to resident altercation on 06/02/22. Resident #62 stated the other Resident aggressively claimed Resident #62 stole a Bible. Resident #62 stated the other resident, yelled at me saying you stole my Bible. Resident #62 stated that the door of room had been closed and the Resident opened the door to Resident #62's room, walked right in and again began asking where was the Bible. Resident #62 stated she did not report to staff when the resident willfully entered room but stated all staff did after the resident to resident altercation was add an additional anxiety medication so now I am on two (2) anxiety medications over this. Resident #62 expressed feelings of fear and anxiousness that the other resident may come back to yell and falsely accuse again.
Review of Resident #62's medical record showed two (2) progress notes related to the resident to resident altercation on 06/02/22. The two (2) notes were as followed:
-An activities note dated 06/02/22 stated, Patient returned from an afternoon activity and appeared to have observed #5699 in the Activities room. Patient soon became confrontational; advising #5699 that she cannot have anything from the Bingo store (located in the Activities room). #5699 had then informed the patient that she had been looking for her Bible and soon questioned if the patient had possession of it. Patient then responded by stating, I don't have your fu*king Bible! This writer intervened and attempted to deescalate both patients with what seemed to be moderate success. N-UM consulted for needed assistance. #5699 was then escorted down the hallway for interventional purposes and remained compliant. This writer then reminded the patient of the importance of being nice and respectful to her peers. Patient appeared to understand; however, elected to self-propel to #3751 ' s room and soon became excessively tearful. Med Recs Director spoke with the patient and offered to relocate the patient back to her room to talk through her emotions in a more private setting. Patient was agreeable and consented. SW notified.
- A nurses note dated 06/02/22 stated, Patients sister came to the nurses station states patient is anxious from a verbal issue with another resident earlier, is tearful at times. I noted patient is on Buspar and Zoloft scheduled, will alert the physician about something prn for anxiety.
Further review of Resident #62's medical record showed Resident #62 had capacity with a Brief Interview for mental status (BIMS) of 12. The medical record showed a physician order with start date of 06/02/22 that stated, Hydroxyzine HCI Tablet Give 10 mg by mouth every 8 hours as needed for anxiety. The care plan stated, Patient is receiving antianxiety/hypnotic medication related to diagnosis of anxiousness with behaviors of yelling/screaming triggered by unwanted visitors (patients) entering/wandering into patient's room. Administer Hydroxyzine 10 mg po every 8 hours as needed. Monitor for side effects: sedation, dizziness, weakness, unsteadiness, headache. If noted contact MD. The Behavior Symptom flow sheet showed Resident #62 did not have any behaviors
noted on a 30 day look back (05/15/22-06/13/22) except for the date of 06/02/22 when the resident to resident altercation occurred. There was no documentation of a nurse assessment of Resident #62 after the resident to resident altercation or prior to the call to doctor for additional anxiety medication.
An observation on 06/08/22 at 3:50 PM Resident #62 was in bed with light off and door slightly closed. Resident #62 was sleeping.
During an interview on 06/08/22 at 3:50 PM Resident #62 stated that today was the the first day Hydroxyzine was administered. Resident 62 stated, I have been very sleepy and can't stay awake. Resident #62 was asked why the sleepiness and Resident #62 stated that it was the Hydroxyzine because this was the first time ever received. Resident #62 stated that none of the other medications give side effects of sleepiness so it had to be the new medication Hydroxyzine.
An observation at 06/08/22 3:55 PM showed Resident #62 laid back down in bed after interview.
Review of Resident #26's medical record on 06/09/22 at 9:20 AM showed Hydroxyzine was not administered on 06/08/22.
An observation on 06/09/22 at 8:45 AM showed the Northside Medical Cart contained two (2) pre-packaged medications bags of Hydroxyzine for Resident #26. One (1) package of five (5) Hydroxyzine was unopened and one (1) package of four (4) Hydroxyzine had only three (3) Hydroxyzine left in the bag.
An interview on 06/09/22 at 8:46 AM, Registered Nurse (RN) #136 stated it appeared that one (1) Hydroxyzine had been given as one (1) Hydroxyzine was missing from the bag that contained four (4) at one time.
During an interview on 06/09/22 09:20 AM, Director of Nursing (DON) stated there was no evidence of the Hydroxyzine was given on 06/08/22 as it was not documented on the MAR. DON stated unsure when medication was given so monitoring of the effectiveness of the medication did not occur. DON stated the missing medication would be looked into. DON was asked what nursing assessment was administered to indicate the use of a second anxiety medication for Resident #26. DON provided the nurse progress note dated 06/02/22 that stated, Patients sister came to the nurses station states patient is anxious from a verbal issue with another resident earlier, is tearful at times. I noted patient is on Buspar and Zoloft scheduled, will alert the physician about something prn for anxiety.
During an interview on 06/09/22 at 9:31 AM, DON stated that RN #118 verbally just informed DON that Resident # 62 was administered the Hydroxyzine approximately at 10:30 AM-11:00 AM on 06/08/22 but forgot to document that it was administered in the MAR. RN #118 also forgot to document the effectiveness/side effects of the medication in the medical record.
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CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Medical Records
(Tag F0842)
Could have caused harm · This affected 1 resident
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Based on resident interview, observation, record review and staff interview the facility failed to accurately document pain levels for pain management and did not documented the administration of an...
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Based on resident interview, observation, record review and staff interview the facility failed to accurately document pain levels for pain management and did not documented the administration of an anxiety medication or the side effects of the medication after administration. The failed practice was true for two (2) of 32 sampled residents. Resident identifiers: #13 and #62.
Findings included:
a) Resident #13
During an interview on 06/06/22 at 3:34 PM, Resident #13 stated, I have pain. I do take Norco and have a prn Tramadol but the Norco does not always cut it .
Review of Resident #13's medical record showed a diagnosis of chronic pain due to trauma. A physician order with start date of 03/18/22 stated, Norco Tablet 10-325 MG (Hydrocodone-Acetaminophen) *Controlled Drug*Give 1 tablet by mouth every 6 hours as needed for pain. The Medication administration record (MAR) for June 2022 showed Resident received Norco for a pain level of five (5) on 06/06/22 at 8:16 AM and again for a pain level of four (4) on 06/07/22 at 7:41 AM. The MAR also stated, Is resident currently experiencing pain? 1= Yes, 2 = No
every shift The MAR showed a two (2) for no pain on 06/06/22 at 8:15 AM and 06/07/22 at 7:41 AM contradicting pain levels documented when pain medication was administered.
During an interview on 06/07/22 at 3:40 PM, Director of Nursing (DON) stated that the medical record was inaccurate for pain levels and re-education was warranted.
b) Resident #62
During an interview on 06/06/22 at 4:30 PM, Resident #62 stated that there was a problem with another Resident and the problem resulted in a resident to resident altercation on 06/02/22. Resident #62 stated the other Resident aggressively claimed Resident #62 stole a Bible. Resident #62 stated the other resident, yelled at me saying you stole my Bible. Resident #62 stated that the door of room had been closed and the Resident opened the door to Resident #62's room, walked right in and again began asking where was the Bible. Resident #62 stated she did not report to staff when the resident willfully entered room but stated all staff did after the resident to resident altercation was add an additional anxiety medication so now I am on two (2) anxiety medications over this.
Review of Resident #62's medical record showed a diagnosis other specified anxiety disorders. Resident #62 had capacity and had a brief interview of mental status (BIMS) of 12. A physician order dated 06/02/22 stated,Hydroxyzine HCl Tablet (06/02/22) Give 10 mg by mouth every 8 hours as needed for Anxiety. A second physician order dated 02/18/22 stated, Buspirone HCl Tablet 10 MG (02/18/22). Give 10 mg orally two times a day for anxiety. The care plan stated, Patient is receiving antianxiety/hypnotic medication related to diagnosis of anxiousness with behaviors of yelling/screaming triggered by unwanted visitors (patients) entering/wandering into patient's room.
An observation on 06/08/22 at 3:50 PM Resident #62 was in bed with light off and door slightly closed. Resident #62 was sleeping.
During an interview on 06/08/22 at 3:50 PM Resident #62 stated that today was the the first day Hydroxyzine was administered. Resident 62 stated, I have been very sleepy and can't stay awake. Resident #62 was asked why the sleepiness and Resident #62 stated that it was the Hydroxyzine because this was the first time ever received. Resident #62 stated that none of the other medications give side effects of sleepiness so it had to be the new medication Hydroxyzine.
An observation at 06/08/22 3:55 PM showed Resident #62 laid back down in bed after interview.
Review of Resident #26's medical record on 06/09/22 at 9:20 AM showed Hydroxyzine was not administered on 06/08/22.
An observation on 06/09/22 at 8:45 AM showed the Northside Medical Cart contained two (2) pre-packaged medications bags of Hydroxyzine for Resident #26. One (1) package of five (5) Hydroxyzine was unopened and one (1) package of four (4) Hydroxyzine had only three (3) Hydroxyzine left in the bag.
An interview on 06/09/22 at 8:46 AM, Registered Nurse (RN) #136 stated it appeared that one (1) Hydroxyzine had been given as one (1) Hydroxyzine was missing from the bag that contained four (4) at one time.
During an interview on 06/09/22 09:20 AM, Director of Nursing (DON) stated there was no evidence of the Hydroxyzine was given on 06/08/22 as it was not documented on the MAR. DON stated unsure when medication was given so monitoring of the effectiveness of the medication did not occur. DON stated the missing medication would be looked into.
During an interview on 06/09/22 at 9:31 AM, DON stated that RN #118 verbally just informed DON that Resident # 62 was administered the Hydroxyzine approximately at 10:30 AM-11:00 AM on 06/08/22 but forgot to document that it was administered in the MAR. RN #118 also forgot to document the effectiveness/side effects of the medication in the medical record.
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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
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on observation, interview and record review, the facility failed to serve food to residents at the same table in the nor...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on observation, interview and record review, the facility failed to serve food to residents at the same table in the north dining room as well as in resident rooms. Resident #1 was put to bed without sheets. Resident identifiers #1. North Dining room and north hall rooms 105, 112 and 115. Facility Census 111.
Findings included:
a) Resident #1 - No sheets on Bed
On 06/07/22 at 12:30 PM, observed resident laying in her bed with no sheets. During an inteview with Registered Nurse (RN) Unit #133 at 12:35 PM verified the resident should not be in bed without any sheets. RN Unit Manager #133 further stated, Resident just got back from getting a shower and then the lunch cart came so the aide who has the resident probably did not have time to make the bed. Not that it changes anything but, yes, I will address it.
d) North Hall
On 06/07/22 at 12:00 PM during an observation of the noon meal tray pass on the North Hall, rooms 105 to 115 found, staff did not serve each resident in rooms [ROOM NUMBER] at the approximate times. This allowed one resident in each room named, to eat their meal while the other resident in the room observed.
--room [ROOM NUMBER]- Bed B passed at 12:06 PM - Bed A passed at 12:30 PM.
--room [ROOM NUMBER]- Bed A passed at 12:07 PM - Bed B passed at 12:19 PM.
--room [ROOM NUMBER]- Bed A passed at 12:15 PM - Bed B passed at 12:34 PM.
During an Interview with the Dietary Manager (DM) at 12:25 PM on 06/07/22, she verified the trays were not passed correctly. She stated that trays should be passed at approximately the same time to rooms with 2 residents, so residents don't have to watch another resident eat.
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CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0688
(Tag F0688)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on observation, interview, and record review, the facility failed to ensure residents with contractures had intervention...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on observation, interview, and record review, the facility failed to ensure residents with contractures had interventions in place to prevent further decline. This was true for three (3) of five (5) resident reviewed for the care area of limited range of motion (ROM) during the long-term care survey process. Resident identifiers: #26, #65, and #73. Facility census: 111.
Findings included:
a) Resident #26
During a resident interview, on 06/06/22 at 6:04 PM, Resident #26 pointed to a splint that was resting on top of the nightstand and stated, I'm supposed to wear that splint on my hand [pointing to her left hand] every day but the staff doesn't always know how to put it on correctly without hurting me, so I just let it go. When asked if she would wear the splint if it was applied appropriately and did not cause her discomfort Resident #26 stated, Yes. I know I should be wearing it every day. When asked how long it ha been since she had worn the splint to her hand Resident #26 replied, It's been months upon months.
Observation, on 06/07/22 at 9:28 AM, found Resident #26 up in her wheelchair and dressed for the day. Resident #26 was not wearing her left-hand splint. The splint was seen resting on top of the nightstand beside resident's bed.
A subsequent medical record review was completed revealing the following physician order dated 01/17/20: Splint management to left hand: on in the morning and off in the afternoon with ADL [activities of daily living] care.
There was an Occupational Therapy Discharge summary, dated [DATE], which noted, Per patient only one CNA [certified nursing assistant] is reported to consistently don resting hand splint. The discharge summary also stated, Patient has been able to tolerate wearing roll splint for up to four (4) hours with smaller roll and with thumb placed on top. The CNA who consistently donned splint for patient has not been working for the past month. Patient has had increased difficulty getting splint on on a daily basis with having different inconsistent staff working with her.
There was a 04/09/22 Nurse Practitioner note stating the following plan, Resident had a CVA [cardiovascular accident] with left sided weakness. Resident remains weak to the left side. Continue splint management to left hand: on in the morning and off in the afternoon with ADL [activities of daily living] care.
During an interview, on 06/07/22 at 9:57 AM, the Director of Nursing (DON) confirmed Resident #26 was not wearing her left hand splint and stated the resident did have a history of refusals. The DON stated the donning of splints was originally a restorative staff member's responsibility but there is not an official restorative program operating now. The DON completed a brief review of Resident #26's electronic health record to determine nurse aides were documenting a mixture of refusals to don hand splint or noting that resident was not available due to being out of the facility. The DON acknowledged that Resident #26 stated it was her belief that many nursing assistants did not know how to correctly apply the hand splint which would result in the resident experiencing pain and refusing to don the splint as a result. The DON also acknowledged that when it was documented that resident was unavailable due to being out of the facility, Resident #26 was out of the facility because she goes to dialysis on Monday, Wednesday, and Friday. The DON agreed that nursing staff would be getting resident up and dressed before her departure on those days and that marking resident unavailable - out of building was not the appropriate documentation to be using since the attempt should be made to don the hand splint prior to the resident's departure.
On 06/07/22 at 10:21 AM, the DON reported the restorative program stopped amidst COVID and the responsibility of splints was never officially transferred over to the nursing program. The DON stated that splints never appeared on the Treatment Administration Record (TAR) so nurses could officially oversee the splint being worn. The DON stated she was in the process of correcting that oversight.
b) Resident #73
An observation on 06/06/22 at 5:40 PM found, Resident #73 had right arm contracture with no protection in place.
A review of Resident #73's medical record revealed, a Physicians order for:
--Splint to right upper extremity: on in the morning with ADL care and off in the afternoon with ADL care: to prevent worsening of contracture to right upper extremity. With an order date 12/14/19.
A second observation on 06/08/22 at 1:37 PM found, Resident #73 did not have the right upper arm splint in place.
On 06/08/22 at 1:50 PM Registered Nurse #5 (RN) verified Resident #73 did not have his splint in place. She verified the residents' orders at this time. RN #5 retrieved the splint from Resident #73's room and put it on at this time.
c) Resident #65
An observation during initial tour on 06/06/22 at 4:45 PM showed Resident #65 laid in bed with a visible contracture to the left arm.
During an interview on 06/06/22 at 4:45 PM Resident #65 stated, I have contractures on my left arm and left leg. I have splints but those are in the closet because no one has ever taught staff how to put them on so the splints just stay in the closet.
Review of Resident #65's medical record showed an Occupational Therapy Plan of Treatment dated 04/25/22 stated, following education, staff will be able to don left resting hand and elbow splint with min A (Target date 05/08/22). A physician order dated 08/17/21 stated, Gentle passive range of motion to left upper extremity, before donning splint: patient to wear resting hand splint and elbow extension splint for 6-8 hours a day. Staff to don in AM and doff in PM. [NAME] resting hand splint first and then elbow extension splint so patient is wearing them simultaneously. The [NAME] stated, Gentle passive range of motion to left upper extremity, before donning left elbow splint as ordered. The Care plan stated, PREVENTIVE: Patient is at risk for developing pressure ulcers/injuries related history of CVA with residual left sided hemiplegia, also with dx: depression, COPD, pulmonary fibrosis, and CAD, presence of contractures, impaired range of motion and decreased sensation, incontinence, use of L PRAFO boot, left elbow and resting hand splint, need for assist to reposition, in bed and or chair most of the time, has episodes of pain, and receives medications with potential side effects. Goal- Patient will not develop any pressure ulcer/injury through next review unless deemed unavoidable Interventions: 1.Gentle passive range of motion to left upper extremity, before donning splint: patient to wear resting hand splint and elbow extension splint for 6-8 hours a day. Staff to don in AM and doff in PM. [NAME] resting hand splint first and then elbow extension splint so patient is wearing them simultaneously.
An observation on 06/07/22 at 10:32 AM showed Resident #65 laid in bed with no hand or elbow splint in place.
During an interview on 06/07/22 at 10:40 AM, Director of Nursing (DON) stated that there was a physician order for splints and confirmed splints were stored in Resident #65's closet with the physician order not being followed.
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CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Drug Regimen Review
(Tag F0756)
Could have caused harm · This affected multiple residents
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Based on policy review, record review, and staff interview, the facility failed to ensure a drug regimen of each resident was completed at least once a month by a licensed pharmacist. This was true ...
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Based on policy review, record review, and staff interview, the facility failed to ensure a drug regimen of each resident was completed at least once a month by a licensed pharmacist. This was true for four (4) of six (6) residents reviewed for unnecessary medication reviews during the annual long-term care process. Resident identifiers: #93, #75, #59, #73. Facility census: 111.
Review of the facility's policy entitled Medication Regimen Review (MRR) Time Frame, with a revision date of 05/03/21, found the following guidance, The medication regimen of each patient is reviewed at least once a month by a licensed Consultant Pharmacist.
Findings included:
a) Resident #75
A medical record review was completed on 06/09/22 at 8:31 AM. A monthly medication regimen review (MRR) was not on file for the months of July 2021 and August 2021.
During an interview, on 06/09/22 at 9:40 AM, the Director of Nursing (DON) reported the facility was in transition switching to Remedi Senior Care (a business that provides pharmacy services to long-term care facilities) and there was no official pharmacist in the building to complete MRR reviews in July 2021 and August 2021.
b) Resident #93
A medical record review was completed on 06/08/22 at 9:10 AM. A monthly medication regimen review (MRR) was not on file for the months of July 2021 and August 2021.
During an interview, on 06/09/22 at 9:40 AM, the Director of Nursing (DON) reported the facility was in transition switching to Remedi Senior Care (a business that provides pharmacy services to long-term care facilities) and there was no official pharmacist in the building to complete MRR reviews in July 2021 and August 2021.
c) Resident #73
An unnecessary medication regimen review (MRR) for Resident #73 on 06/08/22 found, No MMR was completed July 2021, August 2021, or December 2021.
During an interview on 06/08/22 04:48 PM the Director of Nursing (DON) stated that no pharmacist reviewed Resident 73's Medication July 2021 and August 2021. She stated the facility was in transition from Stonerise to Remedy. The DON stated that the MMR was missed and not completed for Resident #73 in December 2021.
d) Resident #59
Review of Resident #59's medical record showed no monthly drug regimen review for the months of July 2021 and August 2021.
During an interview on 06/08/22 at 4:35 PM, Director of Nursing (DON) stated that the facility was in transition during July 2021 and August 2021 from Stonerise to Remedy and there was no licensed pharmacist drug regimen review available for Resident #59 during the transition months.
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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.
- • 43% turnover. Below West Virginia's 48% average. Good staff retention means consistent care.
Concerns
- • 48 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.
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About This Facility
What is Martinsburg Healthcare Center's CMS Rating?
CMS assigns MARTINSBURG HEALTHCARE 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 Martinsburg Healthcare Center Staffed?
CMS rates MARTINSBURG HEALTHCARE CENTER's staffing level at 3 out of 5 stars, which is average compared to other nursing homes. Staff turnover is 43%, compared to the West Virginia average of 46%. This relatively stable workforce can support continuity of care.
What Have Inspectors Found at Martinsburg Healthcare Center?
State health inspectors documented 48 deficiencies at MARTINSBURG HEALTHCARE CENTER during 2022 to 2025. These included: 48 with potential for harm.
Who Owns and Operates Martinsburg Healthcare Center?
MARTINSBURG HEALTHCARE CENTER is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility is operated by COMMUNICARE HEALTH, a chain that manages multiple nursing homes. With 120 certified beds and approximately 116 residents (about 97% occupancy), it is a mid-sized facility located in MARTINSBURG, West Virginia.
How Does Martinsburg Healthcare Center Compare to Other West Virginia Nursing Homes?
Compared to the 100 nursing homes in West Virginia, MARTINSBURG HEALTHCARE CENTER's overall rating (4 stars) is above the state average of 2.7, staff turnover (43%) is near the state average of 46%, and health inspection rating (3 stars) is at the national benchmark.
What Should Families Ask When Visiting Martinsburg Healthcare Center?
Based on this facility's data, families visiting should ask: "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" "Can I speak with family members of current residents about their experience?"
Is Martinsburg Healthcare Center Safe?
Based on CMS inspection data, MARTINSBURG HEALTHCARE CENTER has a clean safety record: no substantiated abuse findings (meaning no confirmed cases of resident harm), no Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death), and is not on the Special Focus Facility watch list (a federal program monitoring the lowest-performing 1% of nursing homes). The facility has a 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 Martinsburg Healthcare Center Stick Around?
MARTINSBURG HEALTHCARE CENTER has a staff turnover rate of 43%, which is about average for West Virginia nursing homes (state average: 46%). Moderate turnover is common in nursing homes, but families should still ask about staff tenure and how the facility maintains care continuity when employees leave.
Was Martinsburg Healthcare Center Ever Fined?
MARTINSBURG HEALTHCARE CENTER has no federal fines on record. CMS issues fines when nursing homes fail to meet care standards or don't correct problems found during inspections. The absence of fines suggests the facility has either maintained compliance or corrected any issues before penalties were assessed. This is a positive indicator, though families should still review recent inspection reports for the full picture.
Is Martinsburg Healthcare Center on Any Federal Watch List?
MARTINSBURG HEALTHCARE CENTER is not on any federal watch list. The most significant is the Special Focus Facility (SFF) program, which identifies the bottom 1% of nursing homes nationally based on persistent, serious quality problems. Not being on this list means the facility has avoided the pattern of deficiencies that triggers enhanced federal oversight. This is a positive indicator, though families should still review the facility's inspection history directly.