MORGANTOWN HEALTHCARE CENTER
For profit - Corporation
120 Beds
COMMUNICARE HEALTH
Data: November 2025
1 Immediate Jeopardy citation
Trust Grade
41/100
#53 of 122 in WV
Photo by Morgantown Healthcare Center
Photo by Addie T
Photo by Addie T
1 / 5 photos
Last Inspection: May 2025
Inspected within the last 6 months. Data reflects current conditions.
Overview
Morgantown Healthcare Center has a Trust Grade of D, indicating below-average quality and some concerns about care. They rank #53 out of 122 nursing homes in West Virginia, placing them in the top half of facilities, and #2 of 4 in Monongalia County, meaning there is only one local option better than this facility. While the facility's issues have improved over time, decreasing from 25 to 10 incidents reported, there are still significant concerns, including a high staff turnover rate of 63%, which is above the state average. Additionally, they have faced fines totaling $24,798, which is concerning but average for the area. Strengths include average RN coverage, which is crucial for catching potential health issues, but weaknesses are highlighted by incidents such as a large chef's knife being left in a dementia care unit, posing a serious risk to residents, and ongoing pest control issues with ants reported by families. Overall, families should weigh these strengths and weaknesses carefully when considering this facility for their loved ones.
- Trust Score
- D
- In West Virginia
- #53/122
- Safety Record
- High Risk
- Inspections
- Getting Better
- Staff Stability ⚠ Watch
- 63% turnover. Above average. Higher turnover means staff may not know residents' routines.
- Penalties ✓ Good
- $24,798 in fines. Lower than most West Virginia facilities. Relatively clean record.
- Skilled Nurses ✓ Good
- Each resident gets 51 minutes of Registered Nurse (RN) attention daily — more than average for West Virginia. RNs are trained to catch health problems early.
- Violations ⚠ Watch
- 47 deficiencies on record. Higher than average. Multiple issues found across inspections.
41/100
Top 43%
Review needed
25 → 10 violations
★★★☆☆
3.0
Overall Rating
★★★☆☆
3.0
Staff Levels
★★★☆☆
3.0
Care Quality
★★★☆☆
3.0
Inspection Score
↔
Stable
2023: 25 issues
2025: 10 issues
The Good
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
Facility shows strength in fire safety.
The Bad
3-Star Overall Rating
Near West Virginia average (2.7)
Meets federal standards, typical of most facilities
Staff Turnover: 63%
16pts above West Virginia avg (46%)
Frequent staff changes - ask about care continuity
Federal Fines: $24,798
Below median ($33,413)
Minor penalties assessed
Chain: COMMUNICARE HEALTH
Part of a multi-facility chain
Ask about local staffing decisions and management
Staff turnover is elevated (63%)
15 points above West Virginia average of 48%
The Ugly 47 deficiencies on record
1 life-threatening
May 2025
10 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
Investigate Abuse
(Tag F0610)
Could have caused harm · This affected 1 resident
Based on medical record review, staff interview, the facility failed to take actions to thoroughly investigate an alleged violation related to physical abuse. Resident identifier #76. Facility census:...
Read full inspector narrative →
Based on medical record review, staff interview, the facility failed to take actions to thoroughly investigate an alleged violation related to physical abuse. Resident identifier #76. Facility census: 116.
Findings included:
a) Resident #76
A record review found an allegation from 06/06/24 where a staff member allegedly fingerpainted with feces on Resident #76.
A reportable was completed with the following details:
-On 06/06/24 an anonymous call was placed to the corporate hotline. The caller alleged that a Nurse Aide (NA) defecated on a male resident and drew pictures on the resident with her feces. The anonymous caller may have been a disgruntled employee who believed that this NA got her terminated.
During an interview on 04/30/25 at approximately 10:00 AM with the Assistant Administrator, he verified that he helped complete some of the resident interviews after the allegation was reported on 06/06/25. He stated that he was unsure if the allegation had occurred. He continued to state that at the time he believed that it was a disgruntled employee.
A review of an investigation revealed that the issue was reported to Nurse Aide Registry on 06/06/24, the NA no longer works at the facility, but a situation did occur just not as reported by caller.
Continued review of the reportable found no witness statements from the employees that may have knowledge of the allegation.
During the interview on 05/01/25 at 9:30 AM the Administrator verified that there was no documentation or statements from all staff working at the time or that may have knowledge of the allegation.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0657
(Tag F0657)
Could have caused harm · This affected 1 resident
Based on staff interview and record review, the facility failed to update Resident #107's care plan for discontinuation of an anticoagulant and to clarify Resident #264's care plan for level of assist...
Read full inspector narrative →
Based on staff interview and record review, the facility failed to update Resident #107's care plan for discontinuation of an anticoagulant and to clarify Resident #264's care plan for level of assistance needed for activities of daily living. These failed practices were a random opportunity for discovery and had the potential to affect a limited number of residents. Resident Identifiers: #107 and #264. Census: 116.
Findings included:
a) Resident #107
On 04/29/25 at 03:56 PM, Resident #107 had an order for Lovenox Injection which was discontinued on 02/17/25. The resident's current care plan (revised 02/18/25) stated, Resident is at risk for abnormal bleeding or hemorrhage due to anticoagulant/antiplatelet use for prophylaxis. Resident will be free from abnormal bleeding / hemorrhaging through review date. Educate resident / resident representative on benefits and potential risks of anticoagulant drug use. Encourage resident to use electric razor when shaving, soft bristled toothbrush. If excessive bleeding / hemorrhage occurs, provide emergency care. Monitor for s/sx [signs and symptoms] of bleeding (i.e. bruising, petechiae, epistaxis, GI bleeding, hematuria, nose bleeds, tarry/black stools bleeding gums). Notify medical provider, resident / resident representative, as needed. Provide anticoagulant//antiplatelet medication per medical providers order. Monitor for effectiveness, and side effects (bleeding, embolism). Report abnormal findings to medical provider, resident / resident representative. The Administrator confirmed there was not a current order on 04/30/25 at 12:05 PM and stated, It's not there .okay.
b) Resident #264
On 05/06/25 at 10:15 AM, Resident #264's care plan stated: Helper does ALL of the effort or 2 or more helpers assist. The state surveyor interviewed Minimum Data Set (MDS) Nurse #44 and MDS Nurse #120. Information for the care plan is based on the usual performance during the look back dates per report. The MDS Nurse's stated Activities of Daily Living may fluctuate and Resident #254's
care may change if patient is resistive to care. If cooperative - maybe one person. When asked how the nursing assistants know when to use one or two person to assist a resident, it would depend on how the resident's behavior is that day. The State Surveyor interviewed the Administrator on 05/06/25 and reviewed the care plan and interview with MDS Nurses. The Administrator stated, I agree. when questioning how the nursing assistant would know if the person is a one or two person assist.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0679
(Tag F0679)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to provide activities intended to enhance the resident's sense of well-being and to promote or enhance physical, cognitive, and ...
Read full inspector narrative →
Based on observation, interview, and record review, the facility failed to provide activities intended to enhance the resident's sense of well-being and to promote or enhance physical, cognitive, and emotional health to ensure the resident's highest practicable state of well-being. Resident Identifier: #110. Facility Census:116.
Findings Included:
a) Resident #110:
Resident #110 was diagnosed with cardiomyopathy, heart failure, hypertension, muscle weakness, localized edema, pain in left and right knees, diabetes mellitus - on insulin, and lack of coordination.
During an interview with Resident #110 on 04/29/25 at 2:22 PM, the resident stated that he was unable to get out of bed. Upon being asked what activities he has planned for him, the resident said that there isn't much being offered. He reported that he spends his day lying in bed and sometimes watches TV.
A review of Resident #110's Care Plan revealed that residents' activity interests were listed as:
-Bingo
-Hunting
-Fishing
-Watching TV
-Baking
-Cooking
-Spending time outside
-Gardening
An observation on 04/30/25, at approximately 3:13 PM revealed the resident in bed.
Another observation and interview with the resident, on 05/01/25 at approximately 2:12 PM, revealed the resident was in bed watching TV. Resident stated that he was supposed to have a 1:1 activity, but no one had visited him since 04/23/25.
The resident was observed throughout the survey process from 04/29/25 to 05/06/25 and was not observed participating in any activity.
The Director of Nursing (DON) provided copies of the resident's activity participation sheets, and activity plan. The documents revealed that the resident had not had any activities from 04/23/25 to 04/30/25. DON confirmed that they were the only participation sheets available for Resident #110.
During an interview with Activity Staff (AS) #30 on 05/01/25 at approximately 10:18 AM, it was revealed that resident has been care-planned for self-directed activity. AS #30 stated that resident does not like to go out of his room.
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, and staff interview, the facility failed to address and notify the physician about an incorrect medication order. It also neglected to ensure that t...
Read full inspector narrative →
Based on observation, interview, and record review, and staff interview, the facility failed to address and notify the physician about an incorrect medication order. It also neglected to ensure that the order was corrected and updated. This was a random opportunity for discovery. Additionally, the facility failed to complete a Speech Therapy Evaluation per physician's order in a timely manner for Resident #107. This was also a random opportunity for discovery and had the potential to affect a limited number of residents. Resident Identifiers: #221 and #107. Facility Census: 116.
Findings Included:
a) Resident #221
During observation of medication administration on 05/01/25 at 8:45 AM, RN #19 stated that Resident #221 was prescribed 37.5 MG of Metoprolol. RN #19 further stated that the resident would be administered half (½) a tablet.
Inspection of the medication revealed that the pharmacy had provided Metoprolol 75 MG tablets. RN #19 administered Metoprolol 37.5 MG (1/2 tablet) during med pass on 05/01/25 at 8:49 AM.
At approximately 10:08 AM on 05/01/25, a review of Resident #221's orders revealed the following order:
-Metoprolol Tartrate 50 MG oral tablet. Give 37.5 MG two times a day for HTN [hypertension].
During an interview with RN #19 at 11:15 AM, the RN confirmed that the dose ordered by the physician had been accurately administered.
RN #19 also confirmed that the physician's prescription should have stated Metoprolol Tartrate 75 MG.
After the surveyor's intervention, at 12:05 PM on 05/01/25, the Director of Nursing (DON) confirmed that the order entered by the physician was inaccurate. The DON further stated that the order would be changed to Metoprolol Tartrate 75 mg tablets.
b) Resident #107
On 04/29/25, Resident #107 was observed by the state surveyor in the hallway eating his lunch meal. The resident was coughing while eating. The unit nurse observed the coughing and went to assist the resident.
Orders for the following interventions included:
CXR STAT
Diagnostic
Active
4/29/2025 15:20
GuaiFENesin Liquid 100 MG/5ML
Give 10 milliliter by mouth every 4 hours as needed for Cough
Pharmacy Active 4/29/2025 19:19
ST to eval and treat as indicated
No directions specified for order.
Other Active
4/29/2025
Nursing Progress Note stated:
4/29/2025 16:20 Resident noted to have increased coughing this shift. NP [Nurse Practitioner] to assess resident. New orders to start PRN [as needed] tussin 10ml q4h, obtain CXR, CBC, BMP, procal STAT, ST [Speech Therapy] to eval. Orders placed in PCC [electronic medical record] and MPOA [medical power of attorney] aware. Labs drawn and pending pickup at this time.
A chest x-ray was completed on 4/30/2025 8:29:06 AM.
On 05/05/25 at 12:41 PM, the Administrator confirmed there was no Speech Therapy evaluation per order. The Administrator stated, They didn't do it not happening until today. The resident was not evaluated by speech therapy until surveyor intervention.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
Based on observation and interviews, the facility failed to ensure the resident environment over which it had control was as free from accident hazards as possible. This was a random opportunity for d...
Read full inspector narrative →
Based on observation and interviews, the facility failed to ensure the resident environment over which it had control was as free from accident hazards as possible. This was a random opportunity for discovery of a resident smoking in non-designated areas. Resident Identifier: #79. Facility census 116.
Findings included:
a) Resident #79
On 04/30/25 at 11:54 AM, surveyor observed Resident #79 smoking outside the front door on the sidewalk.
On 05/01/25 at 8:10 AM, there was a second observation of Resident #79 smoking out front of the facility in a non-smoking area.
During an interview on 05/01/25 at 8:13 AM, the Assistant Administrator stated that the facility did not have any smokers.
During a continued interview on 05/01/25 at 8:15 AM, the Assistant Administrator stated that she was not supposed to be out there smoking, but that's where she goes. He verified at this time that Resident #79 was smoking in a non-smoking area.
An observation of the area found no ash can, no fire blanket, nor a fire extinguisher in the vicinity. A No Smoking sign was displayed.
During an interview with the Corporate Administrator and the Director of Nursing (DON) on 05/01/25 at 8:19 AM, she stated that Resident #79 was supposed to sign out and go off the facility property, but Resident #79 continues to smoke there. She continued to say that they made the resident a place across the parking lot in a grassy area at the top of a hill to smoke but she won't go over there. The DON stated that the resident was grandfathered in and could smoke at the facility. The DON and Corporate Administrator confirmed Resident #79 was not supposed to smoke in the non-smoking area.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
Could have caused harm · This affected 1 resident
Based on observations, interview, and record review, the facility failed to ensure that the oxygen concentrator for a resident with a tracheostomy was set to deliver the exact dose of oxygen prescribe...
Read full inspector narrative →
Based on observations, interview, and record review, the facility failed to ensure that the oxygen concentrator for a resident with a tracheostomy was set to deliver the exact dose of oxygen prescribed by the physician. Resident Identifier: #94. Facility Census: 116.
Findings included:
a) Resident #94
Resident #94 is diagnosed with the following:
-Traumatic Brain Injury
-Dependence on supplementary oxygen
-Seizures
-Epilepsy
-Paraplegia
-Tracheostomy
-Gastrostomy.
Physicians Orders stated the following:
-Cool air mist via trach collar continuous with O2 bled in at 5LPM
-Suction via trach and prn (lung sounds pre and post, O2 sat pre and post) every shift and as needed
-Trach-Type Shiley Size 6
-Trach care q shift and prn as needed
-Replace inner cannula during trach care q day and prn every shift and as needed
-Have the same size trach and one size smaller at bedside at all times
-Change trach ties Mon, Wed, Fri, and prn
-Change suction tubing and canister once per week and prn - every shift every Fri AND as needed
-Change O2 Mask and initial and date tubing - every day shift every Fri for 02 mask/tubing care
-Trach: Ambu Bag at bedside
During an observation of resident on 04/29/25 08:12 AM, resident was asleep, and the oxygen concentrator was noted to be set to 4.0 Liters per minute.
A review of the physician's orders showed that the resident was to receive oxygen at 5 liters per minute.
During an observation on 04/30/25 2:00 PM, the oxygen concentrator was noted to be set to deliver 4.0 liters per minute.
On 05/01/25 at approximately 12:14 PM during an observation, accompanied by RN #19, the oxygen concentrator was noted to be set to deliver 4.5 liters per minute
RN #19 confirmed that the concentrator should be set up to deliver 5.0 liters per minute.
RN #19 checked physician's order and confirmed that the physician's order specified 5 Liters per minute. RN #19 adjusted the oxygen concentrator to deliver the prescribed dose.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Medical Records
(Tag F0842)
Could have caused harm · This affected 1 resident
Based on record review and staff interview, the facility failed to ensure one (1) of 29 residents reviewed during the long-term care survey process for Physician Orders for Scope of Treatment (POST) f...
Read full inspector narrative →
Based on record review and staff interview, the facility failed to ensure one (1) of 29 residents reviewed during the long-term care survey process for Physician Orders for Scope of Treatment (POST) forms completed per directions specified by the [NAME] Virginia Center for End-of-Life Care in conjunction with the [NAME] Virginia Health Care Decisions Act (16-30-1). Resident identifiers: #42. Facility census: 116.
Findings included:
a) Resident #42
Record review on 04/30/25 at 8:55 AM, revealed section for Section D (Signature of Resident, or Guardian /Medical power of Attorney -MPOA Mandatory) was not completed with a MPOA Signature, a verbal signature in place dated 03/03/24 on Resident #42's active Physician Order for Scope of Treatment Form (POST Form).
During an interview on 05/01/25 at 10:08 AM, the Director of Nursing (DON), confirmed Resident #42's POST form was incorrect without an MPOA signature in a timely manner.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0802
(Tag F0802)
Could have caused harm · This affected multiple residents
Based on record review and staff interview, the facility failed to maintain the dietary staff's appropriate competencies for food service handling. This failed practice had the potential to affect mor...
Read full inspector narrative →
Based on record review and staff interview, the facility failed to maintain the dietary staff's appropriate competencies for food service handling. This failed practice had the potential to affect more than a limited number of residents. Facility Census: 116.
Findings included:
a) Food Safety Certificates
The State Food Safety Certificate of training had expired for the Certified Dietary Manager #161 on 02/08/24.
-The Certified Dietary Manager #161 renewed the certificate of training on 04/30/25 following survey intervention.
The State Food Safety Certificate of training had expired for Dietary Aide #166 on 02/09/24.
-On 04/30/25 at 3:44 PM, the Regional Certified Food Manager #189 stated, Dietary Aide #166 had resigned on 04/23/25.
Dietary Aide #166 had worked without a Certificate of Training for Food Safety on the following dates:02/10/25, 0214/25, 02/15/25, 02/16/25, 02/17/25, 02/19/25, 02/20/25, 02/21/25, 02/24/25, 02/25/25, 02/25/25, 02/26/25, 02/28/25, 03/01/25, 03/02/25, 03/04/25, 03/05/25, 03/06/25, 03/07/25, 03/10/25, 03/11/25, 03/12/25, 03/14/25, 03/15/25, 03/16/25, 03/18/25, 03/19/25, 03/20/25, 03/21/25, 03/24/25, 03/25/25, 03/28/25, 03/31/25, 04/01/25, 04/02/25, 04/05/25, 04/06/25, 04/07/25, 04/11/25, 04/12/25, 04/13/25, 04/14/25, 04/16/25, 04/17/25, 04/19/25, 04/20/25, 04/21/25 and 04/22/25.
The Administrator confirmed the expired certificates, on 05/01/25 at 9:50 AM, and stated the Regional Certified Food Manager #189 had told me yesterday.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview and observation, the facility failed to store food in accordance with professional stand...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview and observation, the facility failed to store food in accordance with professional standards for food service safety. This failed practice had the potential to affect more than a limited number of residents. Facility Census: 116.
Findings Included:
a) On 04/29/25 at 07:15 AM, the kitchen investigation was initiated. Cookies were found in the freezer with an incomplete date (no year). The Regional Certified Food Manager #189 stated, I'll discard.
b) On 04/30/25 at 11:50 AM, the A-Wing pantry was investigated. The following items were found:
-[NAME] pickles open and not dated
-Cotton candy - open and not dated
-Refrigerator temperature 76 degrees Fahrenheit.
Items in the pantry were confirmed by Licence Practical Nurse #28 at 12:00 PM.
c) On 04/30/25 at 12:01 PM, the B-Wing pantry was investigated. The following items were found:
-[NAME] John's sandwich was not sealed or dated with a used by date
-Multiple Individual juice cups (Orange, Apple and Cranberry) were not dated
-Refrigerator temperature was 44 degrees Fahrenheit.
Items in the pantry were confirmed by Registered Nurse #19 at 12:09 PM.
d) Interview with Regional Food Manager #189
On 05/01/25 at 10:19 AM, the Regional Certified Food Manager #189 stated that opened food items are to be labeled and dated for seven (7) days and items have to be dated in the refrigerator.
CONCERN
(E)
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 interviews, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment ...
Read full inspector narrative →
Based on observations 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 water management. This practice had the potential to affect all residents that reside in the facility. Facility census: 116.
Findings included:
a) Water Management
During facility record review of the water management revealed, the documentation was not maintained to prevent growth of water borne pathogens including description of the building water system. The flow diagram did not Identify the buildings water systems for which Legionella control measures are needed.
No documentation was provided describing the building water systems using text or testing protocols.
On 05/05/25 at 2:20 PM, the Maintenance Director verified the facility did not maintain the water management program. He stated that it would be corrected.
Jun 2023
24 deficiencies
1 IJ (1 affecting multiple)
CRITICAL
(K)
Immediate Jeopardy (IJ) - the most serious Medicare violation
Accident Prevention
(Tag F0689)
Someone could have died · This affected multiple residents
.
Based on observation, record review, and staff interview the facility failed to ensure the resident environment over which it had control was as free from accident hazards as possible. A large chef'...
Read full inspector narrative →
.
Based on observation, record review, and staff interview the facility failed to ensure the resident environment over which it had control was as free from accident hazards as possible. A large chef's knife was found lying on the sink in the dementia care unit. The knife handle was leaned up against the sprayer making it more accessible to the residents. The knife was easily reached and accessed by the Surveyor from the resident's side of the counter.
The memory care unit had a census of 24 ambulatory residents with diagnosis of Dementia and/or Alzheimer's Disease. Any of the 24 Residents could have obtained access to the knife potentially causing serious harm and/or death to self or others due to their cognitive impairments and decreased safety awareness.
The state agency (SA) determined this to be an immediate jeopardy (IJ) which placed all twenty-four (24) Residents at risk for serious harm and/or death. The facility was notified of the IJ on 06/06/23 at 12:40 PM. The facility submitted a Plan of Correction (POC) at 2:00 PM on 06/06/23 at which time it was accepted by the SA. The plan of Correction read as follows:
a. The knife was immediately removed by Memory Unit Manager at 11:06am on 6/6/23.
b. A sweep was performed by the Administrator/Designee throughout the building to ensure that no other accident/safety hazards were present throughout the facility at 12:45 pm on 6/6/23.
c. An in-service was immediately conducted by the administrator/designee to all staff to ensure no staff leaves hazardous items within reach of residents on 6/6/23, anyone not available for the training will be educated before they return prior to their first worked shift.
d. The Administrator/designee will audit the facility each shift daily for four weeks for any hazardous items left within reach of residents and then as needed thereafter to ensure there are no hazardous items within reach of residents.
e. Trends identified will be reported monthly to the Quality Improvement Committee (QIC) for any additional follow up and/or in-servicing until the issue is resolved then randomly thereafter as determined by the QIC committee
f. Corrective Action Completion date 6/6/23.
Upon return to the facility at 9:11 PM on 06/06/23, two (2) employees were found to be working which did not have the specified in-service training prior to the first worked shift, as stated in the plan of correction. Licensed Practical Nurse (LPN) #171 and Nurse Aide (NA) #170 were interviewed by Surveyor and both employees stated they did not receive any in-services prior to starting shift at 7:00 PM. The Administrator was informed at 9:20 PM of the employees working without being in-serviced. The employees were then provided with the in-service training by the Administrator.
On 06/07/23, the state agency (SA) completed review of in-service trainings and found all employees had been educated as indicated in the POC. Observation and tour of the memory unit determined all hazards had been removed, all storage doors secured, and no other accident hazards were present. The IJ was abated on 06/07/23 at 10:00 AM at which time a deficient practice remained and the scope and severity was decreased from a K to an E.
The IJ began on 06/05/23 when the night shift nurse used the knife and left it out in reach of residents. The IJ ended on 06/07/23 when the SA abated the immediacy.
A deficient practice remained because the facility failed to ensure medication and treatment carts were secured and locked while unattended by staff.
This failed practice was a random opportunity and had the potential to affect all residents residing on the memory unit. The remaining deficient practice had the potential to affect more than an isolated number of residents.
Resident identifiers: #49, #103, #87, #62, #114, #40, #13, #41, #96, #64, #89, #95, #101, #99, #93, #33, #35, #83, #78, #3, #43, #100, #68, #108. Facility census: 116.
Findings included:
a) Memory Unit Knife
On 06/06/23 at 11:05 AM, an observation was made of a large chef knife lying the sink of the kitchenette area. The knife was leaned up against the sink water sprayer, with the handle sticking up above the raised counter, in the dementia care unit. The knife was easily accessed from the resident's side of the counter by surveyor. The knife was approximately eight (8) inches long and had a sharp edge.
On 06/06/23 at 11:06 AM the Resident Service Director (RDS) confirmed the knife had been there since last night (06/05/23) when a nurse aide was cutting up vegetables for her own consumption. Nurse Aide #84 was named by unit manager as to be the one that left the knife out during her shift the night before (06/05/23). Resident Service Director (RDS) agreed the knife should not have been left out, and instead stored in a drawer at the back side of the kitchenette. The RDS then picked up the knife and moved it to the back counter, out of reach to residents. When the RDS was asked if anyone had been in the kitchen area this morning (06/06/23), she stated, I was back here this morning getting ice water for medication pass, but I never paid any attention to the sink area.
At 1:30 PM on 06/06/23 the Administrator confirmed all Residents residing on the memory unit were ambulatory and were considered to be Residents who wandered.
On 06/06/23 at 2:10 PM, a baby doll was observed laying in the sink where the chef knife was previously located . NA #61 stated, Yea one of Residents puts the doll into the sink sometimes. Resident #101 was then observed reaching across the counter of the Kitchenette in the memory unit and obtaining a foil wrapped sandwich that was lying on the lower counter. NA #61 intervened and said, They pilfer over here all the time on counter, they like to grab and go. NA #61 was asked if she had saw the knife which was leaned up on the kitchen sink sprayer in the sink earlier and she stated, I really didn't pay any attention, but that's bad news.
Record review showed all 24 Residents residing on the memory unit had a diagnosis of some form of dementia. Residents #41 and #78 also had a diagnosis of delirium due to physiological condition. Resident #49 also had a diagnosis of Paranoid Personality Disorder and Delusional disorder.
Review of the Residents most recent MDS, section C showed only two (2) residents to have a Brief Interview for Mental Status Score (BIMS) score above 8. A cutoff score of 13 is recommended to indicate the presence of any cognitive impairment. A score of 0 to 7 suggests severe impairment.
During an interview on 06/07/23 at 9:30 AM, the Administrator stated he did not condone what happened with the knife being left out over on the memory unit. The Administrator stated, That was a careless act, the memory unit is supposed to be a specially designed place for that population to be safe and wander about. The Administrator further stated all staff have been educated on Resident safety on the memory unit and something like that will not happen again.
b) D Wing Medication Carts
On 06/06/23 at 9:14 PM, observations made on D wing, revealed two (2) medication carts were unlocked and unattended.
During an interview at 06/06/23 at 9:16 PM, LPN #132 acknowledge both medication carts were left unlocked and unattended.
On 06/06/23 at 9:30 PM, the Administrator was notified of the two (2) medication carts being unlocked and unattended.
.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Grievances
(Tag F0585)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on observation, policy review, family interview and staff interview the facility failed to consider a voiced concern of ...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on observation, policy review, family interview and staff interview the facility failed to consider a voiced concern of a residents family as a grievance and failed to act promptly to investigate the voiced concern. This was a random opportunity for discovery and was only true for Resident #270. Resident identifier: #270. Facility Census: 116
Findings included:
a) Policy Review
A review of the facility policy titled Resident Grievance with a review date of 05/30/19 read as follows:
.Procedure:
1. Prevent Ongoing Violations
a. Upon receipt of an oral, written or anonymous grievance submitted by a resident, the Grievance Official will take immediate action to prevent further potential violation of any resident right while the alleged violation is being investigated, if indicated.
.3. Investigation
a. The Grievance Official shall complete an investigation of the resident's grievance.
b. This may include a review of facility processes, programs and policies, as well as interviews
with staff, residents, and visitors, as indicated, and any other review deemed necessary by
the Grievance Official.
b) Resident #270
During an interview on 06/06/23 at 2:00 PM, Resident #270's representative stated, (Resident # 270's name)'s room smells like urine. Her hair is greasy, and she has had no showers since she has been admitted . I spoke to the social worker today about her room and the shower situation. The Social worker stated, the resident got two baths a week, If I wanted her to have more I could come in and bathe her.
During an observation on 06/06/23 at 3:15 PM Resident # 270's hair appeared dirty and disheveled.
During an observation on 06/07/23 at 8:30 AM Resident # 270's hair still appeared dirty and disheveled.
The DON provided a shower schedule on 06/07/23 at 9:00 AM, this schedule indicated Resident # 270 was to receive showers on Thursday and Saturday.
During a record review on 06/07/23 at 9:30 AM, Resident #270 medical records revealed an admission date of 05/25/23.
Further review of the medical record revealed shower task documentation as follows:
-05/25/23 coded resident refused
-05/27/23 coded not applicable
-05/29/23 coded not applicable
-05/30/23 coded not applicable
-06/01/23 coded not applicable
During an interview on 06/07/23 at 10:30 AM, the Director of Nursing (DON) acknowledged the resident had not received a shower since admission on [DATE]. She stated I will make sure she receives one today.
During an interview on 06/07/23 at 11:22 AM, the Director of Social Worker (DSW) #40, stated, I spoke to Resident # 270's family yesterday, I told the Nurse Aide about the urine smell in the residents room so she could take care of it. I also spoke to her about her schedule to receive showers two (2) times a week and she was allowed to give her baths if she did not feel that she was receiving adequate care. I always explain to the family member if the resident has capacity and refuses to take a shower or bath then we can not make them.
When asked if she had spoken to the resident or observed the room for a urine smell, DSW #40 stated, No.
When asked if the Resident had received a shower since her admission? DSW #40 stated, No, I assume she has.
When asked if she had filed a grievance or concern form related to these concerns, DSW #40 stated,
she had not.
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 record review and staff interview, the facility failed to provide a transfer/discharge notice to the resident/residen...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on record review and staff interview, the facility failed to provide a transfer/discharge notice to the resident/resident representative or the ombudsman for one (1) of four (4) residents reviewed for the care area of hospitalization, during the long term care survey. Resident identifier #75. Census 116.
Findings Included:
a) Resident #75
Record review on 06/05/23 at 4:16 PM, indicated resident #75 was hospitalized on [DATE].
On 06/06/23 at 11:10 AM, a copy of the transfer/discharge form and bed hold policy that was presented regarding resident's hospitalization on 05/23/23 was requested.
On 06/12/23 at 12:09 PM, an interview with the Administrator and the Director of Nursing (DON), confirmed they did not have a discharge/transfer form or a bed hold policy for this resident's hospitalization on 05/23/23.
.
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 record review and staff interview, the facility failed to provide a bed hold policy to the resident/resident represen...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on record review and staff interview, the facility failed to provide a bed hold policy to the resident/resident representative for one (1) of four (4) residents reviewed for the care area of hospitalization, during the long term care survey. Resident identifier: #75. Census 116.
Findings Included:
a) Resident #75
Record review on 06/05/23 at 4:16 PM, indicated Resident #75 was hospitalized on [DATE].
On 06/06/23 at 11:10 AM, a copy of the transfer/discharge form and bed hold policy regarding resident's hospitalization on 05/23/23 was requested.
On 06/12/23 at 12:09 PM, an interview with the Administrator and the Director of Nursing (DON), confirmed they did not have a discharge/transfer form or a bed hold policy for this resident's hospitalization on 05/23/23.
.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Assessments
(Tag F0636)
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 complete an accurate Minimum Data Set (MDS) for one (1) of ...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on record review and staff interview, the facility failed to complete an accurate Minimum Data Set (MDS) for one (1) of 26 sampled residents reviewed during the long term care survey. Resident identifier: #60. Census:116.
Findings included:
a) Resident #60
On 06/08/23 at 10:30 AM, a medical record review of Resident #60's MDS indicated the resident did not have behaviors under section E of the MDS. The surveyor reviewed all MDSs since the resident's admission:
Quarterly MDS ARD 12/18/22 indicated no behaviors
Modification of Quarterly MDS ARD 12/18/22 indicated no behaviors
On 06/08/23 at 10:45 AM the surveyor requested from the Director of Nursing (DON), copies of all of the resident's progress notes and MDSs.
On 06/12/23 at 2:13 PM, record review of the provided progress notes found notes of behaviors the resident has had throughout his stay. A synopsis of the notes regarding behaviors are listed below:
04/29/23 Behavior Note - paranoid behaviors - called family who came to visit
03/28/23 Behavior Note - paranoid behaviors - he called 911
02/08/23 Nurses Note - Patient appears to be adjusting to new surroundings
12/22/22 Nurses Note - Increased Buspirone from 10 milligrams (mg) bis in die (BID) to 15 mg BID per (physician name)
12/15/22 Nurses Note - (physician name) to see resident this shift order received to increase residents Seroquel from 100 mg to 200 mg quaque [NAME] somni (QHS)
12/13/22 Behavior Note - Family reached out regarding resident stating that staff members are going to cut off his legs and rip off skin. Daughter requesting an increase or change in medicine. (physician name) consult filled out. Staff to monitor.
11/23/22 Behavior Note - Patient called 911 from his room at 9:00 stating he wants to go home. Patient tries to take himself to the bathroom and turn off bed alarm before anyone can assist him
11/21/22 Nurses Note - Resident seen this shift by Dr. (name of physician), new order given to increase Seroquel dose for evening and night. 4 PM dose changed to 37.5 mg per oral (PO) daily and 100 mg PO at bedtime.
11/19/22 Order Note - Labs ordered - Resident having episodes of aggression with staff this shift. Barricading self with bathroom door against main door; educated on importance of not doing this but continued to do it for multiple attempts of this nurse to get into room.
11/17/22 Nurses Note - Resident seen by (physician name) new order to increase Seroquel from 50 mg to 75 mg at bedtime. Continue behavior charting every shift. Follow up in a week.
10/28/22 Behavior Note - Resident continually ringing out this shift and finally brought out to nurses station. Stating he is having seizures. Having baseline tremors and anxiety. Daughter talked to resident and he calmed down and went to bed
10/28/22 Behavior Note - Resident stated he fell short of breath. Resident's heat on high in room. Resident agreeable to have heat turned down.
10/27/22 Behavior Note - Resident self ambulating out of wheelchair. Resident turned off chair alarm. Resident reminded to use call light and having help when ambulating.
10/13/22 Order Note - (physician name) in house to assess resident. New orders for Seroquel 25 mg at 1700 and Seroquel 50 mg QHS.
10/11/22 Nurses Note - Resident with increased paranoia behaviors, stating he isn't going to go to sleep because someone is trying to hurt him. This nurse explained that no one would hurt him here and that this is a safe place. Resident brought to nurses station for redirection. Resident currently sitting at desk talking/joking with this nurse. Consult filled out for (physician name) to see resident.
On 06/13/23 at 9:14 AM, a staff interview with the Director of Social Services #40 confirmed the behavior section, section E of the MDS, indicated there were no behaviors but there was documentation throughout the resident's stay indicating he was indeed having behaviors.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
PASARR Coordination
(Tag F0644)
Could have caused harm · This affected 1 resident
.
Based on record review and staff interview, the facility failed to complete a new Pre admission Screening (PAS) when a resident received a new psychiatric diagnosis for one (1) of five (5) residents...
Read full inspector narrative →
.
Based on record review and staff interview, the facility failed to complete a new Pre admission Screening (PAS) when a resident received a new psychiatric diagnosis for one (1) of five (5) residents reviewed for the category of unnecessary medications, psychotropic medications, and medication regimen review, during the long term care survey. Resident identifier #26. Census 116.
Findings Included:
a) Resident #26
A record review on 06/05/23 at 2:39 PM, provided a completed PAS but no level II needed This PAS was dated 02/23/17 and Section III, number 30 was answered NONE. The Electronic Medical Record (EMR) indicated, during the resident's stay at the facility, he received a diagnosis of Bipolar Disorder, Current Episode Depressed, Mild or Moderate Severity, Unspecified. This diagnosis was given to the resident on 04/18/2023. There was no updated PAS scanned into the EMR.
On 06/06/23 at 11:10 AM, the surveyor requested a copy of the most recent PAS from the Director of Nursing (DON).
On 06/06/23 at 12:30 PM, a copy of the most recent PAS was provided to the surveyor. The same PAS from EMR, dated 02/23/17, was what was provided to the surveyor.
A staff interview was conducted on 06/06/23 at 1:39 PM, with the Director of Social Services #40. Staff #40 stated she is new and does not know if a PAS was done after the resident received a diagnosis of Bipolar disorder. She stated the full time social worker is out but she would ask the admissions department to see if they have a more recent PAS. No further information was provided to surveyors prior to exit.
.
CONCERN
(D)
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 observation, medical record review, family interview and staff interview the facility failed to provide care required...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on observation, medical record review, family interview and staff interview the facility failed to provide care required to maintain hygiene to a resident who was dependent for Activities Of Daily Living (ADL) care. This is true for one (1) of three (3) residents reviewed for ADL care are during the Long Term Care Survey Process. Resident Identifiers: Resident #270. Facility Census: 116
Findings Included:
a) Resident #270
During an interview on 06/06/23 at 2:30 PM, Resident #270's representative stated, (Name of Resident # 270's) room smells like urine. Her hair is greasy, and has had no showers since she has been admitted . I spoke to the social worker today about her room and the shower situation. The Social worker stated the resident got two baths a week, If I wanted her to have more I could come in and bathe her.
During an observation on 06/06/23 at 3:15 PM, Resident # 270's hair appeared dirty and disheveled.
During an observation on 06/07/23 at 8:30 AM, Resident # 270's hair still appeared dirty and disheveled.
The Director of Nursing (DON) provided a shower schedule on 06/07/23 at 9:00 AM, this shower schedule indicated Resident # 270 was to receive showers on Thursday and Saturday.
During a record review 06/07/23 at 9:30 AM, of Resident #270's medical records revealed her admission date was 05/25/23.
Further review of the medical record revealed shower task documentation as follows:
-05/25/23 coded resident refused
-05/27/23 coded not applicable
-05/29/23 coded not applicable
-05/30/23 coded not applicable
-06/01/23 coded not applicable
During an interview on 06/07/23 at 10:30 AM the Director of Nursing (DON) acknowledged the resident had not received a shower since admission on [DATE]. She stated I will make sure she receives one today.
During an interview on 06/07/23 at 11:22 AM, the Director of Social Worker(DSW) #40 stated, I spoke to Resident # 270's family yesterday, I told the Nurse Aide about the urine smell in the residents room so she could take care of it. I also spoke to her about her being scheduled to receive showers two times a week and she was allowed to give her baths if she did not feel she was receiving adequate care. I always explain to the family member that if the resident has capacity and refused to take a shower or bath then we can not make them.
.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on record review and staff interview, the facility failed to follow their suicide prevention policy for one (1) of 26 sa...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on record review and staff interview, the facility failed to follow their suicide prevention policy for one (1) of 26 sampled residents reviewed during the long term care survey process. Resident identifier #75. Census 116.
Findings Included:
a) Resident #75
On 06/06/23 at 11:10 AM, the surveyor requested a copy of the resident's psychiatric notes/evaluations, copy of care plans, copy of pharmacy recommendations, and a copy of the resident's Pre admission Screening (PAS).
Record review revealed the resident had suicidal ideation's since he had been at the facility. Resident #75 was admitted to facility on 10/12/22.
On 10/18/2022 at 4:29 PM, Social Worker #172 documented in a progress note, During trauma informed care screening resident stated suicidal ideation multiple times. Resident stated he has thoughts and feelings of not wanting to be alive r/t to feeling like he is not getting progress out of SNF placement. Social worker inquired if he had a plan, and resident held his finger to his head in the shape of a gun and stated he just wanted to do this. Social worker asked if this was a reoccurring feeling or if there were triggers and he stated he has felt suicidal in the past r/t time in the army and his past divorces, but he stated he currently feels suicidal because of SNF placement. Resident stated progress in therapy helps him not feel suicidal. Social worker reported this to (social worker's name) LSW, (Assistant Director of Nursing's name) ADON, and the nurse on resident's hallway.
On 10/18/2022 at 4:44 PM, a nurses note written by Registered Nurse (RN) #163 stated, Social Worker came to RN and notified that pt had made remarks that he wanted to harm himself. This RN notified both (Nurse Practitioner's Name) NP and (Physician's Name) MD. No further orders were given at this time. RN also notified DON
No other intervention was documented in the residents medical record. Then approximately seven (7) months later, on 05/11/23 at 7:00 PM, social worker #40 documented, Observed resident in the courtyard and said hello to resident. Resident expressed that he would like to shoot himself and reported this is due to feelings of being alone and hopelessness. Alerted other social worker for assistance and spent time creating plan for resident involving the facility pet as well as activities and making new friends. Nursing staff was alerted and resident's room was moved closer to nurses station for observation. Nurse alerted to notify physician of resident suicidal thoughts. 15 minutes checks were initiated pending further physician orders.
The same day, 05/11/23 at 10:00 PM, Licensed Practical Nurse (LPN) #32 documented the following, MD (physician's name) notified of the resident suicidal ideation's per SW. MD gave new orders to continue frequent checks and to ensure no firearms in the building. Resident has been moved to a RM adjacent to the Nurses Station away from the exit and to ensure frequent checks by nursing staff. Resident feeling more sad coz his roommate was getting many visitors all day long and he has nobody that visits him. Support provided and reassured by nursing staff. Will continue to monitor.
13 days later on 05/24/23 at 2:47 PM, SW #26 documented, MSW (SW name) notified by MSW (SW name) that the IDT team is recommending resident to be sent out for inpatient psychiatric stabilization due to consistent +SI for last couple weeks. MSW called MARS line and spoke with (name redacted to ensure confidentiality), regarding availability on the CRC Adult Unit. Per (name redacted to ensure confidentiality), , CRC Adult Unit is full at this time. MSW called (name of local psychiatric hospital) and spoke with name redacted to ensure confidentiality), who took the intake. After the intake, MSW received call from (name redacted to ensure confidentiality), in Admissions at (name of local psychiatric hospital). Per (name redacted to ensure confidentiality), resident would meet criteria for admission to their facility. (name redacted to ensure confidentiality), faxed over a checklist and stated that once the labs are back, then to fax the documents and labs from the checklist to them. MSW confirmed fax # with (name redacted to ensure confidentiality), . Facesheet and additional documentation faxed. Will fax labs once they result. MSW will continue to follow.
At 2:59 PM, the same day, SW #40 documented she left a message for the resident's conservator regarding a call back about a psychiatric evaluation for the resident.
The same day, 05/24/23 at 9:20 PM, SW #26 documented, MSW reviewed PHQ-9 Assessment that was done by SW (SW name) and noticed that resident reported thoughts of being better off dead or thoughts of hurting himself. MSW notified bedside nurse, (nurses name), and asked for frequent checks to be completed. (nurses name) stated she would check in on him throughout her shift. MSW will continue to follow.
The next day, 05/25/25 at 10:51 AM, SW #40 documented, Spoke to conservator (conservator's name). Discussed in detail the nature of the resident's mental health concerns including active SI. Conservator reported this is the first time she has been made aware of this situation, and that she is in agreement to send resident to (name of local psychiatric hospital) for evaluation and stabilization. Conservator requested status update when more is known, but social worker did let her know that resident was on track to be admitted at (name of local psychiatric hospital) on 05/25/23. Conservator reported this was fine.
Resident was finally sent out for inpatient psychiatric services at (Name of local psychiatric hospital) on 05/25/23 and returned to the facility on [DATE].
On 06/12/23 at 10:02 AM a staff interview with th DON and the Administrator was conducted. The surveyor questioned them in regards to the note which was written by SW #40 on 05/11/23, who stated the physician ordered 15 minute checks for resident. The DON stated, there is no documentation for the 15 minute checks. Another progress note was written by the LPN three (3) hours later on the 05/11/23, stated the same physician gave new orders to continue frequent checks. The surveyor questioned if this meant to continue the 15 minute checks and the DON and Administrator replied they believe this means every two (2) hours. The surveyor asked if every two (2) hours is not the standard of care that every resident is checked on and the Administrator responded yes.
On 06/12/23 at 1:00 PM, the DON provided the facility's Policy for Suicide Prevention. A review of CommuniCare Family of Companies Policies and Standard Procedures, Subject: Suicide Prevention, Policy # NS-1042-01 found the following:
.Scope: This policy is applicable to all adult living centers.
Definition: Suicidal ideation's: forming specific thoughts or verbalizing a plan with the intent to self-destruction
Policy: It is the policy of this facility to promote resident centered care by providing assessments to identify residents with suicidal thoughts and ideation's and to assist them in obtaining the proper mental health care.
Procedure:
1. Educate staff caregivers to be alert for residents with suicidal ideation's or thoughts regarding self-harm and/or of suicide. Those at greater risk include but not limited to:
a. Residents on antidepressant medication
B. Residents that have experienced a recent life changing event including but not limited to:
i. Newly admitted to facility
ii. Loss of spouse/close family or friend
iii. Deteriorating /declining health
iv. History of previous unsuccessful attempts
v. History of drug abuse/alcohol abuse
2. Educate staff to take all threats of self-harm seriously and report immediately to the nursing supervisor
3. Educate staff to report unusual items not normally found in room including a make-shift noose from clothing/other, medications or pills found hidden, large plastic bags
4. The nurse will:
a. Assess the resident immediately
b. Take all ideations and verbalizations of suicide seriously
c. Proved 1:1 supervision until physician contacted
d. Contact the physician or transfer immediately if threat is imminent or if physician contact is delayed
e. Contact family/guardian of concerns
f. Document the assessment and discussions in medical records using the resident's direct words if possible
g. Transport to acute care for psychiatric consultation as appropriate
A staff interview with the DON on 06/12/23 at 1:47 PM, confirmed she reviewed the policy she provided the surveyor and she believes they provided 1:1 intervention by moving his room close to the nurses station, stating staff could see in his room. The DON confirmed there is no documentation to prove there was someone 1:1 with the resident prior to contacting the physician nor any documentation that 15 minute checks were being done as ordered by the physician, other than a note about him moving rooms. The surveyor explained there is no 15 minute documentation provided and there is no guarantee someone was watching him from the nurses station, when they had other residents to care for.
.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
Could have caused harm · This affected 1 resident
.
Based on observation, resident interview and staff interview, the facility failed to ensure respiratory care was provided according to professional standards of practice. This was a random opportuni...
Read full inspector narrative →
.
Based on observation, resident interview and staff interview, the facility failed to ensure respiratory care was provided according to professional standards of practice. This was a random opportunity for discovery and was only true for Resident #32. Resident Identifier: #32. Facility Census: 116.
Findings Included:
a) Resident #32
On 06/05/23 at 12:45 PM, an observation was made of a continuous positive airway pressure (CPAP) mask laying on top of the CPAP machine. The CPAP mask was not stored in a respiratory bag. Resident #32 stated, It has never been put in a bag. Registered Nurse (RN) #108 confirmed the CPAP mask was not being stored in a respiratory bag. RN #108 stated, let me get one.
On 06/06/23 at 2:40 PM, an additional observation was made of the CPAP mask laying on top of CPAP machine. The CPAP mask was not stored in a respiratory bag. The resident was not present in the room. Licensed Practical Nurse LPN) #145 confirmed the CPAP mask was not being stored in a respiratory bag. LPN #145 stated, I'll go get one.
The care plan was reviewed regarding the CPAP machine. The review found no preference regarding the storage of the CPAP mask was found. The resident did not voice any concerns regarding storage of the CPAP mask on 06/05/23 at 12:45 PM
On 06/05/23 at 1:00 PM and on 06/06/23 at 3:00 PM, the Administrator was notified of the CPAP mask was not being stored in a respiratory bag.
.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0806
(Tag F0806)
Could have caused harm · This affected 1 resident
.
Based on observation, staff interview, and record review the facility failed to provide a resident on the memory unit with an alternate meal preference during lunch. This was a random opportunity fo...
Read full inspector narrative →
.
Based on observation, staff interview, and record review the facility failed to provide a resident on the memory unit with an alternate meal preference during lunch. This was a random opportunity for discovery and only affected Resident #93. Resident identifier: #93. Facility census: 116.
Findings included:
a) Resident #93
On 06/05/23 at 1:31 PM, Resident #93 pushed her lunch plate to the side. Resident #93 said to Nurse Aide (NA) #84, They told me I could have a sandwich. NA #84 told the Resident They are not the boss; you eat what you have on your plate. Resident dropped her head, and her bottom lip began to quiver. The Resident got tears in her eyes as she sat and watched her table mates eat their lunch. Activity Director #45 was asked what happens when a resident wants something else to eat? AD #45 stated to NA #84 Are you going to call the kitchen and see if there is something else she can have, maybe a mechanical snack? AD #45 stated due to her diet she could not have a sandwich. AD #45 said, she does this all the time. The diet ticket stated: Regular Dysphasia/Puree Diet.
At 1:41PM on 06/05/23, a sandwich was noted to be laying on the table in front of Resident #93. Licensed Practical Nurse (LPN) #123 stated, I got her a sandwich, but now she is nibbling at the pureed broccoli from her plate. She is always wanting something else.
Record review showed a diet order for Regular diet, Dysphasia Puree texture, Regular consistency. May have Dysphasia Advanced snacks.
A list of Dysphasia Advanced snacks was provided by the Administrator to include cottage cheese, applesauce, pudding, yogurt and ice cream.
During an interview at 2:17 PM on 06/12/23 the administrator stated Resident #93 should not have to eat a snack with everyone else getting a meal, and NA #84 should have never denied Resident #93 another meal choice. The Administrator further stated he would have dietary re-evaluate the resident to see if her diet can be advanced and she can tolerate having a sandwich in her diet moving forward.
.
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, record review and staff interview the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary environment and to help preve...
Read full inspector narrative →
.
Based on observation, record review and staff interview the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary environment and to help prevent the development and transmission of communicable diseases and infections. Proper infection control procedures were not taken during medication pass on the memory unit. Family was not provided with the proper personal protective equipment during visitation to Resident's room. This failed practice had the potential to affect more than a limited number of residents and was a random opportunity for discovery. Resident identifiers: #35 and #104. Facility census: 116.
Findings included:
a) Resident #35
On 06/06/23 at 8:52 AM, during observation of medication pass on the memory unit, Licensed Practical Nurse (LPN) #62 placed Resident # 35's eye drops and nasal spray on the seat of a empty cushioned chair in the common living room while she administered the residents oral medications. LPN #35 did not put a barrier down or sanitize the surface prior to placing the multiuse medications on the seat. LPN #62 then administered the nose spray to each nostril and eye drops to both eyes. LPN #35 returned the eye drops and nasal spray to the mediation cart drawer that contained other residents' mediations.
During an interview on 06/06/23 at 11:28 AM the DON verified medications are sometimes given out in the common living area and stated, That's just the way we've always done it [administer medications on the memory unit] so we don't have to chase them around. The DON further verified the eye drops and the nasal spray should not have been set directly on the seat of the chair (without a barrier and prior to cleaning the surface) due to infection control issues, and definitely should not have been returned to medication cart. The DON stated, Putting them back in the drawer with the other medications was not the smartest thing to do, that just caused an infection control breach for all those other medications.
b) Resident #104
During an observation on 06/06/23 at 8:50 AM Resident #104's room had a droplet precaution sign on the door. There were three (3) visitors in residents #104 room, not wearing the appropriate PPE.
An immediate interview with LPN #171 stated, everyone that enters the rooms must wear a gown, mask and gloves, including visitors. There is a sign on the door that states stop see nurse before entering. I will educate the visitors on wearing the PPE.
Interview with DON at 9:05 am stated, we can not make the visitors wear the PPE.
Interview with DON at 9:20 am stated there is a sign on the door stated to report to the nurses station but if they don't come back to the nurse station before going into the room how are we supposed to know the visitors are in the room.
This surveyor stated, several staff members were observed passing the room and the wound nurse was standing by the door as two visitors entered the room, no one stopped them or educated on the use of the PPE.
A record review on 06/06/23 at 8:57 AM Resident #104 medical records revealed a Physician order dated 06/05/23 droplet isolation and precaution due to pneumonia.
No other information was provided by the end of the survey.
.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Resident Rights
(Tag F0550)
Could have caused harm · This affected multiple residents
.
Based on observation, policy review and staff interview the facility failed to treat residents with dignity and respect by not providing a dignified dining experience and failing to knock on doors b...
Read full inspector narrative →
.
Based on observation, policy review and staff interview the facility failed to treat residents with dignity and respect by not providing a dignified dining experience and failing to knock on doors before entering. The facility also failed to treat Resident #35 with dignity and respect during a medication administration. These were random opportunities for discoveries. The practice had the potential to affect more than a limited number of residents. Resident Identifiers: #111, #56, #4, #87, #57 and #35. Facility Census: 116.
Findings Included:
A) Policy Review
A review of the facility policy titled Residents Rights with no effective or review date revealed the following.
.Procedure:
I.i. Knock before entering residents room if door is closed-wait for answer.
b) Dignified Dining Experience
During a main dining room observation on 06/07/23 at 8:05 am two (2) staff members were assisting residents with their breakfast meal while standing beside and towering over them.
During an interview on 06/07/23 at 8:08 AM, the Director of Nursing (DON), acknowledged Nurse Aide (NA) #54 and Payroll Specialist #92, was standing up assisting residents Resident #85 and Resident #57 with the breakfast meal which was not dignified.
c) Privacy for residents
During a dining observation on 06/06/23 at 12:53 PM on B wing Nurse Aide (NA) #66 was serving lunch trays, they entered Resident #111 room without knocking and waiting for response. NA #66 stated to Resident #111, I have to go get help to pull you up so you can eat your lunch. NA #66 proceeded to leave the room and went across the hall to get assistance from another NA which was in the room. She went into Resident #56 and #4's room, without knocking and stating to the other NA in the room, I need your help pulling up (Resident #111) name. NA #66 then went back into Resident #111's room without knocking.
When asked why they did not knock on the residents door before entering the room, NA #66 stated, I did not know I had to knock before I went in I was just trying to deliver trays.
During an interview on 06/06/23 at 12:55 PM the DON was informed of the above situation and stated a proper inservice will be conducted for all staff on knocking prior to entering residents rooms.
d) Resident #35
On 06/06/23 at 8:53 AM, Licensed Practical Nurse (LPN) #62 administered Flonase Allergy Relief Nasal Spray (2 sprays in both nostrils) and Systane Balance Ophthalmic Solution eye drops (1 drop in both eyes) to Resident #35 while the resident was setting in the common living area of the memory unit with other residents present. No privacy was provided for the Resident.
During an interview on 06/06/23, the Director of Nursing (DON) stated they allow nurses to give medications to the residents in the common living area, however eye drops, and nose spray was a different ballgame and should not be. The DON stated, They [medication nurses] need to be taking the Residents to a private area for that.
.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on observation, resident interview, record review and staff interview the facility failed to develop or implement a comp...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on observation, resident interview, record review and staff interview the facility failed to develop or implement a comprehensive person-centered care plan with measurable objectives for each resident. This was true for four (4) of 26 residents reviewed during the Long-Term Care Survey Process. Resident Identifiers: Resident #86, Resident #44, Resident #97, Resident #96. Facility Census: 116
Findings Included:
a) Resident #86
A record review on [DATE] at 9:17 AM, of Resident #86's medical record revealed an admission date of [DATE].
Further review of the medical record revealed a care plan with an initiated date of [DATE] which read as follows:
Focus: The Resident has little activity involvement the resident is a recent admission to center
Goal: Resident will participate in activities of choice through review date.
Inventions: Assist with transport to activities as needed.
Invite resident to schedule activities.
Further medical record review revealed the activity preference interview for admission was completed on [DATE]. Section C. Activity Pursuit Patterns was coded for reading the newspaper, watching [NAME] news, History Channel [NAME] Heroes and listens to country western music and reads bible daily.
None of the interests voiced by Resident #86 was reflected in his care plan.
During an interview on [DATE] at 4:00 PM the Activity Director (AD) #45 stated, I know the care plans are not correct, I can't get caught up. I don't have enough staff. The documentation is not being done. I am doing the best I can.
During an interview on [DATE] at 1:50 PM the Administrator and the AD #45 acknowledged the care plans need to be person centered to meet the residents needs.
b) Resident #44
On [DATE] at 3:23 PM, a record review was completed for Resident #44. The review found the resident has a diagnosis of Post-Traumatic Stress Disorder (PTSD). Upon reviewing the care plan, an intervention under the care area of PTSD, was not implemented as written. The intervention stated, Social worker will provide weekly and as needed psychosocial support.
On [DATE] at 12:58 PM, an interview was held with the Social Services (SS) #40. SS #40 stated, I'm new and the resident doesn't like new faces .the full-time social worker is on vacation ([DATE]-[DATE]) and told me to wait until she got back to meet her. The resident was in isolation so I wasn't introduced to her.
On [DATE] at 1:00 PM, an interview was held with SS #28. SS #28 stated, I don't know what (Name of Social Worker #95) does .I'm not here full-time. I saw the resident on Friday ([DATE]) and I'll see her tomorrow ([DATE]) probably.
On [DATE] at 3:06 PM, an interview was held with Resident #44. Resident #44 stated, We (Name of Social Worker #95) try to see each other at least every two weeks .I am lucky I get to see my therapist weekly via zoom.
On [DATE] at 3:30 PM, the Administrator and Director of Nursing (DON) were notified and confirmed the care plan was not being implemented regarding the weekly social worker visits to provide psychosocial support.
No further information was obtained during the long-term survey process.
c) Resident #97
An Electronic Medical Record (EMR) review was conducted on [DATE] at 2:27 PM. The Physician Order for Scope of Treatment (POST) form reflected the resident's wishes of Cardiopulmonary Resuscitation (CPR), Full Treatments, and Medically Assisted Nutrition for a Time-limited trial of 30 days but no surgically-placed tubes. The EMR care plan for resident's code status simply stated Full Code, not reflecting the resident's specific wishes.
On [DATE] at 11:10 AM, the surveyor requested a copy of the resident's POST form, current orders, and care plans. The requested documents were received on [DATE] at 12:30 PM.
On [DATE] a record review of the copies provided indicated the POST form reflects: CPR, Full Treatments, and Time-limited trial of 30 days but no surgically-placed tubes. The physician order reflects: Full-code; the resident's care plan reflects: Full Code.
On [DATE] at 9:55 AM, a staff interview with the Director of Nursing (DON) confirmed the resident's order and his care plan does not list everything indicated on his POST form. The DON stated she had never heard of writing a specific code status order and the care plans are automatically populated for Full Code or Do Not Resuscitate (DNR).
d) Resident #96
Resident #96 was admitted to the Memory Care unit on [DATE].
On [DATE] at 12:48 PM , the Activity Director #45 was observed asking the nurse for batteries for Resident #45's hearing device. The Nurse found some batteries and handed them to AD #45. AD #45 put the batteries in the hearing device and said maybe she can hear us now; she uses this all the time.
Review of the Residents care plan showed no mention of the Resident residing on a locked memory unit. Further review of the Resident's care plan showed no interventions for use of headphone hearing device.
On [DATE] 10:18 AM, Resident service director stated Resident #96 does use the hearing device provided by activities every day. Resident prefers to wear headphones rather than the hearing aids. The headphones were hooked to a microphone box apparatus and helped Resident out a lot for participating in activities. The RSD verified the hearing device should be care planed for Residents everyday use.
On [DATE] at 10:03 AM the Administrator agreed any Resident residing on the memory unit should have that specified and included on the care plan. The Administrator stated, We have a lot of work to do for the memory unit, we will make that part of the audits.
.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0657
(Tag F0657)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on medical record review and staff interview, the facility failed to revise care plans for Resident #15 regarding discon...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on medical record review and staff interview, the facility failed to revise care plans for Resident #15 regarding discontinuation of anticoagulant use, activities for Resident #100 and behavioral interventions for Resident #60. This was true for three (3) of 26 residents reviewed during the long-term survey process. Resident Identifiers: #15, #100 and #60. Facility Census: 116.
Findings Included:
a) Resident #15
On 06/07/23 at 11:30 AM, a record review was completed for Resident #15. The record review found the care plan stated, the resident is at risk for abnormal bleeding or hemorrhage due to anticoagulant/antiplatelet use (Lovenox). The review found the anticoagulant was discontinued on 03/15/23.
On 06/07/23 at 1:00 PM, the Director of Nursing (DON) was notified and stated, I will get it changed right away.
No further information was obtained during the long-term survey process.
b) Resident #100
A record review on 06/07/23 at 2:00 PM, of Resident #100's medical record revealed a care plan with an initiated date of 09/12/22 and revision date of 03/27/23 with a read as follows:
Focus: Resident enjoys music, religious services and family visits.
Goal: Patient will agree to participate in activities such as music, ball toss at least one time week through next review period.
Inventions: Introduce peers to patients with similar recreational interest if present in the center.
Further medical record review revealed the activity preference quarterly was completed on 03/30/23. Section C. Activity Pursuit Patterns was coded for watching Westerns, [NAME], The [NAME] Show, The Golden Girls and listens to country gospel music. Resident enjoys spending time in the courtyard.
The care plan was not revised to reflect the residents identified interests.
During an interview on 06/07/23 at 4:00 PM, the Activity Director (AD) #45 stated, 'I know the care plans are not correct, I can't get caught up. I don't have enough staff. The documentation is not being done. I am doing the best I can.
During an interview on 6/12/23 at 1:50 PM the Administrator and the AD #45 acknowledged the care plans need to be person centered to meet the residents needs.
c) Resident #60
On 06/12/23 at 2:13 PM, a record review of the resident's progress notes show nine (9) times it is documented the resident had behaviors. Of those nine (9) instances, four (4) have documented nonpharmalogical intervention. Two (2) times the resident's family was able to calm resident and two (2) times staff were able to redirect the resident.
On 04/29/23 a Behavior Note indicated the resident was having paranoid behaviors and the intervention used was to call the resident's family who came to visit and helped assure resident.
On 03/28/23 a Behavior Note indicated the resident was having paranoid behaviors and he called 911. There was no intervention documented.
On 12/13/22 a Behavior Note stated the resident's family reached out regarding the resident making statements that staff members are going to cut off his legs and rip off his skin. The resident's daughter requested an increase or change in medicine.
On 11/23/22 a Behavior Note stated the resident called 911 from his room stating he wanted to go home. This note also stated the resident tries to take himself to the bathroom and turn off his bed alarm before anyone can assist him. No intervention was listed.
On 11/19/22 an Order Note states labs were ordered due to the resident having episodes of aggression with staff that shift. He barricaded himself with bathroom door against his main door. The intervention documented was the resident was educated on importance of not doing this but he continued to do it.
On 10/28/22 a Behavior Note stated the resident was continually ringing out stating he was having seizures. The note states, .Having baseline tremors and anxiety . The intervention was to bring the resident to the nurses station and call his daughter who was able to calm him down and get him to go to bed.
On 10/28/22 a Behavior Note indicated the resident stated he felt short of breath. The resident's heat was found to be on high in his room. The intervention was to assist the resident in turning his heat down.
On 10/27/22 a Behavior Note stated the resident was self ambulating without his wheelchair and the resident turned off his wheelchair alarm. The intervention was to remind the resident to use his call light and not to ambulate without assistance.
On 10/11/22 a Nurses Note states the resident had increased paranoia behaviors, stating he isn't going to go to sleep because someone is trying to hurt him. The intervention used was the nurse assuring the resident no one would hurt him here and this is a safe place. Resident was also brought to nurses station where he sat and talked and joked with the nurse.
On 06/07/23 at 11:09 AM, a record review of Resident # 60's care plan was conducted.
The Focus read as follows, Patient is receiving antipsychotic medication due to a diagnosis of Dementia and exhibits mood and behavior problems as a result. Patient exhibits mood changes for no apparent reason, can get upset and aggressive. Resident received unwanted aggression with no injuries on 01/20/23 by resident(6505).
The Goal on this care plan is, Patient behaviors will be managed with the lowest possible dose AEB no recurrence of previous behavior (ie: hitting, kicking, slapping)and will have no side effects noted through next review period related to medication use.
The Interventions for this care plan are listed as follows:
Administer Seroquel as ordered. Monitor for side effects: mood/behavior changes, constipation, drowsiness, headache, trouble sleeping. If noted contact MD.
ANTIPSYCHOTIC side effect monitoring list #1: Dystonia: torticollis(stiffness of neck), Anticholinegic symptoms:Dry Mouth, blurred vision, constipation, urinary retention. Hypotension, Sedation/drowsiness, increased falls/dizziness, Cardiac abnormalities(tachycardia, bradycardia, irregular H.R; NMS). Anxiety/agitation, blurred vision, sweating/rashes, headache, urinary retention/hesitancy,pseudoparkinsonism: cogwheel rigidity, bradykinesia, tremors, appetite change/weight change.
ANTIPSYCHOTIC side effect monitoring list #2 not limited to: insomnia, confusion. Akathisia: restlessness, pacing, inability to sit still, anxiety, sleep disturbances. Tardive dyskinesia: lip smacking/chewing, abnormal tongue movement, spasmodic movement of the arms/legs, rocking/swaying, blood abnormalities, sore throat, seizures, photosensitivity.
Attempt a GDR as indicated per center protocol.
Complete AIMs assessment per center protocol.
Do not hurry or rush patient in any task or activities.
Hold dose if sleepy
Pharmacy consultant to review medications monthly.
Provide frequent contact and reassurance. Focus on abilities and accomplishments.
Reduce noise and activity levels. Keep distractions to a minimum.
Remove the patient from the upsetting situation slowly and quietly.
Use a calm, reassuring approach. If patient can tell what the problem is, try to eliminate the source of agitation.
None of the interventions on the above care plan are the interventions the facility is actually documenting they are using when the resident has behaviors.
On 06/13/23 at 9:14 AM, a staff interview was conducted with the Director of Social Services #40, who could not tell the surveyor what types of behaviors the resident has nor the interventions the facility uses to help with his behaviors. Staff #40 concurred the interventions they are using do not match the interventions on the resident's care plan.
.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0679
(Tag F0679)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on observation, record review, resident interview and staff interview, the facility failed to implement an ongoing resid...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on observation, record review, resident interview and staff interview, the facility failed to implement an ongoing resident centered activities program designed to meet the interest of and support the physical, mental and psychosocial well-being of each resident. This practice was found true for four (4) of ten (10) Residents reviewed for the Activity Care Area during the Long-Term Care Survey Process (LTCSP). Resident Identifier: Resident #86, #44, #100 and #108. Facility Census: 116
Findings Included:
a) Resident #86
During the initial tour of the facility on 06/05/23 at 2:15 PM Resident #86 was laying in bed with family present. Family stated Resident watches TV and reads the newspaper and bible daily. But we have not brought his bible here, we thought they would let him borrow one, since he was here for a short stay. They said they receive the newspaper here but have not gotten one to read.
During a record review on 06/06/23 at 8:30 PM Resident #86 medical records revealed an activity preference interview for admission was completed on 05/22/23. Section C. Activity Pursuit Patterns was coded for reading the newspaper, watching [NAME] news, History Channel [NAME] Heroes and listens to country western music and reads bible daily.
Further review of the medical record revealed a care plan with an initiated date of 05/22/23 with a reads as follows:
Focus: The Resident has little activity involvement the resident is a recent admission to center
Goal: Resident will participate in activities of choice through review date.
Inventions: Assist with transport to activities as needed.
Invite resident to schedule activities.
Further documentation was provided by the Activity Director (AD) #45 on 06/07/23, the civility participation record was void of any activity documentation on the following days:
-05/23/23
-05/25/23
-05/26/23
-05/27/23
-05/28/23
-05/29/23
-05/30/23
-05/31/23
-06/01/23
-06/03/23
-06/04/23
-06/05/23
-06/06/23
Several observation made throughout the Long Term Survey on 06/05/23 to 06/08/23, Resident #86 did not have a newspaper or a bible to read in his room.
During an interview on 06/07/23 at 4:00 PM the AD #45 stated we chart daily, but not everything gets documented, some of my staff don't have time to document everything. But we do activities daily. I just don't have enough staff to keep in the memory unit and the long term unit all day long.
This issue of no bible or newspaper in Resident #86 room was discussed with the AD and no documentation of activities being provided to Resident #86. no other information was provided.
During an interview on 6/12/23 at 1:50 PM the Administrator and the AD acknowledged the lack of activities especially in the memory unit and activity participation documentation not being completed. The Administrator stated the activities need to improve and we will be working on it.
b) Resident #44
During a record review on 06/06/23 at 8:45 PM Resident #44 medical record revealed a quarterly Activity preference interview dated 04/18/23. Section C. Activity Pursuit Patterns was coded likes Bingo, enjoys sketching and painting on canvas, watching cooking TV shows, CNN news, Netflix and Hallmark movies and listening to different kinds of music. Also coded uses I-pad daily for playing games, enjoys working in the flower boxes and sitting outside and Religious activities.
Further review of the medical record revealed a care plan with a initiated date of 07/28/18 and revision date of 04/18/23 included the following:
Focus: Resident enjoys activities such as arts and crafts, religious services, outings, using her laptop, teaching Hebrew, reading, gardening, playing bingo, reading and writing the monthly newsletter and facetiming friends.
Goal: Resident will participate in activities that promote socialization with peers consistent with resident likes such as arts and crafts, creative cooking, gardening, bingo games one (1) time a week. through next review.
Inventions included: Assist with finding television channels and movies that are consistent with
residents like and interest such as football, Olympics, doctor who, PBS.
Encourage participation in group activities of interest such as outings, arts and
crafts, gardening, board games and basketball.
Further documentation was provided by the Activity Director (AD) #45 on 06/07/23, the activity participation record was void of any activity documentation on the following days:
-05/26/23
-05/27/23
-05/29/23
-05/30/23
-05/31/23
-06/03/23
-06/04/23
A review of the monthly activity calendar provided by the AD revealed Resident #44's activity preferences were held on the following days with no documentation of attendance/refusal.
-05/27/23 Bingo 2:00 PM
-05/28/23 Bingo 11:00 PM
-05/29/23 Bingo 2:00 PM
-05/30/23 Bingo 2:00 PM
-05/30/23 Planting flowers 4:00 PM
-06/03/23 Bingo 2:00 PM 2:00 PM
-06/04/23 Gospel Sing 2:00 PM
-06/05/23 Bingo 2:00 PM
This issue was discussed with the AD on 06/07/23 at 4:00 PM, AD #45 stated we chart daily, but not everything gets documented, some of my staff don't have time to document everything. But we do activities daily. I just don't have enough staff to keep in the memory unit and the long term unit all day long.
During an interview on 6/12/23 at 1:50 PM the Administrator and the AD acknowledged the lack of activities especially in the memory unit and activity participation documentation not being completed. The Administrator stated the activities need to improve and we will be working on it.
c) Memory Care unit
On 06/07/23 at 2:30 PM a review of the June activity calendar revealed a cooking class at 2:00 PM.
During a memory unit observation on 06/07/23 from 2:40 to 3:00 PM no cooking class was taking place. Activity Leader #160 was in a common living area sitting in a chair beside a resident, there was no TV/music or other sensory stimulation being provided to the memory unit residents.
This issue was discussed with AD #45 she stated, I am doing the best I can and we do stuff over there.
d) Resident #100
An observation of Resident #100 crying and wandering in the hallway on the unit was made at 3:00 m on 06/07/23. Nurse Aide #120 assisted Resident trying to comfort her.
During a record review on 06/06/23 at 8:57 PM Resident #100 medical record revealed a quarterly Activity preference interview dated 03/30/23. Section C. Activity Pursuit Patterns was coded, watches westerns, [NAME], the [NAME] Show, the Golden Girls and listens to Country gospel music.
A review Resident #100's care plan on 06/07/23 at 2:00 PM, revealed a care plan with an initiated date of 09/12/22 and revision date of 03/27/23 with a reads as follows:
Focus: Resident enjoys music, religious services and family visits.
Goal: Patient will agree to participate in activities such as music, ball toss at least one time week through next review period.
Inventions: Introduce peers to patients with similar recreational interest if present in the center.
Further documentation was provided by the Activity Director (AD) #45 on 06/07/23, the activity participation record was void of any activity documentation on the following days:
-05/25/23
-05/26/23
-05/28/23
-05/30/23
-05/31/23
-06/01/23
-06/04/23
-06/07/23
This issue of the above observation on the memory unit of no scheduled activities taking place, or no sensory stimulation being provided to the residents on the Memory Unit.The AD stated I am doing the best I can and we do stuff over there.
This issue of Resident #100 not being in activities or no documentation of activities was discussed with the AD on 06/07/23 at 4:00 PM the AD #45 stated we chart daily, but not everything gets documented, some of my staff don't have time to document everything. But we do activities daily. I just don't have enough staff to keep in the memory unit and the long term unit all day long.
During an interview on 6/12/23 at 1:50 PM the Administrator and the AD acknowledged the lack of activities especially in the memory unit and activity participation documentation not being completed. The Administrator stated the activities need to improve and we will be working on it.
e) Resident #108
On 06/06/23 Surveyor was on memory unit from 2:00 to 2:30 PM observing bingo being held as group activity. The Bingo was being played in a separate area from the common living room.
Resident #108 was noted to be sitting in the common living room without any activity being provided for her to participate in. As the Surveyor walked past the common living area, R #108 asked surveyor, Hey can you turn the TV on, I don't want to just set here and do nothing. Surveyor asked the Activity Director (AD) #45 if the resident could have the tv turned on? AD #45 walked over to resident and asked what do you watch on TV? The Resident Replied, Well anything beats nothing.
Review of Resident #108's Activity Assessment completed 03/23/23 indicated the resident prefered bingo as an activity in relation to games, and listening to music, arts and crafts or bingo in the afternoon.
Review of the residents Activity Participation log from 05/23/23 to 06/07/23 showed the Resident did not participate in any activities on 05/25/23, 05/26/23, 05/28/23, 05/30/23, 05/31/23, 06/01/23, 06/06/23 and 06/07/23.
.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0688
(Tag F0688)
Could have caused harm · This affected multiple residents
.
Based on record review and staff interview the facility failed to provide range of motion (ROM) assistance as ordered to ensure the resident maintains, and/or improves to his/her highest level of RO...
Read full inspector narrative →
.
Based on record review and staff interview the facility failed to provide range of motion (ROM) assistance as ordered to ensure the resident maintains, and/or improves to his/her highest level of ROM. This was true for three (3) of three (3) residents reviewed for ROM. Resident identifiers: #53, #71 and #80. Facility Census: 116
Findings Included:
a) Resident #53
Record review on 06/06/23 at 1:53 PM showed Resident #53 had an order for:
-- Nursing staff to assist with Passive range of motion (ROM) to bilateral lower extremity for exercise. one time a day, This order was dated 12/28/22.
Documentation of the last twenty nine (29) days showed Resident #53 received ROM therapy seven (7) days (for a total of 112 minutes), refused nine (9) days, seven (7) days were documentation as not applicable and no documentation for six (6) days. This was confirmed with the Director of Nursing on 06/06/23 at 3:15 PM.
The documentation was as follows:
05/08/23 Not applicable
05/09/23 Not applicable
05/10/23 Resident Refused
05/11/23 Resident Refused
05/12/23 received 8 minutes
05/13/23 Received 3 minutes
05/14/23 Received 8 minutes
05/15/23 Not applicable
05/16/23 Received 5 minutes
05/17/23 Received 15 minutes
05/18/23 Resident Refused
05/19/23 Not applicable
05/20/23 Received 15 minutes
05/21/23 No documentation
05/22/23 Not applicable
05/23/23 Resident Refused
05/24/23 Resident Refused
05/25/23 Resident Refused
05/26/23 Received 8 minutes
05/27/23 No documentation
05/28/23 No documentation
05/29/23 No documentation
05/30/23 No documentation
05/31/23 No documentation
06/01/23 Resident Refused
06/02/23 Not applicable
06/03/23 Resident Refused
06/04/23 Not applicable
06/05/23 Resident Refused
b) Resident #71
Record review on 06/06/23 at 1:53 PM found Resident #71 had an order for:
-- Nursing staff to perform bilateral range of motion (ROM) lower extremity exercise 3 x 15 reps daily and encourage resident to get out of bed (OOB) into power chair daily. one time a day. This order was dated 01/04/23.
Documentation of ROM exercises for the last twenty nine (29) days could not be located. According to the Director of Nursing (DON) on 06/06/23 at 3:15 PM there is no documentation of ROM exercises being completed. She states they do but there is no documentation of it. During an interview with Resident #71 on 06/07/23 at 8:26 AM, he states they do it sometimes.
c) Resident #80
Record review on 06/06/23 at 1:53 PM revealed, Resident #80 had an order for:
-- Nursing staff to assist with:
(1) ambulation up to 50 feet with gait belt, w/c follow, right upper extremity hemi-walker with assist x 2 for safety around 10:30 am
(2) transfers/sit to stand balance at wall rail with gait belt
(3) assist with home exercise program given to resident by PT daily.
(4) Passive ROM to shoulders, elbow, wrist and digits 3 x 10 reps daily. This order was dated 04/24/23.
Documentation of the last twenty nine (29) days shows Resident #80 received ambulation up to 50 feet with gait belt, w/c follow therapy seven (7) days (for a total of 115 minutes), refused five (5) days, thirteen (13) days were documented as not applicable and no documentation for four (4) days. This was confirmed with the Director of Nursing on 06/06/23 at 3:15 PM.
Documentation of the last twenty nine (29) days shows Resident #80 received transfers/sit to stand balance at wall rail therapy nine (9) days (for a total of 120 minutes), refused five (5) days, nine (9) days were documented as not applicable and no documentation for six (6) days. This was confirmed with the Director of Nursing on 06/06/23 at 3:15 PM.
Documentation of the last twenty nine (29) days shows Resident #80 received assistance with home exercise program given to resident by PT daily nine (9) days (for a total of 101 minutes), refused five (5) days, nine (9) days were documentation as not applicable and no documentation for six (6) days. This was confirmed with the Director of Nursing on 06/06/23 at 3:15 PM.
Documentation of the last twenty eight (28) days shows Resident #80 received Passive ROM to shoulders, elbow, wrist and digits 3 x 10 reps daily seven (7) days (for a total of 101 minutes), never refused, twelve (12) days were documented as not applicable and no documentation for nine (9) days. This was confirmed with the Director of Nursing on 06/06/23 at 3:15 PM.
.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected multiple residents
.
Based on record review, staff interview and observation, the facility failed to ensure medications were dated upon opening and kept in proper temperature controls in accordance with the accepted pro...
Read full inspector narrative →
.
Based on record review, staff interview and observation, the facility failed to ensure medications were dated upon opening and kept in proper temperature controls in accordance with the accepted professional standards of practice. These were random opportunities for discovery. Facility Census: 116.
Findings Included:
a) Temperature Log
On 06/06/23 at 8:43 AM, a tour of the medication room was completed on A wing. The medication refrigerator temperature log was not complete. The following dates were left blank:
--06/01/23 AM check: no initials or title listed
--06/01/23 PM check: no temperature, initials or title listed
On 06/06/23 at 9:00 AM, the Director of Nursing (DON) was notified and confirmed the temperature log should be complete.
b) A wing medication cart
On 06/06/23 at 10:05 AM, the A wing medication cart was reviewed. The following medication was found to be undated upon the initial administration:
--Lumigan ophthalmic solution for Resident #21
--Flonase nasal spray for Resident #26
--Lispro insulin Kwik pen for Resident #75
--Lispro insulin Kwik pen for Resident #97
--Lantus insulin Kwik pen for Resident #17
On 06/06/23 at 10:15 AM, Registered Nurse (RN) #102 confirmed the medication was not dated upon the initial administration.
c) B wing medication cart
On 06/06/23 at 10:15 AM, the B wing medication cart was reviewed. The following medication was found to be undated upon the initial administration:
--Flonase nasal spray for Resident #47
On 06/06/23 at 10:33 AM, Licensed Practical Nurse (LPN) #9 confirmed the medication was not dated upon the initial administration.
On 06/06/23 at 10:56 AM, the Director of Nursing (DON) was notified and confirmed the medication should be dated upon the initial administration.
.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Menu Adequacy
(Tag F0803)
Could have caused harm · This affected multiple residents
.
Based on observations, resident interview and staff interview the facility failed to provide menu items according to each residents preference. Also the facility failed to provide notification of ch...
Read full inspector narrative →
.
Based on observations, resident interview and staff interview the facility failed to provide menu items according to each residents preference. Also the facility failed to provide notification of changes of the menu to residents when the menu needed to be changed. These failed practices had a potential to affect all residents receiving nourishment from the facility kitchen. Resident Identifiers: Resident #27, Resident #80 and Resident #51. Facility Census: 116
Findings Included:
a) Menus
During a dining observation on 06/06/23 beginning at 12:20 PM on D wing Resident #108's lunch meal ticket revealed they should have had:
Spaghetti
Caesar Salad
Garlic Bread
Deluxe Fruit Salad
Observations of Resident #108's tray revealed Spaghetti, mixed vegetables, garlic bread and mixed fruit.
During an interview on 06/06/23 at 12:50 PM, Nurse Aide (NA) #154 acknowledged there was no Caesar salad on Resident #108 tray. She stated that no one received salad on the tray today.
An observation of the menu displayed in the halls for the Residents reads as follows;
Spaghetti
Caesar Salad
Garlic Bread
Deluxe Fruit Salad
During an interview on 06/06/23 at 3:45 PM, the Culinary Director (CD) stated the salad was not of good quality to serve, so I provided the residents with a vegetable medley, it was a last minute change so I was not able to change the meal tickets. We get limited menu items so we have to substitute a lot.
During a main dining room observation on 06/07/23 found several residents' meal tickets indicated they were to receive a chocolate ice cream. The Administrator was present in the dining room and asked the CD if the Resident could have their chocolate ice cream. The kitchen brought out orange sherbet. The CD stated they did not have chocolate ice cream. The orange sherbet is all we have.
During a family interview on 06/07/23 at 3:30 PM confirmed the meal tray ticket never matches what my husband gets on the tray, it's always a guessing game.
b) Resident #27
On 06/05/23 at 12:30 PM during the initial interview of the Long Term Care Survey Process, Resident #2, stated she doesn't get the food she orders for her meals. Her example was she orders a chef salad and only receives a large garden salad. She is a diabetic and tries to limit her carbohydrates and needs protein to sustain her hunger until dinner.
On 06/06/23 at 11:34 AM records indicate she is on a consistent carbohydrate diet (CCD), regular texture, regular consistency, no salt packet. Her special request on the dietary assessment reflects she request a yogurt cup, banana, cranberry juice and raisin bran cereal daily on her breakfast tray.
Observation of her breakfast tray on 06/07/23 and 06/08/23 found she did not have a yogurt cup or banana on her tray. This was verified by the Administrator on 06/08/23 at 8:30 AM. According to the Culinary Director #109 on 06/08/23 at 10:03 AM, they were out of both items noted above and did not substitute anything in their place. Therefore, she only received dry cereal and juice.
On 06/07/23 at 12:38 PM, observation of a chef salad on her tray found it was not prepared according to the recipe provided by the Culinary Director #109. Her salad had bagged lettuce with carrots and red cabbage, cucumber, and shredded cheese with salad dressing on the side. According to the recipe provided a chef salad is to have turkey breast, whole skinless, cooked, deli with a hard boiled egg. Neither the turkey breast nor the hard boiled egg was provided. This was confirmed with the Director of Nursing on 06/07/23 at 12:55 PM.
c) Resident #80
On 06/05/23 at 11:58 AM during the initial interview of the Long Term Care Survey Process Resident #80 commented the food sucks, you never get all you are suppose to and they tell you they have ran out and it will be on next truck but it never comes.
On 06/06/23 at 10:05 AM a record review shows Resident #80 is on a consistent carbohydrate diet (CCD), regular texture, thin consistency. He is a diabetic.
Observation and a conversation with him concerning his lunch tray on 06/08/23 at 12:30 PM found him upset over his meal. He states This is just an example of what I'm talking about. Never get what you are suppose to. He had deluxe macaroni and cheese, tomato basil salad, a roll, and a cookie. He stated he did not like the macaroni and cheese nor the tomato basil salad.
The surveyors had tested a lunch meal tray on this date prior to this conversation and compared the recipe to the meal provided. Neither the tomato salad nor the deluxe macaroni and cheese were prepared according to the recipe. The cookie provided was too hard to break, let alone eat. This was confirmed with the Administer on 06/08/23 at 12:16 PM.
d) Resident #51
A resident interview was conducted on 06/05/23 at 12:55 PM, Resident #51 states the food has improved but is very bland; they are served the same thing over and over. Resident #51's biggest complaint is her room is at the end of the hall, therefore they are served last. This results in the facility running out of tea and lemonade before they serve her room, so she has to drink the red drink instead. Resident #51 also stated they do not have a calendar/menu in their room nor are they told ahead of time what they are being served that day. Resident #51 says the facility has alternatives but she doesn't know until she is served her food that she wants something else, then has to wait a long time to get the alternative.
.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0804
(Tag F0804)
Could have caused harm · This affected multiple residents
.
Based on observation and staff interview the facility failed to serve food which was palatable and at an accurate temperature. This failed practice had the potential to affect more than an isolated ...
Read full inspector narrative →
.
Based on observation and staff interview the facility failed to serve food which was palatable and at an accurate temperature. This failed practice had the potential to affect more than an isolated number of residents. Facility Census: 116.
Findings Included:
a) Kitchen
On 06/08/23 six (6) state surveyors tasted the noon time meal for palatability. The Macaroni and Cheese which was the main entrée tasted of a lot of garlic and left the taste on our palates. The tomato basil salad was tasteless and not palatable and also did not contain the onion and bell pepper. The mashed potatoes were also tasteless and not palatable. The beef steak with onions, the onions were still raw and unable to cut. The sugar cookies were very hard, unable to break in half or unable to chew.
On 06/08/23 the CM provided recipes,
~Macaroni and Cheese:
-American cheese 48 slices
-Swiss Cheese 16 slices
-Margarine .25 pound
-all purpose flour one (1) cup
-Milk two (2) quart
-Water one and half (1.5) gallon
-Vegetable oil one (1) tablespoon (Tbsp)
-Salt .50 teaspoon (Tsp)
-Macaroni one and half (1.5) pounds
-Cheddar Cheese one and quarter (1.25) pounds
-Pepper half (.50) Tsp
-Bread crumbs .25 quart
-Parmesan cheese three (3) Tbsp
-Parsley flakes two (2) Tbsp
-Garlic Powder one (1) Tbsp
-Onion Powder one (1) Tbsp
-Paprika one (1) Tsp
~Tomato Basil Salad
-Yellow Onion
-Green Bell Pepper
-Tomato
-Vinegar
-Sugar
-Black Pepper
-Basil Leaf
~Mashed Potatoes
-Mashed Potato Mix
-Water
-Margarine
~Beef with [NAME] Onions
-Onion saute in margarine
-beef patty
-Black pepper
During an interview on 06/08/23 at 12:35 PM the Administrator acknowledged the lack of ingredients in following the recipes and the cookies were very hard.
On 06/12/23 at 12:53 PM , temperatures were obtained on the lunch meal tray at the time of service. The following temperatures were obtained by the CD using his thermometer:
-Chicken cottage pie 110 degrees
-Sliced Carrots 105 degrees
-Carton of milk 60 degrees
The CD acknowledged the temperatures were not accurate. Then stated we don't use the pellets anymore, they were not working to keep the food warm enough so now we have the insulated plate holders, but I guess they are working properly either.
b) Noontime meal on 06/07/23
Observations of the kitchen beginning at 11:45 am on 06/07/23 found the dietary staff was having difficulty getting the food to proper temperature to serve it. They finally began serving the food at 12:55 pm. The dietary department decided to serve the residents in the dining room from the steam table in the dining room. The certified dietary manager made some instant mashed potatoes to serve to the residents in the dining room. The CDM was observed preparing the mashed potatoes and then pouring them from the pan used for preparation to the serving pan which was placed on the stream table in the dining room. When the CDM was transferring the potatoes from the pot used for preparation to the serving pan it was noted the mashed potatoes had a runny consistency. They were easily poured from one pan to another and did not need to be spooned ouy or scrapped out of the pan.
Culinary Aide #140 was observed serving the residents seated in the dining room from the steam table located in the dining room. CA #140 placed the mashed potatoes prepared by the CDM on the plates. The potatoes ran across the plate because their consistency was so thin. CA #140 also placed gravy on the mashed potatoes which made them runnier. The mashed potatoes were not at a consistency to hold their form.
CA #140 was also serving mixed vegetables which according to the menu should have been served with a four (4) ounce scoop, the scoop being used by CA #140 appeared to be too small. The CDM was asked what size scoop was being used to serve the vegetables, he stated that is a two (2) ounce scoop. When asked if the menu called for a four (4) or two (2) ounce scoop he stated, I thought it said two (2) ounces. Let me go look. The CDM and this Surveyor looked at the menu and confirmed the residents should be getting four (4) ounces of vegetables. The CDM then instructed CA #140 to begin serving two (2) scoops of the vegetables. At the time of this change Resident #76, #99, #34, #38 and #60 had all ready been served the incorrect serving size of vegetables.
At 1:55 pm on 06/07/23 the Nursing Home Administrator (NHA) was asked to come into the dining room. Upon his arrival he was asked to observe the plate of Resident #60 who had all ready left the dining room. On his plate remained the runny mashed potatoes with gravy on top. The NHA was asked if the potatoes had the proper consistency. He agreed they did not, and they were not holding their form as they should. As this observation was coming to a close Resident #38 was observed by this surveyor and the NHA to be licking his divided plate. This was pointed out to the administrator who stated, We will get him some more food.
The NHA then asked the CDM to thicken up the mashed potatoes before serving them to any other residents.
.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected multiple residents
.
Based on observation, policy review and staff interview the facility failed to store food in accordance with professional standards for food safety. The facility failed to label and date food items ...
Read full inspector narrative →
.
Based on observation, policy review and staff interview the facility failed to store food in accordance with professional standards for food safety. The facility failed to label and date food items which were open and failed to dispose of expired food items. The facility also stores non resident foods in the nourishment room refrigerator. This failed practice had the potential to affect all residents currently receiving nourishment from the facility's kitchen and the nourishment rooms. Facility Census: 116
Findings Included:
A) Policy Review
A review of the facility policy titled Food Storage revised date of 09/17 read as following:
.Procedures
.5. All foods will be stored wrapped or in covered containers, labeled and dated .
b) Dry Storage
An initial tour of the kitchen with the Culinary Director (CD) beginning on 06/05/23 at 12:16 PM , of the dry storage revealed the following issues:
-chili powder- no open/use by date
-an open bag of bread crumbs was on the floor.
The Culinary Director (CD) acknowledged the failure to label food items with a Date Opened and/or Use by Date. Also indicated the item needed to be discarded because it was not dated. CD also stated they breadcrumbs needed to be discarded because they were on the floor.
c) Walk in Refrigerator
An initial tour of the kitchen with the CD beginning on 06/05/23 at 12:16 PM , the walk in refrigerator contained the following issues:
-a tray of egg omelets with no label of product or no open/use by date
-an opened package of pancakes with no open/use by date
The CD acknowledged the failure to label food items with a Date Opened and/or Use by Date. Also indicated the item needed to be discarded because they were not dated.
d) Memory Unit Refrigerator
An initial tour of the memory unit kitchen with CD beginning on 06/06/23 at 11:07 AM found the following issues in the refrigerator:
:
-an opened bottle of syrup no open/use by date
-an opened bottle of street sauce no open/use by date
-an opened bottle of honey mustard no open/use by date
-an opened bottle of BBQ sauce no open/use by date
-an opened bottle of Ranch dressing no open/use by date
-an opened container of sour cream no open/use by date
The CD acknowledged the failure to label food items with a Date Opened and/or Use by Date. Also indicated the item needed to be discarded because they were out of date or not dated.
e) Memory Unit Freezer
An initial tour of the memory unit kitchen with CD beginning on 06/06/23 at 11:07 AM found the following issues in the freezer:
-an opened pint Strawberry Ice Cream no open/use by date
-an opened box of pizza bagel no open/use by date
-an opened bag of chicken tenders no open/use by date
-an opened bag of tater tots no open/use by date
-an opened box of chicken cordon blue patties no open/use by date
- an opened bag of mini corn dogs no open/use by date
The CD acknowledged the failure to label items with a date open and or use by date. Also indicated the item needed to be discarded because they were not dated.
The Resident Manager stated that is the staff's food they fix at night for their dinner/lunch. None of that food belongs to the Residents.
The CD acknowledged only residents items are allowed in the Residents refrigerator/freezer.
f) A wing nourishment room
An initial tour of the A wing nourishment room with CD beginning on 06/06/23 at 11:45 AM revealed the following issues:
-an opened bottle of mayonnaise no open/use by date
-a bottle of pink lemonade no name or date
The CD acknowledged the failure to label items with a date open and or use by date. Also indicated the item needed to be discarded because they were not dated. Also stated the pink lemonade belongs to the staff and discarded.
.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0839
(Tag F0839)
Could have caused harm · This affected multiple residents
.
Based on record review, professional board interview, and staff interview the facility failed to ensure Social Service Director (SSD) was licensed with the [NAME] Virginia Board of Social Work in ac...
Read full inspector narrative →
.
Based on record review, professional board interview, and staff interview the facility failed to ensure Social Service Director (SSD) was licensed with the [NAME] Virginia Board of Social Work in accordance with applicable state laws. This was a random opportunity for discovery and has a potential to affect more than an isolated number of residents. Facility Census: 116.
Findings Included:
a) Social Service Director
On 06/12/23 the facility was asked to provide a professional license or all professional staff including the Social Service Director (SSD) #40. A review of the documentation provided by the facility for SSD #40 found the following: An application for Social Work License (LSW/LGSW/LCSW) this application was completed by SSD #40 on 05/26/23. SSD #40 began working at the facility on 05/04/23 as the SSD.
At 3:07 pm on 06/12/23 the [NAME] Virginia Board of Social Work was contacted via telephone. When asked if a person was able to work as social worker prior to their license being approved, the Board Employee indicated you could not start working until your application was approved. She looked through her files and indicated she had not received the application from SSD #40 yet. She stated if she had mailed it on 05/26/23 we should have it by now but I am not seeing it on any of our mail logs and we have not began to process it yet. She indicated the process was lengthy and required obtaining college transcripts and test scores from the other state. When asked if SSD #40 was able to legally practice social work in the state of [NAME] Virginia the board employee indicated she should not be practicing until she gets her license application approved. Simply submitting the application does not grant you the ability to start practicing Social Work in [NAME] Virginia. She further stated, You have to be licensed in the state your client resides. Therefore since the nursing home is in [NAME] Virginia she would need to be licensed in [NAME] Virginia.
An interview with the Nursing Home Administrator on 06/24/23 at 3:41 pm confirmed SSD #40 did not have a [NAME] Virginia Social Work License. He stated, I thought she could start working with just the application. When asked if SSD #40 had been working as a social worker and completing assessments, he confirmed she was. He indicated he would have her stop and would call the board to expedite the process of getting her a license.
Medical record reviews of residents currently residing in the facility found SSD #40 wrote social service progress notes in the record of Resident #119, Resident #75, Resident #15, Resident #40, and Resident #83.
A review of the job description for SSD #40 which was titled Social Worker found the following under the heading Education, 1. Baccalaureate degree in Social Services or equivalent, with licensure in state of WV as Social Worker.
.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Medical Records
(Tag F0842)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on medical record review and staff interview the facility failed to ensure a complete and accurate medical record. The f...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on medical record review and staff interview the facility failed to ensure a complete and accurate medical record. The facility failed to ensure the Physician Orders for Scope of Treatment (POST) forms were completed per directions specified by the [NAME] Virginia Center for End of Life Care. This wass true for six (6) of 26 reviewed for the Long-Term Care Survey Process. Resident identifiers: #109, #97, #44, #16, #51 and #26. Facility census: 116.
Findings included:
a) Resident #109
During a record review on [DATE] at 10:23 AM Resident #109's medical record revealed a Physician Orders for Scope of Treatment (POST) form showed that verbal consent was obtained from the resident's representative on [DATE]. The consent was not witnessed by two (2) staff members. However, the resident representative's actual signature was never obtained.
The 2021 POST form guidance titled, Using the POST Form: Guidance for Health Care Professionals, 2021 edition, available on-line, stated, If the incapacitated patient's MPOA [medical power of attorney] representative or health care surrogate is unavailable at the time of form completion, this section can be signed by two witnesses for verbal confirmation of agreement from the patient's MPOA representative or health care surrogate. The form should be signed at the earliest available opportunity.
During an interview on [DATE] at 1:38 PM, the Social Worker #40 acknowledged Resident #109's representative had not signed the POST form even though the representative visits almost daily.
b) Resident #44
On [DATE] at 3:19 PM, a review of the POST form found section C, entitled medically administered fluids and nutrition, did not have a designated timeframe listed for the intravenous fluids (IVF).
On [DATE] at 1:20 PM, the Administrator was notified and stated, yes that is incomplete.
No further information was obtained during the long-term survey process.
c) Resident #97
Record review on [DATE] at 2:27 PM, indicated the resident had a Physician Order for Scope of Treatment (POST) in place but that the physician order was not as specific as the POST itself.
On [DATE] at 11:10 AM, the surveyor requested a copy of the resident's POST form and current orders. The surveyor received the requested copies on [DATE] at 12:30 PM. Review of the copies provided indicated that the POST form reflected: CPR, Full Treatments, Time-limited trial of 30 days but no surgically-placed tubes; the physician order reflects: Full-code.
On [DATE] at 9:55 AM, a staff interview was had with the Director of Nursing (DON), confirming that the resident's order did not list everything indicated on his POST form. The DON stated that she had never heard of writing a specific code status order.
d) Resident #16
An Electronic Medical Record (EMR) review was conducted on [DATE] at 3:10 PM. This review found an incomplete POST form. Section C indicated the resident selected intravenous (IV) fluids for a trial period, but did not specify the amount of time. This portion was left blank.
A staff interview with the Administrator on [DATE] at 1:20 PM, confirmed the POST form was incomplete by leaving the IV fluids section blank.
e) Resident #51
An Electronic Medical Record (EMR) review was conducted on [DATE] at 3:26 PM. This review found an incomplete POST form. Section C indicated the resident selected intravenous (IV) fluids for a trial period, but did not specify the amount of time. This portion was left blank.
A staff interview with the Administrator on [DATE] at 1:20 PM, confirmed that the POST form was incomplete by leaving the IV fluids section blank.
f) Resident #26
An Electronic Medical Record (EMR) review was conducted on [DATE] at 2:43 PM. This review found an incomplete POST form. Section C indicated the resident selected intravenous (IV) fluids for a trial period, but did not specify the amount of time. This portion was left blank.
A staff interview with the Administrator on [DATE] at 1:20 PM, confirmed that the POST form was incomplete by leaving the IV fluids section blank.
.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0847
(Tag F0847)
Could have caused harm · This affected multiple residents
.
Based on record review, resident interview and staff interview, the facility failed to explain the binding arbitration agreement in a form and manner easily understood by residents. This was true fo...
Read full inspector narrative →
.
Based on record review, resident interview and staff interview, the facility failed to explain the binding arbitration agreement in a form and manner easily understood by residents. This was true for three (3) of three (3) residents reviewed under the care area of arbitration. Resident identifiers: #2, #47, and #44. Facility Census: 116.
Findings included:
a) Binding Arbitration Agreement
On 06/13/23 at 8:30 AM, a review of the facility arbitration agreement was completed. The review found the facility arbitration agreement had all the required information including all definitions of the key words.
On 06/13/23 from 8:30 AM to 9:00 AM, three (3) residents (Resident #2, Resident #47 and Resident #44) were interviewed regarding the facility arbitration agreement. All three (3) residents had a Brief Interview of Mental Status (BIMS) of 15, the highest score indicating no cognitive impairment. All three (3) residents stated, I don't know if I signed the agreement and I don't remember what they told me about it.
On 06/13/23 at 9:05 AM, an interview was completed with the Admissions Coordinator #168. The Admissions Coordinator stated, the arbitration agreements are in the admissions packet .I explain they do not have to sign it, before you go in front of a judge we try to settle it and they can revoke it within six (6) months of signing it.
On 06/13/23 at 9:10 AM, upon clarification of the timeframe for revocation, the Admissions Coordinator #168 stated, I couldn't remember the timeframe .oh it's 30 days .I've only been here for seven (7) days. An additional clarification of the process regarding a judge being present, the Admissions Coordinator stated, I talk to them upon admission about the process. With Surveyor intervention, the clarification was made that a judge is not present during the arbitration process but one (1) or more neutral arbitrators are present.
On 06/13/23 at 9:13 AM, the Administrator was notified the definition of arbitration was not clear and the Admissions Coordinator #168 could not clarify the time frame for revocation of the agreement nor who would conduct the process. The Administrator stated, okay.
.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Room Equipment
(Tag F0908)
Could have caused harm · This affected multiple residents
.
Based on observation and staff interviews the facility failed to maintain equipment in safe operating conditions. The ice machines did not have a one inch air gap for drainage. This failed practice ...
Read full inspector narrative →
.
Based on observation and staff interviews the facility failed to maintain equipment in safe operating conditions. The ice machines did not have a one inch air gap for drainage. This failed practice had the potential to affect all residents currently receiving nutrition from the facility kitchen. Facility Census: 116
Findings included:
a) Ice Machine Drain
An initial tour of the kitchen with the Culinary Director (CD) beginning on 06/05/23 at 12:16 PM revealed the ice machine water drain was touching the floor drain without a one (1) inch gap allowing for the potential for contaminants to enter the line and travel to the ice machine.
During an interview on 06/07/23 at 10:10 AM Director of Plant Maintenance #49 acknowledged the ice machine did not have a one inch gap, stating it would be fixed immediately.
.
May 2023
1 deficiency
CONCERN
(F)
📢 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 F0925
(Tag F0925)
Could have caused harm · This affected most or all residents
.
Based on observation, family interview, and staff interview, the facility failed to maintain an effective pest control program so that the facility was free of ants. This was a random opportunity fo...
Read full inspector narrative →
.
Based on observation, family interview, and staff interview, the facility failed to maintain an effective pest control program so that the facility was free of ants. This was a random opportunity for discovery that had the potential to affect all residents residing in the building. Resident identifier: #105. Facility census: 116.
Findings included:
a) Resident #105
On 05/15/23 at 12:50 PM, Resident #105 was observed sitting in the hallway in his wheelchair outside his room, with his lunch tray on the overbed table in front of him. Resident #105's room was at the end of the hallway, near the outside door. Two (2) family members were with him. Resident #105's family members stated they have been killing ants in the hallway. Upon observation, live and dead ants were seen on the floor. The resident's family members stated this is not the first time they had seen ants in the facility. Resident #105's family stated they thought the ants were coming in through the door leading to the outside, as the seal at the bottom of the door did not appear completely intact. They also stated they had seen ants come out from under the floor molding in the hallway.
On 05/15/23 at 1:00 PM, the Administrator confirmed ants were present in the hallway where Resident #105 was sitting in his wheelchair. The Administrator stated he would have maintenance address this issue.
.
Oct 2021
12 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Resident Rights
(Tag F0550)
Could have caused harm · This affected 1 resident
.
Based on observation and staff interview, the facility failed to treat one (1) of the 28 sample residents in the long-term care survey process with dignity and respect. The facility insisted Residen...
Read full inspector narrative →
.
Based on observation and staff interview, the facility failed to treat one (1) of the 28 sample residents in the long-term care survey process with dignity and respect. The facility insisted Resident #55 must wear a large blue brief instead of a smaller size. As a result, Resident #55's brief leaked throughout the night resulting in Resident #55's bed being saturated with urine. Resident Identifier: Resident #55. Facility Census: 105.
Findings included:
a) Resident #55
During an interview, on 10/11/21 at 11:55 AM, Resident #55 stated Nurse Aide (NA) #106 insists resident wear a large brief which does not fit Resident #55 comfortably. Resident #55 weighs approximately 112 pounds, and the large brief is looser fitting and bulges in some areas. Resident #55 then showed surveyor the blue brief the resident was wearing to demonstrate how it fit. Resident #55 stated as a result of wearing large briefs, the brief leaked last night resulting in the bedding becoming wet. Resident #55 reported not only was it embarrassing but it also interrupted quality sleep time needing to wait for the NA to answer the call light and change the bedding.
The Director of Nursing (DON), on 10/12/21 at 8:24 AM, reported upon admission every resident would be measured to determine the appropriate brief sizing.
On 10/12/21 at 9:00 AM, the Director of Staff Education stated every NA is trained on how to correctly measure a resident and how to use the brief sizing chart to determine a resident's correct brief size. The Director of Staff Education agreed to personally measure Resident #55 to determine if the right size brief was being used.
The Director of Staff Education, on 10/12/21 at 10:55 AM, reported Resident #55 should be wearing a white brief which correlated to a small. The Director of Staff Education confirmed the blue brief was the incorrect size for Resident #55.
.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0558
(Tag F0558)
Could have caused harm · This affected 1 resident
.
Based on observation and staff interview, the facility failed to provide a homelike environment by not providing a resident reachable access to a personal telephone. This was a random opportunity fo...
Read full inspector narrative →
.
Based on observation and staff interview, the facility failed to provide a homelike environment by not providing a resident reachable access to a personal telephone. This was a random opportunity for discovery. Resident identifier: #89. Facility census: 105.
Findings included:
a) Resident #89
During an interview on 10/11/21 at 11:55 AM, Resident #89, stated, I can't reach my phone when I get phone calls. Resident #89 stated that the personal phone was out of reach most days.
An observation on 10/11/21 at 11:55 AM found Resident #89's personal phone sat on the nightstand beside the bed. The nightstand was positioned at the head of the bed making the personal phone out of reach for Resident #89.
An interview on 10/11/21 at 3:55 PM, the Assistant Director of Nursing (ADON) #139, confirmed Resident #89's phone was out of reach and will care plan that the phone is to be in reach at all times.
.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0578
(Tag F0578)
Could have caused harm · This affected 1 resident
.
Based on record review and staff interview, the facility failed to ensure one (1) of 28 residents reviewed during the long-term care survey process had a Physician Orders for Scope of Treatment (POS...
Read full inspector narrative →
.
Based on record review and staff interview, the facility failed to ensure one (1) of 28 residents reviewed during the long-term care survey process had a Physician Orders for Scope of Treatment (POST) form completed per directions specified by the [NAME] Virginia Center for End-of-Life Care in conjunction with the [NAME] Virginia Health Care Decisions Act (16-30-1). Resident identifier: Resident #69. Facility census: 105.
Findings included:
a) Resident #69
A medical record review was completed on 10/11/21 at 1:15 PM. A [NAME] Virginia Physician Orders for Scope of Treatment (POST) form, signed and dated 01/04/21, was in the chart.
Section C, entitled Medically Administered Fluids and Nutrition, was left completely blank. Section C offers the patient the opportunity to indicate if they do or do not desire IV fluids as well as the opportunity to indicate if they do or do not wish to have a feeding tube.
In 2002, the POST form was incorporated into the [NAME] Virginia Health Care Decisions Act (16-30-25.) POST forms are standardized forms used to reflect orders by a qualified physician for medical treatment of a person in accordance with that person's wishes.
The directions for completing the POST form, compiled by the [NAME] Virginia Center for End of Life, require accurately documenting a patient's treatment preferences, which would include accurate documentation of Resident #69's wishes regarding a feeding tube and IV fluids.
During an interview on 10/12/21 at 8:21 AM, the Administrator confirmed the POST form was not completed in its entirety and the form should be updated.
.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected 1 resident
.
Based on resident interview, observation, and staff interview, the facility failed to provide one (1) of 28 sample residents a safe, clean, comfortable, and homelike environment. The facility failed...
Read full inspector narrative →
.
Based on resident interview, observation, and staff interview, the facility failed to provide one (1) of 28 sample residents a safe, clean, comfortable, and homelike environment. The facility failed to change a soiled privacy curtain in a timely fashion. Resident identifier: #62. Facility census: 105.
Findings included:
a) Resident #62
During a resident interview, on 10/11/21 at 11:39 AM, Resident #62 pointed out over 20 small, brown stains, ranging from the size of a pencil eraser to a quarter, on the privacy curtain in the middle of the room. Resident #62 stated that the stains have been there for several days and wished it could be cleaned.
Registered Nurse (RN) #26 entered Resident #62's room on 10/11/21 at 11:46 AM and stated that she would guess the brown spots were soy sauce, noting they had Chinese food several days ago. RN #26 acknowledged it is the responsibility of all facility staff to create a homelike environment and promptly address any cleaning needs when identified. RN #26 stated the dirty privacy curtain will be changed out for a clean one and then sent to laundry.
.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected 1 resident
.
Based on record review and staff interview, the facility failed to ensure a resident fall resulting in a fracture was reported to the required agencies. This was true for one (1) of five (5) falls r...
Read full inspector narrative →
.
Based on record review and staff interview, the facility failed to ensure a resident fall resulting in a fracture was reported to the required agencies. This was true for one (1) of five (5) falls reviewed. Resident identifier: Resident #304. Facility census: 105.
Findings included:
a) Resident #304
An electronic health record review was completed on 10/12/21 at 9:23 AM. Resident #304 experienced a fall on 11/25/20 at 9:15 AM. A subsequent x-ray revealed Resident #304 had sustained a hip fracture during the fall. Resident #304 was then transferred to the hospital for treatment.
A review of the November 2021 Reportables log revealed the facility had not reported the fall with major injury.
During an interview, on 10/12/21 at 1:15 PM, the Administrator reported, We didn't report the fall with fracture. At that time, we weren't reporting falls that were sent out of the building. The Administrator further explained corporate guidance was later provided and clarification given. The facility began reporting falls sent out of the building in May 2021.
The Federal regulation 483.12(c)(1) directs facilities should ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury.
.
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...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on medical record review and staff interview, the facility failed to provide evidence a resident/resident's representative was provided a written Notice of Transfer for an acute hospital transfer. This was true for two (2) of three (3) residents reviewed for hospitalization. Resident identifiers: #69 and #304. Facility census: 105.
Findings included:
a) Resident #69
A medical record review was completed on 10/12/21 at 11:32 AM. The record review revealed Resident #69 was transferred to the hospital on [DATE]. The record did not reflect the resident/resident's representative was provided a written Notice of Transfer indicating the reason for the transfer, the effective date of transfer, the location to which the resident was being transferred and a statement of the resident's appeal rights.
During an interview on 10/12/21 at 1:45 PM, the Medical Records Director reported the facility was unable to provide evidence a written Notice of Transfer was provided to Resident #69.
a) Resident #304
A medical record review was completed on 10/12/21 at 9:23 AM. The record review revealed Resident #304 was transferred to the hospital on [DATE]. The record did not reflect the resident/resident's representative was provided a written Notice of Transfer indicating the reason for transfer, the effective date of transfer, the location to which the resident was being transferred and a statement of the resident's appeal rights.
During an interview on 10/12/21 at 11:45 AM, the Medical Records Director reported the facility was unable to provide evidence a written Notice of Transfer was provided to Resident #304.
.
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...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on medical record review and staff interview, the facility failed to provide evidence a resident/resident's representative was provided a written Bed Hold Notice upon transfer. This was true for two (2) of three (3) residents reviewed for hospitalization. Resident identifiers: #69 and #304. Facility census: 105.
Findings included:
a) Resident #69
A medical record review was completed on 10/12/21 at 9:23 AM. The record review revealed Resident #304 was transferred to the hospital on [DATE]. The record did not reflect the resident/resident's representative was provided a written Bed Hold Notice upon transfer.
During an interview on 10/12/21 at 1:45 PM, the Medical Records Director reported the facility was unable to provide evidence a written Bed Hold Notice was provided to Resident #69.
b) Resident #304
A medical record review was completed on 10/12/21 at 11:32 AM. The record review revealed Resident #304 was transferred to the hospital on [DATE]. The record did not reflect the resident/resident's representative was provided a written Bed Hold Notice upon transfer.
During an interview on 10/12/21 at 11:45 AM, the Medical Records Director reported the facility was unable to provide evidence a written Bed Hold Notice was provided to Resident #304.
.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
Could have caused harm · This affected 1 resident
.
Based on observation and staff interview, the facility failed to provide respiratory care consistent with professional standards of practice. A nebulizer mask was on the bedside table with no protec...
Read full inspector narrative →
.
Based on observation and staff interview, the facility failed to provide respiratory care consistent with professional standards of practice. A nebulizer mask was on the bedside table with no protective covering. This observation was a random opportunity for discovery. Resident identifier: #57. Facility Census: 105.
Findings included:
a) Resident #57
An observation on 10/11/21 at 11:38 AM found Resident #57's nebulizer mask on the bedside table with no protective covering. Registered Nurse (RN) #26 confirmed the nebulizer mask was uncovered and stated that facility protocol required the nebulizer mask to be placed in a bag. RN #26 went on to say the nebulizer machine had not been used for over a month and should have been removed from the resident's room.
.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0810
(Tag F0810)
Could have caused harm · This affected 1 resident
.
Based on observation, record review and staff interview, the facility failed to provide a two (2) handled spouted cup for a resident at meal times. This was a random opportunity for discovery. Resid...
Read full inspector narrative →
.
Based on observation, record review and staff interview, the facility failed to provide a two (2) handled spouted cup for a resident at meal times. This was a random opportunity for discovery. Resident identifier: #70. Facility census: 105.
Findings included:
a) Resident #70
An observation on 10/12/21 at 8:10 AM showed Resident #70 had two (2) eight (8) ounce cups of liquid on the breakfast tray. Resident #70 was unable to drink out of the two (2) cups and struggled with one cup not being able to get the drink as desired.
Further observation on 10/12/21 at 8:10 AM of Resident #70's food tray showed a tray card that stated, 2 handled cup (1 each).
An interview on 10/12/21 at 8:25 AM, Speech Therapist (ST) #169 stated that the two (2) cups on Resident #70's trays were not correct or recommended by therapy. ST #169 stated that the cups on Resident #70's tray should be the two (2) handled spouted cups with handles on both sides.
A review of Resident #70's medical recorded verified a care plan that stated, Spouted cups with all meals. The therapy recommendation note also verified Resident #70 was to be provided a two (2) handled cup with lid at meals.
.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected 1 resident
Based on observation and staff interview, the facility failed to store, label and date foods in a sanitary manner in accordance with professional standards. This deficient practice had the potential t...
Read full inspector narrative →
Based on observation and staff interview, the facility failed to store, label and date foods in a sanitary manner in accordance with professional standards. This deficient practice had the potential to affect a limited number of residents. Facility Census 105 .
Findings included:
a) Kitchen/Pantries
On 10/11/21 at 11:13 AM initial tour with Food Service Director (FSD) #5, an observation of the walk in refrigerator found no label or date on the following food items: bacon, sausage gravy, egg omelets, cheese slices were wrapped in plastic and opened shredded cheese. The FSD agreed that all items should be discarded due to not being labeled or dated.
On 10/11/21 at 11:28 AM observation with FSD in the walk in freezer found veal wrapped in plastic wrap with no date. The FSD agreed the frozen veal should have been thrown away and the FSD discarded the veal.
On 10/11/21 at 11:40 AM observation with FSD on PAC unit pantry refrigerator found the following:
-one (1) container with no name or date and three (3) small food containers with no name or date.
On 10/11/21 at 11:55 AM an observation with the FSD of the A Hall pantry refrigerator found the following:
-no name or date on one (1) bag of chicken wings
-no name or date on one (1) wrapped hot pocket
The FSD agreed all items in both pantry refrigerators should have been labeled and dated. The FSD discarded all items not labeled or dated in both pantry refrigerators.
.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Medical Records
(Tag F0842)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on record review and staff interview, the facility failed to maintain an accurate medical record for one (1) of 28 sampl...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on record review and staff interview, the facility failed to maintain an accurate medical record for one (1) of 28 sample residents reviewed during the Long Term Care Survey. Resident identifier: #97 Facility census: 105.
Findings included:
a) Resident #97
Resident #97 was admitted on [DATE]. Medical diagnoses included dementia, Alzheimer's, and major depressive disorder. The Brief Interview of Mental Status (BIMS) was scored 00 on the quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) 07/01/21. The BIMS score indicates severe cognitive impairment.
In an interview with Resident #97's family member on 10/12/21 at 11:28 AM revealed Resident #97 had dental posts placed with the lower denture inserted in the lower jaw in 2016.
A review of the physician orders during this survey found an order dated 04/10/19 for Check dentures for all 0-rings and replace any missing 0-rings three (3) times daily. 0-rings are in nurses cart. (Completed by Nurse Only).
In an interview with Resident #97's family member on 10/12/21 at 11:28 AM revealed Resident #97 had not had 0-rings and/or used the lower denture beginning in 2019. The family member was unsure of the exact date. The family member further explained that one (1) post became infected and had to be removed. After several attempts by a local dentist to adjust the lower denture, it was determined the dentures would not fit Resident #97 and therefore had no further use for the 0-rings.
A review of the Medication Administration Record (MAR) revealed evidence of Resident #97 being checked for 0-rings three (3) times per day.
In an interview with the Assistant Director of Nursing (ADON) and in the presence of the Nursing Home Administrator (NHA), on 10/12/21 at 3:18 PM revealed on 07/31/21 at 9:44 AM, the ADON entered an order to discontinue the the 0-ring check. The NHA stated that he thought this order had been changed. The ADON agreed the MAR contained evidence the 0-rings were being checked when no 0-rings were being used.
.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0921)
Could have caused harm · This affected 1 resident
.
Based on observation and staff interview, the facility failed to provide a safe environment by the use of an extension cord connected to an electronic device for Resident #100. This was a random opp...
Read full inspector narrative →
.
Based on observation and staff interview, the facility failed to provide a safe environment by the use of an extension cord connected to an electronic device for Resident #100. This was a random opportunity for discovery. Resident identifier: #100. Facility census: 105.
Findings included:
a) Resident #100
An observation on 10/11/21 at 1:42 PM found an extension cord from the electrical outlet to an electronic tablet device on the bed of Resident #100. Based on an interview on 10/11/21 at 1:43 PM with Licensed Practical Nurse (LPN) #22 stated that no electrical extension cords are permitted for safety reasons. LPN #22 removed the extension cord from the residents room.
.
Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated
K - Pattern
L - Widespread
Actual Harm
G - Isolated
H - Pattern
I - Widespread
Potential for Harm
D - Isolated
E - Pattern
F - Widespread
No Harm (Minor)
A - Isolated
B - Pattern
C - Widespread
Questions to Ask on Your Visit
- "What changes have you made since the serious inspection findings?"
- "Why is there high staff turnover? How do you retain staff?"
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • Licensed and certified facility. Meets minimum state requirements.
Concerns
- • Multiple safety concerns identified: 1 life-threatening violation(s). Review inspection reports carefully.
- • 47 deficiencies on record, including 1 critical (life-threatening) violation. These warrant careful review before choosing this facility.
- • $24,798 in fines. Higher than 94% of West Virginia facilities, suggesting repeated compliance issues.
- • Grade D (41/100). Below average facility with significant concerns.
Bottom line: Trust Score of 41/100 indicates significant concerns. Thoroughly evaluate alternatives.
✓ Report will be sent to your email
About This Facility
What is Morgantown Healthcare Center's CMS Rating?
CMS assigns MORGANTOWN HEALTHCARE CENTER an overall rating of 3 out of 5 stars, which is considered average nationally. Within West Virginia, this rating places the facility higher than 99% of the state's 100 nursing homes. This mid-range rating indicates the facility meets federal standards but may have areas for improvement.
How is Morgantown Healthcare Center Staffed?
CMS rates MORGANTOWN HEALTHCARE CENTER's staffing level at 3 out of 5 stars, which is average compared to other nursing homes. Staff turnover is 63%, which is 16 percentage points above the West Virginia average of 46%. High turnover can affect care consistency as new staff learn residents' individual needs. RN turnover specifically is 60%, which is notably high. RNs provide skilled clinical oversight, so turnover in this role can affect medical care quality.
What Have Inspectors Found at Morgantown Healthcare Center?
State health inspectors documented 47 deficiencies at MORGANTOWN HEALTHCARE CENTER during 2021 to 2025. These included: 1 Immediate Jeopardy (the most serious level, indicating potential for serious harm or death) and 46 with potential for harm. Immediate Jeopardy findings are rare and represent the most serious regulatory concerns. They require immediate corrective action.
Who Owns and Operates Morgantown Healthcare Center?
MORGANTOWN 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 115 residents (about 96% occupancy), it is a mid-sized facility located in MORGANTOWN, West Virginia.
How Does Morgantown Healthcare Center Compare to Other West Virginia Nursing Homes?
Compared to the 100 nursing homes in West Virginia, MORGANTOWN HEALTHCARE CENTER's overall rating (3 stars) is above the state average of 2.7, staff turnover (63%) is significantly higher than the state average of 46%, and health inspection rating (3 stars) is at the national benchmark.
What Should Families Ask When Visiting Morgantown Healthcare Center?
Based on this facility's data, families visiting should ask: "What changes have been made since the serious inspection findings, and how are you preventing similar issues?" "How do you ensure continuity of care given staff turnover, and what is your staff retention strategy?" "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" These questions are particularly relevant given the facility's Immediate Jeopardy citations and the facility's high staff turnover rate.
Is Morgantown Healthcare Center Safe?
Based on CMS inspection data, MORGANTOWN HEALTHCARE CENTER has documented safety concerns. Inspectors have issued 1 Immediate Jeopardy citation (the most serious violation level indicating risk of serious injury or death). The facility has a 3-star overall rating and ranks #1 of 100 nursing homes in West Virginia. Families considering this facility should ask detailed questions about what corrective actions have been taken since these incidents.
Do Nurses at Morgantown Healthcare Center Stick Around?
Staff turnover at MORGANTOWN HEALTHCARE CENTER is high. At 63%, the facility is 16 percentage points above the West Virginia average of 46%. Registered Nurse turnover is particularly concerning at 60%. RNs handle complex medical decisions and coordinate care — frequent RN changes can directly impact care quality. High turnover means new staff may not know residents' individual needs, medications, or preferences. It can also be disorienting for residents, especially those with dementia who rely on familiar faces. Families should ask: What is causing the turnover? What retention programs are in place? How do you ensure care continuity during staff transitions?
Was Morgantown Healthcare Center Ever Fined?
MORGANTOWN HEALTHCARE CENTER has been fined $24,798 across 1 penalty action. This is below the West Virginia average of $33,327. While any fine indicates a compliance issue, fines under $50,000 are relatively common and typically reflect isolated problems that were subsequently corrected. Families should ask what specific issues led to these fines and confirm they've been resolved.
Is Morgantown Healthcare Center on Any Federal Watch List?
MORGANTOWN 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.