WYOMING HEALTHCARE CENTER
For profit - Corporation
60 Beds
COMMUNICARE HEALTH
Data: November 2025
2 Immediate Jeopardy citations
Trust Grade
0/100
#122 of 122 in WV
Photo by Wyoming Healthcare Center
Last Inspection: March 2024
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
Wyoming Healthcare Center has received a Trust Grade of F, indicating significant concerns about the facility, which is among the poorest rated in West Virginia. They rank #122 out of 122 facilities in the state and are the only option in Wyoming County, meaning there are no better local alternatives. The facility's overall performance is worsening, with issues increasing from 4 in 2023 to 21 in 2024. Staffing is rated average with a turnover of 36%, which is better than the state average, but they have faced serious compliance issues, including over $268,000 in fines, indicating ongoing problems. Notably, there have been critical incidents, such as failing to protect residents from abuse by one individual and not providing appropriate dietary care, which raises serious concerns about resident safety and care quality. While there are some strengths in staffing retention, the overall environment shows troubling signs that families should consider carefully.
- Trust Score
- F
- In West Virginia
- #122/122
- Safety Record
- High Risk
- Inspections
- Getting Worse
- Staff Stability ○ Average
- 36% turnover. Near West Virginia's 48% average. Typical for the industry.
- Penalties ○ Average
- $268,733 in fines. Higher than 68% of West Virginia facilities. Some compliance issues.
- Skilled Nurses ✓ Good
- Each resident gets 45 minutes of Registered Nurse (RN) attention daily — more than average for West Virginia. RNs are trained to catch health problems early.
- Violations ⚠ Watch
- 43 deficiencies on record. Higher than average. Multiple issues found across inspections.
0/100
Bottom 1%
Review needed
4 → 21 violations
★☆☆☆☆
1.0
Overall Rating
★★★☆☆
3.0
Staff Levels
★★★☆☆
3.0
Care Quality
★☆☆☆☆
1.0
Inspection Score
↔
Stable
2023: 4 issues
2024: 21 issues
The Good
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
-
Staff turnover below average (36%)
12 points below West Virginia average of 48%
Facility shows strength in fire safety.
The Bad
1-Star Overall Rating
Below West Virginia average (2.7)
Significant quality concerns identified by CMS
Staff Turnover: 36%
Near West Virginia avg (46%)
Typical for the industry
Federal Fines: $268,733
Well above median ($33,413)
Significant penalties indicating serious issues
Chain: COMMUNICARE HEALTH
Part of a multi-facility chain
Ask about local staffing decisions and management
The Ugly 43 deficiencies on record
2 life-threatening
Mar 2024
21 deficiencies
1 IJ (1 facility-wide)
CRITICAL
(L)
Immediate Jeopardy (IJ) - the most serious Medicare violation
Free from Abuse/Neglect
(Tag F0600)
Someone could have died · This affected most or all residents
⚠️ Facility-wide issue
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and staff interview, the facility failed to ensure residents were free from physical, sexua...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and staff interview, the facility failed to ensure residents were free from physical, sexual, and verbal abuse. Multiple incidents took place in which Resident #213 inappropriately touched and verbally and physically assaulted other residents. The facility failed to properly document, investigate, or report these incidents of abuse. The facility was unable to identify any victims of the abuse due to the failure to properly document and investigate each incident of abuse. Resident identifier: 213. Facility census: 55.
The state agency (SA) determined these failures caused the victims of Resident #213's abuse to suffer physical and psychosocial harm. Because the victims were unable to be identified, the reasonable person standard was applied. Due to the facility's failure to identify the victims and properly investigate the abuse, proper services were unable to be provided to the victims after an instance of abuse, causing further psychosocial harm. Not only did these failures harm the victims of Resident #213's abuse, it also placed them and the remaining 55 residents in the facility at risk of serious harm/death due to the facility's failure to investigate and put proper interventions in place to ensure Resident #213 would not abuse other residents in the future. This placed all residents in an Immediate Jeopardy (IJ) situation.
The facility was first notified of the IJ at 06:44 PM on 03/25/24. The SA received the Plan of Correction (POC) at 08:15 PM on 03/25/24. The SA accepted the POC at 08:20 PM on 03/25/24.
The SA observed for the implementation of the POC and the IJ was abated at 03:45 PM on 03/26/24.
Resident Ientifiers: #213. Facility Census: 55.
Findings included:
a) Resident #213
'
At approximately 03:00 PM on 03/25/24, a record review for Resident #213 was conducted as part of the sample selection process. During this process, progress notes were reviewed, which indicated multiple incidents of sexual, physical, and verbal abuse directed at other residents in the facility, by Resident #213. These progress notes were cross referenced with the facility's incident and reportables logs, revealing none of these incidents were investigated or reported.
Progress notes of the incidents are as follows:
On 02/13/24 at 6:23 PM Resident #213 touched a female resident inappropriately
On 02/19/24 at 11:54 AM, Resident #213 rubbed a female resident's arm and stated, Tell me you love me.
On 2/19/24 at 12:30 PM, Resident #213 backed their wheelchair into another resident's wheelchair repeatedly. When female resident asked Resident #213 to quit, he replied I will hit you.
On 02/19/24 at 1:43 PM, Resident #213's sister stated the resident was told if their behaviors continued, they would be sent out of the facility. Resident #213 stated they were trying to get kicked out of the facility.
On 02/22/24 at 10:13 AM, Resident #213 touched a female resident on the abdomen in a downward motion.
On 02/28/24 at 8:05 PM, Resident #213 was at the nurses station pointing at another female resident and making fun of them. The female resident became upset and started crying. Resident #213 became defensive when he was told to leave the female resident alone.
On 02/29/24 at 1:07 AM, Resident #213 kept trying to touch a female resident, and kept grabbing them by the hand. Resident became defensive when he was told they could not touch other residents. Resident #213 stated he wanted to get kicked out of the facility so they could go home.
On 03/03/24 at 7:50 PM, Resident #213 was observed arguing with another resident. Unit Manager was called to the dining room to help with the situation and Resident #213 drew his hand back to hit Unit Manager, but stopped themselves. Resident then pushed another resident's geri-char at the nurses station and stated do whatever you got to do, send me out of here, I want out of here.
At 12:45 PM on 03/05/24, Resident #213 was passing another resident in the hallway and became combative and started kicking the other resident in the leg and hand.
At 10:35 AM on 03/23/24, Resident #213 was banging closet doors together, causing a disruption for his roommate. Resident #213 went to the dining room and banged a book against a table, calling another resident an idiot and telling them to bring it on.
On 03/23/24 at 4:19 PM, Resident #213 was being pushed by a family member down the hallway, when another resident passed by, Resident #213 stated he's the one I tried to knock the piss out of earlier.
At 3:05 AM on 03/24/24, Resident #213 was trying to get into another female resident's room. Resident #213 told his roommate to shut their mouth when he woke the roommate up by banging dresser drawers.
At 10:47 PM on 03/24/24, Resident #213 was coming down the hall and kicked another resident's door. Resident #213 was in another female's personal area and was told not to touch her.
At 1:09 AM on 03/25/24, Resident #213 was found in the floor of another female resident's room. Resident #213 stated they were trying to help the female resident to bed.
B) Staff Interview
Resident #213 was at a local behavioral health hospital from [DATE] until 03/22/24, upon return to facility, the resident's behaviors worsened, according to Unit Manager (UM) #5.
At 3:40 PM on 03/25/24, an interview was conducted with the Administrator and Unit Manager concerning Resident #213. The Administrator, when asked what interventions had been put into place to protect other residents, they stated, Activities sets with them during the day. Unit Manager stated, Resident #213 comes to my office during the day. However, staff could not verify what interventions were in place during evening and weekend hours. Facility staff verified that Resident #213 was not under direct supervision at all times. Resident was observed at various locations in the facility while not under direct supervision. Unit Manager stated He can retain what you tell him, but he does what he wants. He wants to get kicked out to go home. The behaviors have escalated since, probably, January when referring to Resident #213's behaviors.
When asked the identity of the victims of Resident #213's abusive behavior, both the Administrator and UM #5 stated they did not know the identities. The Administrator confirmed there were no incident reports nor were there any investigations into the abuse toward other residents.
At approximately 1:55 PM on 03/26/24, and interview was conducted with Social Services Designee (SSD) #30 concerning Resident #213 and their behaviors. SSD #30 stated the resident was like this during their last stay at the facility as well. As far as I know, this is how they have always been. SSD #30 stated Resident #213 will tell you all the time they want a girlfriend. I know Resident #213 is trying to get kicked out of the facility, and that is probably why the resident is doing mischievous things, in order to get kicked out, because he thinks he is able to go home. SSD #30 states Resident #213 knows exactly where to go to get what they want. If the resident sees something on a desk that they want, it belongs to them. They pretty much have no boundaries at all.
C) Behavior Monitoring
At approximately 4:00 PM on 03/25/24, a review of the behavior monitoring task sheets for Resident #213 was conducted. Upon review of Nurse Aide behavior monitoring task sheets the following behaviors were noted:
02/09/24 at 10:43 PM- Repetitive motions and rummaging. Redirection was attempted-behaviors unchanged.
02/11/24 2:58 PM- Disrobing in public. Redirection attempted- behaviors unchanged.
02/14/24 at 6:16 PM- Disrobing in public and rummaging. Redirection attempted-behaviors worsened
02/15/24 at 5:19 PM- Disrobing in public, entering other residents ' room/personal space, rummaging. Redirection attempted-behaviors worsened.
02/20/24 at 6:16 PM- Disrobing in public. Redirection attempted-behaviors unchanged.
02/24/24 at 6:44 PM- Grabbing others, physically aggressive towards others, disrobing in public, throwing/smearing bodily waste, wandering. Redirection attempted-behaviors unchanged.
02/28/24 at 6:38 PM- Disrobing in public, entering other residents ' room/personal space, repetitive motions, rummaging, wandering. Redirection attempted-behaviors worsened.
02/29/24 at 5:22 PM- grabbing others, kicking others, pushing others, physically aggressive towards others, express frustration/anger at others, disruptive sounds, disrobing in public, rummaging, wandering. Redirection attempted- behaviors worsened.
03/03/24 at 10:35 PM- Kicking others, physically aggressive towards others, cursing at others, express frustration/anger towards others, screaming at others, threatening others, entering other residents ' room/personal space. Redirection attempted-behaviors unchanged.
03/05/24 at 5:43 PM- Kicking others, physically aggressive towards others, express frustration/anger at others, screaming at others, agitated. Redirection attempted-behaviors unchanged.
03/23/24 at 11:18 AM-Kicking others, physically aggressive toward others, cursing at others, express frustration/anger at others, screaming at others, threatening others, disruptive sounds, entering other resident's room/personal space, agitated, anxious, restless, elopement, exit seeking, refusing care, wandering. Redirection attempted-behaviors unchanged
03/24/24 at 12:26 AM- Express frustration/anger at others, entering other residents' room/personal space. Redirection attempted-behaviors unchanged.
03/24/24 at 3:02 PM- Grabbing others, kicking others, pushing others, physically aggressive towards others, accusing of others, cursing at others, express frustrations/anger at others, threatening others, disrobing in public, entering other residents' room/personal space, public sexual acts, repetitive motions, rummaging, spitting, agitated, anxious, restless, elopement, exit seeking, insomnia, not sleeping, pacing, wandering, withdrawn/isolating. Redirection attempted-behaviors worsened.
03/24/2024 at 10:57 PM- Physically aggressive towards others, express frustration/anger towards others, threatening others, entering other residents' room/personal space, agitated, wandering. Redirection attempted-behaviors unchanged.
D) Change of Condition Form
A change of condition form from 02/19/24 for Resident was reviewed. The symptoms and signs for the change of condition are as follows:
Resident inappropriate with females, states he is trying to get kicked out, going through other residents ' belongings, other residents are fearful.
The change of condition form is dated for 02/19/24 at 1:30 PM.
E) Observation
After notifying the facility of the IJ and accepting the POC, while observing for the implementation of the POC, the following observations were made:
At approximately 12:37 PM on 03/26/24, Resident #213 was escorted to their room from the dining room, pushed into the room, and left there alone, after the facility instructing one (1) on one (1) care to be provided to resident at all times. At 12:53 PM, Activities Leader (AL) #71 entered Resident #213's room. AL #71 was asked if education regarding one on one care for the resident had been provided, to which they stated, No, not at this time. AL #73 then walked past surveyors and into the hallway, leaving Resident #213 alone in their room, once again. At approximately 12:47 PM, a Nurse Aide escorted Resident #213 out of their room into the Unit Managers office.
f) Facility's PLan of Correction
The facility's accepted Plan of Correction read as follows:
3-25-24 Abatement Plan
1. Resident # 213 was placed on 1:1 direct observation with a facility staff member until physician
interventions are successful in managing behaviors. An immediate fax reporting of allegation
was completed and sent to OHFLAC. The physician was notified with new orders as follows;
increased Trazadone to 150mg at bedtime, changed his Paxil to bedtime, and 1 on 1 with staff
member. The residents care plan was updated with new orders and 1:1 observation
intervention.
2. All residents in the facility have the potential to be affected by the alleged deficient practice. All
alert residents were interviewed by the Unit Managers to identify other concerns and no other
issues were identified.
3. All staff members in the facility on 3-25-24 were immediately re-educated on reporting
allegations of abuse immediately to OHFLAC, APS, Ombudsman or other licensing board as
warranted by the Unit Manager. All staff were educated on notifying a supervisor of any
allegation immediately to assist with interventions necessary for immediate protection of
residents. All staff not available on 3-25-24 will be re-educated on reporting allegations of
abuse and notifying a supervisor immediately prior to the start of their next scheduled shift.
4. The Unit Managers will monitor progress notes daily to identify potential concerns of abuse. The
Administrator and Director of Nursing will review incident and accident reports daily for two
weeks, then three times a week for two weeks, then monthly for three months to identify
potential concerns. Any allegations will be reported to OHFLAC, Ombudsman, APS and other
licensing boards as warranted. All allegations of abuse and neglect will be reviewed at the
facilities Quality Assurance and Performance Improvement meeting each month.
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 ensure residents were treated in a dignified manner. Resident #162 was administered medication in the dining room on two (2) occasion...
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Based on observation and staff interview, the facility failed to ensure residents were treated in a dignified manner. Resident #162 was administered medication in the dining room on two (2) occasions and Resident #36 was taken to Bingo and the day lounge to watch television in a shirt soiled with tube feeding. These were random opportunities for discovery. Resident identifiers: #36 and #162. Facility Census: 55.
Findings included:
a) Resident #36
On 03/27/24 during a medication administration observation at approximately 1:30 PM, Resident #36's shirt became soiled with tube feeding when some of the feeding spilt from the syringe used during the feeding. Resident #36's shirt was not changed, and she was taken to the dining room to play Bingo. At 3:05 PM on 03/28/24 Resident #36 was observed sitting in the lounge area with other residents watching a movie. She was still wearing the soiled shirt.
Registered Nurse #85 observed the resident with the surveyor at 3:05 PM on 03/27/24 and confirmed her shirt needed to be changed.
b) Resident #162
On 03/27/24 at 11:11 am, Resident #162 indicated to the surveyor she was in pain and needed her pain pill. The surveyor alerted facility staff of Resident #162's request.
At approximately 11:25 AM Licensed Practical Nurse (LPN) #63 entered the dining room and administered Resident #162 two (2) Tylenol. She was overheard telling the resident, This is Tylenol, it is not time for your other pain pill yet.
An immediate interview with LPN #63 after she exited the dining room, found she had given the Resident Tylenol at the request of Resident #162's assigned nurse. She stated, She said to give her the Tylenol now because she would have to pull the oxycodone from the emergency stock.
At 11:41 Am on 03/27/24 LPN #63 again entered the dining room and administered Resident #162 another pill. The LPN motioned to the surveyor in a manner to alert her to the fact that she had given Resident #162 her scheduled oxycodone.
The corporate Registered Nurse #85 was made aware of the surveyor observations on 03/27/24 at approximately 11:50 AM.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Assessment Accuracy
(Tag F0641)
Could have caused harm · This affected 1 resident
Based on record review and staff interview the facility failed to identify a diagnosis of schizoaffective disorder on a quarterly Minimum Data Set (MDS). This was a random opportunity for discovery an...
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Based on record review and staff interview the facility failed to identify a diagnosis of schizoaffective disorder on a quarterly Minimum Data Set (MDS). This was a random opportunity for discovery and was true for Resident #20. Resident identifier: #20. Facility census: 55.
Findings included:
a) Resident #20
On 03/27/24 at 10:03 AM a record review on Resident #20 found the Pharmacy recommendations on 01/05/24. The FNP (Family Nurse Practitioner) had a note stating to add medical diagnosis of schizoaffective disorder and bipolar disorder to the resident's medical record.
Further record review on 03/27/24 showed bipolar disorder on Resident #20's medical diagnosis, however, it did not show a medical diagnosis for schizoaffective disorder.
A review of the quarterly MDS with an Assessment Reference Date (ARD) of 03/08/24 revealed Resident #20 had a diagnosis of schizoaffective disorder .
During an interview on 03/27/24 at 11:00 AM a staff interview with the Corporate Nurse #85, Regional Director #85 and Administrator all confirmed the Diagnosis for Schizoaffective Disorder was not on the MDS
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 update the Preadmission Screening and Resident Review (PASRR) for Resident #6, after the resident was diagnosed with a major mental...
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Based on record review and staff interview, the facility failed to update the Preadmission Screening and Resident Review (PASRR) for Resident #6, after the resident was diagnosed with a major mental disorder after admission to the facility. This was true for one (1) of 16 residents reviewed during the survey process. Resident identifier: #6. Facility census: 55.
Findings included:
a) Resident #6
At approximately 2:30 PM on 03/25/24, a record review was conducted for Resident #6. During the Record review, the PASRR for Resident #6 was reviewed.
The PASARR, dated 08/19/10, had None marked under the current diagnosis tab of the MI/MR (Mental Illness/Mental Retardation) assessment portion.
Upon further review, Resident #6 was diagnosed with major depressive disorder in 2017 and a new PASARR was not completed.
At approximately 1:41 PM on 03/27/24, an interview was conducted with the Director of Nursing (DON). During this interview, the DON acknowledged there was no diagnosis on the PASRR for major depressive disorder. The DON also acknowledged Resident #6 had been diagnosed with major depressive disorder in 2017, and the PASRR on file was the most up to date, having not been redone to reflect the diagnosis
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0645
(Tag F0645)
Could have caused harm · This affected 1 resident
.
Based on record review and staff interview, the facility failed to add a diagnosis of schizoaffective disorder for one (1) of (16) residents reviewed for the care area of pre-admission screening and...
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Based on record review and staff interview, the facility failed to add a diagnosis of schizoaffective disorder for one (1) of (16) residents reviewed for the care area of pre-admission screening and resident review (PASARR) this failed practice had the potential to affect a limited number of residents in facility. Resident identifier: #20. Facility census: 55.
Findings include:
A review of Resident #20's medical record on 03/27/24 found the resident received a diagnosis of Schizoaffective disorder prior to admission.
Further Record review of Resident #20's medical record on 03/27/24 of the pre-admission screening and resident review ( PASARR) found the PASARR did not contain a diagnosis of schizoaffective Disorder.
An interview on 03/27/24 at 10:10 AM, with Regional Director #86 and Corporate Nurse #85 confirmed the PASARR for Resident #20 did not contain a diagnosis of Schizoaffective Disorder.
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 record review, observation and staff interview the facility failed to revise Resident #36's care plan when the use of a vest for positioning was discontinued. This was true for one (1) of 1...
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Based on record review, observation and staff interview the facility failed to revise Resident #36's care plan when the use of a vest for positioning was discontinued. This was true for one (1) of 16 sampled residents. Resident Identifier: #36. Facility Census: 55.
Findings include:
a) Resident #36
A record review of Resident #36's care plan on 03/26/24 found the following intervention related to Activities of Daily Living (ADL) performance, Up in high back tilt wheelchair with pommel cushion and vest for positioning.
An observation of Resident #36 on 03/25/24 and 03/27/24 found the resident was up in the wheelchair but was not wearing a vest as directed in her care plan.
An interview with Nurse Aide #64 at 12:58 PM on 03/27/24 confirmed the resident did not have a vest in place. Nurse Aide #64 stated, She use to have one but we have not used that with her for sometime now.
An interview with the Director of Nursing (DON) on 03/27/24 at approximately 2:00 PM found the resident no longer used the vest. She indicated, it had messed up so they switched it to the seat belt. She agreed the care plan needed to be revised.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
Based on record review and staff and resident interview, the facility failed to complete neurological assessments after a fall for Resident #213 and #31, failed to notify the physician of hyperglycemi...
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Based on record review and staff and resident interview, the facility failed to complete neurological assessments after a fall for Resident #213 and #31, failed to notify the physician of hyperglycemia results for Resident #8, and to administer medication per physician's order for Resident #49. This was true for four (4) out of four (4) residents reviewed for quality of care during the survey process. Resident identifiers: #213, #31, #8, #49. Facility census: 55.
Findings included:
a) Resident #213
At approximately 10:00 AM on 03/27/24, a record review was conducted for Resident #213 concerning falls at the facility. Upon review, it was determined neurochecks were incomplete for Resident #213 following multiple falls.
For a fall at 5:15 PM on 10/20/23, the daily fourth check was not completed.
For a fall at 6:35 PM on 12/26/23, the daily second and daily third checks were not completed. The daily fourth check was completed on 03/15/24.
For a fall at 7:00 PM on 02/14/24, the fourth one-hour check was documented taking place at 02/14/24 at midnight. The neuro check should have taken place at midnight on 02/15/24.
For a fall at 7:00 PM on 02/14/24, the second four-hour check to be completed at 8:00 AM on 02/15/24, was completed on 03/11/24.
For a fall at 7:00 PM on 02/14/24, the third four-hour check to be completed at 12:00 PM on 02/15/24, was completed on 03/11/24.
For a fall at 7:00 PM on 02/14/24, the fourth four-hour check to be completed at 4:00 PM on 02/15/24, was completed on 03/11/24.
For a fall at 7:00 PM on 02/14/24, the third daily check to be completed at 04:00 PM on 02/18/24, was completed on 03/24/24.
For a fall at 7:00 PM on 02/14/24, the fourth daily check to be completed at 04:00 PM on 02/19/24, was incomplete.
For a fall at 11:45 PM on 03/24/24, the first one-hour check was entered for 03/24/24 at 12:30 AM.
For a fall at 11:45 PM on 03/24/24, the second one-hour check was entered for 03/24/24 at 1:30 AM.
For a fall at 11:45 PM on 03/24/24, the fourth one-hour check was entered for 03/24/24 at 2:30 AM.
For a fall at 11:45 PM on 03/24/24, the first four-hour check was not completed.
For a fall at 11:45 PM on 03/24/24, the first daily check was not completed.
An interview with the Director of Nursing (DON) on 03/27/24 at 1:41 PM confirmed the neurochecks for Resident #213 were incomplete.
b) Resident # 8
A review of Resident #8's medical record on 03/26/24 found a physician order which indicated if Resident #8's blood sugar was greater than 350 mg/dl the physician was to be notified.
A review of the resident's blood sugars from 08/01/23 to current found the following dates when the resident's blood sugar was greater than 350:
-- 08/05/23 at 9:38 PM blood sugar was 483.
-- 08/07/23 at 9:35 PM blood sugar was 385.
-- 08/16/23 at 9:00 PM blood sugar was 363.
-- 08/22/23 at 9:00 PM blood sugar was 359.
-- 08/23/23 at 5:00 PM blood sugar was 482.
-- 08/25/23 at 9:00 PM blood sugar was 408.
-- 09/08/23 at 5:00 PM blood sugar was 405.
-- 09/14/23 at 9:00 PM blood sugar was 382.
-- 09/19/23 at 9:00 PM blood sugar was 467.
-- 12/21/23 at 9:00 PM blood sugar was 442.
-- 02/06/24 at 5:00 PM blood sugar was 429.
-- 02/09/24 at 5:00 PM blood sugar was 400.
-- 03/09/24 at 5:00 PM blood sugar was 399.
-- 03/11/24 at 5:00 PM blood sugar was 458.
-- 03/19/24 at 11:00 am blood sugar was 359.
During an interview with the Director of Nursing (DON) on 03/26/24 at 3:21 PM she was asked to provide documentation to show the physician was notified of Resident #8's elevated blood sugars on the aforementioned dates.
In the morning of 03/27/24 the DON was asked if she was able to find any evidence the physician was notified of Resident #8's elevated blood sugars, and she confirmed she was not.
c) Resident #31
A review of Resident #31's medical record on 03/27/24 found Resident #31's neurological assessments were not always completed as ordered. The following neurological assessments were missing the following assessments:
-- Neurological Assessment with an effective date of 08/23/23 was missing the following checks:
- Daily First
- Daily Second and
- Daily Fourth.
-- Neurological Assessment with an effective date of 09/02/23 was missing the following checks:
- 4 hour 4th
- Daily 1st
- Daily 3rd
-- Neurological Assessment with an effective date of 09/24/23 was missing the following checks:
- 4 hour 4th
- Daily 1st
- Daily 2nd
- Daily 3rd
- Daily 4th
-- Neurological Assessment with an effective date of 12/10/23 had the following incomplete checks:
-Daily Fourth.
-- Neurological Assessment with an effective date of 01/06/24 were missing the first daily check.
An interview with the Director of Nursing (DON) at 2:55 PM on 03/27/24 confirmed the neurological assessments were not completed.
d) Resident #49
During an interview on 03/25/24 at 1:50 PM Resident #49 expressed concern that he had been having trouble getting his Trulicity (an injectable diabetes medicine that helps control blood sugar levels). Resident stated, I've started it, stopped it and then started it again because they can't get it.
Record review showed an order for Trulicity Subcutaneous Solution Pen-injector 0.75 MG/0.5ML (Dulaglutide). Inject 0.75 mg subcutaneously one time a day every Wed for Diabetes. Order start date 01/15/24.
Review of Resident #49's Medication Administration Record (MAR) showed four (4) of the ten (10) ordered doses were not administered since the medication has been ordered.
Review of the Electronic Medication Administration Record Note (EMAR) notes showed the following dates to have been omitted:
1/31/2024 1:38 PM EMAR note text stated: Trulicity Subcutaneous Solution Pen-injector 0.75 MG/0.5ML. Inject 0.75 mg subcutaneously one time a day every Wednesday for Diabetes Medication not available. Called Pharmacy to reorder. Will be available on evening medication run.
2/7/2024 at 9:34 AM EMAR note text stated: Trulicity Subcutaneous Solution Pen-injector 0.75 MG/0.5ML. Inject 0.75 mg subcutaneously one time a day every Wednesday for Diabetes awaiting from pharmacy.
2/28/2024 at 10:57 AM EMAR note text stated: Trulicity Subcutaneous Solution Pen-injector 0.75 MG/0.5ML. Inject 0.75 mg subcutaneously one time a day every Wednesday for Diabetes Medication not available will contact pharmacy.
3/13/2024 at 10:41 AM Electronic Medication Administration Record Note (EMAR) text stated: Trulicity Subcutaneous Solution Pen-injector 0.75 MG/0.5ML. Inject 0.75 mg subcutaneously one time a day every Wednesday for Diabetes. Awaiting order from pharmacy.
03/27/24 at 10:30 AM the Director of Nursing (DON) verified the missed doses of the Trulicity medication for Resident #49. The DON stated, We have been having a hard time getting the Trulicity. I will contact the Nurse Practitioner and see if we can get the order changed to something else.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0687
(Tag F0687)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on observation, family interview, staff interview and record review the facility failed to provide toenail care to Resid...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on observation, family interview, staff interview and record review the facility failed to provide toenail care to Resident #29. This failed practice was a random opportunity for discovery and had the potential to affect a limited number of residents. Resident identifier: #29. Facility census: 55.
Findings included:
a) Resident #29
On 03/25/24 at 12:30 PM Resident #29's husband stated he would like to get her toenails cut. They [facility staff] told him she wasn't eligible, and no one has ever come back to do anything else about it. The resident's toenails on both feet were observed to be thick, yellow in color and curled over top the ends of the toes on both feet.
Record review showed no grievance or concerns for toenail care.
Resident #29 was admitted to the facility on [DATE].
On 03/26/24 at 2:02 PM electronic health records Licensed Practical Nurse (LPN) #19 stated they have to sign up for [name of contracted services company] then if they are eligible, they can get the services. If they are not eligible, they also have a local podiatrist in town that can see them. LPN #19 verified they should have services provided regardless of if they qualify. LPN #19 further stated the Licensed Social Worker (LSW) takes care of the [name of contracted services company] services.
On 03/26/24 at 2:51 PM the Licensed Social Worker (LSW) stated I sent the referral for [person at referral base] at [name of contracted services company] after the family requested toenails to be trimmed. [name of contracted services company] don't offer the services to Resident #29 due to resource amount. The family went through a Medicaid advisor. On 3/15/24 I received email back that resident was not eligible [name of contracted services company]. Nurses usually would usually take it from there. To be honest have not followed up on it anymore.
On 03/26/24 at 3:30 PM the Director of Nursing (DON) observed Resident #29's toenails in the presence of resident family members. The family reiterated the request to have the toenails trimmed. The DON stated, This is something my staff wouldn't be comfortable with due to the condition and thickness and of the toenails. I will follow up and see where we are at with outside services.
Record review showed the following progress note post surveyor intervention:
On 03/27/2024 at 3:06 PM Nurses Note stated received return call from [local podiatry office] and was notified that a packet must be completed to obtain an appointment. Referral packet completed and faxed with fax confirmation received.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
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Based on 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. Resident #31 did not have h...
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Based on 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. Resident #31 did not have his fall interventions in place. The facility to failed to implement fall interventions for Resident #213 regarding his risk for elopement. This was true for two (2) of the 16 sampled residents. Resident identifiers: #31 and #213. Facility Census: 55.
Findings Include:
a) Resident #31
A review of Resident #31's medical record on 03/26/24 found a fall intervention of bed bolsters to the bed.
An observation with the Director of Nursing (DON) and Registered Nurse #85 on 03/26/24 at 10:18 AM confirmed Resident #31's bed bolsters were not in place as directed by his care plan.
b) Resident #213
At approximately 3:30 PM on 03/25/24, a review of the care plan for Resident #213 was conducted. During the review, it was noted Resident #213 was care planned to have a wanderguard device on their leg and wheelchair due to wandering behaviors and a history of elopement.
At approximately 10:30 AM on 03/26/24, a review of orders for Resident #213 was conducted. During this review, it was discovered Resident #213 did not have orders for a wanderguard device until 03/25/24, following surveyor intervention.
At approximately 10:30 AM a wandering observation tool completed by the facility on 03/04/24 was reviewed. This assessment stated the resident did not have a history of wandering or elopement. A progress note was reviewed from 10/06/23 at 12:23 PM stating the resident cut off their wanderguard device with a butterknife and exited the facility through the front door.
At approximately 1:41 PM on 03/27/24, an interview was conducted with the Director of Nursing (DON). During the interview, the DON confirmed the care plan intervention for a wanderguard device due to wandering behaviors. The DON acknowledged the orders for the wanderguard device were not being entered until 03/25/24.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Tube Feeding
(Tag F0693)
Could have caused harm · This affected 1 resident
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Based on observation, record review and staff interview the facility failed to ensure a resident who is fed by enteral means receives the appropriate treatment and services to prevent complications ...
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Based on observation, record review and staff interview the facility failed to ensure a resident who is fed by enteral means receives the appropriate treatment and services to prevent complications of the enteral feeding tube unless unavoidable. Resident Identifier: Resident #36. Facility Census: 55.
Findings Include:
a) Resident #36
An observation of medication administration for Resident #36 began on 03/27/24 beginning at 1:10 PM found Licensed Practical Nurse (LPN ) #35 was preparing medication for Resident #36. LPN #35 stated, I am giving medication to (Name of Resident #36) this is her noon and 2:00 PM medications. LPN #35 was asked to read each medication as she was pulling them from the medication cart. LPN #35 indicated she was giving the following medication:
1. Isosource 1.5
2. Haldol Tablet five (5) milligrams
3. Midodrine 10 milligrams
4. Norco 5-325 milligrams
5. Baclofen 10 milligrams
LPN #35 crushed the Haldol, Midodrine, Norco, and baclofen all together. She stated, I have to crush them because they are administered in her feeding tube.
LPN #35 took Resident #36 to her room and began the medication administration at 1:20 PM on 03/27/24. LPN #35 poured the crush medication into a cup. She then added 200 milliliters (mls) of tap water to the medication. LPN #35 then attached the syringe to the feeding tube and began pouring the water with the medication into the syringe. The syringe became disconnected and some of the water and medication leaked onto Resident #36's shirt. LPN #35 then reattached the syringe and continued to pour the water and medication into the syringe. LPN #35 poured all the water into the tube except for 20 milliliters left in the bottom of the cup. An observation of the remaining water found there was medication still left in the water as evidenced by particles of the medication still floating in the water and settled in the bottom of the cup.
LPN #35 then poured about 250 mls of the isosource into the syringe. Once all the Isosource was emptied out of the cup she told the resident thank you and confirmed she was finished administering the medication. She confirmed there was 20 mls of water with medication in it still left in the cup. LPN #35 failed to flush the feeding tube with water after administering Resident #36's isosource. LPN #35 also failed to the check gastric volume residual (GVR) before beginning the medication administration and enteral feeding.
a) Resident #36
An observation of medication administration for Resident #36 began on 03/27/24 at 1:10 PM. Licensed Practical Nurse (LPN ) #35 was preparing medication for Resident #36. LPN #35 stated, I am giving medication to (Name of Resident #36) this is her noon and 2:00 PM medication. LPN #35 was asked to read each medication as she was pulling them from the medication cart. LPN #35 indicated she was giving the following medication:
1. Isosource 1.5
2. Haldol Tablet five (5) milligrams
3. Midodrine 10 milligrams
4. Norco 5-325 milligrams
5. Baclofen 10 milligrams
LPN #35 crushed the Haldol, Midodrine, Norco, and baclofen all together. She stated, I have to crush them because they are administered in her feeding tube.
LPN #35 took Resident #36 to her room and began the medication administration at 1:20 PM on 03//27/24.
LPN #35 poured the crush medication into a cup.
She then added 200 milliliters (mls) of tap water to the medication.
LPN #35 then attached the syringe to the feeding tube and began pouring the water with the medication into the syringe.
The syringe became disconnected and some of the water and medication leaked onto Resident #36's shirt.
LPN #35 then reattached the syringe and continued to pour the water and medication into the syringe.
LPN #35 poured all the water into the tube except for 20 milliliters left in the bottom of the cup.
An observation of the remaining water found there was medication still left in the water as evidenced by particles of the medication still floating in the water and settled in the bottom of the cup.
LPN #35 then poured about 250 mls of the Isosource into the syringe.
Once all the Isosource was emptied out of the cup she told the resident thank you and confirmed she was finished administering the medication.
She confirmed there was 20 mls of water with medication in it still left in the cup.
Resident #36 had the following orders:
1. May give medications via enteral tube. May combine all medications unless contraindicated. Flush with 30 mls of water before and after medication administration every shift, The 30 ML flush was omitted and not completed by LPN #35.
2. To verify function of an enterable tube prior to feeding or prior to medication administration: Check gastric residual volume (GRV) prior to each use. If residual is greater than 150 mls, hold feeding/medications and notify medical provider for further instruction. LPN #35 failed to check the gastric residual volume (GRV). This was omitted.
3. Baclofen Tablet 10 mg due at 2:00 PM. LPN #35 failed to administer this medication in its entirety.
4. Isosource 1.5 250 ml due at 12:00 PM. This medication was administered an hour and half late.
5. Haloperidol give 5 mg via peg tube three times a day due at 2:00 PM, LPN #35 failed to administer this medication in its entirety.
6. Norco oral tablet 5-325 mg. Give 1 tablet by mouth every eight hours due at 2:00 PM. LPN #35 failed to administer this medication in its entirety.
7. Water for enteral flush Give 120 ml via peg - tube three times a day for hydration. LPN #35 omitted this 120 ml flush.
At 1:45 PM on 03/27/24 the Director of Nursing was notified of LPN #35 failing to flush the tube and failing to check the GVR before administering medications and enteral feeding and no further information was provided.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0700
(Tag F0700)
Could have caused harm · This affected 1 resident
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Based on record review and staff interview, the facility failed to properly assess Resident #213 for the use of bed rails. This was true for one (1) of one (1) residents reviewed for bed rails durin...
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Based on record review and staff interview, the facility failed to properly assess Resident #213 for the use of bed rails. This was true for one (1) of one (1) residents reviewed for bed rails during the long term care survey process. Resident identifier: 213. Facility census: 55.
Findings include:
A) Resident #213
At approximately 09:30 AM on 03/26/24, an observation of bed rails on Resident #213 ' s bed was made while investigating accident hazards.
At approximately 10:00 AM on 03/26/24, a review of the care plan for Resident #213 was conducted. During the review, it was noted that Resident #213 was not care planned to have bed rails on their bed.
At approximately 10:15 AM on 03/26/24, a bed evaluation provided by Corporate RN (CRN) #85 stated the resident had interest in bed rails. However, there was no bed rail safety evaluation completed for the resident.
CRN #85 confirmed there was no bed rail safety evaluation done on Resident #213. CRN #85 stated There ' s not a bed rail safety evaluation here for that resident. I don ' t even know what a bed rail safety evaluation is.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0726
(Tag F0726)
Could have caused harm · This affected 1 resident
Based on observation, staff interview and record review the facility failed to ensure Licensed Practical Nurse (LPN) #35 had the appropriate nurse competencies to ensure a resident who was fed by ente...
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Based on observation, staff interview and record review the facility failed to ensure Licensed Practical Nurse (LPN) #35 had the appropriate nurse competencies to ensure a resident who was fed by enteral means received the appropriate treatment and services to prevent complications of the enteral feeding tube unless unavoidable. LPN #35 did not administer medications and or feedings to Resident #36 via the enteral tube in a correct manner. The facility was unable to show LPN #35's competencies and skills regarding feeding tube care was reviewed upon her hire to the facility in January of 2024. Resident identifier: #36. Facility census: 55.
Findings included:
a) Resident #36
An observation of medication administration for Resident #36 began on 03/27/24 beginning at 1:10 PM found Licensed Practical Nurse (LPN ) #35 was preparing medication for Resident #36. LPN #35 stated, I am giving medication to (Name of Resident #36) this is her noon and 2:00 PM medications. LPN #35 was asked to read each medication as she was pulling them from the medication cart. LPN #35 indicated she was giving the following medication:
1. Isosource 1.5
2. Haldol Tablet five (5) milligrams
3. Midodrine 10 milligrams
4. Norco 5-325 milligrams
5. Baclofen 10 milligrams
LPN #35 crushed the Haldol, Midodrine, Norco, and baclofen all together. She stated, I have to crush them because they are administered in her feeding tube.
LPN #35 took Resident #36 to her room and began the medication administration at 1:20 PM on 03/27/24.
LPN #35 poured the crush medication into a cup. She then added 200 milliliters (mls) of tap water to the medication.
LPN #35 then attached the syringe to the feeding tube and began pouring the water with the medication into the syringe.
The syringe became disconnected and some of the water and medication leaked onto Resident #36's shirt.
LPN #35 then reattached the syringe and continued to pour the water and medication into the syringe.
LPN #35 poured all the water into the tube except for 20 milliliters left in the bottom of the cup.
An observation of the remaining water found there was medication still left in the water as evidenced by particles of the medication still floating in the water and settled in the bottom of the cup.
LPN #35 then poured about 250 mls of the isosource into the syringe. Once all the Isosource was emptied out of the cup she told the resident thank you and confirmed she was finished administering the medication.
She confirmed there was 20 mls of water with medication in it still left in the cup. LPN #35 failed to flush the feeding tube with water after administering Resident #36's isosource. LPN #35 also failed to the check gastric volume residual (GVR) before beginning the medication administration and enteral feeding.
At 1:45 PM on 03/27/24 the Director of Nursing was notified of LPN #35 failing to flush the tube and failing to check the GVR before administering medications and enteral feeding and no further information was provided.
At 5:00 PM on 03/27/24 the facility was asked to provide the nursing competencies which were performed with LPN #35 upon her hire to the facility. The facility provided several competencies which were completed with LPN #35 but non were related to care and services required for residents who have and enteral feeding tube. This was reviewed with the Director of Nursing (DON) at 5:56 PM on 03/27/24 and no further information was provided.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0744
(Tag F0744)
Could have caused harm · This affected 1 resident
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Based on record review and staff interview, the facility failed to notify the physician of a change in baseline behaviors immediately, for a resident with dementia. This was true for one (1) of thre...
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Based on record review and staff interview, the facility failed to notify the physician of a change in baseline behaviors immediately, for a resident with dementia. This was true for one (1) of three (3) residents reviewed for dementia care during the long-term care survey process. Resident identifier: #213. Facility census: 55.
Findings include:
At approximately 3:30 PM on 03/25/24, a record review was conducted for Resident #213. It was noted Resident #213 had the following diagnosis: Dementia in other diseases classified elsewhere, unspecified severity, with other behavioral disturbances.
On 03/22/24, Resident #213 returned from a local behavioral health facility for behaviors. Upon review of behavioral monitoring task sheets, it was determined the resident had worsening behaviors and the physician was not notified until surveyor intervention for an Immediate Jeopardy (IJ) situation, on 03/25/24. The behaviors noted from the task sheets were:
03/23/24 at 11:18 AM-Kicking others, physically aggressive toward others, cursing at others, express frustration/anger at others, screaming at others, threatening others, disruptive sounds, entering other resident's room/personal space, agitated, anxious, restless, elopement, exit seeking, refusing care, wandering. Redirection was attempted and behaviors were unchanged.
03/24/24 at 12:26 AM- Express frustration/anger at others, entering other residents' room/personal space. Redirection was attempted and the behaviors were unchanged.
03/24/24 at 3:02 PM- Grabbing others, kicking others, pushing others, physically aggressive towards others, accusing of others, cursing at others, express frustrations/anger at others, threatening others, disrobing in public, entering other residents' room/personal space, public sexual acts, repetitive motions, rummaging, spitting, agitated, anxious, restless, elopement, exit seeking, insomnia, not sleeping, pacing, wandering, withdrawn/isolating. Redirection was attempted and the behavior worsened.
03/24/2024 at 10:57 PM- Physically aggressive towards others, express frustration/anger towards others, threatening others, entering other residents' room/personal space, agitated, wandering. Redirection attempted-behaviors unchanged.
At approximately 1:41 PM on 03/27/24, an interview was conducted with the Director of Nursing (DON). During the interview, the DON confirmed the physician was not notified of the resident's behaviors until after surveyor intervention.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Unnecessary Medications
(Tag F0759)
Could have caused harm · This affected 1 resident
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Based on observation, record review and staff interview the facility failed to ensure the facility's medication error rate was five (5) percent or less. The facility's medication error rate was 16.6...
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Based on observation, record review and staff interview the facility failed to ensure the facility's medication error rate was five (5) percent or less. The facility's medication error rate was 16.67 percent. Resident identifier: Resident #36. Facility census: 55.
Findings include:
a) Resident #36
An observation of medication administration for Resident #36 began on 03/27/24 at 1:10 PM. Licensed Practical Nurse (LPN ) #35 was preparing medication for Resident #36. LPN #35 stated, I am giving medication to (Name of Resident #36) this is her noon and 2:00 PM medication. LPN #35 was asked to read each medication as she was pulling them from the medication cart. LPN #35 indicated she was giving the following medication:
1. Isosource 1.5
2. Haldol Tablet five (5) milligrams
3. Midodrine 10 milligrams
4. Norco 5-325 milligrams
5. Baclofen 10 milligrams
LPN #35 crushed the Haldol, Midodrine, Norco, and baclofen all together. She stated, I have to crush them because they are administered in her feeding tube.
LPN #35 took Resident #36 to her room and began the medication administration at 1:20 PM on 03//27/24.
LPN #35 poured the crush medication into a cup.
She then added 200 milliliters (mls) of tap water to the medication.
LPN #35 then attached the syringe to the feeding tube and began pouring the water with the medication into the syringe.
The syringe became disconnected and some of the water and medication leaked onto Resident #36's shirt.
LPN #35 then reattached the syringe and continued to pour the water and medication into the syringe.
LPN #35 poured all the water into the tube except for 20 milliliters left in the bottom of the cup. An observation of the remaining water found there was medication still left in the water as evidenced by particles of the medication still floating in the water and settled in the bottom of the cup.
LPN #35 then poured about 250 mls of the Isosource into the syringe. Once all the Isosource was emptied out of the cup she told the resident thank you and confirmed she was finished administering the medication. She confirmed there was 20 mls of water with medication in it still left in the cup.
Resident #36 had the following orders:
1. May give medications via enteral tube. May combine all medications unless contraindicated. Flush with 30 mls of water before and after medication administration every shift, The 30 ML flush was omitted and not completed by LPN #35.
2. To verify function of an enterable tube prior to feeding or prior to medication administration: Check gastric residual volume (GRV) prior to each use. If residual is greater than 150 mls, hold feeding/medications and notify medical provider for further instruction. LPN #35 failed to check the gastric residual volume (GRV). This was omitted.
3. Baclofen Tablet 10 mg due at 2:00 PM. LPN #35 failed to administer this medication in its entirety.
4. Isosource 1.5 250 ml due at 12:00 PM. This medication was administered an hour and half late.
5. Haloperidol give 5 mg via peg tube three times a day due at 2:00 PM, LPN #35 failed to administer this medication in its entirety.
6. Norco oral tablet 5-325 mg. Give 1 tablet by mouth every eight hours due at 2:00 PM. LPN #35 failed to administer this medication in its entirety.
7. Water for enteral flush Give 120 ml via peg - tube three times a day for hydration. LPN #35 omitted this 120 ml flush.
LPN #35 had seven (7) opportunities for medication administration and made seven (7) medication errors. Another surveyor observed 35 medication administration opportunities. This created seven (7) errors out of 45 opportunities for a medication error rate of 16.67 %.
At 1:45 PM on 03/27/24 the Director of Nursing was notified of the above errors made by LPN #35, and no further information was provided.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Medical Records
(Tag F0842)
Could have caused harm · This affected 1 resident
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Based on record review and staff interview, the facility failed to maintain an accurate and complete record for two (2) of 16 residents reviewed during the survey process. Residents #19 and #26 d...
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Based on record review and staff interview, the facility failed to maintain an accurate and complete record for two (2) of 16 residents reviewed during the survey process. Residents #19 and #26 did not have an accurate and complete record. Resident #19's record had an incomplete transfer form. Resident #26's record was incomplete in Physician's Scope of Orders for Treatment (POST) form. Resident Identifiers: #19 and #26 . Facility Census: 55.
Findings Include:
a) Resident #19
On 03/26/24 at 11:00 AM, a record review was completed for Resident #26. The review found the resident was transferred to an acute care facility on 03/15/24. However, the transfer form was reviewed, and the date was listed as 01/28/24.
On 03/26/24 at 11:30 AM, the Administrator and the Corporate Registered Nurse (RN) #85 were notified and confirmed the transfer date on the transfer form was incorrect.
b) Resident #26
On 03/26/24 at 10:00 AM, a record review was completed for Resident #26. The review found the Physician's Scope of Orders for Treatment (POST) form was not complete. The POST form was signed by Resident #26 and the Resident Representative. However, the signatures did not have a date for when the POST form was signed. The date was left blank.
On 03/26/24 at 10:31 AM, the Administrator was notified of the incomplete POST form. The Administrator confirmed the signatures on the POST form were not dated.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected multiple residents
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Based on observation and staff interview, the facility failed to provide a clean homelike environment in the dining room. This was found during the observation of the lunch meal on 03/25/24 and has ...
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Based on observation and staff interview, the facility failed to provide a clean homelike environment in the dining room. This was found during the observation of the lunch meal on 03/25/24 and has the potential to affect more than an isolated number of residents. Facility Census: 55.
Findings included:
a) During an observation of the noon time meal on 03/25/24 it was noted the ceiling around the vent in the dining room was dirty.
On 03/26/24 at 3:00 PM the Director of Plant Maintenance confirmed the ceiling around the vent needed to be cleaned.
On 03/27/24 during an observation of the lunch meal the ceiling around the vent in the dining room was still dirty and had not been cleaned.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Investigate Abuse
(Tag F0610)
Could have caused harm · This affected multiple residents
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Based on record review and staff interview, the facility failed to investigate allegations of abuse from Resident #213 to other residents in the facility. This was true for 1 out of 1 resident re...
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Based on record review and staff interview, the facility failed to investigate allegations of abuse from Resident #213 to other residents in the facility. This was true for 1 out of 1 resident reviewed for allegations of abuse. This has the potential to affect more than a limited number of residents. Resident identifier: 213. Facility census: 55.
Findings include:
a) Resident #214
Progress Notes
At approximately 3:00 PM on 03/25/24, a record review for Resident #213 was conducted as part of the sample selection process. During this process, progress notes were reviewed, which indicated multiple incidents of sexual, physical, and verbal abuse directed at other residents in the facility, by Resident #213. These progress notes were cross referenced with the facility's incident and reportables logs, revealing none of these incidents were investigated or reported.
Progress notes of the incidents are as follows:
On 02/13/24 at 6:23 PM Resident #213 touched a female resident inappropriately.
On 02/19/24 at 11:54 AM, Resident #213 rubbed a female resident's arm and stated, Tell me you love me.
On 2/19/24 at 12:30 PM, Resident #213 backed their wheelchair into another resident's wheelchair repeatedly. When female resident asked Resident #213 to quit, they replied I will hit you.
On 02/19/24 at 01:43 PM, Resident #213's sister stated the resident was told if their behaviors continued, they would be sent out of the facility. Resident #213 stated they were trying to get kicked out of the facility.
On 02/22/24 at 10:13 AM, Resident #213 touched a female resident on the abdomen in a downward motion.
On 02/28/24 at 08:05 PM, Resident #213 was at the nurses' station pointing at another female resident and making fun of them. The female resident became upset and started crying. Resident #213 became defensive when they were told to leave the female resident alone.
On 02/29/24 at 01:07 AM, Resident #213 kept trying to touch a female resident, and kept grabbing them by the hand. Resident #213 became defensive when they were told they could not touch other residents. Resident #213 stated they wanted to get kicked out of the facility so they could go home.
On 03/03/24 at 7:50 PM, Resident #213 was observed arguing with another resident. The Unit Manager was called to the dining room to help with the situation and Resident #213 drew their hand back to hit Unit Manager but stopped themselves. Resident then pushed another resident's geri-char at the nurses' station and stated, do whatever you got to do, send me out of here, I want out of here.
At 12:45 PM on 03/05/24, Resident #213 was passing another resident in the hallway and became combative and started kicking the other resident in the leg and hand.
At 10:35 AM on 03/23/24, Resident #213 was banging closet doors together, causing a disruption for their roommate. Resident #213 went to the dining room and banged a book against a table, calling another resident an idiot and telling them to bring it on.
On 03/23/24 at 04:19 PM, Resident #213 was being pushed by a family member down the hallway, when another resident passed by, Resident #213 stated, He's the one I tried to knock the piss out of earlier.
At 03:05 AM on 03/24/24, Resident #213 was trying to get into another female resident's room. Resident #213 told his roommate to shut their mouth when they woke roommate up by banging dresser drawers.
At 10:47 PM on 03/24/24, Resident #213 was coming down the hall and kicked another resident's door. Resident #213 was in another female's personal area and told not to touch her.
At 01:09 AM on 03/25/24, Resident #213 was found in the floor of another female resident's room. Resident #213 stated they were trying to help the female resident to bed.
b) Staff interview:
At approximately 3:40 PM on 03/25/24, an interview was conducted with the Administrator and Unit Manager (UM) #5 about the allegations of abuse. When asked about the investigation status and the identities of the victims of Resident #213's abusive behavior, both the Administrator and UM #5 stated they did not know the identities. The Administrator confirmed there were no incident reports nor were the incidents reported to the required state agencies and no investigations had been completed.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected multiple residents
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Based on record review and staff interview, the facility failed to develop and/or implement a care plan for 1:1 visits, a diagnosis for Schizoaffective Disorder, Bed Rails, Wander Guard, Trauma and ...
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Based on record review and staff interview, the facility failed to develop and/or implement a care plan for 1:1 visits, a diagnosis for Schizoaffective Disorder, Bed Rails, Wander Guard, Trauma and Dementia diagnosis, Fall Interventions, and Tube Feeding. This was true for eight (8) of 16 sampled residents reviewed during the long term care survey process. Resident identifiers: 36, 33, 7, 25, 48, 20, 213, and 31 Facility census: 55
Findings include:
a) Resident #36
On 03/26/24 at 10:15 AM the Activity Director Provided a 1:1 list stating Resident #36 was to have 1:1 visits daily.
A record review on 03/26/24 at 11:00 AM of Resident #36's care plan revealed Resident #36 was not care planned to receive daily 1:1 visits.
On 03/26/24 at 11:36 AM during a staff interview with the Administrator, it was confirmed the care plan did not include Resident #36's 1:1 visits with activities.
b) Resident # 33
On 03/26/24 at 10:15 AM the Activity Director Provided a 1:1 list stating Resident #33 was to have 1:1 visits daily.
A record review on 03/26/24 at 11:00 AM of Resident #33's care plan revealed Resident #33 was not care planned to receive daily 1:1 visits.
On 03/26/24 at 11:36 AM during a staff interview with the Administrator, it was confirmed the care plan did not include Resident #33's 1:1 visits with activities.
C) Resident #7
On 03/26/24 at 10:15 AM the Activity Director Provided a 1:1 list stating Resident #7 was to have 1:1 visits daily.
A record review on 03/26/24 at 11:00 AM of Resident #7's care plan revealed Resident #7 was not care planned to receive daily 1:1 visits.
On 03/26/24 at 11:36 AM during a staff interview with the Administrator, it was confirmed the care plan did not include Resident #7's 1:1 visits with activities.
d) Resident #25
On 03/26/24 at 10:15 AM the Activity Director Provided a 1:1 list stating Resident #25 was to have 1:1 visits daily.
A record review on 03/26/24 at 11:00 AM of Resident #25's care plan revealed Resident #25 was not care planned to receive daily 1:1 visits.
On 03/26/24 at 11:36 AM during a staff interview with the Administrator, it was confirmed the care plan did not include Resident #25's 1:1 visits with activities.
e) Resident #48
On 03/26/24 at 10:15 AM the Activity Director Provided a 1:1 list stating Resident #48 was to have 1:1 visits daily.
A record review on 03/26/24 at 11:00 AM of Resident #48's care plan revealed Resident #48 was not care planned to receive daily 1:1 visits.
On 03/26/24 at 11:36 AM during a staff interview with the Administrator, it was confirmed the care plan did not include Resident #48's 1:1 visits with activities.
f) Resident # 20
On 03/27/24 at 10:03 AM a record review on Resident #20 found the Pharmacy recommendations on 01/05/24 revealed the FNP (Family Nurse Practitioner) had a note stating to add medical diagnosis of Schizoaffective Disorder and Bipolar Disorder.
Further record review on 03/27/24 showed Schizoaffective Disorder was not in the care plan
On 03/27/24 at 11:00 AM a staff interview with Corporate Nurse #85, confirmed the Diagnosis for Schizoaffective Disorder was not on Care plan
G1) Resident #213
At approximately 9:30 AM on 03/26/24, an observation of bed rails on Resident #213's bed was made while investigating accident hazards.
At approximately 10:00 AM on 03/26/24, a review of the care plan for Resident #213 was conducted. During the review, it was noted Resident #213 was not care planned to have bed rails on their bed.
At approximately 1:41 PM on 03/27/24, an interview was conducted with the Director of Nursing (DON). During the interview, the DON acknowledged the bed rails were on Resident #213's bed and they were missing from the care plan.
G2) Resident #213
At approximately 3:30 PM on 03/25/24, a review of the care plan for Resident #213 was conducted. During the review, it was noted Resident #213 had a focus of At risk for impaired psychosocial wellbeing related to history of trauma and/or trauma related symptoms. The following interventions were put into place: Same sex caregiver, removal of clothing slowly, remove from areas where smoking is permitted or cook outs occur.
At approximately 11:30 AM on 03/26/24, an interview was conducted with the Administrator and Corporate RN (CRN) #85 concerning the care plan for Resident #213. The Administrator stated the facility has no caregivers of the same sex as Resident #213 employed. CRN #85 stated We can't offer same sex caregivers to the resident because we don't have them. The Administrator and CRN #85 confirmed the focus and interventions listed, but could not verify the cause of the trauma or the reason for the interventions listed in Resident #213's care plan.
At approximately 1:55 PM on 03/26/24, an interview was conducted with Social Services Designee (SSD) #30. During the interview, SSD #30 stated I know Resident #213 was in a car accident when they were younger but that is the only trauma I know of. When asked about the interventions in place (same sex caregiver, removal of clothes slowly, remove from areas where smoking is permitted or cook outs occur), SSD #30 stated I didn't put these in here. I'm not sure who did it or why they are here.
G3) Resident #213
At approximately 3:30 PM on 03/25/24, a record review was conducted for Resident #213. It was noted Resident #213 had the following diagnosis: Dementia in other diseases classified elsewhere, unspecified severity, with other behavioral disturbances.
Upon review of the care plan for Resident #213, it was determined there was no focus, goal, or intervention in the care plan that mentioned dementia.
At approximately 1:41 PM on 03/27/24, an interview was conducted with the Director of Nursing (DON). During the interview, the DON confirmed the diagnosis and the absence of dementia from Resident #213's care plan.
h) Resident #31
A review of Resident #31's medical record on 03/26/24 found a fall intervention of bed bolsters to bed at all times.
An observation with the Director of Nursing (DON) and Registered Nurse #85 on 03/26/24 at 10:18 AM confirmed Resident #31's bed bolsters were not in place as directed by his care plan.
i) Resident #36
A review of Resident #36's care plan on the morning of 03/27/24 found the following care plan interventions related to the use of a feeding tube:
-- Administer flushes per medical providers order.
-- Check for placement and residuals per policy.
-- Provide tube feeding per medical provider orders.
-- Secure tube to prevent dislodging.
An observation of medication administration for Resident #36 began on 03/27/24 beginning at 1:10 PM found Licensed Practical Nurse (LPN ) #35 was preparing medication for Resident #36. LPN #35 stated, I am giving medication to (Name of Resident #36) this is her noon and 2:00 PM medication. LPN #35 was asked to read each medication as she was pulling them from the medication cart. LPN #35 indicated she was giving the following medication:
1. Isosource 1.5
2. Haldol Tablet five (5) milligrams
3. Midodrine 10 milligrams
4. Norco 5-325 milligrams
5. Baclofen 10 milligrams
LPN #35 crushed the Haldol, Midodrine, Norco, and baclofen all together. She stated, I have to crush them because they are administered in her feeding tube.
LPN #35 took Resident #36 to her room and began the medication administration at 1:20 PM on 03/27/24. At this time it was noted the feeding tube was not secured to the residents abdomen as directed in the care plan.
LPN #35 poured the crush medication into a cup. She then added 200 milliliters (mls) of tap water to the medication. LPN #35 then attached the syringe to the feeding tube and began pouring the water with the medication into the syringe. The syringe became disconnected and some of the water and medication leaked onto Resident #36's shirt. LPN #35 then reattached the syringe and continued to pour the water and medication into the syringe. LPN #35 poured all the water into the tube except for 20 milliliters left in the bottom of the cup. An observation of the remaining water found there was medication still left in the water as evidenced by particles of the medication still floating in the water and settled in the bottom of the cup.
LPN #35 then poured about 250 mls of the isosource into the syringe. Once all the Isosource was emptied out of the cup she told the resident thank you and confirmed she was finished administering the medication. She confirmed there was 20 mls of water with medication in it still left in the cup.
Resident #36 had the following orders:
-- May give medications via enteral tube. May combine all medications unless contraindicated. Flush with 30 mls of water before and after medication administration every shift, The 30 ML flush was omitted and not completed by LPN #35. Therefore the intervention to administer flushes per medical order was not implemented.
-- To verify function of an enterable tube prior to feeding or prior to medication administration: Check gastric residual volume (GRV) prior to each use. If residual is greater than 150 mls, hold feeding/medications and notify medical provider for further instruction. LPN #35 failed to check the gastric residual volume (GRV). This was omitted. The intervention to check placement and residual was also not implemented.
-- Water for enteral flush Give 120 ml via peg - tube three times a day for hydration. LPN #35 omitted this 120 ml flush. Again the intervention to provide flushes per the medical provider order was not implemented.
At 1:45 PM on 03/27/24 the Director of Nursing was notified of the above errors made by LPN #35, and no further information was provided.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0801
(Tag F0801)
Could have caused harm · This affected most or all residents
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Based on record review and staff interview, the facility failed to employ qualified dietary staff by failing to have each member of the dietary staff obtain food handlers cards before working in the...
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Based on record review and staff interview, the facility failed to employ qualified dietary staff by failing to have each member of the dietary staff obtain food handlers cards before working in the dietary department. This has the potential to affect more than a limited number of residents. Facility census: 55.
Findings include:
A) Culinary Aide (CA) #62
At approximately 9:00 AM on 03/27/24, an interview was conducted with the Culinary Director (CD). The CD provided a list of employees with food handlers cards. Upon review, it was determined that CA #62 did not have a food handlers card and had been employed in dietary since 01/02/24.
The CD stated They just work weekends and I never see them, so it has been hard to get them to get the food handlers card.
According to [NAME] Virginia code §16-2-16, all counties in [NAME] Virginia must require food safety certificates for food employees.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected most or all residents
Based on observation and staff interview, the facility failed to store food in a safe and sanitary manner and maintain sanitary equipment. This had the ability to affect more than a limited number of ...
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Based on observation and staff interview, the facility failed to store food in a safe and sanitary manner and maintain sanitary equipment. This had the ability to affect more than a limited number of residents. Facility census: 55.
Findings included:
a) Temperature logs
At approximately 11:07 AM on 03/25/24, during a tour of the kitchen, it was discovered that the breakfast temperature logs were incomplete. [NAME] #59 stated the temperature logs were not done due to new employee training.
The Culinary Director (CD) confirmed the temperature logs were not done. CD stated the employee must have put the temperature logs on a separate sheet of paper somewhere to show the trainee how to fill out the logs, and just forgot to fill out the logs.
b) Expired beans
At approximately 11:15 AM on 03/25/24, during a tour of the kitchen, a container of pinto beans was discovered in the reach-in refrigerator. The beans were dated 03/16/22-03/22/24.
The CD acknowledged the expired beans and stated, I don ' t know why those are still in there but I will throw those away right now.
c) Microwave
At approximately 11:43 AM during a tour of the nourishment room, the microwave was observed having grime on the inside, as well as a paper towel with yellow stains on it, stuck to the plate inside the microwave.
The surveyor asked the CD if the microwave was used to prepare food for the residents in the facility. The CD stated, Yes, they will bring food in here and heat it up for the residents if they ask. I will get that paper towel out of there now. The CD attempted to remove the paper towel and it remained stuck to the plate. The CD was eventually able to remove it.
d) Can of corn
At approximately 11:15 AM on 03/26/24, during a tour of the kitchen, a dented can of corn was observed sitting on the storage rack in the kitchen.
The CD was informed, and acknowledged, the dented can of corn and stated, I will throw that away right now, it shouldn't have been there.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0868
(Tag F0868)
Could have caused harm · This affected most or all residents
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Based on record review and staff interview the facility failed to have the appropriate members of the quality assessment and assurance committee attend the quarterly meetings. This failed practice h...
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Based on record review and staff interview the facility failed to have the appropriate members of the quality assessment and assurance committee attend the quarterly meetings. This failed practice had the potential to affect all residents residing at the facility. Facility census: 55.
Findings included:
Record Review of the Quality Assurance and Performance Sign in Sheet showed the facility's Medical Director did not attend the second quarter meeting for 2023.
On 03/27/24 at 3:55 PM the Director of Nursing (DON) verified the medical director was not in attendance at the second quarter meeting in 2023
Sept 2023
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0883
(Tag F0883)
Could have caused harm · This affected 1 resident
Based on record review and staff interview the facility failed to offer an eligible resident the pneumococcal immunization for one (1) out of five (5) residents reviewed for immunizations. Resident id...
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Based on record review and staff interview the facility failed to offer an eligible resident the pneumococcal immunization for one (1) out of five (5) residents reviewed for immunizations. Resident identifier: #39. Facility census 57.
Findings included:
a) Resident #39
A review of the medical chart found Resident #39 last received a Pneumovax 23 on 06/14/17 which is more than five (5) years and the Resident is eligible for the Prevnar 20.
On 09/11/23 at 1:47 PM, the Director of Nursing (DON) stated the facility failed to offer Resident #39 the Prevnar 20 vaccine.
Mar 2023
3 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on record review and staff interview the facility failed to ensure all allegations of misappropriation of Resident funds...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on record review and staff interview the facility failed to ensure all allegations of misappropriation of Resident funds and or financial exploitation was reported to all state agencies as required. This was true for one (1) of five (5) sampled residents reviewed for a complaint investigation. Resident Identifier: #57. Facility Census: 55.
Findings Included:
a) Resident #57
A review of Resident #57's medical record on 02/27/23 found the resident was admitted to the facility on [DATE] following a recent Cebrovascular Accident (CVA). Contained in the medical record was a Checklist for Surrogate Selection form which was completed on 04/07/21. This form appointed Resident #57's nephew (Family Member (FM) #2) as his Healthcare Surrogate (HCS).
Contained in the record was an additional Checklist for surrogate selection. This selection was signed by the physician on 04/20/21. Noted on the form was the following hand written note, APS has been assigned due to family unable, unwilling and trying to take financial advantage. This HCS appointed an APS worker to be his healthcare decision maker.
Further review of the record found a social service progress note dated 04/15/21 at 12:15 pm which read as follows SS (Social Services) has made an APS (Adult Protective Service) referral on resident's behalf due to SS has been informed by resident and another person who called anomiously [SIC] stated family members are trying to get residents money. SS has already called residents bank about the circumstances and they have flagged his account. Also they are driving his vehicles with out permission. This note was written by the Facility's Social Worker.
An additional Social Service Progress note dated 04/15/21 at 3:14 pm read as follows, APS is now HCS and will be opening up a case due to financial exploitation by nephew which was his HCS.
An additional social service progress note dated 06/30/21 at 11:08 am which read as follows, SS contacted Sheriff's office per resident because he states his nephew is out in his 2011 maroon Colorado truck with no insurance etc. Also states they have got his property signed over in his name and have taken some personal belongings of his. Policies [SIC] coming to facility to speak with resident.
There was nothing contained in the medical record to indicate FM #2 was reported to the State Agency or law enforcement as required within the appropriate time frames after the allegation of financial exploitation became knowledge of the facility staff.
Law enforcement was eventually notified on 06/30/21 which was two (2) and one (1) half months after the allegation was made. The information was never reported to the state agency as required.
An interview with the Nursing Home Administrator and the Social Worker on 02/28/23 at 10:09 am confirmed this allegation was not reported to the state agency and was not reported to the police department until 06/30/21.
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CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Assessment Accuracy
(Tag F0641)
Could have caused harm · This affected 1 resident
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Based on medical record review and staff interview the facility failed to ensure the Minimum Data Set (MDS) was accurate in the care area of falls for Resident #53. This was true for one (1) of four...
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Based on medical record review and staff interview the facility failed to ensure the Minimum Data Set (MDS) was accurate in the care area of falls for Resident #53. This was true for one (1) of four (4) residents reviewed for falls during a Complaint Survey. Resident Identifier: #53. Facility Census: 55.
Findings Included:
a) Resident #53
Review of Resident #53s medical record review found resident had two (2) falls on 11/30/22 with minor injuries and on 12/16/22 with no injury.
Further review of the medical record found a MDS with an assessment reference date (ARD) of 12/22/22. Review of this MDS found section J falls and indicated Resident #53 had the following falls:
-no injury- 2 or more falls.
-minor injury- one (1) fall.
-major injury- one (1) fall.
Total of four (4) falls
On 03/01/22 at 11:00 am the Director of Nursing (DON) reviewed the MDS with ARD of 12/22/22 for Resident #53. She confirmed the MDS was not coded correctly. It should have been coded for two (2) falls; one (1) with no injury and one (1) with minor injury.
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CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0745
(Tag F0745)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on record review, family interview and staff interview the facility failed to provide medical related social services to...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on record review, family interview and staff interview the facility failed to provide medical related social services to enable each resident to attain or maintain the highest practicable physical, mental and psychosocial well- being. This was true for one (1) of five (5) sampled residents reviewed during a complaint investigation. Resident Identifier: #57. Facility Census: 55.
Findings Included:
a) Resident #57
A review of Resident #57's medical record found the resident was admitted to the facility on [DATE] with a private insurance as his payor source. The resident was switched to Private Pay on 04/22/21 and was private pay for his room and board until his discharge on [DATE]. The room and board was 389 dollars a day. The resident gave permission to pay the facility via a cashiers check in the sum $33,918.55. This payment was posted to his account on 06//25/21. The facility did issue a refund to the resident in the amount of $6,058.55 on 10/14/21.
An phone interview with Resident #57's niece (Family Member (FM) #1) who is the person currently caring for Resident #57 on 02/27/23 at 11:49 am confirmed she had spoke to Resident #57's private insurance company about the residents bill and she was told that the facility billed it wrong and they were billing him as an outpatient for therapy and they did not know he was still in the facility after 04/22/21. FM #1 then stated the Private insurance company told her to have the facility rebill for the days they did not pay for but the facility refused to do so. She indicated the facility staff took the resident into a room and pressured him to pay his bill before he was discharged . She stated, it was the facility staff and an Adult Protective Service worker. FM #1 indicated Resident #57 wanted to call her and have her involved but the staff did not allow him to do that. She indicated the resident had some cognitive issues at the time as a result of his CVA and should have had someone to speak for him in this meeting.
FM #1 stated she was at the hospital with Resident #57 and when he was sent to the facility she had to return to her home out of state to work. She stated she called the facility soon after his admission and told them she was wanting to take him to live with her or at the least a facility near where she lives so she could look in on him. She stated that no one would listen to her and just kept telling her APS was involved now. She stated it was not until the end of June when they finally approved her to take him home. She stated that she came and got him on 07/01/21. She stated that he would not have owed such a bill if they would have allowed her to take him home sooner as she wanted to do. She stated she advised them the hospital had appointed her HCS., but the facility would never appoint her as the HCS. She indicated she wanted to make his healthcare decisions and was never given the opportunity. Instead the DHHR was appointed to act as his HCS.
An Interview with with the Social Worker on 02/27/23 at 12:30 pm. confirmed the facility had appointed Resident #57's Nephew (FM #2) as the HCS upon admission. When asked why she chose FM #2 opposed to FM #1 she stated, The hospital told me they had appointed FM #2 and I just followed suit.
A review of the hospital discharge records which were contained in Resident #57's medical record at the facility found the following notes which indicate that FM #1 was in fact the involved family at the hospital and she had been appointed the HCS not FM #2 as asserted by the Social Worker.
Hospital Progress notes:
CM Narrative Note:: 3/26 G4S Spoke w/(First name of FM #1) (FM #1's phone Number which is still her current phone number at the time of this review) PT (patient) lives alone, still drives and independent before stroke. PCP (primary care physician) Dr. (first name of doctor) at (name of local clinic) No DME/HH (Durable Medical Equipment/Home Health) and none needed at DC (discharge) No hx (history of) falls. DC plan - PT/OT eval recommended SNF (skilled Nursing Facility) provided choice forms, family chose (Name of Facility and current phone number) Will start process and continue to follow up.
Pt, arrived from Neurological Intensive Care Unit. No distress noted. NIECE in room. Requesting urinal will continue to monitor.
Left hand grip improving. Will have a follow up swallow test tomorrow. Can Have applied sauce consistency per MD. Nieces at bedside.'
Patient extubated, no signs of distress. Talking in a low garbled voice. Foley DC. Spoke with (First name of FM #1) - his MPOA/niece to give updates. also spoke to and gave updates to a niece from out of state.
There was no mention of FM #2 in the records from the hospital. He was appointed by the facility on 04/07/21. He was removed as the HCS on 04/20/21 due to FM #2 attempting to financially exploit Resident #57. APS was appointed HCS on 04/20/21. The medical record was void of any information related to why FM #1 was not appointed HCS at the facility. The hospital information indicated she was the decision maker at the hospital and not FM #2. The Social Worker indicated she suggested the attending physician appoint FM #2 because he was who the hospital appointed but hospital records indicate this is not accurate.
An additional interview with the NHA and Social Worker on 02/28/23 beginning at 10:09 am. again confirmed the Social Worker suggested the attending physician appoint FM #2 because the hospital had appointed him. When the Social Worker was made aware of the above mentioned notes which were contained in the facility's medical record she remained silent. The Social Worker then indicated she did not know about FM #1 until closer to the time of his discharge on [DATE]. However a review of Resident #57's profile in his electronic medical record indicated the social worker added FM #1 as an authorized person to receive health information on 03/30/21 the day after Resident #57 was admitted to the facility. The social worker also added FM #1's phone number to the profile page. When asked why she never suggested FM #1 be appointed HCS she stated, I can't remember.
The medical record was void of any information concerning FM #1 until 6/22/21 2:04 pm when the social work wrote, SS spoke with (First name of APS worker)/APS worker and he is in agreement to allow resident to to live with niece (First name of FM #1) in (Abbreviation of State FM #1 lives in) . SS then contacted (Name of FM #1) to get a date she would want to pick resident up from facility. July 1st is the date set at this time. SS ask (First name of FM #1) to call SS and advise of time of d/c.
The next social service progress note which mentioned FM #1 was dated 06/28/21 at 4:34 pm, the social worker wrote, SS spoke with (First Name of APS worker)/APS today in regards to them filing for conservative/guardian. (First name of APS worker) advised the process has been canceled. Resident niece (First name of FM #1) who is going to live on July 1st with is upset because resident has paid his bill in full until June 30th. She called and stated she had been in contact with (Name of Insurance Company) and they stated they have paid for his stay. SS advised niece (First name of FM #1) that (Name of insurance company) quit paying on April 22. SS advised that APS filed for an appeal to try and get additional time and they denied him the appeal. She stated there was no way he owned [SIC] that much money and she needed to know the case number for denial and she needed this information before she hired an attorney.
The final note in the medical record which mentioned FM #1's name was written by the discharging nurse on 07/01/21 at 3:40 pm which read as follows, Discharge plan of care and instructions reviewed with (First and Last name of FM #1)-niece. Resident leaving facility at this time with all personal belongings in private vehicle.
The social worker and/or the NHA was unable to provide any additional information as to why FM #1 was not a suggested HCS for Resident #57 despite her involvement at the hospital. The facility knew she was a family member and had her telephone number but never asked her to serve as the HCS despite the hospital paper work stating she was the surrogate and decision maker while he was in the hospital.
FM #1 asserted during the telephone interview she would have taken him home as soon as the insurance stopped paying his room and board had the facility involved her in the decision. She stated, Had I known he was going to be charged so much for staying there I would have taken him out sooner. I wanted him here closer to me anyway from the beginning, but the facility kept saying APS is making the decisions. She stated she had already researched rehab facility's in her area and if they would not accept him she had planned to continue his therapy on an outpatient basis. She stated,He has been living in my home with me and my daughter since 07/01/21 and has done nothing but improve.
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Sept 2022
4 deficiencies
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 ensure the ombudsman was notified of all residents' transfe...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on record review and staff interview, the facility failed to ensure the ombudsman was notified of all residents' transfers to the hospital. This was true for one (1) of four (4) residents reviewed for the care area of hospitlizations. Resident indentifier: #35. Facility census: 53.
Findings included:
a) Resident #35
Review of Resident #35's medical records showed the resident was transferred to the hospital on [DATE] due to decreased level of consciousness.
During an interview on 09/27/22 at 2:02 PM, the Administrator stated a list of the facility's discharges for August 2022 had been sent to the ombudsman on 08/30/22 but Resident #35 was not on this list. The Administrator stated she corrected this today.
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CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0657
(Tag F0657)
Could have caused harm · This affected 1 resident
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Based on observation, record review and staff interview, the facility failed to accurately revise the comprehensive care plan for one (1) of two (2) residents reviewed for the care area of pressure ...
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Based on observation, record review and staff interview, the facility failed to accurately revise the comprehensive care plan for one (1) of two (2) residents reviewed for the care area of pressure ulcers. Resident identifier: #44. Facility census: 53.
Findings included:
a) Resident #44
Review of Resident #44's physician's orders showed an order written on 09/21/22 to cleanse the pressure ulcer to left outer ankle with wound cleanser, pat dry, and apply sure prep.
On 09/27/22 at 10:34 AM, Registered Nurse #38 was observed performing the treatment to Resident #44's left outer ankle pressure ulcer. RN #38 stated Resident #44 had other pressure ulcers that healed.
Review of Resident #44's comprehensive care plan showed the following focus, [Resident's name has pressure area to right outer ankle. Pressure area to left ankle has resolved. This focus was updated on 09/21/22.
During an interview on 09/28/22 at 8:55 AM, the Director of Nursing confirmed Resident #44's care plan was incorrect, and the resident had a current left ankle pressure ulcer and resolved right ankle pressure ulcer.
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CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
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Based on record review and staff interview, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice. The facility failed to follow p...
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Based on record review and staff interview, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice. The facility failed to follow physician's orders for medication parameters and failed to perform neurological assessments according to professional standards of practice. This had the potential to affect one (1) of 15 residents reviewed during the long-term care survey process. Resident identifier: #35. Facility census: 53.
Findings included:
a) Resident #35
1) Medication parameters
Review of Resident #35's physician's orders showed an order written on 02/21/22 for the medication atenolol, 25 mg, to be given twice a day for hypertension. The physician's order stated to hold the medication for a pulse rate less than 60.
Review of Resident #35's Medication Administration Record (MAR) showed Atenolol had been administered on 09/10/22 at 9:00 AM when the resident's pulse was documented as 56.
During an interview on 09/27/22 at 11:19 AM, the Administrator confirmed Resident #35 had been administered Atenolol on 09/10/22 when the resident's pulse was less than 60.
2) Neurological assessments
Review of Resident #35's medical records showed the resident had experienced a fall on 07/29/22 at 10:00 PM. Neurological assessments were obtained immediately after the fall, every 15 minutes for three (3) times, every 30 minutes for two (2) times, every hour for two (2) times, and every two (2) hours for two (2) times, ending on 07/30/22 at 5:45 AM. The neurological assessments were not performed again until 07/30/22 at 1:45 PM. The neurological assessments had not been performed for eight (8) hours. The neurological assessments were then continued every four (4) hours until the resident was transferred to the hospital due to decreased level of consciousness on 07/30/22 at 7:58 PM.
During an interview on 09/27/22 at 2:59 PM, the Director of Nursing confirmed neurological checks had not been completed for Resident #35 after the unwitnessed fall on 07/29/22.
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CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Pharmacy Services
(Tag F0755)
Could have caused harm · This affected 1 resident
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Based on record review and staff interview the facility failed to maintain accurate documentation for administration and dispensing of pain medication for Resident #46 and #55. This failed practice ...
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Based on record review and staff interview the facility failed to maintain accurate documentation for administration and dispensing of pain medication for Resident #46 and #55. This failed practice was a random opportunity for discovery. Resident identifiers: #46, and #55. Facility census: 53.
Findings included:
a) Resident #46
Review of Resident #46's orders indicated an order for pain medication, Percocet Tablet 5-325 mg give one tablet by mouth every 6 hours as needed for pain. Start date of 05/02/22.
Record review of the residents Medication Administration Record (MAR) compared to the individual resident's-controlled substance record (used to sign controlled substances out of medication cart) indicated the following discrepancies in documentation for Percocet Tablet 5-325 mg administered by Licensed Practical Nurse (LPN) #64 in September 2022:
09/21/22 - no tablets were signed out of inventory. One (1) tablet was documented as administered at on the MAR at 9:53 PM.
09/22/22 - One (1) tablet was signed out of inventory at 9:53 PM and one (1) tablet signed out at 6:00 AM, and one (1) tablet at 8:40 PM. Only one (1) tablet was administered on the MAR at 5:20 AM for 09/22/22.
b) Resident #55
Review of resident's orders indicated an order for pain medication, Hydrocodone Tablet 10-325 mg give one tablet by mouth every 6 hours as indicated for pain. Start date of 04/21/22.
Record review of the residents Medication Administration Record (MAR) compared to the individual resident's-controlled substance record (used to sign controlled substances out of medication cart) indicated the following discrepancies in documentation for Hydrocodone Tablet 10-325 administered by Licensed Practical Nurse (LPN) #64 in September 2022:
09/04/22 - Total of 4 tablets were removed from the emergency mediation dispensing system under Resident #55's name with unknown times by LPN #64. Only two (2) tablets were administered, one tablet at 6:20 AM, and the other tablet at 10:24 PM.
09/07/22 - One (1) tablet was signed out of the medication cart inventory at 9:00 PM and one (1) tablet signed out at 6:00 AM. Only one (1) tablet was administered on the MAR at 9:53 PM for 09/07/22.
09/23/22 - One tablet was signed out of medication cart inventory at 7:00 AM with a line drawn through it and error waste dropped written over it. The waste was not co-signed or witnessed by another nurse per standards of care. Another entry was made by LPN #64 the next line below dated 09/23/22 on the inventory sheet with a scribbled line for date at 7:00 AM indicated one table was removed. The resident's MAR showed one (1) tablet was administered on the MAR at 5:41 AM.
c) Policy review
Record review of the facility's policy titled, Medication Administration - General Guidelines, dated 09/01/20, showed that staff the individual that administers the mediation dose record the administration on the resident's MAR directly after the medication is given. At the end of medication pass, the person administering the medications reviews the MAR to ensure necessary doses were administered and documented. In no case should the individual who administered the doses report off duty without first recording the administration of any medications.
d) Staff Interview
During an interview on 09/27/22 at 2:53 PM the Director of Nursing (DON) reviewed the documentation entered by LPN #64 on Residents #46 and #55 MAR in comparison to the Controlled Substance Log. The DON stated, We just disciplined her for similar stuff recently. The DON agreed the documentation was hard to follow, not accurate, and unacceptable.
During an interview on 09/28/22 at 8:30 AM the Administrator stated, We started working on this issue last night regarding [LPN #64's first name] carelessness with documentation and poor job performance, we are doing a full audit for controlled substances. We cannot allow this kind of stuff .
e) Personnel File
Review of LPN #46's personnel file showed an employee disciplinary notice dated 08/25/22, signed by the employee on 09/09/22. The written warning showed LPN #64 failed to follow documentation expectations and failed to complete daily unit charge nurse duties as assigned. Types of violations that occurred during the disciplinary action included: failure to follow instructions, carelessness, unsatisfactory quality, and violation of company policies or procedures.
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Jun 2021
14 deficiencies
1 IJ
CRITICAL
(J)
Immediate Jeopardy (IJ) - the most serious Medicare violation
Quality of Care
(Tag F0684)
Someone could have died · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on observation, record review, family interview, and staff interviews, the facility failed to ensure residents received ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on observation, record review, family interview, and staff interviews, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the physician orders. The facility failed to ensure care was delivered for residents who are at high risk of aspiration. This is true for one (1) or one (1) residents who have orders for no straws. This failure was determined to be an immediate jeopardy (IJ) to Resident #45.
The facility was notified of the IJ at 2:28 p.m. on 06/15/21. The facility submitted their first abatement plan of correction (APOC) at 4:02 p.m., and the state agency (SA) requested changes. A second APOC was submitted at 4:39 p.m. the SA again requested changes. The third APOC was submitted by the facility at 4:57 p.m. the SA again requested changes. A fourth and final APOC was submitted by the facility at 5:10 p.m. and was accepted by the SA at 5:10 p.m. After observing for implementation of the APOC the IJ was abated at 8:00 a.m. on 06/16/21.
The approved APOC included:
1. The Nurse Aide (NA) immediately stopped using the straw in Resident #45's drink. Clinical Case Supervisor and RN (Registered Nurse) Unit charge nurse called resident's Medical Power of Attorney immediately at which time the MPOA to sign an informed refusal of care to allow resident to use straws in her drink. The attending physician said to honor family wishes. RNAC (Registered Nurse Assessment Coordinator) updated Plan of Care immediately to allow the use of straws. NA was immediately educated by Clinical Case Manager on following resident [NAME].
2. All other residents who have an order for no straws have the potential to be affected by the alleged deficient practice. The DNS (director of nursing services) checked all other residents Plans of Care and no other residents were identified as being affected by the alleged deficient practice. All nursing staff on duty were in-serviced immediately by the DNS or designee. All nursing staff will be in-serviced on the importance of tray ticket compliance for each resident. All nursing staff that are not at the facility will be in-serviced immediately upon return to work before going to the floor.
3. The nursing staff will review the [NAME] at the beginning of each shift for 3 months. The UCN's will notify NAs immediately during the shift if there is a change in the [NAME]. The UCN's will monitor throughout each shift that residents [NAME] is followed. The CCS or designee will monitor residents care daily to ensure the [NAME] is being followed for 3 months.
4. Daily monitoring of the resident's [NAME] will be conducted by CCS or designee to assure implementation of the [NAME]. The CCS or designee will discuss any findings with the DNS. The DNS will review any findings in QAA monthly for 3 months.
After the immediacy was abated a deficient practice remained and the scope and severity was decreased from a J to an D. A deficient practice remained for Resident #45 who did not receive her ice cream as ordered by the physician. These failed practices were true for 1 of 17 sampled residents. Resident identifier: #45. Facility census: 53.
Findings included:
a) Resident #45 - IJ
A review of Resident #45's medical record beginning at 8:30 a.m. on 06/15/21 found the following physician order, ST (Speech Therapy) Other- No Straws with liquids. The date for this order was 05/27/21.
A review of Resident #45's [NAME] found the following under the heading of Eating/Nutrition: . No Straws with liquids.
An observation of Resident #45 at 10:30 a.m. on 06/15/21 found the resident had a straw in her bedside water pitcher.
Observation of the noon-time meal on 06/15/21 beginning at 12:33 p.m. found Nurse Aide (NA) #31 entered the room to assist Resident #45 with her meal. The resident had a red liquid drink which was identified by NA #31 as Kool-Aid. NA #31 attempted to let Resident #45 consume the drink without a straw, but Resident #45 stated she needed something over it. Resident #45 stated she could not drink it like that (with a straw). NA #31 removed the straw from Resident #45's water pitcher and placed it in the red drink and placed it to Resident #45's lips. Resident #45 drank from the straw and coughed slightly as if to clear her throat.
An interview with the Director of Nursing Services (DNS) and NA #31 at 12:46 p.m. on 06/15/21, again confirmed Resident #45 had a straw in her red drink. NA #31 confirmed she took the straw from her water pitcher because the Resident asked for it. When asked if no straws was printed on Resident #45's tray ticket, NA #31 reviewed the tray ticket and stated, yes, it is.
An interview with Speech Therapist (ST) #54 at 12:49 p.m. on 06/15/21 confirmed Resident #45 should not have straws. She stated, When she uses a straw it puts the liquid farther back in her mouth and she has less time to prepare to swallow. ST #54 stated Resident #45 coughs more when using a straw. When asked what Resident #45 would be at risk for if given a straw, ST #54 stated it increases her risk of aspiration (breathing food, salivia, liquids or vomit into the lungs).
ST #54 then provided a Swallowing Clinical Consult dated 05/14/21 at 3:45 p.m. Upon review of this consult the following was noted on the consult (Typed as Written): Pharyngeal phase: Patient with delayed cough on thin by straw suggestive of possible aspiration. Otherwise, no coughing, choking, or wet vocal quality suggestive of functional pharyngeal swallow. Silent aspiration cannot be ruled out at bed side. Recommendations: .2. No Straws. This consult was completed at the local hospital during Resident #45's last hospital stay. ST #54 stated this was sent back with the resident from the hospital when she was readmitted on [DATE].
b) Resident #45 - Ice Cream
A review of Resident #45's medical record beginning at 8:30 a.m. on 06/15/21 found the following physician order, Ice Cream with lunch and dinner tray. This order had a start date of 06/03/21.
Observation of the noon-time meal on 06/15/21 beginning at 12:33 p.m. found Nurse Aide (NA) #31 entered the room to assist Resident #45 with her meal. Observation of the meal tray found no ice cream included on the tray.
An interview with the Director of Nursing Services (DNS) and NA #31 at 12:46 p.m. on 06/15/21, confirmed there was no ice cream on her tray. When asked if ice cream was listed on the tray ticket, NA #31 stated, yes it is, but she usually does not eat it anyway.
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CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0578
(Tag F0578)
Could have caused harm · This affected 1 resident
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Based on record review and staff interview, the facility failed to ensure the resident's responsible party dated the Physician Orders for Scope of Treatment (POST) form when completed for one (1) of...
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Based on record review and staff interview, the facility failed to ensure the resident's responsible party dated the Physician Orders for Scope of Treatment (POST) form when completed for one (1) of (17) residents reviewed for the care area of advance directives. Resident identifier: #8. Facility census: 53.
Findings included:
a) Resident #8
On 06/14/21 at 2:47 PM, review of the resident's POST form found section E of the form was signed by the resident's responsible party; however, the responsible party failed to date the form when signed.
The POST form is used for the patient's end-of-life treatment preferences to be known and respected.
According to the direction from the WV End of Life center for completing the POST form . The patient (or incapacitated patient's MPOA medical power of attorney/representative or health care surrogate) must sign and date this section for the form to be legally valid.
On 06/16/21 at 12:39 PM, The Director of Nursing (DON) confirmed the POST form was not signed.
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CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Investigate Abuse
(Tag F0610)
Could have caused harm · This affected 1 resident
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Based on observation, resident interview, staff interview, and medical record review the facility failed to investigate an incident of unknown origin. This practice was true for one (1) out of one (...
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Based on observation, resident interview, staff interview, and medical record review the facility failed to investigate an incident of unknown origin. This practice was true for one (1) out of one (1) reviewed for accidents during the Long Term Care Survey Process. Resident Identifier #6. Facility census 53.
Findings Included:
a) Resident #6
On 06/14/21 at 11:42 AM, during an interview with Resident #6, she stated on Mother's Day I fell out of bed getting off the bed pan, spent all day at the hospital. They ran over my big toe with the lift and ripped off my toenail pulling off my sock during a shower, that's why I don't take a shower anymore,
An observation of Resident #6 on 06/15/21 at 9:30 AM, found a band aid on her second toe on the right foot. The band aide was not dated or initialed in accordance with the facility practice. The resident said her big toe was ran over by the lift and the little toe nail was ripped off by her sock. Three (3) toes injured on the right foot.
On 06/15/21 at 9:54 AM, during an interview with License Practical Nurse (LPN) #70, in regards to the band aid she stated, the wound nurse (Name of Registered Nurse (RN) #90) would know, not me. When asked what happened and how long the Band Aid had been on Resident #6's toe. LPN #70 stated, I don't know what happened or how long it has been there. LPN #70 further stated, she goes to the foot and ankle clinic it probably happened when they cut her nails, her last appointment was on 05/18/21.
On 06/15/21 at 9:56 AM, during an interview with Nursing Assistant NA #76, about the band aid on Resident #6's toe, she stated her nails are thick probably got hung on something, I have been off the last couple of days, When asked if the band aide was there last day she worked, NA #76 stated I don't think so, but I have a bad memory.
On 06/15/21 at 10:04 AM, during an interview RN #7, stated It probably happened during nail trimming, she goes to the Foot and Ankle Clinic. RN #7 pulled band aid off, and stated looks like someone cut it during nail trimming. She is a diabetic and gets nails trimmed every two weeks, but it does not look that old. Maybe someone trimmed her nails PRN (as needed). RN #7 asked the resident about her toenail resident stated, they pulled the little toe nail off with the sock and ran over my big toe with the lift about a month ago. RN #7 asked patient who trimmed her nails last. Patient stated I don't know who trimmed my nails last or what happened, (First Name of NA #76) noticed it RN #7 looked at treatment ordered, and stated there are no notes for PRN nails trimmed or band aid. There is no incident report on her toe.
On 06/15/21 at 10:11 AM, RN #90 stated I trimmed her nails two weeks ago, but I didn't put the band aid on, someone else must of put it on. There are no orders for a band aid on her toe according to RN #90.
On 06/15/21 at 10:15 AM, during an interview with the Director of Nursing (DON) #69 about Resident #6's three (3) toe injuries, The DON confirmed she had looked at the medical record and found nothing about her toes. She confirmed there was no incident report or investigation as to what had happened on all three (3) occasions.
On 06/15/21 at 11:05 AM DON #69 stated, the resident requested the band aid be put on before going to Bingo. She further stated, she had provided education to the nursing staff about documenting treatments and completing incident reports and investigations into all injuries.
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CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0637
(Tag F0637)
Could have caused harm · This affected 1 resident
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Based on record review and staff interview, the facility failed to ensure a significant change Minimum Data Set (MDS) was completed within 14 days after the resident's physical condition changed. Th...
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Based on record review and staff interview, the facility failed to ensure a significant change Minimum Data Set (MDS) was completed within 14 days after the resident's physical condition changed. This was true for one (1) of 17 resident's reviewed. Resident identifier: #2. Facility census: 53.
Findings included:
a) Resident #2
Record review on 06/15/21 at 1:54 PM, found a quarterly MDS with a assessment reference date (ARD) of 12/23/20.
The next completed MDS was a quarterly with an ARD of 03/17/21.
Comparison of the two (2) MDS found the resident declined in the following areas:
Bed mobility: a decline from a (1)-supervision, one person assist to a (3)- extensive assistance- two (2) person physical assist.
Dressing: a decline from a (2) limited assistance two person assistance to a (3)- extensive assistance of two staff members.
Toilet use: a decline from (1) Supervision two person assistance to a (3) extensive assistance of 2 persons.
Personal Hygiene: a decline from a (2) limited assistance, one staff member to a (3) extensive assistance of 2 staff members.
A Significant Change in Status MDS is required when:
A resident experiences a consistent pattern of changes, with either two or more areas of decline or two or more areas of improvement, from baseline (as indicated by comparison of the resident ' s current status to the most recent CMS-required MDS).
Examples of Decline include, but are not limited to:
Any decline in an ADL physical functioning area (at least 1) where a resident is newly coded as Extensive assistance, Total dependence, or Activity did not occur since last assessment and does not reflect normal fluctuations in that individual ' s functioning.
On 06/15/21 at 2:56 PM, the Registered Nurse Assessment Coordinator (RNAC/MDS) said, I guess I should have done a significant change MDS.
On 06/15/21 at 3:26 PM, the Director of Nursing (DON) was interviewed regarding the significant change MDS. No further information was provided by the close of the survey.
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CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Incontinence Care
(Tag F0690)
Could have caused harm · This affected 1 resident
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Based on observation, staff interview and record review, the facility failed to ensure Resident #250 who is incontinent of her bladder received appropriate treatment and services to prevent urinary ...
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Based on observation, staff interview and record review, the facility failed to ensure Resident #250 who is incontinent of her bladder received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible. Nursing Assistant (NA) #41 did not properly clean Resident #250's catheter during an observation of catheter care. This was true for one (1) of one (1) residents reviewed for catheter care during the long term care survey process. Resident Identifier: #250. Facility Census: 53
Findings Included:
a) Resident #250
On 06/15/21 at 9:21 AM an observation of catheter care was completed for Resident #250. Observed NA # 41, wash the perineal (peri) area. Staff used a personal cleanser, no rinse solution. Staff rinsed the peri area after using the no rinse solution. NA #41 did not support the catheter tube at the opening of the meatus. Staff failed to follow standards of practice during catheter care. NA #41 failed to change the position of the wash cloth. In addition staff failed to cleanse around the urethral meatus, and touched the bed linens with the wash cloth. NA #41 also failed to use a barrier when emptying the catheter bag. Staff placed the gradual (the container used for collecting the urine) directly on the floor.
Directly following the observation during an interview with the Director of Nursing (DON), the DON stated, I will address this with the NA.
On 06/15/21 at 11:45 AM a review of Resident #250's current physician orders, found no current order for a foley catheter. The nursing assessment completed on 06/11/21 revealed resident #250 was admitted with a #18 French foley catheter.
An interview on 06/15/21 at 12:05 PM with the DON confirmed there was no current orders for the foley catheter. She stated, We will take care of that right away.
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CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0692
(Tag F0692)
Could have caused harm · This affected 1 resident
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Based on observation, resident interview, staff interview, and medical record review the facility failed to ensure Resident #351 maintained acceptable parameters of nutritional status. This failed p...
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Based on observation, resident interview, staff interview, and medical record review the facility failed to ensure Resident #351 maintained acceptable parameters of nutritional status. This failed practice was true for one (1) of three (3) resident reviewed for nutrition during the Long-Term Care Survey Process. Resident Identifier #351. Facility census 53.
Findings included:
a) Resident #351
During an interview on 06/14/21 at 1:15 PM, the resident stated I would eat more if I had a salt pack, especially the eggs for breakfast they need salt. Well, everything needs salt. A record review on 06/14/21 at 3:14 PM, found Resident #351 suffered a 10.86% weight loss from 04/13/21 when she weighed 198 pounds on 06/02/21 when she weighed 176.5 pounds.
On 06/15/21 at 3:25 PM, when asked if she wanted to lose weight, Resident #351 stated, No, No, not doing it intentionally, would eat more if I had salt and the food tasted better.
On 06/15/21 at 3:34 PM, Registered Nurse (RN) #7 was asked about the weight/nutrition meeting note dated 06/14/21, which stated Resident #351 was wanting to lose weight. RN #7 asked the surveyor to accompany her to Resident #351's room for an additional interview with the resident. RN #7 and the surveyor spoke with Resident #351 and asked her if she wanted to lose the weight Resident #351 stated, no, no, I don't want to lose weight now, I would eat if it tasted better.
RN#7 asked the Resident if she needed a softer diet, that she could have Physical Therapist (PT) #92 to evaluate her. Resident stated, No, I only have 6 teeth and I don't want dentures I won't wear them She asked patient if she wanted her to talk to doctor about the salt, patient stated yes. RN #7 explained about hypertension, edema, patient stated look at my chart my blood pressure is excellent a few times it was low. RN#7 stated, I will talk to PT #92, the dietary manager and the Doctor.
On 06/16/21 at 1:17 PM, RN #69 interviewed Resident #351 about her weight loss and the resident stated, the nurse made a statement about losing 50 pounds and I said I would like to lose 50 pounds, it was taken out of context, I never wanted to lose weight this way it makes me too weak. I got my salt and now I will eat everything. RN #69 said to resident that she would have the dietician come talk to her, resident stated no I don't need to talk to her I got my salt I will eat everything.
A review of Resident #351's medical record on 06/15/21, found no care plan stating patient's desire to lose weight, or no physicians orders for a modified diet. Her diet order was Regular texture, regular consistency, diet with no salt pack on tray. Resident had capacity to make her own medical decisions and did not want to lose weight and did want a salt packet on her tray. Prior to surveyor intervention, the facility failed to identify why Resident #351 would not eat.
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CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
Could have caused harm · This affected 1 resident
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Based on observation, staff interview, and medical record review, the facility failed to ensure that a resident who needs respiratory care is provided such care, consistent with professional standar...
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Based on observation, staff interview, and medical record review, the facility failed to ensure that a resident who needs respiratory care is provided such care, consistent with professional standards of practice. This failed practice was true for one (1) of two (2) residents reviewed for oxygen. Resident identifier: # 200. Facility census 53.
Findings included:
a) Resident # 200
Observation on 06/14/21 at 11:54 AM, found the resident was receiving oxygen at the rate of 1.5 liters per minute.
On 06/14/21 at 2:57 PM, Nurse Aide #35 was asked what amount of oxygen was Resident # 200 receiving? She stated, two (2) liters.
On 06/14/21 at 2:59 PM, Unit Charge Nurse (UCN) #60 was asked what amount of oxygen was being delivered. UCN #60 stated, he should be on two (2) liters. UCN #60 looked at the oxygen setting and stated it was on 1.5 liters. UCN # 60 was asked to look it the order. After UCN #60 looked at the orders on the electronic chart she stated, Oh no, he is ordered to on 4 liters.
A review of medical records revealed a physicians order for oxygen four (4) liters per minute, continuously, every shift, with a start date 03/12/21.
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CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0697
(Tag F0697)
Could have caused harm · This affected 1 resident
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Based on record review, observation and staff interview the facility failed to consistently evaluate and administer pain medication for one (1) of the two (2) residents reviewed for the care area of...
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Based on record review, observation and staff interview the facility failed to consistently evaluate and administer pain medication for one (1) of the two (2) residents reviewed for the care area of pain. Resident Identifier #251 and #36. Facility census: 53
Findings Included:
a) Resident #251
On 06/14/21 at 12:03 PM, an observation found Resident #251 sitting in her wheelchair crying. When asked what's wrong Resident stated my leg hurts, they told me I am almost out of pain medication.
A review of Resident #251's medical record beginning on 06/14/21 in the afternoon found the following physician order dated 6/8/21: Percocet Tablet 5-325 MG (oxyCODONE-Acetaminophen); Give 2 tablets by mouth every 6 hours as needed for pain.
Further review of the medical record found a nurses note dated 6/9/21 at 12:59 AM, the note read as follows: Resident is alert and oriented with night time confusion, feeds and turns self. Signed own POST (Physician Orders for Scope of Treatment) form.
A review of the Medication Administration Record (MAR) from 6/9/21 through 6/15/21 found a pain scale score documented with 0 (zero) being no pain and 10 being the worse pain experienced on 6/9/21 as a 5 and 6/10/21 as a 3 when administered pain medication. Resident #251 also received pain medication on the following dates and times with no pain score assessed:
06/10/21 at 8:40 p.m.
06/11/21 at 10:20 a.m. and 8:42 p.m.
06/12/21 at 9:07 p.m.
06/13/21 at 9:06 p.m.
06/14/21 at 12:01 p.m.
06/15/21 at 4:18 a.m. and 1:13 p.m.
A review of the pain scale on the task page for an every six hour pain evaluation noted 0 for pain on every occasion except one. On 6/15/21 at 12:00 PM there is a 5 noted for a pain level. No pain medication was given according to the MAR until 1:13 PM on this date. There is no pain level noted on the MAR for 1:13 PM on 6/15/21.
An interview with Resident #251 on 06/15/21 at 2:30 PM, revealed her Cymbalta and Percocet were not given last night. She stated she was in pain all night.
A review of the MAR for 06/15/21 found Resident #251 did not receive a Percocet or Cymbalta.
The cymbalta was coded with an 11 meaning held waiting on pharmacy.
On 6/15/21 at 3:00 PM, an interview was conducted with Licensed Practical Nurse (LPN) #82 and Registered Nurse (RN) #70 regarding the Cymbalta and Percocet as to why Resident #251 did not get Cymbalta and Percocet on 06/15/21. LPN #82 stated that she was unsure. The medication was here this morning. RN #70 offered no explanation.
An interview with RN #69 on 06/15/21 at 3:16 PM, regarding Resident #251 not getting her Cymbalta and Percocet last night. RN #69 stated, the Cymbalta was here, she just did not get it last night.
A review of the Medication Administration Audit showed that on 6/13/21 the Percocet Tablet 5-325 mg tablet was administered at 9:10 PM, but was not documented until 4:10 am on 6/14/21.
An interview with RN #69 on 06/16/21 at 9:49 AM, found the bed-side nurse reported giving the medication but forgot to chart it until 4:10 AM on 6/14/21. The MAR reflects a 9:09 PM on 6/13/21 administration date and time but the audit reflects an administration date and time of 4:10 AM on 6/14/21.
b) Resident #36
A review of medical records revealed Resident # 36 was receiving Hospice services as of 05/11/21.
Diagnosis: Dementia, Chronic Pain, Anxiety Disorder, Chronic Obstructive Pulmonary Disease, Parkinson's Disease, Essential Hypertension, Cervicalgia, Dysphagia, Oropharyngeal Phase, Pressure Ulcer, Bradycardia, and Heart Failure.
On 06/14/21 at 3:48 PM, the granddaughter, Medical Power of Attorney, (MPOA) of Resident #36 stated during a phone interview, that on Friday 06/11/21 and Saturday 06/12/21, the MPOA was told her grandmother was having a bad day with a lot of yelling.The MPOA, stated this was not normal behavior for her grandmother. Then on Saturday 06/12/21, she stated the nurse told her that it was discovered Resident # 36 had not received her medications on Friday and half of the day on Saturday.
A review of medical records revealed that on 6/11/21, Resident #36 was ordered to receive Lorazepam 0.5 ml (Lorazepam is used for anxiety) every 4 hours as needed for anxious mood/behaviors. Morphine Sulfate 0.5 ml (Morphine is used for pain relief) every 2 hours.
Resident # 36 received both medications on 6/10/21 at 7:38 PM. Seventeen hours passed before the resident received her next doses of medications. On 06/11/21 at 10:21 AM, both medications were given. On 06/11/21 the Resident did not receive any more Lorazepam and/or Morphine for until 6:56 AM on 06/12/21. The lapse of time between the doses of the medications was approximately 21 hours.
A review of the Medication Administration Record (MAR) revealed normally Resident #36 received Lorazepam three (3) to four (4) times a day, and the Morphine was administrated four (4) times a day normally.
During review of the medical record, it was noted the mood/behavior sheets and side effect monitoring sheets were on the electronic charts; however, the monitoring sheets had not been completed. On 06/15/21 at 12:00 PM, the DON contacted the physician and a new order was written for Monitoring effectiveness of antianxiety medication Lorazepam (Ativan) and monitoring for absence of side effects related to antianxiety medication Ativan (Lorazepam).
On 06/16/21 at 11:04 AM, the DON agreed the facility failed monitor for side effects and behaviors for the use of Lorazepam.
The facility had two (2) separate places on the Medication Administration Record (MAR) for pain monitoring. The physicians order was for Resident #36 to be monitored every two hours for pain.
From 06/01/21 to 06/14/21 there was 43 times when Morphine was administrated for pain greater than 0. On 30 of those occasions the pain monitoring, documented in two separate places, conflicted.
On 06/16/21 at 3:10 PM, the DON said she would look to see if she had any more information about the pain scale monitoring sheets. No additional information was provided.
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CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Drug Regimen Review
(Tag F0756)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on record review and staff interview, the facility failed to ensure the resident's attending physician provided document...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on record review and staff interview, the facility failed to ensure the resident's attending physician provided documentation as to why a gradual dose reduce (GDR), identified by the pharmacist was clinically contraindicated. This was true for one (1) of five (5) residents reviewed for unnecessary medications. Resident identifier: #8. Facility census: 53.
Findings included:
a) Resident #8
Record review found the pharmacist reviewed the resident's medication on 07/27/20. The pharmacist notified the physician, Residents Amitriptyline 50 mg HS is due for a GDR (gradual dose reduction) evaluation which must be attempted unless clinically contraindicated for reasons that include, but that are not limited to (check all that apply):
--The continued use is in accordance with relevant current standards of practice.
--The residents target symptoms returned or worsened after the most recent attempt at a GDR within the facility.
--An attempt at reduction is likely to impair resident's function and/or cause an increase in behavior.
--Resident is at minimum dose for optimal stability which is also, consistent with diagnosis.
--Discontinuation likely will be harmful to resident and/or others.
--The resident targeted symptoms continue to persist at current dose and a reduction is contraindicated.
The physician reviewed the pharmacist's recommendations on 07/28/20 and checked he disagreed with the pharmacist but the physician failed to check one of the above reasons to suggest the GDR was clinically contraindicated.
Elavil is a medication on the Beers list. The Beers list includes medications with pharmacologic features that make certain drugs particularly hazardous for patients over [AGE] years of age.
Resident #8 is [AGE] years old. The medication is on the Beers list as it can cause sedation, urinary
retention or incontinence, constipation, arrhythmia's, and falls.
On 06/15/21 at 3:29 PM, the Director of Nursing (DON) was unable to provide any evidence the physician documented why the clinical rationale for why a GDR would be clinically contraindicated.
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CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Medical Records
(Tag F0842)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on record review and staff interview the facility failed to ensure Resident #41's and Resident #45's medical record was ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on record review and staff interview the facility failed to ensure Resident #41's and Resident #45's medical record was complete and accurate. This was true for two (2) of 17 sampled residents. Resident Identifier: #45 and #41. Facility Census: 53.
Findings included:
a) Resident #45
A review of Resident #45's medical record beginning at 8:30 a.m. on 06/15/21 found a physicians order for Gentamicin for a diagnosis of a urinary tract infection. Further review of the medical record found a nursing progress note which indicated Resident #45 was receiving Gentamicin for a right hip wound infection.
An interview with the the Director of Nursing (DON) at 8:34 a.m. on 06/16/21 confirmed Resident #45 received the Gentamicin for the right hip wound infection not the UTI. She stated the diagnosis was listed wrong on the order.
b) Resident #41
Record review found the resident was admitted to the facility on [DATE]. A nursing assessment completed on 03/23/21 at 4:42 PM noted the resident did not have a Foley catheter upon admission.
A nursing note written on 03/23/21 at 11:00 PM documented, Has Catheter but there was no place to chart, her output was 500.
On 06/16/21 at 12:03 PM, employee #89 the clinical care supervisor stated the resident had a catheter upon admission the the nursing assessment completed on 03/23/21 at 4:42 PM was incorrect.
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CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
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Based on observation, staff interview and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortabl...
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Based on observation, staff interview and record review, 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. Nurse Aide #41 did not follow appropriate infection control procedures when providing urinary catheter care to Resident #250. This was true for one (1) of one (1) residents reviewed for the care area of Catheters during the Long Term Care Survey. Resident Identifier: #250. Facility Census: 53.
Findings included:
a) Resident #250
On 06/15/21 at 9:21 AM an observation of catheter care was completed for Resident #250. Observed NA # 41, wash the perineal (peri) area. Staff used a personal cleanser, no rinse solution. Staff rinsed the peri area after using the no rinse solution. NA #41 did not support the catheter tube at the opening of the meatus. Staff failed to follow standards of practice during catheter care. NA #41 failed to change the position of the wash cloth. In addition staff failed to cleanse around the urethral meatus, and touched the bed linens with the wash cloth. NA #41 also failed to use a barrier when emptying the catheter bag. Staff placed the gradual (the container used for collecting the urine) directly on the floor.
Directly following the observation during an interview with the Director of Nursing (DON), the DON stated, I will address this with the NA.
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CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0698
(Tag F0698)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on observation, record review and staff interview the facility failed to ensure Resident #45 a resident who requires dia...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on observation, record review and staff interview the facility failed to ensure Resident #45 a resident who requires dialysis received such services consistent with professional standards or practice, the comprehensive person - centered care plan and the residents' goals and preferences. This was true for one (1) of one (1) residents reviewed for the care area of dialysis during the long term care survey process. Resident Identifier: #45. Facility Census: 53.
Findings included:
a) Resident #45
A review of Resident #45's medical record beginning at 8:30 a.m. on 06/15/21 found the following physician order with a start date of 02/18/21 which read as follows, No BP (blood pressure) or venipunture to left upper extremity. Review of Resident #45's [NAME] read, do not draw blood or take b/p in left arm.
Further review of the record found under the vital signs tab in the electronic medical record (EMR) for blood pressures the following dates and times when Resident #45's blood pressure was obtained in her left arm:
-- 02/26/21 at 10:02 a.m.
-- 02/27/21 at 4:13 p.m.
-- 02/28/21 at 1:00 p.m.
-- 03/01/21 at 4:24 p.m.
-- 03/03/21 at 11:00 a.m.
-- 03/04/21 at 6:17 p.m.
-- 03/05/21 at 11:13 a.m.
-- 03/10/21 at 6:06 a.m.
Further review of the record found a Cardiac Cath Procedure report for Resident #45 which indicated the procedure was completed related to a malfunction of the left upper arm fistula. This procedure was completed on 03/04/21. The findings of this procedure read as follows, . We placed a 5 french sheath and we did an angiogram, which showed thrombosed AV fistula. I attempted to cannulate it with a glidewire and glide cath; however the fistula was completely thrombosed and has no sign of patency . The patient will need creation of left possible right upper arm AV fistula.
An interview with the Director of Nursing Services (DNS) at 1:00 p.m. on 06/15/21 confirmed the facility staff had documented they had obtained Resident #45's blood pressure in the left arm when there was orders which indicated it should not have been.
b) Resident #45 Bruit and Thrill of Left AV fistula.
A review of Resident #45's record beginning at 8:30 a.m. on 06/15/21 found a Cardiac Cath Procedure report which indicated the procedure was completed related to a malfunction of the left upper arm fistula. This procedure was completed on 03/04/21. The findings of this procedure read as follows, . We placed a 5 french sheath and we did an angiogram, which showed thrombosed AV fistula. I attempted to cannulate it with a glidewire and glide cath; however the fistula was completely thrombosed and has no sign of patency . The patient will need creation of left possible right upper arm AV fistula.
Further review of the record found a physician order which read, Monitor left upper arm AV graft/fistula- skin integrity and for thrill and bruit. This order had a start date of 02/18/21.
After the test on 03/04/21 which determined Resident #45's fistula was no longer patent and clotted off the facility continued to monitor for bruit and thrill and initialed it daily on the treatment administration record (TAR) which indicated they were monitoring it twice daily for bruit and thrill. Review of the nursing progress notes from 03/04/21 through current found no notes to indicate the fistula was ever absent of bruit and thrill.
RN # 89 was asked to check the residents Bruit and thrill on 06/16/21 at 11:00 am she went into the room and felt the residents arm and said she was not really feeling the fistula. When asked what she checked for just then she stated, I checked the bruit and thrill just by feeling for it. She said, the Bruit is the pulsation you feel and the thrill was the vibration. When asked if you had to listen for anything while checking the bruit and thrill she stated, Well you can if you want but you don't have to you can just feel it. Nurse Surveyor #44981 felt for the thrill but also could not feel it. RN #89 stated, sometimes you can feel her bruit and thrill and sometimes you can not. She stated, when we can't feel it we will call the physician and report it to them.
At 11:11 a.m. on 06/16/21, RN #89 stated. I went ahead and listened with a stethoscope and could not hear fistula. She stated, I will call the physician.
At 11:20 a.m. on 06/16/21 RN #7 went to check Resident #45's bruit and thrill and confirmed it was not present. The Director of Nursing was asked how to check a fistula for bruit and thrill she stated, you listen for the bruit with a stethoscope and feel for the thrill. RN #7 stated with Resident #45 sometimes you can identify the bruit and thrill and sometimes you can not. She stated we document by exception and on the occasions when they can not find the bruit and thrill there should be a note stating they called the physician. RN #7 was unable to provide any notes to indicate the physician was ever notified about the absence of the bruit and thrill for Resident #45's fistula.
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CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Medication Errors
(Tag F0758)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
b) Resident #36
A review of medical records revealed Resident # 36 was a hospice patient as of 05/11/21. Diagnosis included: D...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
b) Resident #36
A review of medical records revealed Resident # 36 was a hospice patient as of 05/11/21. Diagnosis included: Dementia, Chronic Pain, Anxiety Disorder, Chronic Obstructive Pulmonary Disease, Parkinson's Disease, Essential Hypertension, Cervicalgia, Dysphagia, Oropharyngeal Phase, Pressure Ulcer, Bradycardia, and Heart Failure
A review of medical records did reveal that on 05/11/21 Resident # 36 was ordered to receive Lorazepam 0.5 ml (Lorazepam is used for anxiety) every 4 hours as needed for anxious mood/behaviors. Morphine Sulfate 0.5 ml (Morphine is used for pain relief) every 2 hours.
During a review of the medical records it was noted that the Mood/behavior sheets and side effect monitoring sheets were on in the electronic charts. The Director of Nursing (DON) was asked for copies of these monitoring sheets.
On 06/15/21 at 12:00 PM, DON provided copies of new physician's orders for Monitoring effectiveness of antianxiety medication Lorazepam (Ativan) and monitoring for absence of side effects related to antianxiety medication Ativan (Lorazepam).
On 06/16/21 at 11:04 AM, DON agreed the facility failed to do monitoring for the Lorazepam effectiveness and side effects from the medication.
A copy of the Note to Attending Physician/Prescriber dated 05/24/21. Read as follows:
Resident has a PRN (as needed) order for Lorazepam 1 mg Q4H (every four hours), a psychotropic medication. These orders are limited to 14 days but may be extended beyond 14 days provided rationale is documented and a time duration is specified.
Diagnosed condition: Anxiety
Reason for extended PRN order: (handwritten) pt is comfort only
There was no extended duration time noted and no other information for a rationale given from the physician. DON stated she had no ther information.
Based on observation, record review, and staff interview, the facility failed to ensure two (2) of five (5) residents reviewed for unnecessary medications received gradual dose reductions unless clinically contraindicated and did not receive psychotropic PRN (as needed) drugs beyond 14 days without rationale documented in the residents medical record. Resident identifiers: #8 and #36. Facility census: 53.
Findings included:
a) Resident #8
Record review found the pharmacist reviewed the resident's medication on 07/27/20. The pharmacist notified the physician, Residents Amitriptyline 50 mg HS (at bedtime) is due for a GDR (gradual dose reduction) evaluation which must be attempted unless clinically contraindicated for reasons that include, but that are not limited to (check all that apply):
--The continued use is in accordance with relevant current standards of practice.
--The residents target symptoms returned or worsened after the most recent attempt at a GDR within the facility.
--An attempt at reduction is likely to impair resident's function and/or cause an increase in behavior.
--Resident is at minimum dose for optimal stability which is also, consistent with diagnosis.
--Discontinuation likely will be harmful to resident and/or others.
--The resident targeted symptoms continue to persist at current dose and a reduction is contraindicated.
The physician reviewed the pharmacist's recommendations on 07/28/20 and checked he disagreed with the pharmacist but the physician failed to check one of the above reasons to suggest the GDR was clinically contraindicated.
Elavil is a medication on the Beers list. The Beers list includes medications with pharmacologic features that make certain drugs particularly hazardous for patients over [AGE] years of age.
Resident #8 is [AGE] years old. The medication is on the Beers list as it can cause sedation, urinary
retention or incontinence, constipation, arrhythmia's, and falls.
On 06/15/21 at 3:29 PM, the Director of Nursing (DON) was unable to provide any evidence the physician documented why the clinical rationale for why a GDR would be clinically contraindicated.
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MINOR
(C)
Minor Issue - procedural, no safety impact
Staffing Information
(Tag F0732)
Minor procedural issue · This affected most or all residents
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Based on record review and staff interview, the facility failed to maintain correct staffing by counting the director of nursing (DON) in the facility's registered nurse (RN) count. This was true fo...
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Based on record review and staff interview, the facility failed to maintain correct staffing by counting the director of nursing (DON) in the facility's registered nurse (RN) count. This was true for two (2) of the days reviewed for the following dates 5/17/21, 5/21/21, 5/22/21 and 5/30/21. This failed practice had the potential to affect all residents currently residing in the facility.
Facility Census: 53
Findings included:
Review of the Nursing Staffing sheets and time cards for the dates of 5/17/21 and 5/21/21 shows the DON was counted in the facility's RN count. Only staff hours for staff directly responsible for resident care per shift can be counted on the staffing sheets.
Interview with the Executive Director # 21 on 6/16/21 at approximately 2:15 PM, confirmed that the DON was counted in the RN daily numbers on 05/17/21 and 05/21/21.
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Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated
K - Pattern
L - Widespread
Actual Harm
G - Isolated
H - Pattern
I - Widespread
Potential for Harm
D - Isolated
E - Pattern
F - Widespread
No Harm (Minor)
A - Isolated
B - Pattern
C - Widespread
Questions to Ask on Your Visit
- "What changes have you made since the serious inspection findings?"
- "What safeguards are in place to prevent abuse and neglect?"
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • 36% turnover. Below West Virginia's 48% average. Good staff retention means consistent care.
Concerns
- • Multiple safety concerns identified: Federal abuse finding, 2 life-threatening violation(s), $268,733 in fines. Review inspection reports carefully.
- • 43 deficiencies on record, including 2 critical (life-threatening) violations. These warrant careful review before choosing this facility.
- • $268,733 in fines. Extremely high, among the most fined facilities in West Virginia. Major compliance failures.
- • Grade F (0/100). Below average facility with significant concerns.
Bottom line: This facility has a substantiated abuse finding. Extreme caution advised. Explore alternatives.
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About This Facility
What is Wyoming Healthcare Center's CMS Rating?
CMS assigns WYOMING HEALTHCARE CENTER an overall rating of 1 out of 5 stars, which is considered much below average nationally. Within West Virginia, this rating places the facility higher than 0% of the state's 100 nursing homes. A rating at this level reflects concerns identified through health inspections, staffing assessments, or quality measures that families should carefully consider.
How is Wyoming Healthcare Center Staffed?
CMS rates WYOMING HEALTHCARE CENTER's staffing level at 3 out of 5 stars, which is average compared to other nursing homes. Staff turnover is 36%, compared to the West Virginia average of 46%. This relatively stable workforce can support continuity of care.
What Have Inspectors Found at Wyoming Healthcare Center?
State health inspectors documented 43 deficiencies at WYOMING HEALTHCARE CENTER during 2021 to 2024. These included: 2 Immediate Jeopardy (the most serious level, indicating potential for serious harm or death), 40 with potential for harm, and 1 minor or isolated issues. Immediate Jeopardy findings are rare and represent the most serious regulatory concerns. They require immediate corrective action.
Who Owns and Operates Wyoming Healthcare Center?
WYOMING 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 60 certified beds and approximately 53 residents (about 88% occupancy), it is a smaller facility located in NEW RICHMOND, West Virginia.
How Does Wyoming Healthcare Center Compare to Other West Virginia Nursing Homes?
Compared to the 100 nursing homes in West Virginia, WYOMING HEALTHCARE CENTER's overall rating (1 stars) is below the state average of 2.7, staff turnover (36%) is near the state average of 46%, and health inspection rating (1 stars) is much below the national benchmark.
What Should Families Ask When Visiting Wyoming 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?" "What safeguards and monitoring systems are in place to protect residents from abuse or neglect?" "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 substantiated abuse finding on record.
Is Wyoming Healthcare Center Safe?
Based on CMS inspection data, WYOMING HEALTHCARE CENTER has documented safety concerns. The facility has 1 substantiated abuse finding (meaning confirmed case of resident harm by staff or other residents). Inspectors have issued 2 Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death). The facility has a 1-star overall rating and ranks #100 of 100 nursing homes in West Virginia. Families considering this facility should ask detailed questions about what corrective actions have been taken since these incidents.
Do Nurses at Wyoming Healthcare Center Stick Around?
WYOMING HEALTHCARE CENTER has a staff turnover rate of 36%, which is about average for West Virginia nursing homes (state average: 46%). Moderate turnover is common in nursing homes, but families should still ask about staff tenure and how the facility maintains care continuity when employees leave.
Was Wyoming Healthcare Center Ever Fined?
WYOMING HEALTHCARE CENTER has been fined $268,733 across 1 penalty action. This is 7.5x the West Virginia average of $35,766. Fines at this level are uncommon and typically indicate a pattern of serious deficiencies, repeated violations, or failure to correct problems promptly. CMS reserves penalties of this magnitude for facilities that pose significant, documented risk to resident health or safety. Families should request specific documentation of what issues led to these fines and what systemic changes have been implemented.
Is Wyoming Healthcare Center on Any Federal Watch List?
WYOMING 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.