GLENWOOD HEALTHCARE CENTER
For profit - Corporation
80 Beds
COMMUNICARE HEALTH
Data: November 2025
Trust Grade
70/100
#25 of 122 in WV
Last Inspection: February 2025
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
Glenwood Healthcare Center has received a Trust Grade of B, indicating it is a good choice for families seeking care, as it ranks #25 out of 122 facilities in West Virginia, placing it in the top half. In Mercer County, it stands out as the top facility among four options available. The facility is improving, with reported issues decreasing from 18 in 2023 to 8 in 2025. Staffing is average, with a 3/5 star rating and a turnover rate of 46%, which is close to the state average. While there have been no fines, which is a positive sign, there are concerns regarding cleanliness, as some air conditioning units were found dirty, and residents have reported dissatisfaction with the food quality and temperature, indicating areas that need attention.
- Trust Score
- B
- In West Virginia
- #25/122
- Safety Record
- Low Risk
- Inspections
- Getting Better
- Staff Stability ⚠ Watch
- 46% turnover. Above average. Higher turnover means staff may not know residents' routines.
- Penalties ✓ Good
- No fines on record. Clean compliance history, better than most West Virginia facilities.
- Skilled Nurses ✓ Good
- Each resident gets 48 minutes of Registered Nurse (RN) attention daily — more than average for West Virginia. RNs are trained to catch health problems early.
- Violations ⚠ Watch
- 33 deficiencies on record. Higher than average. Multiple issues found across inspections.
70/100
Top 20%
No red flags
18 → 8 violations
★★★★☆
4.0
Overall Rating
★★★☆☆
3.0
Staff Levels
★★★☆☆
3.0
Care Quality
★★★★☆
4.0
Inspection Score
↔
Stable
2023: 18 issues
2025: 8 issues
The Good
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
Facility shows strength in fire safety.
The Bad
Staff Turnover: 46%
Near West Virginia avg (46%)
Higher turnover may affect care consistency
Chain: COMMUNICARE HEALTH
Part of a multi-facility chain
Ask about local staffing decisions and management
The Ugly 33 deficiencies on record
Feb 2025
8 deficiencies
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 and staff Interview, the facility failed to revise the care plan for Resident #49 in the area of weight management. Resident identifier: #49. Facility census: 80.
Findings inclu...
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Based on record review and staff Interview, the facility failed to revise the care plan for Resident #49 in the area of weight management. Resident identifier: #49. Facility census: 80.
Findings included:
a) Resident #49
Multiple care areas in the care plan had interventions that included weight management and monitoring
02/12/25 9:20 PM, the Director of Nursing (DON) confirmed Resident #49 had an order for no weights in February. The DON confirmed there was no documented weight for January and there were multiple areas in the care plan for weights to be obtained and monitored. The DON stated, Just about every care plan. The DON reported the patient had multiple refusals for weights to be obtained and had requested no weights.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0676
(Tag F0676)
Could have caused harm · This affected 1 resident
Based on observations and staff interview, the facility failed to appropriately dispose of a soiled brief for #46. This was a random opportunity for discovery during the Long - Term Care Survey proces...
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Based on observations and staff interview, the facility failed to appropriately dispose of a soiled brief for #46. This was a random opportunity for discovery during the Long - Term Care Survey process. Facility Census: 80 Resident identifier: #46
Findings included:
a) Resident #46
02/10/25 11:32 AM the surveyor observed Resident #46 being provided ADL care by Nurse Aide (NA) #75 behind the curtain. The surveyor waited outside the doorway and noticed a soiled brief was placed on the fall mat on the left side of the bed by NA #75. The fall mat was lying on the floor.
02/10/25 11:36 AM Unit manager Registered Nurse (RN) # 71 was coming down the hall by the surveyor. The surveyor asked about the brief and now soiled linens that were observed placed on the fall mat by NA# 75.
RN# 71 went into the room and saw the soiled brief and soiled wash cloths were on the fall mat. RN #71 came back to the door to this surveyor and stated They(NA's) should not be placing any soiled items on the bare floor.
02/10/25 11:41 AM this surveyor observed NA #75 place soiled items in a trash bag and clean floor mat.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0688
(Tag F0688)
Could have caused harm · This affected 1 resident
Based on Record Review, Staff Interview and Observation, the facility failed to provide posey palm protectors bilaterally as ordered for Resident #30 to prevent further avoidable reduction of range of...
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Based on Record Review, Staff Interview and Observation, the facility failed to provide posey palm protectors bilaterally as ordered for Resident #30 to prevent further avoidable reduction of range of motion (ROM). Resident identifier: #30. Facility census: 80.
Findings included:
a) Resident #30
Medical record review revealed bilateral palm posey/protectors were ordered for Resident #30.
Two (2) observations for no right palm protector for Resident #30 were completed on 02/10/25 and 02/11/25.
On 02/11/25 10:45 AM, no right palm protector was observed on Resident #30. On 02/11/25 10:45 AM, Licensed Practical Nurse ( LPN) #39 confirmed no palm protector on the right hand for Resident #30. LPN #39 stated, I'm not sure about it. I will have to find it. LPN reported later that staff found the palm protector in laundry and an order for the resident to wear the palm protectors for 6-8 hours was confirmed.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Incontinence Care
(Tag F0690)
Could have caused harm · This affected 1 resident
Based on observation, record review and staff interview, the facility failed to provide appropriate care and services regarding indwelling catheter care. This was a random opportunity for discovery. R...
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Based on observation, record review and staff interview, the facility failed to provide appropriate care and services regarding indwelling catheter care. This was a random opportunity for discovery. Resident identifier: #23. Facility census: 80.
Findings included:
a) Resident #23
The facility's policy titled Catheter Care, with approval date 03/01/24, gave instructions to check that collection bag is not on the floor and is draining properly and secured allowing for no reflux of urine back to the bladder.
On 02/10/25 at 11:56 AM, Resident #23 was observed lying in bed with his bed in the lowest position. The resident's indwelling catheter urine collection bag was lying on the floor. There was a plastic basin under the resident's bed, but the indwelling catheter urine collection bag was not in the basin. The indwelling catheter urine collection bag was identified on the bag as a Sterigear Fig Leaf lite brand. This brand had a cover attached to the front of the bag to protect the resident's dignity by preventing the urine in the bag from being viewed by others.
During a second observation on 02/10/25 at 4:10 PM, Resident #23's indwelling catheter urine collection bag continued to be lying on the floor. This was confirmed by Registered Nurse (RN) #3.
During an interview on 02/11/25 at 2:29 PM, the Administrator stated she believed the dignity cover attached to the front of the urine collection bag was folded under the collection bag, which prevented the collection bag from lying on the floor. The Administrator was informed that the dignity cover was not folded under the collection bag when observed by the surveyors. The Administrator confirmed the facility's policy did not give instructions to fold the dignity cover under the collection bag.
Review of the Fig Leaf lite collection bag product fact sheet provided by the facility stated the built-in, attached cover was to hide fluid from view to restore patient dignity and improve the environment for caregivers and visitors. The product fact sheet gave no information regarding use of the attached cover as an infection control measure.
During an interview on 02/12/25 at 2:19 PM, the Infection Preventionist (IP) stated plastic basins are kept under urine collection bags in case the bags fall off the bed.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
Could have caused harm · This affected 1 resident
Based on observation, record review, and staff interview, the facility failed to ensure oxygen therapy services were administered in accordance with professional standards of treatment. Resident #42 a...
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Based on observation, record review, and staff interview, the facility failed to ensure oxygen therapy services were administered in accordance with professional standards of treatment. Resident #42 and Resident #73's oxygen flow rates were not set at the physician prescribed rates. In addition, Resident #42's oxygen concentrator was not functioning properly. These were random opportunities for discovery. Resident I=identifiers: #42 and #73. Facility census: 80.
Findings included:
a) Resident #42
On 02/10/25 at 12:12 PM, Resident #42 was observed to be wearing oxygen by nasal cannula at a flow rate of 1.5 liters per minute (LPM).
Review of Resident #42's physician's orders showed an order written on 05/25/23 for Oxygen 2 LPM via nasal cannula continuously every shift for shortness of breath.
On 02/11/25 at 9:00 AM, Resident #42 was again observed to be wearing oxygen by nasal cannula at a flow rate of 1.5 LPM.
On 02/11/25 at 10:45 AM, Registered Nurse (RN) #47 confirmed Resident #42's oxygen was set to 1.5 LPM and should have been set to 2 LPM. RN #47 attempted to increase the resident's oxygen to 2 LPM but the oxygen concentrator was not working properly and would not stay at 2 LPM. RN #47 stated she would obtain a new oxygen concentrator for the resident.
b) Resident #73
On 02/10/25 at 11:19 AM, Resident #73 was observed to be wearing oxygen by nasal cannula at a flow rate of 2 liters per minute (LPM).
Review of Resident #73's physician's orders showed an order written on 10/15/24 for O2 [oxygen] at 4L via NC [nasal cannula] continuous for SOB [shortness of breath] or s/s [signs and symptoms] of hypoxia.
On 02/11/25 at 9:16 AM, Resident #73 was again observed to be wearing oxygen by nasal cannula at a flow rate of 2 LPM.
On 02/11/25 at 10:27 AM, Registered Nurse (RN) #47 confirmed Resident #73's oxygen was set to 2 LPM and should have been set to 4 LPM.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Medical Records
(Tag F0842)
Could have caused harm · This affected 1 resident
Based on record review and staff interviews, the facility failed to ensure medical records were maintained accurately for two (2) of 27 residents. The facility did not obtain clarification for duplica...
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Based on record review and staff interviews, the facility failed to ensure medical records were maintained accurately for two (2) of 27 residents. The facility did not obtain clarification for duplicate orders for bilateral posy palm protectors for Resident #30. Resident #12 had an incorrect order regarding PO (by mouth) medications. Resident identifiers: #12 and #30. Facility census: 80.
Findings include:
a) Resident #12
During record review on 01/11/25 at approximately 10:00 AM Resident has an order stating NPO(nothing by mouth).
Further record review revealed an order placed on 02/08/25 for Amoxicillin-Pot Clavulanate Tablet 875-125 MG Give one (1) tablet by mouth two times a day for bacterial infection for five (5) days Pneumonia -start date-02/08/2025 2100
Further record review of the Medication Administration Record (MAR) revealed the medication was given on 02/08/25 PM and on 02/09/25 AM and PM and on 02/10/25 AM. Review of the MAR gave the indication that the medication was given by mouth.
During an interview, on 02/11/25 at 10:30 AM with Registered Nurse (RN) # 71, the RN stated the order was not reviewed by clinical team and assured the medication was not given by mouth.
02/11/25 10:40 AM during an interview with Registered Nurse (RN) #3 the RN stated she gave the medicine crushed via peg tube. The RN said, She takes nothing by mouth, I give all meds via peg tube.
b) Resident #30
On 02/10/25 3:50 PM, a palm protector for the left hand was observed on Resident #30. No palm protector for the right hand was observed. Bilateral palm posey/protectors were ordered for Resident #30. The orders stated, Patient to have palm posey/protector daily to prevent skin breakdown on bilateral hands 2-4 hours. and Bilateral upper extremity palm guards for 6-8 hours daily. Two observations by the State Surveyor for no right palm protector occurred on 02/10/25 and 02/11/25.
On 02/11/25 10:45 AM, duplicate orders for bilateral posey palm protectors wearing schedule with different times for Resident #30 were confirmed by Licensed Practical Nurse ( LPN) #39. LPN #39 was unable to state palm protector wearing schedule when asked by the State Surveyor. LPN #39 stated, I'm not sure .I would have to look at the order.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
Based on observations and staff interview, the facility failed to ensure they ahdered to safe and sanitary infection control practices. Direct care staff member was observed throwing a soiled brief an...
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Based on observations and staff interview, the facility failed to ensure they ahdered to safe and sanitary infection control practices. Direct care staff member was observed throwing a soiled brief and linens on a fall mat that was lying on the floor in the resident's room. This was a random opportunity for discovery during the Long - Term Care Survey process Resident identifier: #46. Facility census: 80.
Findings included:
a) Resident #46
02/10/25 11:32 AM the surveyor observed Resident #46 being provided ADL care by Nurse Aide (NA) #75 behind the curtain. The surveyor waited outside the doorway and noticed a soiled brief was placed on the fall mat on the left side of the bed by NA #75. The fall mat was lying on the floor.
02/10/25 11:36 AM Unit manager Registered Nurse (RN) # 71 was coming down the hall by the surveyor. The surveyor asked about the brief and now soiled linens that were observed placed on the fall mat by NA# 75.
RN# 71 went into the room and saw the soiled brief and soiled wash cloths were on the fall mat. RN #71 came back to the door to this surveyor and stated They(NA's) should not be placing any soiled items on the bare floor.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected multiple residents
Based on observation, record review, and staff interview, the facility failed to ensure a safe, clean, comfortable, home-like environment. Packaged terminal air conditioner (PTAC) units contained dirt...
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Based on observation, record review, and staff interview, the facility failed to ensure a safe, clean, comfortable, home-like environment. Packaged terminal air conditioner (PTAC) units contained dirt and debris. These were random opportunities for discovery. Resident identifiers: #1, #57, #23. Facility census: 80.
Findings included:
a) PTAC units
On 02/10/25 at 11:44 PM, the packaged terminal air conditioner (PTAC) unit in Resident #57's room was observed to have debris, including an adhesive bandage, in it.
On 02/10/25 at 12:04 PM, the PTAC unit in Resident #23's room was observed to have debris in it.
On 02/10/25 at 12:07 PM, the PTAC unit in Resident #1's room was observed to have dirt in it.
On 02/11/25 at 10:35 AM, the Housekeeping Manager and Regional Manager confirmed the dirt and debris in the PTAC units for Residents #57, #23, and #1. They stated PTAC units are cleaned by the Maintenance Department.
On 02/11/25 at 10:50 AM, the Maintenance Director stated the PTAC units are cleaned every three (3) months. He confirmed the dirt and debris in the PTAC units for Residents #57, #23, and #1 and stated the units would be cleaned. The Maintenance Director was asked when these units were last cleaned. He provided paperwork documenting the units had been cleaned on 12/10/24.
Dec 2023
3 deficiencies
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Menu Adequacy
(Tag F0803)
Could have caused harm · This affected multiple residents
Based on observations, resident interviews and staff interview the facility failed to provide notification of changes of the menu by not noting or updating on the menu and/or residents were not notifi...
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Based on observations, resident interviews and staff interview the facility failed to provide notification of changes of the menu by not noting or updating on the menu and/or residents were not notified of the change, when substituting foods. This had a potential to affect all residents receiving nourishment from the facility kitchen. Resident Identifiers: # 4 and #51 Facility Census: 79.
Findings included:
a) Resident #51
During an interview on 12/18/23 at 10:41 AM, Resident #51 stated the food was awful, very bland and no variety. The resident said, They do not follow the menu. And I get things on my dislikes list like fish and carrots. I have a bad allergic reaction to Shrimp so I don't eat anything from the water.
During an observation on 12/19/23 at 12:32 PM, Resident #51's noon meal tray had egg noodles, meatballs on the plate, no vegetables or no roll. and a bowl of peaches. During an immediate interview Nurse Aide (NA) #23 acknowledged Resident #51 received no vegetable and/or roll on her noon time tray. During a review of the dietary menu the substitute vegetable was Spinach half (1/2) cup. During an interview on 12/19/23 at 12:36 PM, the Administrator was made aware of the Resident #51 not receiving a vegetable and a roll.
During an interview, on 12/19/23 at 12:53 PM, the administrator produced the noon tray meal ticket, it was void of a substitute vegetable. She stated, We took her a salad for her vegetable. The Administrator was unable to tell me what the substitute vegetable was or if it was available.
b) Resident #4
During an observation on 12/18/23 at 11:52, Resident #4's meal tray ticket stated the following:
-Pureed chicken pot pie
-pureed dinner roll/bread
-marinated green bean salad
-ground pineapple tidbits
During an immediate interview with Licensed Practical Nurse (LPN) #102 they acknowledged the tray had sliced peaches and pears, it was void of the ground pineapple tidbits.
During an interview on 12/18/23 at 1:40 PM, the Administrator acknowledged the menu was not being followed for the Renal Dysphasia Diet for Resident #4.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0804
(Tag F0804)
Could have caused harm · This affected multiple residents
Based on observation, resident interview and staff interview the facility failed to serve food that was palatable and at an accurate temperature. This failed practice had the potential to affect more ...
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Based on observation, resident interview and staff interview the facility failed to serve food that was palatable and at an accurate temperature. This failed practice had the potential to affect more than an isolated number of residents. Resident Identifiers: Resident #51. Facility Census: 78.
Findings Included:
a) Resident Interview
During an interview on 12/18/23 at 10:41 AM Resident #51 stated the food was awful, very bland and had no variety. The food was always cold. They did not follow the menu. And they got things on their dislikes list like fish and carrots. Resident #51 said I have a bad allergic reaction to Shrimp, so I don't eat anything from the water.
b) Test Tray
On 12/19/23 at 11:49 AM two (2) state surveyors tasted the noon time meal for palatability. The Noon meal consisted of the following:
Meatballs with egg noodles
Sliced Carrots
Rosemary Roll
Spiced Peaches the roll was tasteless and not palatable. There was no rosemary seasoning on the rolls.
During an interview on 12/19/23 at 11:51 AM the Culinary Aide #78 stated the aides put the butter and rosemary on before they started to rise, we needed to put something on them after they baked.
On 12/19/23 at 11:49 AM Culinary Aide #78 tested the noon meal tray with the facility thermometer.
The temperatures were as follows:
Meatballs: 149 degrees
Carrots: 110 degrees
Spiced Peaches: 140 degrees
Culinary Aide #78 stated the peaches are served warm, they are spiced peaches we cook them on the stove in the flavoring.
Culinary Aide #78 acknowledged the temperature of the carrots was not acceptable to serve to the Residents.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview the facility failed to establish and maintain an infection prevention and control progr...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. These were random opportunities for discovery: a half-consumed bottle of diet soda was on the medication cart, and an improper wearing of a mask in a resident care area. Facility census: 78.
Findings included:
a) Housekeeper #30
On 12/18/23 at 10:20 AM on [NAME] Hall it was noted that Housekeeper #30 was standing inside the doorway of room [ROOM NUMBER] with her mask not covering her nose and upper lip. When asked about the mask not being worn properly Housekeeper #30 shook her head back and forth before placing the mask over her nose and mouth.
On 12/19/23 at 1:04 PM, ED #56 was informed of the above findings.
b) Medication cart on [NAME] Hall
On 12/18/23 at 10:30 AM it was noted a half-consumed bottle of diet soda was on the medication cart. This was verified with Clinical Manager Registered Nurse (CMRN) #92. CMRN #92 removed the diet soda from the medication cart.
On 12/18/23 at 10:37 AM, Licensed Practical Nurse (LPN) #35 stated the soda was for a resident and was not hers.
On 12/19/23 at 12:09 PM, the Executive Director (ED) #56 said the soda belonged to Resident #78. She went on to say LPN #35 told her she buys a soda for Resident #78 to take with her medications.
During an interview on, 12/19/23 at 12:54 PM, Resident #78 had just received her lunch and was asked how the lunch was and Resident #78 stated it tasted good. It was noted a regular soda (not a diet soda) was on her table. Resident #78 was asked if the nurses normally give her soda to take her medications with. Resident #78 stated she has her own soda because that is all she drinks. Resident #78 was asked if she drinks diet or regular soda. Resident #78 said she never drinks diet only regular.
On 12/19/23 at 1:02 PM ED #56 was informed of the interview with Resident #78. ED #56 said she did not think Resident #78 was reliable enough to know if she was given soda or was drinking her own. Resident #78 at this time was able to make her preference know for what kind of soda she liked and that she has her own on her bedside table.
Aug 2023
9 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
.
Based on record review and staff interview the facility failed to ensure residents receive treatment and care in accordance with professional standards of practice, by failing to follow physician or...
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.
Based on record review and staff interview the facility failed to ensure residents receive treatment and care in accordance with professional standards of practice, by failing to follow physician orders regarding weights and medication administration. This was true for four (4) of sampled residents reviewed during the complaint survey. Resident identifiers: #51, #29, #42, and #43. Facility census 76.
Findings included:
a) Resident #42
A review of the Medication Administration Audit Report (MAAR) found Resident #42 received scheduled medication outside of the hour before and hour after timeframe on more than one (1) occasion.
In addition, the nursing staff failed to document why the medication was administered late.
On 08/02/23, License Practical Nurse (LPN) #3 failed to administer Insulin Lispro injector pen scheduled to be given after meals at 6:30 PM. The documented time of administration was 8:11 PM.
On 08/02/23, LPN #3 failed to administer Insulin Lispro injector pen scheduled to be given after meals at 6:30 PM. The documented time of administration was 8:54 PM.
On 08/07/23, LPN #3 failed to administer Insulin Lispro injector pen scheduled to be given after meals at 6:30 PM. The documented time of administration was 10:03 PM.
On 08/09/23, LPN #3 failed to administer Insulin Lispro injector pen scheduled to be given after meals at 6:30 PM. The documented time of administration was 8:04 PM.
On 08/10/23, LPN #3 failed to administer Insulin Lispro injector pen scheduled to be given after meals at 6:30 PM. The documented time of administration was 8:50 PM.
On 08/11/23, LPN #3 failed to administer Insulin Lispro injector pen scheduled to be given after meals at 6:30 PM. The documented time of administration was 10:08 PM.
On 08/12/23, LPN #3 failed to administer Insulin Lispro injector pen scheduled to be given after meals at 6:30 PM. The documented time of administration was 9:17 PM.
On 08/14/23, all 12 of the medications that were scheduled to be given at 8:00 AM by LPN #93 were documented as given at 10:25 AM.
On 08/28/23, LPN #9 failed to administer Insulin Lispro injector pen scheduled to be given after meals at 6:30 PM. The documented time of administration was 10:52 PM.
On 08/28/23 at 5:00 PM, the Director of Nursing (DON) confirmed all the medications were given late. The DON said they were going to investigate. At the close of the survey no additional information was provided.
b) Resident #43
On 08/02/23, LPN #74 gave the following medications scheduled for 12:00 PM at 2:32 PM.
Cyclobenzaprine three (3) times a day for muscle spasm relief,
Magnesium Oxide three (3) times a day
House Supplement three (3) times a day for weight loss with meals.
On 08/02/23 LPN #120 gave a Hydrocodone which was scheduled to be given at 12:00 AM at 3:58 AM.
On 08/28/23 at 5:00 PM, the DON confirmed all the medications were given late. The DON said they were going to investigate. At the close of the survey no additional information was provided.
c) #29
During a record review on 08/29/23 at 2:30 PM, Resident #29's medical record revealed a physician order dated 07/25/23, which read: weekly weights times four (4) weeks.
Further record review revealed the following weights:
-07/26/23 85.5 pounds #
-08/03/23 88 #
-08/16/23 89.5 #
During an interview on 08/29/23 3:30 PM the Director of Nursing (DON) stated weekly weights should have been obtained at the beginning of the week on the following weeks:
-07/25/23
-08/01/23
-08/08/23
-08/15/23
-08/22/23
The DON also stated, I guess we didn't have them in the chart for 08/08/23 or 08/22/23. I will check with the Dietary Manager and see if she has them.
During an interview on 08/30/23 at 8:14 AM, the Culinary Director (CD) acknowledged there was no weights obtained for Resident # 29 for the week of 08/08/23 and 08/22/23.
During an interview on 08/30/23 at 8:15 AM, the Administrator acknowledged there was no weights obtained for Resident # 29 for the week of 08/08/23 and 08/22/23.
d) Resident #51
During a record review on 08/29/23 at 12:16 PM, Resident #51's medical record revealed the following weights.
-07/02/23 121.2#
-07/19/23 121.4#
-07/27/23 124#
-08/08/23 114#
-08/16/23 117 #
During an interview on 08/29/23 at 3:57 PM, the CD stated, I enter the weights in PCC, the Nurse Aides obtains the weights. I do a nutrition assessment when there is a significant change, quarterly and admission. If there is a 3%, 5% or 10% loss I notify the dietician.
During an interview on 08/29/23 at 4:05 PM, the CD stated we sometimes have a weekly weight meeting, there is no notes put in the medical records, we keep a sign in sheet.
The CD was asked about Resident #51's unexplained 10 pound weight loss on 08/08/23. The CD stated He his doing better since he had COVID, ( two (2) years ago) he just did not bounce back.
During an interview on 08/29/23 at 4:42 PM, the DON stated, Resident #51 was in the hospital in April and has lost weight ever since. He had the weight loss on 08/08/23 of eleven pounds and I questioned the scales. I wondered if when they moved the scales they messed them up and they were weighing incorrectly.
The DON was asked was there a reweigh done? The DON stated there is no reweigh in the computer, so I guess not.
During an interview on 08/30/23 at 8:14 AM, the CD acknowledged there was no weights obtained for
Resident #51 for week of 08/22/23.
During an interview on 08/30/23 at 8:15 AM, the Administrator acknowledged there was no weights obtained for Resident #51 for week 08/22/23, and no reweigh obtained for the ten pound weight loss on 08/08/23.
e) Policy Review
A review of the facility policy titled Resident Height and Weight with no date read as follows.
.Procedure for obtaining weight:
4. Accurate weight:
.d) Document the weight, the scale and the unusual events associated with obtaining the weight in the Electronic Health Record (EHR)
e) Document weight in EHR indicating method of weight obtainment.
9. Reweigh Parameters:
a) A plus/minus of five (5) pounds of weight in one (1) week will result in:
i) Reweigh within 24 hours
(1) Validation with nurse for accurate weight
(2) Notify Interdisciplinary Team (IDT)/doctor/family, if indicated
10. Reporting Weights
a) Weight loss concerns will be discussed at the weekly clinical meetings.
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 F0800
(Tag F0800)
Could have caused harm · This affected 1 resident
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Based on observation, medical record review and staff interview the facility failed to provide residents with a diet that met the needs of each resident and conserved the nutritional value, and met ...
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Based on observation, medical record review and staff interview the facility failed to provide residents with a diet that met the needs of each resident and conserved the nutritional value, and met the preferences of each resident. This was true for one (1) of one (1) sampled residents reviewed for nutrition during a complaint survey . Resident identifier: #56. Facility Census: 76.
Findings Included:
a) Resident #56
During a tour of the kitchen on 08/29/23 at 11:32 AM, the Culinary Director (CD) was assisting with serving the noon meal.
The CD was using a four (4) ounce scoop to serve pureed spaghetti, which according to the menu should have been served with a eight (8) ounce scoop. The CD was not measuring the scoops properly. One(1) of the scoops served was half full, and one(1) was a quarter full. The CD was asked what size scoop should be used to serve the spaghetti, she stated It should be eight (8) ounce that is why I have to do two (2) scoops. Resident #56 name receives double portions so the resident would get six (6) total.
During an interview on 08/29/23 at 11:47 AM, the Administrator was made aware of Resident #56 not getting the correct portions for his noon time meal.
During a record review on 08/29/23 at 12:23 PM Resident #56 medical records revealed a care plan which read as follows.
-Focus:
Resident is at risk for aspiration, swallowing disorders. Resident snacks throughout the day, complains of being hungry
-Goal:
Resident will maintain current weight without significant weight loss through next review date.
-Interventions:
Diet: Dysphagia Advanced, Double Portions .
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
Menu Adequacy
(Tag F0803)
Could have caused harm · This affected 1 resident
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Based on observation, record review, resident interview and staff interview the facility failed to provide the residents with menu items according to their preferences. This was a random opportunity...
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Based on observation, record review, resident interview and staff interview the facility failed to provide the residents with menu items according to their preferences. This was a random opportunity for discovery and was true for Resident #29 and Resident #35. Resident identifiers: Resident #29 and Resident # 35. Facility Census: 76
Findings included:
a) Resident #29
During the initial tour of the admission Observation Unit (AOU) 08/29/23 at 8:12 AM, an observation of Resident #29's breakfast tray meal ticket dated 08/29/23 read as follows:
Biscuit and gravy 1 serving
Hashbrown ½ cup
Hot cereal ½ cup
An observation of Resident #29's meal tray found they had a Biscuit with gravy and tater tots. There was no hot cereal on the tray.
During an interview on 08/29/23 at 8:12 AM, Nurse Aide (NA)#78 acknowledged Resident #29 did not receive hot cereal on the breakfast meal tray.
b) Resident #35
During the initial tour of the admission Observation Unit (AOU) 08/29/23 at 8:12 AM, an observation of Resident #35's breakfast tray meal ticket dated 08/29/23 read as follows:
Biscuit and gravy 1 serving
Hashbrown ½ cup
Hot cereal ½ cup
An observation of Resident #35's meal tray found they had a Biscuit with gravy and tater tots. There was no hot cereal on the tray.
During an interview on 08/29/23 at 8:15 AM NA #26 acknowledged Resident #35 did not receive hot cereal on the breakfast meal tray.
During an interview on 08/29/23 at 8:28 AM the Culinary Director was notified Resident #29 and Resident #35 did not receive hot cereal for breakfast. No further information was provided.
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
Antibiotic Stewardship
(Tag F0881)
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 complete and accurate line listing for surveillances to ensure Antibiotic Stewardship is being used. This was a random oppo...
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Based on record review and staff interview the facility failed to ensure a complete and accurate line listing for surveillances to ensure Antibiotic Stewardship is being used. This was a random opportunity for discovery and was true for Resident #65. Resident identifier: #65. Facility census 76.
Findings included:
a) Resident #65
During a review of the line listing it revealed, Resident #65 with given a complete round of Augmentin for seven days despite the fact she did not meet McGeer's criteria and had no growth on the results of the Urine Analysis (UA).
On 08/29/23 at 1:48 PM Infection Preventionist (IP) was asked why Resident #65 got seven (7) days of antibiotic. IP said the daughter of Resident #65 threw a fit and would not let her stop it and the attending physician could be shown the Antibiotic Stewardship, but he refused to follow it.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0883
(Tag F0883)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to offer an eligible resident the Pneumococcal conjugate vaccine ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to offer an eligible resident the Pneumococcal conjugate vaccine 20 (PVC 20). This was true for one (1) out of five (5) residents reviewed for immunizations. Resident identifier: #53. Facility census 76.
Findings included:
a) Resident #53
A review of Resident #53's medical record found Resident #53 was admitted on [DATE] with a history of type two (2) diabetes and Chronic respiratory failure.
Resident #53's record showed they received the Pneumococcal 23 on 09/28/18.
During an interview on 09/29/23 at 12:43 PM, Infection Preventionist was asked if Resident #53 was offered the Pneumococcal 20? IP said she thought Resident #53 refused it and would look for the refusal.
On 08/29/23 at 4:10 PM, the IP stated she did not have a signed refusal from Resident #53.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected multiple residents
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Based on observations, and staff interviews, the facility failed to ensure the environment remains as free of accident hazards as is possible. These were random opportunities for discovery and had t...
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Based on observations, and staff interviews, the facility failed to ensure the environment remains as free of accident hazards as is possible. These were random opportunities for discovery and had the potential to affect more than an isolated number of Residents. Facility census 76.
Findings included:
a) Housekeeping Closet
During a tour on 08/29/23 at 8:23 AM, the keys to the housekeeping closet were noted to still be in the keyhole on the door knob. There was not a housekeeper in sight looking down two (2) hallways. At 8:39 am on 08/29/23 Infection Control Staff (ICS) #55 walked by and removed the keys from the door knob on the housekeeping closet.
On 08/29/23 at 11:00 AM, the Administrator was informed of the above events.
On 08/29/23 at 3:11 PM, the Administrator provided sign-in sheets with staff signatures regarding educational information about hazardous materials and storage.
b) admission Observation Unit
During the initial tour of the admission Observation Unit (AOU) on 08/29/23 beginning at 8:12 AM the treatment cart was observed unlocked and unattended.
During the observation time this surveyor continued to be centrally located around the area of treatment cart, there was no nurse in the area.
During an interview on 08/29/23 at 8:19 AM, Licensed Practical Nurse (LPN) #46 acknowledged the treatment cart was left unlocked and unattended and should not have been.
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CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0804
(Tag F0804)
Could have caused harm · This affected multiple residents
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Based on observation, record review and staff interview the facility failed to provide nutritional adequacy by providing inconsistent portions of the food. This failed practice had the potential to ...
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Based on observation, record review and staff interview the facility failed to provide nutritional adequacy by providing inconsistent portions of the food. This failed practice had the potential to affect all residents currently receiving nourishment from the facility's kitchen. Facility Census: 76
Findings Included:
a) Appropriate Portions
During a review of the facility menu provided by the Culinary Director (CD) the noon meal on 08/29/23 read as follows:
Meatsauce
Spaghetti Noodles
Caesar Salad
Garlic Bread
Deluxe Fruit Salad
During a tour of the kitchen on 08/29/23 at 11:32 AM, the CD was assisting with serving the noon lunch meal. The CD was using a pair of tongs to serve spaghetti which according to the menu should have been served with a six (6) ounce scoop, The CD was asked what size scoop should be used to serve the spaghetti, she stated It should be six (6) ounce, but I just eyeball it.
The CD and this Surveyor looked at the menu and confirmed the residents should be getting six (6) ounces of spaghetti. The CD was also serving spaghetti sauce. When asked if the menu called for a four (4) or two (2) ounce scoop she stated, I don' t know, I just grabbed a spoon.
The CD and this Surveyor looked at the menu and confirmed the residents should be getting four (4) ounces of spaghetti sauce. At the time of this change all 46 Residents on the Healthcare unit had been served the incorrect serving size of spaghetti and meatsauce.
The facility provided menu with the portion sizes read as follows:
Meatsauce with 6(six) ounce (oz)
Spaghetti Noodles ½ cup (half)
Caesar Salad 1 ( one) cup
Garlic Bread 1 Each
Deluxe Fruit Salad ½ cup
During an interview on 08/29/23 at 11:47 AM, the Administrator was made aware of the Residents not getting the correct portions
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on observation and staff interview the facility failed to maintain an infection prevention and control program designed ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on observation and staff interview the facility failed to 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. These failed practices were a random opportunity for discovery. Resident identifier: #14. Facility census 76.
Findings included:
a) Resident #14
While on the tour of the facility on 08/29/23 at 8:34 AM, it was noted Registered Nurse (RN) #79 was seen from the hallway providing wound care for Resident #14, without using any Personal Protection Equipment (PPE). There was a sign on the door for Enhanced Barrier Precautions (EBP). The signage read staff providing direct care are to wear gowns and gloves while providing care.
As RN #79 was leaving the room without using hand hygiene she asked why she was not using any PPE. RN #79 said she did not think Resident #14 was still in EBP anymore. This surveyor pointed out the signage on the door. RN #79 said she was only applying tape on Resident #14's wound.
b) Improper handling of soiled linen and not wearing the required PPE
During a tour at the facility, Housekeeper (HK) #20 was seen in room [ROOM NUMBER] removing sheets and blankets from both a and b beds without wearing the required PPE. There was a sign on the door for all staff providing direct care to wear gowns and gloves. Another observation found HK #20 could not fit the linen from both beds inside of one (1) small clear plastic bag. HK #20 left the room carrying the used linen against her body down the hall to the soiled linen room at the far end of the hall.
When HK #20 returned to the room she was asked why she did not wear any PPE. HK #20 because she was never told to do so. She was asked about holding the linen against her clothes and body. She stated she did not know she always does it like that.
The above observations were reported to the administrator on 08/29/23 at 11:00 AM.
At 4:00PM on 08/29/23, the Administrator provided information indicating all staff had been re-educated about infection control precautions.
MINOR
(B)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Minor Issue - procedural, no safety impact
Staffing Information
(Tag F0732)
Minor procedural issue · This affected multiple residents
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Based on record review and staff interview, the facility failed to include the total number of hours worked by nursing staff on the posted Daily Nurse Staffing Form. This deficient practice had the ...
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Based on record review and staff interview, the facility failed to include the total number of hours worked by nursing staff on the posted Daily Nurse Staffing Form. This deficient practice had the potential to minimally affect more than a limited number of residents. Facility census: 76.
Findings included:
a) Daily Nurse Staffing Form
The Daily Nurse Staffing Form was observed at the nursing desk at 8:15 AM on 08/29/23. The Daily Nurse Staffing Form did not include the number of hours worked by Registered Nurses, (RNs), Licensed Practical Nurses (LPNs), and Nursing Assistants (NAs). During an interview on 08/29/23 at 8:45 AM, the Administrator confirmed the Daily Nurse Staffing Form did not include the number of hours worked for the nursing staff. She stated a new Daily Nurse Staffing Form had been developed and would be posted today.
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Jan 2023
6 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0578
(Tag F0578)
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 inappropriately completed and implemented the Physicians Order for Sc...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on record review and staff interview, the facility inappropriately completed and implemented the Physicians Order for Scope of Treatment (POST) form for one (1) one of (1) residents reviewed for advanced directives. The facility changed the resident's wishes for full code to a do not resuscitate. The resident had not granted permission for her wishes for end of life care to be changed. This failed practice had the potential to affect only limited number of residents. Resident identifiers: #30. Facility census: 78.
Findings included:
Observation on [DATE] at 11:49 AM showed Resident #30 coughing and wheezing and very short of breath. Resident was only able to speak in fragmented sentences. Resident was yelling, Oh, Oh every time she coughed. Resident stated, Help me. I can't breathe and it hurts. Surveyor left the resident's room informed Licensed Practical Nurse (LPN) #50 of resident complaints of shortness of breath and pain. LPN #50 stated Yea she didn't look good this morning and I called the doctor and they are making her a DNR (do not resuscitate) comfort care only.
Review of progress note entered on [DATE] at 9:31 AM stated nurse practitioner was contacted at this time regarding resident's status. Resident had been hallucinating and speaking to people that aren't there. Resident had labored breathing with apnea spells. Heath Care Surrogate contacted by social services and code status changed to DNR comfort care. Doctor contacted at this time in regard to pain medication per Nurse Practitioner request. New orders for Roxinol .25 ml every 2 hours as needed for pain. Per the doctor, discontinue all PO (by mouth) medications. Heath Care Surrogate made aware.
Review of Resident #30's medical record on [DATE] at 1:30 PM., showed a POST form that was completed on [DATE] changing the Resident's code status from Full Code (attempt resuscitation) to Do Not Resuscitate (DNR). The post form was noted to be completed verbally by the Resident's health care surrogate, without any witness signatures.
During an interview on [DATE] at 11:15 AM the Residents Health Care Surrogate stated [social service directors #64's name] called him and stated they needed to change Resident to a DNR because she just wasn't doing well. The HCS stated she told him the doctor felt that was best. The HCS said he agreed because he thought it was the right thing to do.
Further review of the resident's medical record on [DATE] at 03:33 PM showed on [DATE] Resident #30 completed a POST form while she was capacitated and expressed her wishes to be a full code. The POST form completed by the Resident on [DATE] did not give permission for a health care surrogate to make decisions or complete a new form in the event the Residents decision making capacity would deteriorate.
On [DATE] at 3:35 PM, the Assistant Director of Nursing (ADON) provided copies of Resident #30's POST forms. The POST form that was completed on [DATE] had a line drawn through the middle of the form and void written across it. The ADON was asked what would have happened if the Resident would have coded last night? The ADON stated, Right! She [resident #30] has been changed back to a full code.
Review of Resident #30's orders showed the following changes were made and implemented for code status:
Full code active on [DATE] at 1:47 PM.
Full code discontinued on [DATE] at 9:29 AM.
DNR Comfort Care Active on [DATE] at 9:30 AM.
DNR Comfort Care Inactive on [DATE] at 1:39 PM.
CPR Active on [DATE] at 1:40 PM.
During an interview on [DATE] at 12:38 PM the Social Service Director #64 was asked to explain why the POST form completed on [DATE] was now voided out? The SSD #64 replied, Yes that's all on me. I talked to the grandson personally and when you all [surveyors] asked for copies of the POST form, I realized what I done, and a new form should have never been completed to change [Resident #30's name] to a DNR. SSD #64 further stated the Nurse Practitioner had come to her on Monday and wanted the grandson called, who was the health care surrogate, to see if they could change the code status and make her comfort care.
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CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
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Based on record review and staff interview, the facility failed to ensure the Hospice agency developed a care plan with measurable goals. In addition, the facility failed to implement their Hospice ...
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Based on record review and staff interview, the facility failed to ensure the Hospice agency developed a care plan with measurable goals. In addition, the facility failed to implement their Hospice care plan for notification of the Hospice agency when the resident experienced nausea and vomiting. The facility failed to implement their care plan for urinary catheter care. This was true for one (1) of 18 residents whose care plans were reviewed during the long-term care survey process. Resident identifier: 58. Facility census: 78.
Finding included:
a-1) Resident #58- Hospice care plan
Record review found the resident was accepted for Hospice services on 11/15/22 for a diagnosis of Parkinson's disease.
A Hospice agency care plan, dated 11/15/22 was located in the electronic medical record.
On 01/24/23 at 8:41 AM, an interview with the DON, confirmed that the most recent documentation the facility had in house from the Hospice agency was a care plan dated 11/15/22. Handwritten on the care plan was the first name of the Hospice social worker, the last name of the Hospice chaplain, as well as nurse visits 2 times a week.
This care plan failed to indicate what specific services Resident #58 was receiving from the Hospice agency. This care plan did not have any measurable goals.
An interview with the DON on 01/24/23 at 3:38 PM, confirmed she could not locate any further documentation from the Hospice agency in house.
On 01/25/23 at 10:39 AM, Social Worker (SW) #64 stated the Hospice agency did not attend the significant change care plan meeting. SW #64 stated Hospice staff are normally emailed an invitation to attend the resident's care plan meetings, but do not usually show up.
On 01/25/23 at 10:58 AM, SW #64 provided a sign in sheet from the IDT (interdisciplinary team)significant change care plan meeting which confirmed Hospice agency staff did not attend.
a-2) Resident #58 - Facility Hospice care plan
Observation at 11:30 AM on 01/23/23, found the resident was in a low bed in his room. His head was handing over the bed with his right cheek resting on the inside rim of the trash can. When asked by the surveyor if he was OK, the resident responded with, I'm sick, I have been throwing up. The surveyor immediately left the resident's room and found Registered Nurse (RN) #46 in the hallway. The surveyor asked RN #46 to check on the resident. RN #46, immediately entered the resident's room. The resident said he was sick and throwing up. RN #46 said, I will see what you are ordered and what you can have. Let me put on some gloves and dump this trash can.
Review of the resident's care plan found the following:
Focus:
Patient has been admitted to Hospice Services related to dx of Parkinson's
Date Initiated: 11/15/2022
Revision on: 11/21/2022
Goal:
Patient will have physical, spiritual and emotional needs met through collaboration of (Name of Hospice) as evidence by being clean, dry, well groom, and will not show signs of unrelieved pain or distress such as crying, fearfulness, moaning, grimacing or guarding daily through next review.
Interventions included:
-Admit to (Name of Hospice service) (address of Hospice Company)
Date Initiated: 11/16/2022
Revision on: 12/03/2022
-Call Hospice for changes in: medications, durable medical equipment, medical supplies, lab work/xrays, secondary physician consults, ambulance transfer, other areas related to terminal disease.
Date Initiated: 11/16/2022
-Hospice is responsible for clinical management of any care related to the patient's
hospice diagnosis. PLEASE CALL HOSPICE FIRST regarding any clinical changes they can discuss the plan of care and proposed changes, nausea/vomiting, anorexia, etc.
At 10:55 AM on 01/24/23, the DON confirmed there was no documentation in the chart indicating the Hospice agency was contacted when the resident was nauseous as indicated in the care plan.
On 1/25/23 at 9:00 AM, the administrator confirmed the Hospice agency was not contacted.
a-3) Resident #58- catheter care
Observation of the Resident on 01/23/23 at 11:30 AM, found the resident was in bed. The catheter drainage bag was laying on the floor beside the bed. Registered Nurse (RN) #46 observed the catheter and said she would take care of the issue.
On 01/24/23 at 10:56 AM, the observation was discussed with the Director of Nursing (DON) and the Assistant DON.
Review of the Resident's care plan found the following:
Focus:
Catheter: Presence of indwelling catheter related to Obstructive Uropathy. Potential for infection and/or dysfunction.
Date Initiated: 07/25/2022
Revision on: 12/07/2022
Goal:
Patient will be free from infection and/or appliance dysfunction through next review period.
Date Initiated: 07/25/2022
Revision on: 12/07/2022
Target Date: 02/05/2023
Interventions included:
Connect indwelling catheter to bedside drainage bag. Ensure bag is positioned beneath the level of the bladder at all times but does not touch the floor. Keep drainage bag covered at all times.
Date Initiated: 07/25/2022
Revision on: 12/07/2022
On 01/24/23 at 10:56 AM, the DON and assistant DON verified the care plan directed the catheter drainage bag should not touch the floor.
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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 have evidence of collaboration with the Hospice agency providing services for one (1) of one (1) resident reviewed for the care are...
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Based on record review and staff interview, the facility failed to have evidence of collaboration with the Hospice agency providing services for one (1) of one (1) resident reviewed for the care area of Hospice. In addition, the facility failed to assess patient's needs and notify the Hospice agency of a change in condition. Resident identifier: #58. Facility census: 78.
Findings included:
a-1) Resident #58
Record review found that resident was accepted for Hospice services on 11/15/22 for a diagnosis of Parkinson's disease.
On 01/24/23 at 8:37 AM, Registered Nurse (RN) #122 was asked where to locate a resident's Hospice agency notes. She responded that she would look for them under the nurses notes but that she is not sure and she would have to find out.
On 01/24/23 at 8:39 AM, Licensed Practical Nurse (LPN) #114 stated she would look for a resident's Hospice agency notes under the miscellaneous tab of the electronic medical record.
On 01/24/23 at 8:41 AM, the DON (Director of Nursing) stated that they would have to request the Hospice notes from the Hospice agency.
Record review of the miscellaneous tab in the electronic record on 01/24/23 at 8:20 AM, indicated that the most recent documentation from the Hospice agency was dated 11/15/22. This care plan was from the date that resident #58 was initially accepted by the Hospice agency.
On 01/24/23 at 8:41 AM, an interview with the DON, confirmed that the most recent documentation the facility had from the Hospice agency, for resident #58, was a care plan dated 11/15/22. Handwritten on the care plan was the first name of the Hospice agency social worker, the last name of the Hospice agency chaplain, as well as nurse visits 2 times a week.
This care plan failed to indicate what specific services resident #58 was receiving from the Hospice agency. This care plan did not have any measurable goals.
An interview with the DON on 01/24/23 at 3:38 PM, confirmed she could not locate any further documentation from the Hospice agency regarding ongoing communication or collaboration of services. The DON said she was contacting the Hospice agency to have them fax over the notes from their visits.
Record review on 01/25/23 8:53 AM, indicates the MDS (Minimum Data Set) triggered a significant change with an ARD (Assessment Reference Date) of 11/24/22. There was no documentation that the Hospice agency staff attended the IDT (interdisciplinary team) care plan that was held on 11/28/22 regarding the significant change.
On 01/25/23 at 10:39 AM, Social Worker (SW) #64 stated that the Hospice agency staff did not attend the significant change care plan meeting. SW #64 stated that Hospice staff are normally emailed an invitation to attend the resident's care plan meetings but do not usually show up.
On 01/25/23 at 10:58 AM, SW #64 provided a sign in sheet from the IDT significant change care plan meeting which confirmed that Hospice staff did not attend.
a-2) Resident #58
Observation at 11:30 AM on 01/23/23, found the resident was in a low bed in his room. His head was handing over the bed with his right cheek resting on the inside rim of the trash can. When asked by the surveyor if he was OK, the resident responded with, I'm sick, I have been throwing up. The surveyor immediately left the resident's room and found Registered Nurse (RN) #46 in the hallway. The surveyor asked RN #46 to check on the resident. RN #46, immediately entered the resident's room. The resident said he was sick and throwing up. RN #46 said, I will see what you are ordered and what you can have. Let me put on some gloves and dump this trash can.
On 01/24/23 at 8:50 AM, RN #46 said she got the resident a towel after cleaning the trash can but she did not initially put the trash can beside the resident. The resident's nursing assistant (NA) #40 said she was not aware the resident was sick and she did not put the trash can beside the bed because, He has a fall mat and we can't put anything on top of a fall mat. The Director of Nursing was present during both of these interviews and confirmed the resident was most likely unable to put the trash can beside his bed himself as he does not get out of bed.
The following day, 01/24/23, the resident's nurses' notes were reviewed. There was no note regarding the events observed on 01/23/23.
Further review of the resident's orders found a current order for Zofran 4 milligrams (mg's) give 1 tablet by mouth every eight (8) hours as needed for nausea/vomiting. Review of the resident's medication administration record (MAR) found the medication was not administered on 01/23/23.
(Zofran is used to prevent nausea and vomiting.) Review of the MAR found the as needed Zofran was last administered on 12/20/22.
On 01/24/23 at 8:44 AM, RN #46 said she told the Resident's nurse about the incident right after it happened yesterday. RN #46 said, I believe I told LPN #114. RN #46 said she was a nurse assistant instructor and not a floor nurse.
Review of the resident's care plan found the following:
Focus: Patient has been admitted to Hospice Services related to dx of Parkinson's
Date Initiated: 11/15/2022
Revision on: 11/21/2022
Goal:
Patient will have physical, spiritual and emotional needs met through collaboration of (Name of Hospice) as evidence by being clean, dry, well groom, and will not show signs of unrelieved pain or distress such as crying, fearfulness, moaning, grimacing or guarding daily through next review.
Interventions included:
-Admit to (Name of Hospice service) (address of Hospice Company)
Date Initiated: 11/16/2022
Revision on: 12/03/2022
-Call Hospice for changes in: medications, durable medical equipment, medical supplies, lab work/xrays, secondary physician consults, ambulance transfer, other
areas related to terminal disease.
Date Initiated: 11/16/2022
-Hospice is responsible for clinical management of any care related to the patient's
hospice diagnosis. PLEASE CALL HOSPICE FIRST regarding any clinical changes they can discuss the plan of care and proposed changes, nausea/vomiting, anorexia, etc.
At 10:55 AM on 01/24/23, the DON confirmed there was no documentation in the chart on 01/23/23 of the resident being assessed when RN #46 told LPN #116 the resident was sick and said he was throwing up. In addition, the DON verified the Hospice agency was not contacted when the resident was nauseous as indicated in the care plan.
On 1/25/23 at 9:00 AM, the administrator said LPN #116 did a late entry in the resident's chart regarding the incident on 01/24/23.
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CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Pressure Ulcer Prevention
(Tag F0686)
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 pressure ulcer care was provided consistent with pro...
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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 pressure ulcer care was provided consistent with professional standards of practice. A Registered Nurse (RN) failed to assess and stage the pressure areas within 24 hours of admission and/or after the development of pressure ulcers. This was true for two (2) of three (3) residents reviewed for the care area of Pressure Ulcers.
Resident identifiers: # 42 and #327. Facility census: 78.
Findings include:
a) Resident #42
Review of Resident #42's medical records found the resident was noted on 12/26/22 to have a stage IV (4) pressure ulcer on sacrum by Employee #133, a Licensed Practical Nurse (LPN). On 01/01/23, Employee #71, a Registered Nurse (RN), measured and staged Resident #42's pressure ulcer on the sacrum. Additionally, the wound assessments completed on 1/3/23 by, RN #71, documented the wrong date the pressure ulcer was first observed and the wound assessments completed on 1/10/23 and 1/17/23 by RN #124, documented the wrong date the pressure ulcer was first observed.
Review of the National Pressure Ulcer Advisory Panel (NPUAP) concerning staging of pressure ulcers reveals; Differentiating pressure ulcers from other wound etiologies is within the domain of registered nurses (RN). As per the Scope and Standards of Nursing Practice detailed in the statement from America Nurse Association (ANA) RNs are expected to assess the patient's skin, stage the wound, and implement an individualized plan of care based on the patient needs. Due to licensed practical (LPN/vocational nurse (LVN) state practice act restrictions, wounds that have the appearance of a pressure ulcer should be inspected and described by the RN.
During an interview with the Nursing Home Administrator (NHA) and Director of Nursing (DON), on 01/25/23 at 12:15 PM, both agreed the process was that an RN would assess wounds within 24 hours of the development of new wounds to assess, measure, stage and initiate the treatment as directed by the physician. They also clarified the above-mentioned wound assessments had the wrong date of development of the sacral wound.
b) Resident #327
Record review found the Resident was admitted to the facility on [DATE]. On 01/13/23 a Licensed Practical Nurse (LPN) completed an admission Initial Evaluation form. The LPN noted the resident was admitted with two (2) pressure areas: one (1) stage I pressure area to the right buttock and one (1) Stage II pressure area to the left buttock.
On 01/14/22, a Registered Nurse (RN) completed a weekly skin check form and noted the resident had 3 open areas on the left buttock, two (2) on the upper buttock near the coccyx and one on the lower buttock with red non-blanchable area. The right buttock had red areas on the lower buttock near the gluteal fold. The open areas were not staged or measured on this assessment.
On 01/16/23, a second Registered Nurse (RN) completed a Skin Grid pressure assessment. The resident had a Stage I pressure on the right buttock measuring 1 centimeters (cm) in length, 2 cm's width, and 0 depth. This wound was determined to be community acquired.
A pressure ulcer on the left buttock, Stage II with 0.5 cm in length, 0.5 cm in width, 0 depth, also community acquired.
On 01/24/23 at 2:36 PM, the Director Of Nursing (DON) confirmed the wounds should have been measured by a Registered Nurse (RN) within 24 hours of admission. She stated, a LPN can not stage pressure ulcers, it is out of their scope of practice. She stated the RN who completed a weekly skin check form on 01/14/23, should have completed a Skin Grid Pressure ulcer form which would have required the RN to stage and measure any areas observed. The DON stated this RN no longer works at the facility. The DON verified the pressure areas were not staged and measured by a RN until 3 days after admission on [DATE].
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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 record review and staff interview, the facility failed to follow the current standards of practice for indwelling Foley catheter's for two (2) of four (4) residents reviewed for the care ar...
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Based on record review and staff interview, the facility failed to follow the current standards of practice for indwelling Foley catheter's for two (2) of four (4) residents reviewed for the care area of catheter during the long-term care survey process. Resident identifiers: #58 and #327. Facility census: 78.
Findings included:
a) Resident #58
Observation of the Resident on 01/23/23 at 11:30 AM, found the resident was in bed. The catheter drainage bag was laying in the floor beside the bed. Registered Nurse (RN) #46 observed the catheter and said she would take care of the issue.
On 01/24/23 at 10:56 AM, the observation was discussed with the Director of Nursing (DON) and the Assistant DON. No further information was provided at the close of the survey.
b) Resident #327
Observation on 01/23/23 at 12:45 PM, found the Resident was in bed. The Resident's catheter bag and tubing were laying on the floor. Nursing Assistant (NA) #40 immediately fixed the issue when notified by the surveyor.
On 01/24/23 at 10:56 AM, the observation was discussed with the Director of Nursing (DON) and the Assistant DON. No further information was provided at the close of the survey.
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CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Medication Errors
(Tag F0758)
Could have caused harm · This affected 1 resident
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Based on record review and staff interview, the facility failed to ensure each resident's drug/medication regimen is managed and monitored to promote or maintain the resident's highest practicable m...
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Based on record review and staff interview, the facility failed to ensure each resident's drug/medication regimen is managed and monitored to promote or maintain the resident's highest practicable mental, physical, and psychosocial well-being for one (1) of five (5) residents reviewed for unnecessary medications. The resident was prescribed a antipsychotic medication in absence of appropriate indication / rational for use, and absence of non-pharmacological interventions attempted before prescribing the medication. Resident identifier: #58. Facility census: 78.
Findings included:
a) Resident #58
Record review found the resident was receiving the antipsychotic medication, Risperdal 0.25 milligrams (mg), give 1 tablet by mouth at bedtime for sexual urges with hallucinogenic fantasies of sexual episode.
(Hallucinogenic is defined as producing hallucinations, such as a hallucinogenic drug.)
Further review found Risperdal was prescribed on 06/07/22. The following is the nursing note prompting the start of the medication:
06/07/22 at 11:36
Nurses Note
Note Text: Please note resident called this nurse to room and stated that he needed to talk with this nurse. Resident is alert and oriented x 3 and able to make own medical decisions and resident stated to this nurse I am a good Christian man and I know this is not right but I need to tell you that I am having strong sexual urges and desire to have a sexual encounter with a woman. Resident appeared red in face and fidgety while speaking to this nurse. This nurse reassured resident that he may speak to this nurse about anything he needs to verbalize and seek help for. This nurse contacted (name of psychiatrist) and new orders given to start Risperdal 0.25 mg give 1 tab PO (by mouth) BID (two times a day) and contact (name of psychiatrist) in x 1 week to give a update and speak to him about also possibly increasing the medication. Made resident aware as he holds capacity and in agreement. Please note (name of nurse practioner) aware and in agreement.
The medical record contained no evidence any non-pharmacological interventions were attempted before ordering the medication.
Review of the medication administration records for June, July, August, September, October, November, December, 2022 and January 2023 found the facility was monitoring for the target behaviors of: sexual aggression, ringing hands and fidgeting for the use of Risperdal.
On 01/24/23 at 3:51 PM, the Director of Nursing (DON), the Social Worker (SW) #64, and the Administrator were asked why an antipsychotic medication was started for the behaviors noted in the 06/07/22 nurses note when there was no indication the resident had a particular person in mind or that he had acted on his urges, and there were no nonpharmalogical interventions attempted before the antipsychotic was started. The nursing home staff were asked if anyone had actually talked to the resident, allowed him to vent his feelings regarding natural desires?
The administrator confirmed that at the time the note was written (06/07/22) the resident did have capacity to make his own medical decisions, was alert and oriented to person, place and time. The administrator said she was sure the facility did something, she would look at the notes.
The administrator provided a copy of a physician's note dated, 05/28/22 noting the following: Alert and oriented x 3. Affect is broad. Thought process are intact. Patient reports feeling more anxious and nervous. Patient stated, would sex have anything to do with my anxiety from the lack of sex? Patient states he just stays in his room, exercise, and does therapy. Just feels anxious all the time. Encouraged patient to participate in activities and go outside for some fresh air.
At the time this note was written the resident was receiving Ativan 0.5 mg a day three times a day for anxiety.
SW #64 confirmed she had no notes in the chart concerning the resident's statements.
On 01/25/23 at 9:29 AM, the DON provided copies of the resident's medication administration record (MAR), the record used by the facility to document when the resident exhibited any of the behaviors noted for the use of Risperdal: sexual aggression, ringing hands and fidgeting. The DON stated she was unable to find documentation the resident had any documented behaviors on the MAR since the medication was started on 06/07/22.
Review of the medical record found a general note written on 11/08/22:
Note Text: It was reported to nurse by CNA (certified nursing assistant) that during rounds, resident was making sexual comments to her. Resident had slid down in the bed and she was going to assist him up in the bed and he stated, So you'll get in bed naked with me? She instructed to resident that his statements were inappropriate. He then yelled, I want you to take off your clothes. Another CNA then came into the room and then he stopped his behavior. He has been confused this shift and attempting to get up out of his bed unassisted. Supervisor made aware. Note left in (name of facility physician's ) file to see him on rounds later today.
Review of the resident orders found the following order, dated 11/08/22, give risperdal now
one time only for increased agitation.
01/25/23 at 12:27 PM, the administrator confirmed the order did not contain how many milligrams of Risperdal to administer on 11/08/22, or what route should be used to administer the medication. Again the record did not indicate any non-pharmalogical interventions were used before giving a one time dose of Risperdal.
The administrator said the resident did not receive an extra dose of Risperdal; however, the nurse initialed the MAR indicated the resident received a 9:00 AM dose, a 9:00 PM dose with the extra dose documented as being given at 6:19 PM. At the time this order was written the resident was receiving Risperdal 2.5 mg. twice a day.
An article from Geriatric Medicine 2009, entitled Sexuality in Nursing Homes: Preserving Rights, Promoting Well-being .
Sexual desire does not disappear with age. Professionals play a key role as advocates for the rights of nursing home residents to express their sexuality.
For many older Americans, entering a long-term care facility means giving up their independence, their homes, their livelihood, and many of their favorite possessions. Often adding to these major losses is the perception that the freedom and privacy to express their sexuality has also been lost. Because society tells us that sex is for the young and healthy, it is mistakenly assumed that sexual desire dwindles after a certain age. Sexual expression by residents in long-term care facilities is often misinterpreted as a behavioral problem, but it may be a sign that an important basic need-the need for human touch, closeness, and intimacy-has been overlooked.
At the close of the survey on 01/25/23, no further information was provided.
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Oct 2021
7 deficiencies
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 observation, medical record review and staff interview, the facility failed to provide an environment free from accident hazards over which it has control. Medication was unsecured and unat...
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Based on observation, medical record review and staff interview, the facility failed to provide an environment free from accident hazards over which it has control. Medication was unsecured and unattended allowing access to the medication by residents, unauthorized staff, or visitors. Resident identifier: #57. Facility census: 66.
Findings Included:
a) Resident #57
An observation on 10/11/21 at 12:14 PM found, Anoro Eleptan 62.5 Aerosol Powder Breath Activated at Resident #57's bed side, unsecured and unattended and allowing access to the medication by residents, unauthorized staff, or visitors.
During an interview with Resident #57 on 10/11/21 at 12:14 PM she stated the nurses usually don't let her keep it her room, but sometimes they do let her keep it until they deliver her lunch tray.
During an interview on 10/11/21 at 12:19 PM, Licensed Practical Nurse (LPN) #16 verified, the Anoro Eleptan 62.5 inhaler should not be left out in the room. LPN #16 removed the 30ml (milliliter) cups at this time. LPN #16 stated that Resident #57 did not have a medication self-administration order.
A medical record review revealed, a physician's order:
-- Anoro Ellipta Aerosol Powder Breath Activated 62.5-25 MCG/INH (Umeclidinium-Vilanterol) 1 puff inhale orally one time a day for COPD (Chronic Obstructive Pulmonary Disease) with a start date 09/10/21.
Further review revealed that Resident #16 did not have a physician's order for medication self-administration.
On 10/13/21 at 12:43 PM the Director of Nursing (DON) was advised about the findings. No other information was provided prior to exit on 10/13/21 at 4:30 PM.
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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 resident interview, observation, staff interview and medical record review the facility failed to provide a therapeutic diet that takes into account the resident's clinical condition and pr...
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Based on resident interview, observation, staff interview and medical record review the facility failed to provide a therapeutic diet that takes into account the resident's clinical condition and preferences, when there is a nutritional indication. This is true for one (1) of one (1) resident reviewed for the care area of dialysis during the Long-Term Care Survey Process (LTCSP). Resident Identifier: #45 Facility Census: 66.
Findings Included:
a) Resident #45
During an interview on 10/11/21 at 1:08 PM, Resident #45 stated the food is horrible, I order doordash a lot. I get too many potatoes, I go to dialysis two times a week and can't have potatoes especially before going to dialysis. Look at this menu, there is potatoes on here everyday.
Review of Resident # 45's medical record on 10/12/21 at 12:00 PM, found the physician order, dated 07/09/21 for. Regular, regular texture, no oranges, no prune juice, no salt packet on tray, sugar substitute, no stewed or fresh tomatoes, no tomato juice, no potatoes.
On 10/12/21 at 12:13 PM, Nursing Aide (NA) #22 served Resident # 45's lunch tray. The Resident was served pork, gravy, broccoli & cheese, scalloped potatoes, pudding and bread. The meal diet ticket on the tray only stated regular, no stewed tomatoes.
In an interview on 10/12/21 at 12:20 PM with the Food Service Director (FSD) #30, this surveyor ask what the substitute was for the potatoes, FSD #30 stated Rice. FSD #30 confirmed Resident #45's physician diet ordered no potatoes. FSD #30 confirmed the care plan intervention was to provide the diet as ordered and the meal served did not follow the care plan.
During an interview on 10/12/21 at 12:28 PM, [NAME] #116, stated (Resident #45 name) received pork, gravy, broccoli & cheese and scalloped potatoes on her lunch tray.
On 10/12/21 at 12:32 PM, FSD #30 and this surveyor, viewed the lunch tray for Resident #45. FSD #30 confirmed Resident #45 received the scalloped potatoes on the lunch tray and the meal diet ticket verified no stewed tomatoes and did not verify no potatoes.
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CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected 1 resident
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Based on observation and staff interview the facility failed to date and label a multi-use insulin pen when first accessed with the initial date. This was true for one (1) of three (3) insulin pens ...
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Based on observation and staff interview the facility failed to date and label a multi-use insulin pen when first accessed with the initial date. This was true for one (1) of three (3) insulin pens observed. This was a random opportunity for discovery during a medication cart check. Resident Identifier: Resident #5. Facility census 66.
Findings included:
a) Medication Cart
On 10/13/21 at 8:41 AM, a review of the medications in the medication cart revealed there was one (1) out of three (3) insulin pens that did not have the date it was first accessed on the pen. This was witnessed and verified by Licensed Practical Nurse #87. The Humulin 70/30 Kwikpen (used to treat and control blood sugar levels in the blood stream) belonged to Resident #5.
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CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected 1 resident
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Based on observation, and staff interview the facility failed to store and handle food in a safe and sanitary manner in the kitchen. This failed practice had the potential to affect a limited number...
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Based on observation, and staff interview the facility failed to store and handle food in a safe and sanitary manner in the kitchen. This failed practice had the potential to affect a limited number of residents that currently reside in the facility. Facility census 66.
Findings included:
During a tour of the kitchen on 10/11/21 at 11:31 PM, the following practices were observed:
-16 white Styrofoam cups, containing food, were in the refrigerator without any dates on the cups or lids to indicate when the food was prepared.
-11 green plastic bowls, containing food items, were in the refrigerator without any dates.
-On a shelf containing square containers and plastic baskets was a metal dish with a blue gift bag laying on the dish. The gift bag had the name of a staff member.
-Large amount of ice buildup in the back of a stand up freezer.
Observation on 10/11/2021 at 11:35 AM, found Dietary Aide # 82 trying to get a pair of tongs hanging on a half-circle ring containing multiple serving ladles, spoons, and tongs. The ring was very high above DA #82's head. Dietary Aide # 82 could only touch the serving ends of the tongs with her fingertips. She struggled and made several attempts before getting the tongs down with an ungloved hand. She than passed the tongs over to Food Service Director #31 who continued to use the tongs to serve food, even though the practice was pointed out at the time.
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CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0561
(Tag F0561)
Could have caused harm · This affected multiple residents
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Based on observation, resident interview and staff interview the facility failed to promote and facilitate resident self-determination through support of resident choice in regards to having access ...
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Based on observation, resident interview and staff interview the facility failed to promote and facilitate resident self-determination through support of resident choice in regards to having access to and choosing their own clothes. This failed practice had the potential to affect more than a limited number of residents that currently reside at the facility. Resident identifiers: Resident #63, # 49, # 61, #12, #17, and #3. Facility census 66.
Findings included:
a) Resident # 63
On 10/11/21 at 10:40 AM, Resident # 63 was sitting in a wheelchair wearing a yellow facility gown. A facility thin, white blanket covered the front of her body. The resident was shaking and saying she was cold.
On 10/11/2021 at 11:00 AM, Nurse Aide (NA) #80 said she is only given a gown to dress everyone in and as far as she knows Resident # 63 has not had her own clothing for three to four weeks. While interviewing this nurse aide, a female staff person walked by (but would not stop to give her name) and stated, I called the Social Worker, and she is going to come and talk to you about this.
Moments later while exiting the room across the hall from Resident # 63 on 10/11/2021 at 11:18 AM, staff were observed carrying large black trash bags into Resident # 63 room.
On 10/11/2021 at 11:50 AM, NA #80 stated she received clothing for Resident # 63, and she dressed her.
b) Resident # 49
During the first phase of the survey process on 10/11/21 at 11:16 AM, Resident # 49 stated he would like to wear his clothes instead of a gown. Resident # 61 was wearing a green facility gown. On further investigation it was noted his closet was empty and there was not any type of dresser or chest of drawers in the room to store clothing.
c) Resident # 61
On 10/11/21 at 11:13 PM, Resident #61 was in his bed wearing a blue facility gown. He was asked if he preferred to wear a facility gown. He shook his head to indicate no and said he would like to wear his clothes. It was noted he did not have anything in his closet, and there was no other furniture in his room to store clothing. He went on to say he has not had any of his clothing for a month.
d) Resident #12
On 10/12/2021 at 8:30 AM, Resident # 12 was laying in her bed wearing a yellow facility gown. The Resident was unable to speak to this surveyor, however; it was noted she had no clothing in her room. The closet was empty except for adult briefs. No other furniture was located in the room to store clothing.
e) Resident #17
On 10/12/2021 at 8:35 AM, Resident # 17 was in a wheelchair wearing a facility gown and became tearful when she was asked about where her clothing was. She stated she did not know. Her closet was empty. There was no other furniture in her room to store clothing.
f) Resident #3
On 10/12/2021 at 8:40 AM, Resident # 3 was sitting in a wheelchair wearing a facility gown with a facility blanket over her shoulders. Resident # 3 was asked if she wanted to wear the facility gown. She stated that is all she has. Her closet was empty, there was no other piece of furniture in the room that would contain clothing.
g) Interviews
During an interview on 10/12/21 at 12:00 PM, the Administrator was asked why Resident's #63, # 49, # 61, #12, #17, and #3 did not have any of their clothing in their rooms. She said it is because they had COVID, and the residents were given a choice to wear a facility gown or their own clothes. The Residents were told the facility would have to bleach their clothing while in the COVID unit.
On 10/13/2021 at 1:30 PM, the Director of Nursing was provided with a list of the residents that did not have their own clothing in their rooms.
On 10/13/2021 at 1:45 PM, Occupational Therapist (OT)# 118 said not all of the residents that had COVID wore a gown, because part of the program when receiving OT was dressing themselves. However, none of the Residents referenced in the deficiency were receiving therapy at this time.
On 10/13/2021 at 2:00 PM, the Administrator stated she spoke the OT # 118 and the residents did have clothes while in the COVID unit only some did not, because they did not want their clothes to be bleached. She went on to say she personally moved some clothes to the rooms as people were being moved from the COVID unit. She was informed that according to the room change record, many of the residents that do not have their clothes have been out of the COVID unit since 10/04/2021. The Administrator stated the staff are currently moving their clothing into the rooms.
On 10/13/2021 at 2:19 PM, Supervisor of Laundry and Housekeeping (SLH) # 75 stated the staff are currently returning the clothing to the people that do not have them. She went on to say that with all the remodeling happening and COVID there is no excuse it was simply missed, and they failed to return the clothing to all of those residents.
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CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
b) Resident #15
During an interview on 10/11/21 at 12:40 PM, Resident # 15 stated its cold in here, I'm cold, I want the heat ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
b) Resident #15
During an interview on 10/11/21 at 12:40 PM, Resident # 15 stated its cold in here, I'm cold, I want the heat turned on. I asked her if she told anyone about the heat, Resident #15 stated they can't get it to work The Resident was asked if this surveyor could check her heater, this surveyor turned the knob to heat setting, cool air blew through the heater.
Nursing Aide (NA) #22 walked by and stated the heat does not get turned on till the end of October.
Observation on 10/12/21 at 8:54 AM, showed Resident #15 laying in bed with two blankets on her, Resident stating I'm cold.
On 10/12/21 at 8:56 AM, Maintenance Assistant (MA) #76 found the room temperature to be 70.5 degrees. The resident still complaining of being cold. MA #76 stated, the heat does not get turned on till the end of October. This surveyor asked What do you do for the resident that are cold before the heat comes on? MA #76 stated, I get them a heater and it seats on the floor.
Based on observation, resident interview and staff interview the facility failed to ensure comfortable and safe temperature levels for the residents. This was a random opportunity for discovery. This failed practice had the potential to affect more than a limited number of Residents that currently reside in the facility. Resident identifiers: #63, #66, #58, #37, and #15. Facility census 66.
Findings included:
a) Rooms 13-28
On 10/11/21 at 10:40 AM, Resident # 63 sitting in wheelchair wearing a yellow facility gown and a facility thin white blanket covering the front of her body. Resident # 63 stated she was cold.
On 10/11/2021 at 10:47 AM, Resident # 66 stated she was cold and only has one warm sweater.
On 10/11/2021 at 10:50 AM, Resident #58 was looking inside of boxes for her shoulder wrap because she was cold.
On 10/11/2021 at 10:55 AM, Resident #37 was wearing a long sleeve shirt, a sweater and a fleece blanket. The resident stated she was cold.
On 10/12/2021 at 8:30 AM Maintenance Assistant # 79 was asked to check the ambient temperatures for random rooms from 13 to 28. The temperatures were 67 to 68 degrees. This was reported to the administrator.
On 10/12/21 at 10:00 PM, the Administrator was asked about the temperatures in residents' rooms being lower than 71 degrees and Residents complaining about being cold. She said, yes the staff heard you talking to the Residents yesterday about them being in blankets and we turned the coolers off. She was informed that the temps today were 67-68 degree. She said, we turned on the boilers today.
On 10/13/2021 at 1:47 PM, the Administrator and Maintenance Supervisor came in to talk about the heating and cooling system and the way it works. The Maintenance Supervisor stated, when the staff report that most of the residents are complaining about being cold or hot they either have to turn the boilers on for heat or the chillers on for cooling. He went on to say one system controls the whole building and once you turn on the boilers and it heats up you cannot just flip over and make it cool again. He said as soon as he was told people were cold, first he turned the coolers off and when they were still cold, so he turned the boilers on. He said the temperature cannot be controlled in each resident room; the residents can only control the floor fan blowing in their rooms.
On 10/13/2021 at 2:44 PM, Maintenance Supervisor provided a log of random ambient temperature checks for the past three (3) weeks. This log sheet revealed there was multiple times the temperature was below 71 degrees:
-09/29/2021 at 12:45 PM rooms 42, and 43 were 69 degrees, room [ROOM NUMBER] was 68 degrees, and rooms 45, 46, 52, and 53 were 70 degrees.
-10/08/2021 at 1:15 PM, rooms 60, 61 and shower room were 69 degrees.
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CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected multiple residents
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Based on observation, staff interview and record review, the facility failed to prevent the spread of infections when staff failed to complete hand hygiene, in between passing meal trays to resident...
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Based on observation, staff interview and record review, the facility failed to prevent the spread of infections when staff failed to complete hand hygiene, in between passing meal trays to residents on the 400 hallway. In addition, Resident #57's nebulizer and supplies were not stored in a sanitary manner to prevent the spread of infections. This failed practice had the potential to affect a limited number of residents. Resident identifier: #57. Facility census: 66
Findings Included:
a) Meal observation on 400 hallway
On 10/11/21 at 11:45 AM, an observation of the lunch time meal, found Nursing Assistant (NA) #74 passing meal trays in the rooms. NA #74 failed to use hand sanitizer in between meal tray passes. NA #74 was asked, Should hand hygiene be completed when passing meal trays? No response was given. After surveyor intervention, NA #74 used the hand sanitizer located on the wall of the 400 hallway.
Review of the policy, Infection prevention and control program, found:
Under hand Hygiene Protocol: All staff shall wash their hands when coming on duty, between patient contacts
An interview with the Director of Nursing (DON) at 11:55 AM on 10/11/21, confirmed staff should have used hand sanitizer in between passing the meal trays to the residents.
b) Resident #57
An observation on 10/11/21 at 12:14 PM found, Resident #57's nebulizer's (A device for administering a medication by spraying a fine mist) mouthpiece, medication cup and tubing were laying on the bed side stand without being placed in a protective bag.
An interview on 10/11/21 at 12:19 PM with Licensed Practical Nurse (LPN) #14- confirmed Resident #57's nebulizer supplies should be placed in a protective bag when not in use.
On 10/13/21 at 12:58 PM, the findings were discussed with the Director of Nursing. No further information was provided prior to the end of the survey on 10/13/21 at 4:30 PM.
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Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated
K - Pattern
L - Widespread
Actual Harm
G - Isolated
H - Pattern
I - Widespread
Potential for Harm
D - Isolated
E - Pattern
F - Widespread
No Harm (Minor)
A - Isolated
B - Pattern
C - Widespread
Questions to Ask on Your Visit
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • No major safety red flags. No abuse findings, life-threatening violations, or SFF status.
- • No fines on record. Clean compliance history, better than most West Virginia facilities.
Concerns
- • 33 deficiencies on record. Higher than average. Multiple issues found across inspections.
Bottom line: Mixed indicators with Trust Score of 70/100. Visit in person and ask pointed questions.
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About This Facility
What is Glenwood Healthcare Center's CMS Rating?
CMS assigns GLENWOOD HEALTHCARE CENTER an overall rating of 4 out of 5 stars, which is considered above average nationally. Within West Virginia, this rating places the facility higher than 99% of the state's 100 nursing homes. This rating reflects solid performance across the metrics CMS uses to evaluate nursing home quality.
How is Glenwood Healthcare Center Staffed?
CMS rates GLENWOOD HEALTHCARE CENTER's staffing level at 3 out of 5 stars, which is average compared to other nursing homes. Staff turnover is 46%, compared to the West Virginia average of 46%. This relatively stable workforce can support continuity of care.
What Have Inspectors Found at Glenwood Healthcare Center?
State health inspectors documented 33 deficiencies at GLENWOOD HEALTHCARE CENTER during 2021 to 2025. These included: 32 with potential for harm and 1 minor or isolated issues.
Who Owns and Operates Glenwood Healthcare Center?
GLENWOOD 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 80 certified beds and approximately 77 residents (about 96% occupancy), it is a smaller facility located in PRINCETON, West Virginia.
How Does Glenwood Healthcare Center Compare to Other West Virginia Nursing Homes?
Compared to the 100 nursing homes in West Virginia, GLENWOOD HEALTHCARE CENTER's overall rating (4 stars) is above the state average of 2.7, staff turnover (46%) is near the state average of 46%, and health inspection rating (4 stars) is above the national benchmark.
What Should Families Ask When Visiting Glenwood Healthcare Center?
Based on this facility's data, families visiting should ask: "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" "Can I speak with family members of current residents about their experience?"
Is Glenwood Healthcare Center Safe?
Based on CMS inspection data, GLENWOOD HEALTHCARE CENTER has a clean safety record: no substantiated abuse findings (meaning no confirmed cases of resident harm), no Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death), and is not on the Special Focus Facility watch list (a federal program monitoring the lowest-performing 1% of nursing homes). The facility has a 4-star overall rating and ranks #1 of 100 nursing homes in West Virginia. While no facility is perfect, families should still ask about staff-to-resident ratios and recent inspection results during their visit.
Do Nurses at Glenwood Healthcare Center Stick Around?
GLENWOOD HEALTHCARE CENTER has a staff turnover rate of 46%, 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 Glenwood Healthcare Center Ever Fined?
GLENWOOD HEALTHCARE CENTER has no federal fines on record. CMS issues fines when nursing homes fail to meet care standards or don't correct problems found during inspections. The absence of fines suggests the facility has either maintained compliance or corrected any issues before penalties were assessed. This is a positive indicator, though families should still review recent inspection reports for the full picture.
Is Glenwood Healthcare Center on Any Federal Watch List?
GLENWOOD 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.