PRINCETON HEALTH CARE CENTER
Non profit - Corporation
120 Beds
Independent
Data: November 2025
Trust Grade
50/100
#85 of 122 in WV
Last Inspection: May 2024
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
Princeton Health Care Center has a Trust Grade of C, which means it is average and sits in the middle of the pack for nursing homes. It ranks #85 out of 122 facilities in West Virginia, placing it in the bottom half, and #4 out of 4 in Mercer County, indicating there are no better local options. The facility is worsening, with issues increasing from 13 in 2023 to 18 in 2024. Staffing is a strength, rated 4 out of 5 stars, and has a turnover rate of 34%, which is lower than the state average, suggesting that staff are more stable and familiar with residents. However, there are concerning deficiencies, including missed hand hygiene opportunities and instances of medication misappropriation, which indicate potential risks for residents. While there are no fines recorded, the facility does have lower RN coverage than 90% of other West Virginia facilities, meaning residents may not receive as much oversight from registered nurses.
- Trust Score
- C
- In West Virginia
- #85/122
- Safety Record
- Low Risk
- Inspections
- Getting Worse
- Staff Stability ○ Average
- 34% turnover. Near West Virginia's 48% average. Typical for the industry.
- Penalties ✓ Good
- No fines on record. Clean compliance history, better than most West Virginia facilities.
- Skilled Nurses ○ Average
- Each resident gets 30 minutes of Registered Nurse (RN) attention daily — about average for West Virginia. RNs are the most trained staff who monitor for health changes.
- Violations ⚠ Watch
- 41 deficiencies on record. Higher than average. Multiple issues found across inspections.
50/100
Bottom 31%
No red flags
13 → 18 violations
★★☆☆☆
2.0
Overall Rating
★★★★☆
4.0
Staff Levels
★☆☆☆☆
1.0
Care Quality
★★★☆☆
3.0
Inspection Score
↔
Stable
2023: 13 issues
2024: 18 issues
The Good
-
4-Star Staffing Rating · Above-average nurse staffing levels
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
-
Staff turnover below average (34%)
14 points below West Virginia average of 48%
Facility shows strength in staffing levels, fire safety.
The Bad
2-Star Overall Rating
Below West Virginia average (2.7)
Below average - review inspection findings carefully
Staff Turnover: 34%
12pts below West Virginia avg (46%)
Typical for the industry
The Ugly 41 deficiencies on record
May 2024
18 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Resident Rights
(Tag F0550)
Could have caused harm · This affected 1 resident
Based on observation and staff interview the facility failed to provide a dignified dining experience by not serving residents sitting together at the same time. This was a random opportunity for disc...
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Based on observation and staff interview the facility failed to provide a dignified dining experience by not serving residents sitting together at the same time. This was a random opportunity for discovery and had the potential to affect a minimal number of residents in the facility. Facility Census: 114 Resident Identifiers: #14, #52, #106
Findings Include:
On 05/08/24 at 12:20 PM in the South Dining room Resident #52 and #106 were observed setting together and Table one (1) and Resident #14 observed setting to herself at Table two (2).
Further observation on 05/08/24 at 12:25 PM revealed Resident #52 was served first at table one (1) then Resident #14 was served at table two (2) at 12:26 PM. Resident #106 waited Three minutes at table one(1) while Resident #52 ate. Resident #106 was served at 12:29 PM.
Staff interview was conducted on 05/08/24 at 12:33PM with Certified Nursing Assistant (CNA) #168 asking why Resident #14 was served before Resident #106 CNA #168 stated because there was a mix up with the ticket and did not want Resident #14's food to get cold.
During Staff interview with the Administrator on 05/08/24 at 1:00 PM the Administrator confirmed Resident #106 should have been served with/after Resident #52 and not had to wait to be served while the other resident sitting at the same table ate their food.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0552
(Tag F0552)
Could have caused harm · This affected 1 resident
Based on medical record review and staff interview the facility failed to ensure an informed consent was obtained for a psychotropic medication. This was true for one (1) of five (5) residents reviewe...
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Based on medical record review and staff interview the facility failed to ensure an informed consent was obtained for a psychotropic medication. This was true for one (1) of five (5) residents reviewed for unnecessary medication during the long term care survey. Resident identifier: #43 Census: 114.
Findings included:
a) Resident #43
On 05/07/24 at 12:50 PM during a medical record review for Resident #43, it was identified that the resident was prescribed aripiprazole 20 mg tablet for inappropriate sexual behaviors related to unspecified psychosis not due to a substance or known physiological condition. During this medical record review an informed consent for psychotropic medication use could not be identified for the use of aripiprazole 20 mg tablet.
On 05/07/24 at approximately 2:45 PM during an interview with the Director of Nursing (DON), the DON agreed that the psychotropic medication aripiprazole 20 mg did not have an informed consent for psychotropic medication use and that she would have this corrected.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0583
(Tag F0583)
Could have caused harm · This affected 1 resident
Based on observation, record review and staff interview the facility failed to ensure residents' information was protected. This failed practice was found true for (1) one of (1) one resident looked a...
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Based on observation, record review and staff interview the facility failed to ensure residents' information was protected. This failed practice was found true for (1) one of (1) one resident looked at for privacy during the Long-Term Care Survey Process. Resident Identifiers #19. Facility Census 114.
Findings include:
a) Resident #19
An observation on 05/06/24 at 11:15 AM, found a sign posted behind Resident #19's bed that read: (Resident # 19 name) has an allergy to Latex.}
Further observation found that the sign was visible from the hallway when the door and curtain were open.
A record review on 05/08/24 at 1:00 PM, revealed that Resident #19 was in fact allergic to Latex.
On 05/08/24 at 2:30 PM, a review of the facilities policy titled {Confidentiality of Personal and Medical Records}, number (8) eight reads: Paper notes or reminders with resident's personal or medical information shall not be left unattended or viewable by unauthorized persons.
During an interview on 05/08/24 at 4:00 PM, the Administrator confirmed that the sign infringed on Resident #19's privacy.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interviews the facility failed to provide a clean, comfortable, and homelike environment. A stron...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interviews the facility failed to provide a clean, comfortable, and homelike environment. A strong unpleasant odor was observed when entering a resident's room. This was a random opportunity for discovery during the long-term care survey process. Room Identifier: room [ROOM NUMBER]. Census: 114.
Findings included:
a) room [ROOM NUMBER]
During a tour of the 200 hall on 05/06/24 at approximately 11:15 AM a strong unpleasant odor was observed when entering room [ROOM NUMBER].
During a tour of the 200 hall on 05/06/24 at 03:05 PM a strong unpleasant odor was again observed when entering room [ROOM NUMBER]. Licensed Practical Nurse (LPN) #91 was asked to help identify the odor in the room. LPN #91 stated that one of the residents will place her soiled undergarments in bags and put them in drawers and that may be what the smell is. She stated she would have the staff help check for what the odor is from and get it cleaned up.
During a tour of the 200 hall on 05/07/24 at 09:06 AM a strong unpleasant odor was still present in room [ROOM NUMBER]. During an interview at this time with the DON, she agreed the room smelled bad and she would have someone come in to clean it.
During an interview with the Administrator on 05/07/24 at 03:15 PM, she stated they had identified the smell to be coming from the packaged thermal air conditioner (PTAC) unit and was replacing the unit.
During an interview with the Administrator on 05/08/24 at approximately 04:30 PM, she stated that the room still had a strong unpleasant odor and that they would continue to work on identifying the cause and correcting it.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Transfer Notice
(Tag F0623)
Could have caused harm · This affected 1 resident
Based on Record review and staff interview the facility failed to notify the Ombudsman of resident #45's discharge to the hospital.This was true for one (1) of one(1) residents reviewed for the carrie...
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Based on Record review and staff interview the facility failed to notify the Ombudsman of resident #45's discharge to the hospital.This was true for one (1) of one(1) residents reviewed for the carrier of hospitalization. Resident identifier; #45. Facility census: 114.
Findings include:
A) Resident #45
A record review found The resident was discharged to the hospital 12/06/2024 at 12:48 pm.
Interviewed Social Worker on 05/06/2024 to ask if the ombudsman was notified of resident discharge to the hospital and she said yes but could not provide verification of that notification.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
PASARR Coordination
(Tag F0644)
Could have caused harm · This affected 1 resident
The facility failed to coordinate assessments with the pre-admission screening and resident review (PASARR) program under Medicaid. The PASARR was not resubmitted for residents with newly evident or p...
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The facility failed to coordinate assessments with the pre-admission screening and resident review (PASARR) program under Medicaid. The PASARR was not resubmitted for residents with newly evident or possible serious mental disorder. This was true for two (2) of six (06) residents PASARR reviewed during the long term care process. This had the ability to affect a limited number of residents. Resident Identifier: Resident #67, Resident #80; Census: 114.
Findings Included:
a) Resident #67
During a medical record review on 05/07/24 at 11:02 AM for Resident #67, the PASARR was dated 05/04/22. Further record review of the residents diagnosis identified an updated diagnosis of delusions due to known physiological condition dated 5/06/22. No further PASARR's were identified to have been completed for this diagnosis dated 05/06/22.
On 05/07/24 at 02:46 PM during an interview with Social Worker #129 she stated she did not have an updated PASARR for the diagnosis of delusions due to known physiological condition dated 5/06/22 and that she would need to complete one.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0645
(Tag F0645)
Could have caused harm · This affected 1 resident
Based on record review and staff interview the facility failed to ensure a resident's Preadmission Screening and Resident Review (PASARR) reflected the diagnoses sheet for pre admission diagnoses. Thi...
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Based on record review and staff interview the facility failed to ensure a resident's Preadmission Screening and Resident Review (PASARR) reflected the diagnoses sheet for pre admission diagnoses. This was true for two (2) of five (5) residents reviewed for the PASARR care area. Resident identifiers: #80, #1, Facility Census: #114
Findings included:
(a) Resident #80
During a record review on 05/07/24, Resident #80's medical record revealed admitting diagnosis for 06/16/22 (admission date) included the following:
-unspecified Psychosis not due to a substance or known physiological condition
According to the Diagnosis Report provided by the facility and the PASARR submitted 10/12/22 the PASARR did not reflect this admitting medical diagnosis.
In an interview with the Social Services/Admissions Director #129 on 05/08/24 at 08:39 AM, it was verified the PASARR should have reflected the Psychosis Disorder upon the admission date of 06/16/22.
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
b) Resident #67
During a medical record review on 05/07/24 at 06:00 PM for Resident #64, the diagnosis of a psychotic disorder with delusions due to known physiological condition was identified. The d...
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b) Resident #67
During a medical record review on 05/07/24 at 06:00 PM for Resident #64, the diagnosis of a psychotic disorder with delusions due to known physiological condition was identified. The diagnosis of a psychotic disorder with delusions due to known physiological condition was dated 05/06/22. Further review of the resident's medical record did not identify a care plan for the diagnosis of the psychotic disorder with delusions due to known physiological condition diagnosis dated 05/06/22.
On 05/08/24 at 10:24 AM During an interview with DON and Social Worker (SW) #129, the DON acknowledged the care plan for the diagnosis of Psychotic disorder with delusions due to known physiological conditions had not been developed and requested that the SW #129 make those corrections.
Based on record review and staff interview, the facility failed to develop a complete and accurate comprehensive care plan for two (2) of 34 residents reviewed in the long-term care survey sample. Resident identifiers: #115, #67. Facility census: 114.
Findings included:
a) Resident #115
Review of Resident #115's comprehensive care plan showed the resident had been living at the facility since 2022. On 02/15/24, the resident was discharged to a family members' home. The resident had diagnoses of traumatic brain disorder and dementia.
A physician's note written on 02/12/24 indicated the resident had received discharge planning and assistance from a state agency.
The discharge summary written on 02/15/24 indicated delivery of durable medical equipment and home health agency visits were arranged prior to discharge. An appointment was also made with the resident's primary care provider and an Adult Protective Services (APS) referral was made.
Review of Resident #115's comprehensive care plan showed no focus was developed regarding discharge planning. A focus written on 11/17/22 and resolved on 11/30/23 indicated the resident was residing in the facility for long-term care. However, no updated focus was developed relating to discharge planning for the resident to be discharged to a family member's home.
On 05/08/24 at 4:00 PM, Registered Nurse (RN) Case Manager #151 stated the state agency had been working with Resident #115's family for a couple of months to arrange discharge. RN Case Manager #151 confirmed no focus relating to the resident's discharge planning had been developed on the resident's comprehensive care plan.
No further information was provided through the completion of the survey process.
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
b) During a facility tour on 05/06/24 at approximately 2:50 PM, it was noted Resident #75 had a Health Team Aide (HTA) sitting at her bedside. At that time, an interview with Resident #75 and the HTA ...
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b) During a facility tour on 05/06/24 at approximately 2:50 PM, it was noted Resident #75 had a Health Team Aide (HTA) sitting at her bedside. At that time, an interview with Resident #75 and the HTA #136 was conducted. HTA #136 revealed, she was providing one on one care to Resident #75 and a HTA sat with Resident #75 24 hours a day providing this service. When asked why, HTA #136 responded, I am not sure, I think she had a fall a while back. HTA #136 was unable to tell me when the one on one was initiated or how long it was to continue. Resident #75 was unable to provide further information.
On 05/08/24 at 12:00 PM, a review of Resident #75 medical record was conducted revealing documentation of one on one care dating back to 09/18/23, at which time she was noted to have had a fall. Resident #75 was sent to the hospital for evaluation after the fall with no injuries noted. Next, on 09/18/23 it was noted in a nurses note Resident #75 had a one on one sitter. A review of Resident #75's care plan for falls revealed no one on one sitter intervention initiated. However, a review of Resident #75's behavioral care plan revealed a one on one sitter intervention initiated on 05/03/24. Further review of Resident #75's physician's orders noted no physician's order for a one on one sitter.
On 05/08/24 at approximately 10:43 AM during an interview with the DON, she stated that Resident #75 has a one on one sitter as an intervention for her frequent falls. She further stated that the Interdisciplinary Team (IDT) determines if it is appropriate for the one on one sitter intervention and they did not get a physician order for this nor does the facility have a policy related to this. When asked how the facility determines the length of time the one on one sitter intervention remains in place, the DON stated the IDT reviews each resident receiving one on one sitters to determine if the intervention is still appropriate, however they do not document this review.
The facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices. The facility failed to obtain the physicians order for one on one (1:1) interventions. This was a random opportunity of discovery during the long term care survey process. This had the ability to affect a limited number of residents. Resident Identifiers; Resident #47, Resident #75, and Resident #101. Facility Census: 114.
Findings Included:
a: Resident #47
On 05/06/24 at 11:13 PM Resident #47 was observed to be sitting in her room with an apparent black eye. A staff member was observed at this time to be sitting in the room with the resident.
On 05/07/24 at approximately 12:15 PM Resident #47 was observed to have a staff member sitting with her in her room.
05/07/24 at 07:45 PM during a medical record review, Resident #47 nursing note dated 05/03/24 identified that the resident had a fall as she was observed sitting in front of toilet in bathroom on floor, resident assessed for injuries noted to have skin tear to behind left ear and left side of face near chin, noted to have bump forming on top of left eyebrow noted to have purple coloring, resident started on neuro checks per facility protocol, vitals within normal limits. resident alarms in place and functioning. Resident denies any pain or discomfort. will continue to observe.
On 05/07 at 08:00 PM during a medical review of the residents care plan for the focus it is noted that the resident is high risk for falls referenced to confusion, reconditioning and poor safety awareness. It also states that the resident often turns alarms off. The goal is identified for Resident #47 to be free of major injury through the review date of 07/31/24. Further review of the care plans, the intervention of a 1:1 sitter was not identified.
On 05/08/24 at approximately 10:43 AM during an interview with the DON, she stated that Resident #47 has a 1:1 sitter as an intervention for her recent fall on 05/03/24. She further stated that the Interdisciplinary Team (IDT) determines if it is appropriate for the 1:1 sitter intervention and they did not get a physician order for this. She stated that the IDT team has not met yet to review this fall but would be meeting on Thursday 05/09/24.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0699
(Tag F0699)
Could have caused harm · This affected 1 resident
Based on record review and staff interview the facility failed to provide services for Post Traumatic Stress Syndrome (PTSD). This failed practice was found true for (1) one of (3) three residents loo...
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Based on record review and staff interview the facility failed to provide services for Post Traumatic Stress Syndrome (PTSD). This failed practice was found true for (1) one of (3) three residents looked at for mood and behavior during the Long-Term Care Survey Process. Resident identifier #76. Facility Census: 114.
Findings included:
a) Resident # 76
A record review on 05/06/24 at 1:06 PM, of the Minimum Data Set (MDS), Section I, revealed that Resident #76 had PTSD.
A record review on 05/08/24 at 11:00 AM, revealed the following trauma related care plan initiated on 10/31/21:
Focus:
(Resident #76 name) has a Trauma history relating to a car accident that left him badly injured 12 years ago. He has had two major strokes and two brain aneurysms. He lost his son due to a heart attack three years ago. He has a strained relationship with his living son and is close with a grandson. He worked as a social worker for many years at DHHR. No triggers reported.
Goal:
(Resident #76 name) will not have an increase in adverse symptoms related to trauma history through next review.
Interventions:
* Be patient and reassuring with (Resident # 76 name).
* Encourage positive visits with friends/family.
* Ensure (Resident #76 name) feels safe during care, offering reassurance as needed.
* (Resident #76 name) enjoys being outdoors, pet visits, black and white movies. Engage in activities of comfort.
* (Resident #76 name) is of the Christian faith. Provide spiritual guidance/materials as needed.
* Identify any possible triggers to past trauma such as people, places, sounds, smells, objects, time of day.
* Report any mood changes to the provider.
* Use communication /picture boards when interacting with (Resident # 76 name).
Further record review showed that Resident # 76, last Trauma Informed Care Assessment was completed on 10/31/21 and revealed that he had (5) five out of 13 life events for PTSD. No triggers had been identified at this time.
During an interview on 05/08/24 at 1:30 PM with the Director of Nursing (DON), she confirmed that resident #76's MDS was marked for PTSD and the last Trauma Informed Care Assessment that she could find was dated 10/31/21. She further stated, I will see what is going on with that.
Further record review on 05/08/24 at 2:00 PM, revealed an Activity Progress Note dated 03/27/24 that has the following documentation within the note: Resident tends to get frustrated when he is unable to communicate his needs/wants and will refuse to talk to you at times. He has had periods of tearfulness.
Further record review revealed a Nurses note dated 03/27/24 that reads: Spoke with (Psychiatric doctor name) about (Resident #76 name) tearfulness and increased depression. He ordered an increase in Rexulti from 0.5mg to 1 mg daily.
No follow-up notes were found to indicate if the medication increase was effective.
During this record review it was found that Resident # 76 had no mention of anyone working with him for his possible triggers of PTSD, only notes that the medications were increased due to tearfulness.
No further information was provided by the end of the survey.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Laboratory Services
(Tag F0770)
Could have caused harm · This affected 1 resident
Based on record review and staff interview, the facility failed to obtain laboratory services as ordered by the physician. This deficient practice had the potential to affect one (1) of five (5) resid...
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Based on record review and staff interview, the facility failed to obtain laboratory services as ordered by the physician. This deficient practice had the potential to affect one (1) of five (5) residents reviewed for the care area of unnecessary medications. Resident identifier: #80. Facility census: 114.
Findings included:
a) Resident #80
Review of Resident #80's physician's orders showed an order for the laboratory test hemoglobin A1c (HgbA1-c ) to be performed every six (6) months. HgbA1-c testing measures the average blood sugar level over the past three (3) months. Resident #80 was on a medication, Ziprasidone (Geodon) for psychosis, that can elevate blood sugar levels.
Review of Resident #80's laboratory results showed HgbA1-c testing had last been performed on 09/07/23.
On 05/08/24 at 1:17 PM, the Director of Nursing (DON) confirmed Resident #80's HgbA1-c testing had not been performed every six (6) months as ordered. She stated a HgbA1-c test would be obtained for the resident today.
No further information was provided through the completion of the survey.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Medical Records
(Tag F0842)
Could have caused harm · This affected 1 resident
b) Resident #86
During a record review on 05/06/24 at 02:29 PM, a review of Resident #86's medical record revealed a Physician Orders for Scope of Treatment (POST) form that failed to include the cont...
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b) Resident #86
During a record review on 05/06/24 at 02:29 PM, a review of Resident #86's medical record revealed a Physician Orders for Scope of Treatment (POST) form that failed to include the contact number of the physician signing the POST order.
The 2021 POST form guidance titled, Using the POST Form: Guidance for Health Care Professionals, 2021 edition, available on-line, stated, Failure to provide a contact number may result in the inability to contact the provider regarding any errors in the form completion that need to be addressed.
During an interview on 05/06/24 at 09:22 AM with the Social Worker (SW), SW #129 acknowledged that the physicain had not entered his contact number on the POST form.
Based on Record review and staff interview the facility failed to ensure that the medical record contained the diagnosis of Post Traumatic Stress Syndrome (PTSD) as indicated on the Minimum Data Set (MDS) and that the Physician Order for Selective Treatment (POST) form was complete and accurate. This failed practice was found true for (2) two of 34 residents reviewed for medical record accuracy during the Long-Term Care Survey Process. Resident identifiers #76, #86. Facility Census 114.
Findings include:
a) Resident #76
A record review on 05/08/24 at 10:19 AM, revealed that Resident #76's MDS with an Assessment Reference Date (ARD) of 03/22/24, Section I, question 16100, is marked yes for PTSD.
Further record review showed that Resident #76 did not have PTSD listed for one of his medical diagnoses. He did however; have a care plan for trauma.
During an interview on 05/08/24 at 1:30PM with the Director of Nursing (DON), she confirmed that resident #76's MDS was marked for PTSD and it was not on the current diagnosis list. She further stated, I will see what is going on with that.
No further information was provided by the end of the survey.
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
Free from Abuse/Neglect
(Tag F0600)
Could have caused harm · This affected multiple residents
Based on record review and staff interview, the facility failed to ensure residents were free from abuse which included misappropriation of medication. This was true for three (3) of three (3) residen...
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Based on record review and staff interview, the facility failed to ensure residents were free from abuse which included misappropriation of medication. This was true for three (3) of three (3) residents reviewed during the survey. Resident identifiers: #10, #20, #81. Facility Census: 114.
This will be cited as past non compliance because the facility identified what had happened and took immediate steps to correct the failure to ensure it does not reoccur. All components of the of plan of correction were completed prior to this survey beginning.
Findings included:
a) Resident #10
Resident #10 had a narcotic medication borrowed for another resident five (5) times in the month of January, 2024. This was discovered when management performed an in house audit on 02/19/24. The facility reported it to the appropriate agencies on 02/19/24 and the five (5) day follow up was faxed on 02/22/24.
The investigation started immediately on 02/19/24 at approximately 12:30 PM. A verbal and written statement was obtained from Licensed Practical Nurse (LPN) #104. The verbal statement relayed the nurse felt she had borrowed the medication for pain management and felt she had the best interest of the resident in pain at that time of judgement. The written statement states, I have borrowed medications in the past but have since been educated not to borrow any medications.
On 02/19/24 Licensed Social Worker (LSW) #129 interviewed Resident #10. The resident was very pleasant, denies any needs and voiced no concerns. No mental anguish or distress noted during the visit.
Education:
A review of staff education was completed on 05/07/24 at approximately 09:00 AM. All staff signatures were obtained and included all employed nurses. The staff signatures were verified via the staff roster.
System Change:
New hires will be provided with education: Narcotics are not to be borrowed for any reasons. If a resident is scheduled a narcotic and you do not have it, first check with med dispense system. If the narcotic is not available in the med dispense then you are to contact pharmacy to see if they can send it or get it sent to back up pharmacy. If they are unable to send the narcotic from main pharmacy or to the back up pharmacy, you are to call the physician to see if there is another medication option available. If you are unable to get into the med dispense system you need to contact Staff Development Coordinator (name typed) to have him assist you. Please make sure to document every attempt to obtain the medication.
An interview was conducted on 05/08/24 at approximately 10:00 AM with the Administrator and the Director of Nursing (DON). Both the Administrator and the DON confirmed the incident which involved Resident #10, #20 and #81 did happen as reported. The Administrator also stated Resident #10 did not miss any doses of her medication due to this finding.
b) Resident #20
Resident #20 had a narcotic medication borrowed for another resident one (1) time in the month of July, 2023. This was discovered when management performed an in house audit on 02/19/24. The facility reported it to the appropriate agencies on 02/19/24 and the five (5) day follow up was faxed on 02/23/24.
The investigation started immediately on 02/19/24 at approximately 12:30 PM. Two written statements were obtained from Licensed Practical Nurse (LPN) #63. They read (1) The reason a medication was borrowed due to the fact I was unable to obtain from pharmacy at time medication was dye because back up does not bring narcotics and was unable to obtain medication from med dispense due to med dispense not working correctly. (2) I did also receive education on not borrowing medications and correct way to obtain medications.
On 02/19/24 Licensed Social Worker (LSW) #129 interviewed Resident #20. The resident was pleasantly confused, He was talkative but did nod off to sleep throughout the visit. Resident appeared to be comfortable by this LSW's observation. No needs voiced during visit. No mental anguish or distress noted.
Education:
A review of staff education was completed on 05/07/24 at approximately 09:00 AM. All staff signatures were obtained and included all employed nurses. The staff signatures were verified via the staff roster.
System Change:
New hires will be provided with education: Narcotics are not to be borrowed for any reasons. If a resident is scheduled a narcotic and you do not have it, first check with med dispense system. If the narcotic is not available in the med dispense then you are to contact pharmacy to see if they can send it or get it sent to back up pharmacy. If they are unable to send the narcotic from main pharmacy or to the back up pharmacy, you are to call the physician to see if there is another medication option available. If you are unable to get into the med dispense system you need to contact Staff Development Coordinator (name typed) to have him assist you. Please make sure to document every attempt to obtain the medication.
An interview was conducted on 05/08/24 at approximately 10:00 AM with the Administrator and the Director of Nursing (DON). Both the Administrator and the DON confirmed the incident which involved Resident #10, #20 and #81 did happen as reported. The Administrator also stated Resident #20 did not miss any doses of her medication due to this finding.
c) Resident #81
Resident #81 had a narcotic medication borrowed for another resident two (2) times in the month of January, 2024. This was discovered when management performed an in house audit on 02/19/24. The facility reported it to the appropriate agencies on 02/19/24 and the five (5) day follow up was faxed on 02/21/24.
The investigation started immediately on 02/19/24 at approximately 12:30 PM. A verbal and written statement was obtained from Licensed Practical Nurse (LPN) #176. The verbal statement relayed the nurse felt she had borrowed the medication for pain management and felt she had the best interest of the resident in pain at that time of judgement. The written statement states, (Resident names) have the same order for (narcotic name). Medication would have been borrowed if (resident name) didn't have any left. Aware this is not the protocol, it is to look in the Pyxis, if there isn't any, contact Registered Nurse (RN) on call, then proceed to contact (Physician name) and pharmacy of needed.
On 02/19/24 Licensed Social Worker (LSW) #129 interviewed Resident #81. The resident was friendly with LSW. She did not answer many questions asked except for ones she replied yeah to. Resident carrying what appeared to be some of her clothing. Was encouraged to rest and put clothing in her room. She did sit on bed and smiled at LSW. No needs acknowledge. No mental anguish or distress observed during visit.
Education:
A review of staff education was completed on 05/07/24 at approximately 09:00 AM. All staff signatures were obtained and included all employed nurses. The staff signatures were verified via the staff roster.
System Change:
New hires will be provided with education: Narcotics are not to be borrowed for any reasons. If a resident is scheduled a narcotic and you do not have it, first check with med dispense system. If the narcotic is not available in the med dispense then you are to contact pharmacy to see if they can send it or get it sent to back up pharmacy. If they are unable to send the narcotic from main pharmacy or to the back up pharmacy, you are to call the physician to see if there is another medication option available. If you are unable to get into the med dispense system you need to contact Staff Development Coordinator (name typed) to have him assist you. Please make sure to document every attempt to obtain the medication.
An interview was conducted on 05/08/24 at approximately 10:00 AM with the Administrator and the Director of Nursing (DON). Both the Administrator and the DON confirmed the incident which involved Resident #10, #20 and #81 did happen as reported. The Administrator also stated Resident #81 did not miss any doses of his medication due to this finding.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0657
(Tag F0657)
Could have caused harm · This affected multiple residents
b) Resident #75
During a facility tour on 05/06/24 at approximately 2:50 PM, it was noted Resident #75 had a Health Team Aide (HTA) sitting at her bedside. At that time, an interview with Resident #75...
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b) Resident #75
During a facility tour on 05/06/24 at approximately 2:50 PM, it was noted Resident #75 had a Health Team Aide (HTA) sitting at her bedside. At that time, an interview with Resident #75 and the HTA #136 was conducted. HTA #136 revealed she was providing one on one care to Resident #75 and that a HTA sat with Resident #75 24 hours a day providing this service. When asked why, HTA #136 responded, I am not sure, I think she had a fall a while back. HTA #136 was unable to tell me when the one on one was initiated or how long it was to continue. Resident #75 was unable to provide further information.
On 05/08/24 at 12:00 PM, a review of Resident #75 medical record was conducted revealing documentation of one on one care dating back to 09/18/23. Further review of Resident #75 record revealed a behavioral care plan with an intervention which read provide one to one observation as needed with an initiation date of 05/03/24.
On 05/08/24 at 1:40 PM an interview with the Quality Assurance Nurse (QAN) was conducted. During this interview QAN acknowledged Resident #75's care plan had not been revised in a timely manner to reflect changes.
Based on observation, medical record review and staff interview, the facility failed to revise the residents comprehensive care plan. Residents had one-on-one (1:1) interventions put in place without being care planned or being care planned timely. This was a random opportunity for discovery during the long term care survey process. Resident identifiers: #47, #75 and #101. Census: 114.
Findings included:
a) Resident #47
On 05/06/24 at 11:13 PM Resident #47 was observed to be sitting in her room with an apparent black eye. A staff member was observed at this time to be sitting in the room with the resident.
On 05/07/24 at approximately 12:15 PM Resident #47 was observed to have a staff member sitting with her in her room.
05/07/24 at 07:45 PM during a medical record review, Resident #47 nursing note dated 05/03/24 identified that the resident had a fall as she was observed sitting in front of toilet in bathroom on floor, resident assessed for injuries noted to have skin tear to behind left ear and left side of face near chin, noted to have bump forming on top of left eyebrow noted to have purple coloring, resident started on neuro checks per facility protocol, vitals wnl. resident alarms in place and functioning. Resident denies any pain or discomfort. will continue to observe.
On 05/07 at 08:00 PM during a medical review of the residents care plan for the focus it is noted that the resident is high risk for falls referenced to confusion, deconditioning and poor safety awareness. It also states that the resident often turns alarms off. The goal is identified for Resident #47 to be free of major injury through the review date of 07/31/24. Further review of the care plans, the intervention of a 1:1 sitter was not identified.
On 05/08/24 at approximately 10:43 AM during an interview with the DON, she stated that Resident #47 has a 1:1 sitter as an intervention for her recent fall on 05/03/24. She further stated that the Interdisciplinary Team (IDT) determines if it is appropriate for the 1:1 sitter intervention and they did not get a physician order for this. The DON further agreed that the resident care plan does not include the 1:1 intervention and stated she would have that completed.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0675
(Tag F0675)
Could have caused harm · This affected multiple residents
The facility failed to create and sustain an environment that humanizes and individualizes each resident's quality of life as they were not provided a person-centered care to honor and support the res...
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The facility failed to create and sustain an environment that humanizes and individualizes each resident's quality of life as they were not provided a person-centered care to honor and support the residents individual preference, choices, values and beliefs. This was a random opportunity for discovery during the long term survey process. This had the ability to affect a limited number of resident's. Resident identifiers: #75, #47, #101. Facility census: 114.
Findings include:
a) During a facility tour on 05/06/24 at approximately 2:50 PM, it was noted Resident #75 had a Health Team Aide (HTA) sitting at her bedside. At that time, an interview with Resident #75 and the HTA #136 was conducted. HTA #136 revealed that she was providing one on one care to Resident #75 and that a HTA sat with Resident #75 24 hours a day providing this service. When asked why, HTA #136 responded, I am not sure, I think she had a fall a while back. HTA #136 was unable to tell me when the one on one was initiated or how long it was to continue. Resident #75 was unable to provide further information.
On 05/08/24 at 12:00 PM, a review of Resident #75 medical record was conducted revealing documentation of one on one care dating back to 09/18/23, at which time she was noted to have had a fall. Resident #75 was sent to the hospital for evaluation after the fall with no injuries noted. Next, on 09/18/23 it was noted in a nurses note Resident #75 had a one on one sitter. A review of Resident #75's care plan for falls revealed no one on one sitter intervention initiated. However, a review of Resident #75's behavioral care plan revealed a one on one sitter intervention initiated on 05/03/24. Further review of Resident #75's physician's orders noted no physician's order for a one on one sitter.
On 05/08/24 at approximately 10:43 AM during an interview with the DON, she stated Resident #75 has a one on one sitter as an intervention for her frequent falls. She further stated the Interdisciplinary Team (IDT) determines if it is appropriate for the one on one sitter intervention and they did not get a physician order for this nor does the facility have a policy related to this. When asked how the facility determines the length of time the one on one sitter intervention remains in place, the DON stated the IDT reviews each resident receiving one on one sitters to determine if the intervention is still appropriate, however they do not document this review.
On 05/08/24 at approximately 11:45 AM an interview with the facility Social Worker (SW) was conducted. The SW verbalized she does not routinely assess the psychosocial well-being of residents receiving one on one sitters, stating There is no time frame set in stone, if they need something or there is a reportable I will assess them. The SW was unable to provide documentation she had assessed Resident #75's psychosocial well-being related to the one on one sitter.
b) Resident #47
On 05/06/24 at 11:13 PM Resident #47 was observed to be sitting in her room with an apparent black eye. A staff member was observed at this time to be sitting in the room with the resident.
On 05/07/24 at approximately 12:15 PM Resident #47 was observed to have a staff member sitting with her in her room.
05/07/24 at 07:45 PM during a medical record review, Resident #47 nursing note dated 05/03/24 identified that the resident had a fall as she was observed sitting in front of toilet in bathroom on floor, resident assessed for injuries noted to have skin tear to behind left ear and left side of face near chin, noted to have bump forming on top of left eyebrow noted to have purple coloring, resident started on neuro checks per facility protocol, vitals within normal limits. Resident alarms in place and functioning. Resident denies any pain or discomfort. will continue to observe.
On 05/07 at 08:00 PM during a medical review of the residents care plan for the focus it is noted that the resident is high risk for falls referenced to confusion, reconditioning and poor safety awareness. It also states that the resident often turns alarms off. The goal is identified for Resident #47 to be free of major injury through the review date of 07/31/24. Further review of the care plans, the intervention of a 1:1 sitter was not identified.
On 05/08/24 at approximately 10:43 AM during an interview with the DON, she stated that Resident #47 has a 1:1 sitter as an intervention for her recent fall on 05/03/24. She further stated that the Interdisciplinary Team (IDT) determines if it is appropriate for the 1:1 sitter intervention and they did not get a physician order for this. The DON further agreed that the resident care plan does not include the 1:1 intervention and stated she would have that completed.
On 05/08/24 at approximately 11:15 AM during an interview with the DON, she stated that the IDT team had not met yet to discuss Resident #47's fall or the continued usage of the 1:1 sitter as a fall intervention. She further stated that they are scheduled to meet on 05/09/24.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Staffing Information
(Tag F0732)
Could have caused harm · This affected multiple residents
Based on observation and staff interview, the facility failed to ensure the Daily Staffing Posting information was accurate and current. The Daily Staffing Posting Form was not posted in a prominent p...
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Based on observation and staff interview, the facility failed to ensure the Daily Staffing Posting information was accurate and current. The Daily Staffing Posting Form was not posted in a prominent place readily accessible to residents and visitors; the Daily Staffing Posting Form did not accurately reflect the direct care staff; and the Daily Staffing Posting Form did not identify the actual number of staff and or the actual hours worked. This was identified during the long-term care survey process of reviewing the sufficient and competent nursing staff. This has the potential to affect potential to affect more than a limited number of residents and visitors. Identifiers: Accurate and current data of direct care, Accurate and current date of actual numbers of staff and or the actual hours worked; and the Daily Staffing Posting Form was not posted in a prominent place readily accessible to residents and visitors. Facility Census: 114.
Findings included:
a) Accurate and current data- direct care staff
On 05/07/24 at approximately 10:15 AM during a review of the Daily Staffing Posting Forms with the Administrator it was identified that the total number of Registered Nurses (RN's) for direct care staff was more than one (1) eight (8) hour shift daily. The Administrator stated that the Registered Nurses with administrative duties are added to this number of RN direct care staff because they help with the floor staff throughout the day. The Labor Classification/ Job Title section of the Centers for Medicare & Medicaid Services- Electronic Staffing Data Submission- Payroll-Based Journal- Long-Term Care Facility- Policy Manual Version 2.6 was reviewed with the Administrator. This section defines that the Labor Classification/Job Title Reporting shall be based on the employee's primary role and their official categorical title. It is understood that most roles have a variety of non-primary duties that are conducted throughout the day (e.g., helping out others when needed). Facilities shall still report just the total hours of that employee based on their primary role. CMS recognizes that staff may completely shift primary roles in a given day. For example, a nurse who spends the first four hours of a shift as the unit manager, and the last four hours of a shift as a floor nurse. In these cases, facilities can change the designated job title and report four hours as a nurse with administrative duties, and four hours as a nurse (without administrative duties). The Administrator agreed that the RN staffing total and the RN total hours worked were not accurate.
b) Accurate and current data-actual number of staff and staff hours worked.
During a record review of the Staffing Posting Forms for 04/14/24, 04/21/24, 04/23/24, 05/01/24 and 05/04/24 and the Detail Hours Overview report of actual hours worked, the following staffing inaccuracies were identified;
*04/14/24-
-The Daily Staffing form day shift 07:00 AM - 07:00 PM identified the total number of Certified Nursing Assistant (CNA) direct care staff was as nine (9) CNA and the total number of hours as 103.5. The Detail Hours Overview report identified the actual total number of CNA direct care was 10 and the actual total number of hours was 112.0.
*04/21/24
-The Daily Staffing form day shift 07:00 AM - 07:00 PM identified the total number of LPN hours was 64. The Detail Hours Overview report identified the actual total number of hours for LPN was 61.5.
-The Daily Staffing form day shift 07:00 AM - 07:00 PM identified CNA total number of hours identified was 126.5. The Detail Hours Overview report identified the actual total number of hours was 135.75.
*04/23/24
-The Daily Staffing form day shift 07:00 AM - 07:00 PM identified the total number Registered Nurse (RN) staff was eight (8) and the total number of hours identified was 64. The Detail Hours Overview report identified the actual total number of RN staff was one (1) and the actual total hours was identified as 8 (eight).
-The Daily Staffing form day shift 07:00 AM - 07:00 PM identified the total number of LPN staff was eight (8) and the total number of hours identified was 56. The Detail Hours Overview report identified the actual total number of LPN staff was six (6) and the actual total hours was identified as 63.75.
-The Daily Staffing form day shift 07:00 AM - 07:00 PM identified the total number of CNA staff was eight (8) and the total number of hours identified was 134.5. The Details Hours Overview report identified the actual total number of CNA staff was 20 and the actual total hours was identified as 161.25.
-The Daily Staffing form day shift 07:00 PM - 07:00 AM identified the total number of LPN staff was five (5) and the total number of hours identified was 52. The Detail Hours Overview report identified the actual total number of LPN staff was four (4) and the actual total hours was identified as 42.5.
-The Daily Staffing form day shift 07:00 PM - 07:00 AM identified the total number of CNA staff was nine (9) and the total number of hours identified was 96. The Details Hours Overview report identified the actual total number of CNA staff was 10 and the actual total hours was identified as 116.75.
*05/01/24
-The Daily Staffing form day shift 07:00 AM - 07:00 PM identified the total number Registered Nurse (RN) staff was eight (8) and the total number of hours identified was 64. The Detail Hours Overview report identified the actual total number of RN staff was one (1) and the actual total hours was identified as eight (8).
-The Daily Staffing form day shift 07:00 AM - 07:00 PM identified the total number of LPN staff hours identified was 62. The Detail Hours Overview report identified the actual total number of LPN staff hours was identified as 64.75.
-The Daily Staffing form day shift 07:00 AM - 07:00 PM identified the total number of CNA staff was 22 and the total number of hours identified was 201. The Details Hours Overview report identified the actual total number of CNA staff was 22 and the actual total hours was identified as 209.25.
-The Daily Staffing form day shift 07:00 PM - 07:00 AM identified the total number of LPN staff hours identified was 48. The Detail Hours Overview report identified the actual total number of LPN staff hours was identified as 46.25.
-The Daily Staffing form day shift 07:00 PM - 07:00 AM identified the total number of CNA staff hours was 103.5. The Details Hours Overview report identified the actual total number of CNA staff hours was as 107.
*05/04/24
-The Daily Staffing form day shift 07:00 AM - 07:00 PM identified the total number of CNA staff was nine (9) and the total number of hours identified was 103.5. The Details Hours Overview report identified the actual total number of CNA staff was 12 and the actual total hours was identified as 142.75.
-The Daily Staffing form day shift 07:00 PM - 07:00 AM identified the total number of CNA staff was nine (9) and the total number of hours identified was 96.5. The Details Hours Overview report identified the actual total number of CNA staff was 10 and the actual total hours were identified as 114.75.
On 05/08/24 at approximately 01:43 PM during an review of the inaccuracies of the Daily Staffing Form with the Administrator, she agreed that the Daily Staffing form reviewed did not reflect the total number of staff or the actual hours worked by the staff.
c) Daily Staffing Posting Form not posted in a prominent place readily accessible to residents and visitors.
On 05/08/24 at approximately 01:47 PM during an interview with the Administrator it was identified that the Daily Staffing Posting form was not posted in a prominent place readily accessible to residents and visitors. The Administrator agreed that the Daily Staffing Posting form is to be posted in a prominent place readily accessible to residents and visitors.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected multiple residents
Based on observation and staff interview the facility failed to ensure cooking/serving pans were completely dry before storing them on the shelf wet nesting. Wet nesting occurs when wet dishes or pots...
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Based on observation and staff interview the facility failed to ensure cooking/serving pans were completely dry before storing them on the shelf wet nesting. Wet nesting occurs when wet dishes or pots and pans are stacked, preventing them from drying, and creating conditions that are ripe for microorganisms to grow. Hot/Cold compress pack was stored in the resident pantry refrigerator where cold snacks are stored. This failed practice was found during the initial kitchen tour during the Long-Term Care Survey and had the potential to affect more than a minimal number of residents residing in the facility. Facility Census: 114
Findings Include:
a) wet nesting
During the initial Kitchen tour on 05/06/24 at 11:00AM with Certified Dietary Manager (CDM) #132 Pans were stacked under the counter, when one was pulled it was observed to be wet on the right side. CDM #123 confirmed staff should have ensured pans were dry before stacking and storing them.
On 05/06/24 at 1:00 PM CDM provided educations signed by staff ensuring dishes are dry when putting them up.
b) Hot/Cold compress in pantry refrigerator
On 05/06/24 at approximately 12:30 PM during inspection of facility North Pantry surveyor observed in the freezer of the refrigerator a hot-cold pack with a resident's name and room number written on it.
During interview with Licensed Practical Nurse (LPN) #22 on 05/06/24 at 12:33PM, LPN #22 confirmed the hot/cold pack should not be in the pantry freezer stating, oh no this should not be here, we have a fridge behind the nurses station for these.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected most or all residents
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 com...
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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. The facility failed practice included: the missed opportunity for hand hygiene was true for 29 of 193 documented hand hygiene observations made by the facility and for 1 (one) of 32 observations made during a medication pass for the medication administration portion of the long term survey process. This failed practice had the potential to affect more than an isolated number of residents. Facility census: 114.
Findings included:
a) Facility
On 05/07/24 at approximately 12:30 PM, a review of the facility Policy and Procedure titled, Infection Prevention and Control Program, section 4, Standard Precautions, dated 12/10/13 with a revision date of 05/18/23, noted the policy read, in part, Hand hygiene shall be performed in accordance with facility's established hand hygiene procedures. Further record review of the facility's Hand Hygiene Observation Tool for the months of February, March and April of 2024 revealed a total of 193 opportunities for hand hygiene with 29 missed opportunities indicating a no answer that hand hygiene was observed as performed.
These missed opportunities were noted to occur on the following dates
02/12/24
02/14/24
02/22/24
03/01/24
03/12/24
03/19/24
03/22/24
04/04/24
04/05/24
04/06/24
04/24/24
04/29/24
During a staff interview conducted on 5/7/24 at 2:34 PM with the Infection Preventionist (IP), the IP stated There should be immediate education provided for all missed opportunities. When asked to provide documentation of education provided to the employees who had missed opportunities the IP acknowledged she was unable to provide proof that immediate education was performed.
Jul 2023
13 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected 1 resident
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Based on record review and staff interview, the facility failed to report an injury of unknown origin to the proper authorities for Resident #72. This was true for one (1) of two (2) residents revie...
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.
Based on record review and staff interview, the facility failed to report an injury of unknown origin to the proper authorities for Resident #72. This was true for one (1) of two (2) residents reviewed for unsafe wandering. Resident identifier: #72. Facility census: 115.
Findings included:
a) Resident #72
Record review found the following nursing note dated 06/13/23 at 6:47 AM:
When a staff member was dressing the resident, he noticed bruising to her left arm and left outer hip that he had not noticed the bruising throughout the night. Upon inspection, the resident had a large bruise on her upper left arm measuring 5 cm (centimeters) wide x 4 cm long, as well as a small bruise to her left outer hip measuring 4 cm wide x 2 cm long. Both bruises were deep purple and yellow in color. The Resident was unable to give a description. Vital signs were assessed and all were found to be within normal limits. The Resident is not displaying any signs or symptoms of pain or discomfort to the site at this time. No swelling or redness to surrounding skin noted, skin is intact.
Review of the medical record revealed the resident had no falls for over a month prior to the discovery of the bruises.
On 07/24/23 at 1:18 PM, the Social Worker (SW) #119 confirmed she was responsible for reporting alleged incidents of abuse/neglect/injuries of unknown origin to the proper authorities. She stated, the bruising to Resident #72 was not reported.
At 1:44 PM on 07/24/23, SW #119 provided a progress note, dated 06/15/23 at 4:06 PM, indicating the interdisciplinary team (IDT) met to discuss the bruises to the left arm and hip. The root cause was described as: Resident ambulates independently on the unit and moves all extremities freely. She is transferred by staff. She is care planned for being at risk for injury to skin. Interventions include daily observation of skin during routine care, staff to ensure environment is free of hazards and trim nails on bath days and as needed. New intervention: staff to provide frequent checks. The medical director and responsible party are aware.
A second progress note written on 06/15/23 at 4:11 PM, Resident has been ambulating up and down the hallways. She has been in and out of others room. No agitation, crying or aggression observed.
On 07/25/23 at 8:32 AM, an interview with the administrator and Director of Nursing revealed the incident was not reported. The Administrator said the IDT team reviewed the incident and felt the Resident just ran into something because she wanders and has poor safety awareness. When asked if anyone actually observed an incident which could have caused injury to the Resident, the response was, no, but we felt she caused the injury herself. We did not think the injury was suspicious and she didn't need any medical treatment. Knowing her and knowing how mobile she is, it wasn't suspicious.
The guidance to surveyors for F 609 directs: . the facility must report alleged violations related to mistreatment, exploitation, neglect, or abuse, including injuries of unknown source and misappropriation of resident property and report the results of all investigations to the proper authorities within prescribed timeframe's .
No further information was provided.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Assessment Accuracy
(Tag F0641)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on medical record review and staff interview, the facility failed to accurately code the Minimum Data Set for resident's...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on medical record review and staff interview, the facility failed to accurately code the Minimum Data Set for resident's diagnosis. This was true for two (2) of five (5) reviewed for unnecessary medications. Resident identifiers: #49 and #79. Facility census: 115.
Findings included:
a) Resident #49
Review of Resident #49's medical records found the resident had been in the hospital from [DATE] through 07/12/23. She was treated for community acquired pneumonia and a urinary tract infection (UTI). Resident is currently on antibiotics for the treatment of pneumonia.
Review of the MDS with a reference date (ARD) of 07/17/23 under section I (current diagnosis) did not have pneumonia or UTI in the last 30 days marked.
Interview with the Director of Nursing (DON) on 07/25/23 at 2:10 pm. She confirmed the MDS with ARD of 07/17/23 was inaccurate. She confirmed the resident was treated in the hospital for a UTI and pneumonia and continued currently on antibiotics for treatment of pneumonia.
b) Resident #79
Review of Resident #79's medical records found he has been diagnosed with Schizophrenia and currently receives an antipsychotic medication (Risperdal).
Further review of his MDS with ARD of 06/09/23, under section I- current diagnosis did not mark his diagnosis of Schizophrenia. The resident has behaviors of he thinks the TV plays music and talks to him when the TV is off. He has self-inflicted wounds from a history of self-harm.
Interview with the Director of Nursing (DON) on 07/25/23 at 2:20 pm. She confirmed the MDS with ARD of 06/09/23 was inaccurate. She confirmed the resident has a diagnosis of Schizophrenia and receives treatment for it.
________________________________________________________________________________________
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0642
(Tag F0642)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to complete a Minimum Data Set (MDS) when the resident w...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to complete a Minimum Data Set (MDS) when the resident was admitted to the hospital. Resident identifier: #53. Facility census: 115.
Findings include:
a) Resident #53
Review of Resident #53's medical record found she was admitted to the hospital on [DATE]. No MDS discharge tracking could be found.
Interview with the Director of Nursing (DON) on 07/24/23 at 11:00 am. She confirmed a discharge MDS tracking form was not completed on 05/0/23.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0655
(Tag F0655)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on record review and staff interview, the facility failed to complete a baseline care plan for one (1) of two (2) newly ...
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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 complete a baseline care plan for one (1) of two (2) newly admitted residents reviewed during the long term care survey. Resident identifier #366. Census 115.
Findings Included:
a) Resident #115
The surveyor requested copies of the resident's most recent minimum data set (MDS,) list of diagnoses, care plans, and Pre admission Screening (PAS) on 07/24/23. A record review of these records indicated the resident was admitted to the facility on [DATE] with the diagnosis of schizophrenia and bipolar disorder. The care plan received did not address either diagnosis.
The PAS, dated 7/5/23, listed both diagnoses. The MDS is still in progress, therefore is not completed. The electronic medical record reviewed on 07/24/23 did not list either diagnoses under the Medical Diagnosis section, but the printed diagnosis list indicated the facility added both diagnoses on 07/24/23 to the list of the resident's diagnosis, with the onset date of 07/07/23.
On 07/25/23 9:40 AM, a staff interview was held with social worker (SW) #119. The surveyor asked SW #119 why the resident did not have a care plan for his diagnosis of schizophrenia and bipolar disorder. SW #119 proceeded to pull up the resident's electronic medical record and showed the surveyor a trauma care plan with schizophrenia and bipolar mentioned. The surveyor presented the copies of the care plan that was provided to the surveyor on 07/24/23, to SW #119, where the trauma care plan did not mention either diagnoses. SW #119 confirmed the facility added schizophrenia and bipolar disorder to the resident's trauma care plan after the surveyor requested copies of the care plan on 07/24/23, but that it was not care planned prior to surveyor intervention.
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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
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on medical record review and staff interview, the facility failed to develop a comprehensive care plan to include the di...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on medical record review and staff interview, the facility failed to develop a comprehensive care plan to include the diagnosis of pneumonia. Resident identifier: #49. Facility census: 115.
Findings include:
a) Resident #49
Review of Resident # 49's medical records show the resident was in the hospital from [DATE] through 07/12/23 and was treated for pneumonia and the resident continues medication for the treatment of pneumonia.
Review of Resident #49's care plan did not have a care plan for pneumonia.
An interview with the Director of Nursing (DON) on 07/24/23 at 11:00 am, confirmed the resident did not have a care plan for pneumonia.
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CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0657
(Tag F0657)
Could have caused harm · This affected 1 resident
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Based on record review, resident interview, and staff interview, the facility failed to update the care plans of two (2) of five (5) residents reviewed for the care area of nutrition after both resi...
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Based on record review, resident interview, and staff interview, the facility failed to update the care plans of two (2) of five (5) residents reviewed for the care area of nutrition after both residents had a weight loss and a diet change. Resident identifiers: #55 and #83. Facility census: 115.
Findings included:
a) Resident #55
Review of the medical record found a nutritional/dietary weight loss note, dated 7/19/2023. The Resident lost 8.4 pounds in 30 days, which was an 6.1% loss and an 11 pound weight loss in 90 days for a 7.8% weight loss. The resident receives a regular sugar substitute diet with fortified foods.
On 7/11/23 the interdisciplinary team met to discuss a current weight of 130.2 pounds which was a 8.4 pound weight loss in 30 days a 6.10% weight loss and a 90 day weight loss of 7.8%. Fortified foods were added to lunch and dinner.
On 07/24/23, the Registered dietician met with the Resident and added chocolate milk to her diet.
Review of the current care plan, revised on 03/14/23, found the following focus/problem:
(Name of Resident) has a potential to have weight fluctuations due to having the diagnosis of dementia, depression, type 2 diabetes, dysphagia, muscle wasting/weakness, history of COVID 19, gastroesophageal reflux disease, anxiety, vitamin deficiency and hypertension.
The goal associated with the focus:
The resident will not experience any unplanned significant weight loss/gain within the next review.
Interventions included:
Provide and serve diet as ordered, revised on 05/25/21.
An interview with the Dietary Manager (DM) #127 on 07/24/23 at 10:43 AM, verified the resident had lost weight. DM #127 confirmed fortified foods were added as well as chocolate milk to her diet.
When asked if the care plan was updated to reflect the changes, DM #127 said the resident has weight fluctuations and we are serving the diet as ordered. The surveyor stated all residents would receive a diet as ordered but how is this intervention specific for this resident? When asked if the care plan reflected an actual weight loss the DM said the resident's weight fluctuates.
The residents weights recorded in the medical record were reviewed with the DM:
07/17/23 127.8 pounds (Lbs)
07/13/23 129.8 Lbs
07/07/23 130.2 lbs.
06/07/23 138.6 Lbs
05/01/23 137.6 Lbs
04/04/23 141.2 Lbs
03/06/23 139.4 Lbs
02/06/23 139.6 Lbs
01/03/23 136.2 Lbs
12/05/23 140.8 Lbs
11/01/23 141.4 Lbs
10/03/22 143.0 Lbs
While it is true the Resident's weight fluctuates, the resident has actually experienced a significant weight loss in 30 days and 90 days. Interventions added to the Resident's diet to address the weight loss were not reflected on the current plan of care.
On 07/25/23 at 8:54 AM, the above care plan was discussed with the administrator. The Administrator said the care plan would be updated.
b) Resident #83
Review of the medical record found a Nutrition/Dietary note dated, 07/12/23
The Resident's care plan meeting was held today. The current diet order is puree with nectar thick liquids. Her current weight is 124.8 lbs, She is receiving house supplements, fortified foods, and protein smoothie.
On 6/23/23 a Nutrition/Dietary Note was found in the medical record: Current diet order is mechanical soft with ground meats. She is receiving multivitamin, fortified foods, house supplement, diuretics and super cereal. Will continue weights per facility protocol.
On 6/22/23 a Nutrition/Dietary Note reflected:
Reviewed due to net loss of 8.4# in in 30 days (an 8.4% loss) & a net loss of 11.8# in 90 days (a 9.2% loss).
Diet remains Pureed with/nectar thick liquids. Overall intake average. has decreased recently to 25-50% of meals. Noted that chocolate milk was added on 06/12/23 as well as a protein smoothie.
On 06/16/23 a Nutrition/Dietary Note reflected:
Note Text: Weight meeting note:
Current weight is 112 lbs, height is 62, Body mass index 21. She has had a loss of 3.60 lb/3.10 %. Current diet order is puree nectar thick. She is receiving a multivitamin, 2 handled sip cup, fortified foods, house supplement, diuretics and super cereal.
Review of the recorded weights in the medical record:
07/07/23 121.0 Lbs
06/20/23 124.8 Lbs
06/13/23 112.4 Lbs
06/07/23 116.0 Lbs
05/15/23 118.0 Lbs
05/01/23 124.4 Lbs
Further review of the physicians orders found:
On 03/11/23 a Pureed texture, nectar/mildly thick consistency, for 2 handled sip cup for liquids was added to the current orders.
Fortified foods, 2 times a day, dated 04/21/23 was added to the current orders.
House supplement 3 times a day, dated 07/12/23 was added to the current orders.
Protein smoothie 2 times a day, dated 06/12/23 was added to the current orders.
Super cereal in the morning for breakfast, dated 08/22/23 was added to the current orders.
Review of the current care plan found the following focus/problem:
(Name of Resident) has a potential to have weight fluctuations due to having the diagnosis of dementia, COPD, respiratory failure, hypertension, anxiety, depression, edema, Gerd (Gastroesophageal reflux disease) , anorexia, vitamin deficiency, adult failure to thrive, protein calorie malnutrition. She is receiving diuretics, initiated on 01/10/22, revised on 03/17/23.
The goal associated with the focus:
Resident will not experience any unplanned significant weight loss/gain within the next review date. Revised on 07/17/23.
Interventions included:
Provide and serve diet as ordered, initiated on 01/10/22
Provide and serve supplements as ordered, initiated on 09/06/22
An interview with the Dietary Manager (DM) #127 on 07/24/23 at 10:43 AM, confirmed the interventions did not include the physician ordered diet specifications of fortified foods, house supplement, protein smoothie, and super cereal. The care plan also did not address dietary would provide a pureed texture diet with nectar/mildly thick consistency liquids and a 2 handled sip cup for the liquids.
On 07/25/23 at 10:46 AM, the above care plan was discussed with the Director of Nursing. No further information was provided.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
Could have caused harm · This affected 1 resident
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Based on facility policy, observations, and staff interview the facility failed to ensure proper storage of Continuous Positive Airway Pressure (C-pap) while not in use. This was a random opportunit...
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Based on facility policy, observations, and staff interview the facility failed to ensure proper storage of Continuous Positive Airway Pressure (C-pap) while not in use. This was a random opportunity for discovery and has the potential to affect a limited number of residents who currently reside in the facility. Resident Identifiers: # 67, and #3. Facility census 115.
Finding included:
Facility Policy, titled, Continuous Positive Airway Pressure date of revision:06/15/17.
*It is very important to keep the C-pap equipment and supplies clean.
*Store in a plastic bag.
a) Resident #67
Observation on 07/23/23 02:53 PM, found the C-pap mask was lying on top of personal items on the nightstand not in a bag.
Observation on 07/24/23 at 10:15 AM, found the C-pap mask was placed on top of various items such as opened bags of chips, bottles of lotions, and soda bottles on the nightstand not in a bag.
Observation on 07/2423 at 2:18 PM, found the C-pap mask was on the nightstand on top mingled with other things, not in a bag.
During an observation on 07/25/23 at 9:56 AM, found the C-pap mask was again on top of personal items, placed on the nightstand not in a bag. This was verified with Registered Nurse (RN) #15.
b) Resident #3
An observation on 07/23/23 at 3:02 PM, found the C-pap mask for Resident #3 was not in a bag, lying on the nightstand.
During an observation on 07/24/23 at 10:12 AM, found the C-pap mask was on the nightstand not in a bag.
An observation on 07/2423 at 2:05 PM, found the C-pap mask was on nightstand not in a bag.
During an observation with RN #15 on 07/25/23 at 9:55 AM, RN #15 confirmed the C-pap mask was not in a bag and lying on the nightstand.
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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 complete temperature logs for their reach-in refrigerator, reach-in freezer, walk-in refrigerator, walk-in freezer, and dishwasher. T...
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Based on observation and staff interview, the facility failed to complete temperature logs for their reach-in refrigerator, reach-in freezer, walk-in refrigerator, walk-in freezer, and dishwasher. This has the potential to affect more than a limited number of residents at the facility. Facility Census 115.
Findings Included:
On 07/23/23 at 2:24 PM, the initial kitchen walk through occurred. [NAME] #34 was in charge of the kitchen that day due to it being a Sunday. Observation found the dishwasher temperature log did not have any documentation for the date of 07/22/23, on the afternoon section of the form. The reach-in refrigerator temperature log did not have documentation for 07/21/22, on the PM Time section of the form, or 07/22/23, for the PM Time section of the form. The reach-in freezer temperature log did not have documentation for 07/21/23, on the PM Time section of the form, or 07/22/23, on the PM Time section of the form. The walk-in refrigerator temperature log did not have documentation for 07/21/23, on the PM Time section of the form, or 07/22/23, on the PM Time section of the form. The walk-in freezer temperature logs did not have documentation for 07/21/23 on the PM Time section of the form, or 07/22/23 on the PM Time section of the form.
A staff interview with [NAME] #34 on 07/23/23 at approximately 2:34 PM, confirmed all the temperature logs were incomplete.
On 07/24/23 at 11:38 AM, the Dietary Manager was notified by surveyors, that on 07/23/23, the temperature logs were incomplete. She acknowledged understanding.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
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Based on observation, staff interview and record review the facility failed to maintain proper infection control standards during medication pass for Resident #8. This failed practice was a random o...
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Based on observation, staff interview and record review the facility failed to maintain proper infection control standards during medication pass for Resident #8. This failed practice was a random opportunity for discovery and had the potential to affect only a limited number of residents. Resident identifier: #8. Facility census: 115.
Findings included:
During observation of medication pass for Resident #8 on 07/24/23 at 09:07 AM, Licensed Practical Nurse (LPN) #20 reached into Resident's medicine cup with her bare fingers, moved the pills around, and pulled out a Memantine capsule. LPN #20 then opened the Memantine capsule and sprinkled the contents into the medication pill crush pouch. LPN #20 stated, I have to crush her medications and mix them in in her protien smoothie to get her to take them. LPN #20 then proceeded to dump the remainder of the pills into the pill crush pouch, crushed the medications, and poured the contents into the Resident's protien smoothie.
Record review of the facility's policy titled, Medication Administration revise date 01/01/23, showed that staff are to remove mediation from source, taking care not to touch medication with bare hand.
Record review showed an order for Memantine 28mg capsule to be given one time a day related to dementia.
On 07/24/23 at 9:47 AM the Administrator was informed of LPN #20's procedure used to handle oral medications during medication preparation. The Administrator stated, Oh no, we drill it onto them not to touch any pills without gloves. They know better. That should have never happened.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0919
(Tag F0919)
Could have caused harm · This affected 1 resident
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Based on observation and staff interview the facility failed to make a call system accessible to the resident at each toilet and bath or shower facility, and should be accessible to a resident layin...
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Based on observation and staff interview the facility failed to make a call system accessible to the resident at each toilet and bath or shower facility, and should be accessible to a resident laying on the floor. This was a random opportunity for discovery. Resident Identifiers: Resident #90. Facility Census: 115.
Findings Included:
a) Bathroom Call Light
During the initial tour of the facility on 07/23/23 at 3:23 PM the bathroom call system cord wrapped around the call system, not reaching the floor.
During an interview on 07/23/23 at 3:26 PM Licensed Practical Nurse (LPN) #172 stated the cord is very tangled, she was unable to get it untangled and unable to get the cord to reach the floor.
During another tour of the facility on 07/24/23 at 9:00 AM, the call light cord was wrapped around and was not accessible to the Resident if lying on the floor.
During an record review on 07/24/23 at 11:00 AM, Resident #90's medical record revealed a care plan with an initiated date of 08/03/23,
Focus: Resident #90's name is moderate risk for falls r/t(related to) Confusion. Resident #90 name cannot use call light at times due to Dementia
Goal: Resident #90's name will be free of injury through the review date.
Interventions included, Place Resident #90 name's call light within reach.
During an interview on 07/24/23 at 12:14 PM, the Administrator acknowledged the call was not accessible to the resident if she was lying on the floor.
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CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Grievances
(Tag F0585)
Could have caused harm · This affected multiple residents
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Based on observation, policy review, resident council meeting and staff interview the facility failed to make grievances forms accessible to all resident and/or residents family/representatives resi...
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Based on observation, policy review, resident council meeting and staff interview the facility failed to make grievances forms accessible to all resident and/or residents family/representatives residing in the facility. This had the potential to affect an unlimited amount of residents living in the facility. Facility census: 115.
Findings Included:
a) Grievance Forms
A review of the facility policy titled Resident and Family Grievances and Communicated Concern with an implementation date 11/28/16 and a revision date 07/17/21, read as follows.
Procedure:
.8. A grievance may be filed anonymously
During the Long Term Care Survey Process from 07/23/23 to 07/25/23 many observations throughout the facility revealed no evidence of grievance forms made accessible to the residents and/or resident representatives.
During the Resident Council Meeting held on 07/25/23 at 10:08 AM, the Residents as a group were asked the question, Do you know how to file a grievance? Do you know where to access your grievance forms? The residents as a group stated No, we don't. We just tell Social Worker # 119 name.
During an interview on 07/25/23 at 10:52 AM, Social Worker(SW) #119 stated I am the grievance official, the residents come to me or the nurses and tell us the issues they are having. The grievance forms are at the nurses station and the residents have to ask for the form.
This surveyor asked what if they wanted to file a grievance anonymously? The SW #119 stated They can write it on a piece of paper and put it under my door.
During the interview the SW #119 acknowledged the residents should have access to grievance forms to file anonymously.
During an interview on 07/25/23 at 11:10 AM, the Administrator was informed of residents not having access to grievance forms to file confidentially.
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CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected multiple residents
b) Resident # 68
On 07/24/23 at 12:02 PM, Resident #68 said today she is getting her Parkinson's medication on time but lots of times she does not. She went on to say sometimes she gets her Parkinson...
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b) Resident # 68
On 07/24/23 at 12:02 PM, Resident #68 said today she is getting her Parkinson's medication on time but lots of times she does not. She went on to say sometimes she gets her Parkinson's medication two (2) hours or later and she gets the shakes. The resident receives Rytary for treatment of Parkinson's Disease.
The following information was found on the website: www.Rytaryhcp.com.
What happens if you don't take your Parkinson's medication on time?
Delaying medications by more than one hour, for example, can cause patients with Parkinson's disease to experience worsening tremors, increased rigidity, loss of balance, confusion, agitation, and difficulty communicating.
On 07/24/23 at 1:02 PM, the administrator was informed of the complaint from Resident # 68 regarding her medications being late. She was asked for a Medication Admin Audit Report.
On 07/24/23 at 1:06 PM, Social Worker (SW) #119 said she has talked to Resident #68 before about her medication, and said, I think she just gets fixated on it, because I have looked into it before, and I did not find any problems. SW #119 said she just spoke to her, and she said the nurse today is very good.
A review of the Medication Admin Audit Report found that on the following days Resident # 68 did not receive her medications on time.
Licensed Practical Nurse #27 administered the medication called Rytary (used for treatment of Parkinson's Disease):
On 06/24/23 scheduled for 11:00 AM, administered on 06/24/23 at 1:59 PM.
On 06/24/23 scheduled for 3:00 PM, administered on 06/24/23 at 5:11 PM.
On 06/25/23 scheduled for 11:00 AM, administered on 06/25/23 at 3:23 PM.
On 06/29/23 scheduled for 11:00 AM, administered on 06/29/23 at 2:46 PM.
On 07/03/23 scheduled for 11:00 AM, administered on 07/03/23 at 2:16 PM.
On 07/04/23 scheduled for 3:00 PM, administered on 07/04/23 at 6:46 PM.
On 07/13/23 scheduled for 11:00 AM, administered on 07/13/23 at 2:52PM.
On 07/17/23 scheduled for 3:00 PM, administered on 07/17/23 at 5:50 PM.
On 07/18/23 scheduled for 11:00 AM, administered on 07/18/23 at 2:34 PM.
On 07/18/23 scheduled for 3:00 PM, administered on 07/18/23 at 5:34 PM.
On 07/20/23 scheduled for 11:00 AM, administered on 07/20/23 at 2:16 PM.
On 07/22/23 scheduled for 11:00 AM, administered on 07/22/23 at 2:54 PM.
On 07/23/23 scheduled for 11:00 AM, administered on 07/23/23 at 1:51 PM.
On 07/23/23 scheduled for 3:00 PM, administered on 07/23/23 at 6:00 PM.
Licensed Practical Nurse #50 administered Rytary.
On 06/25/23 scheduled for 9:00 PM, administered on 06/25/23 at 11:22 PM.
On 06/28/23 scheduled for 9:00 PM, administered on 06/28/23 at 11:11 PM.
On 07/12/23 scheduled for 9:00 PM, administered on 07/12/23 at 11:08 PM.
Licensed Practical Nurse #53 administered Rytary
On 07/02/23 scheduled for 9:00 PM, administered on 07/02/23 at 11:10 PM.
On 07/07/23 scheduled for 9:00 PM, administered on 07/08/23 at 12:09 AM.
On 07/11/23 scheduled for 9:00 PM, administered on 07/11/23 at 11:25 PM.
On 07/14/23 scheduled for 9:00 PM, administered on 07/14/23 at 11:17 PM.
On 07/15/23 scheduled for 9:00 PM, administered on 07/15/23 at 12:33 AM.
Licensed Practical Nurse #82 administered Rytary.
On 07/22/23 scheduled for 9:00 PM, administered on 07/02/23 at 11:06 PM.
Licensed Practical Nurse #92.
On 07/20/23 scheduled for 3:00 PM, administered on 07/20/23 at 6:17 PM.
During an interview with the administrator on 07/24/23 at 2:10 PM, the surveyor provided the information above. The administrator said she would be looking into why the medications were so late so many times and would have the SW #119 go back to complete a report.
Facility policy titled, Medication Administration revision date: 01/91/23.
* Administer within 60 minutes prior to or after scheduled time unless otherwise ordered by physician.
c) Resident #102
Review of Resident #102's physician orders for the review of unnecessary medication found an order for Carvedilol Oral Tablet 3.125 MG (Carvedilol.) Give 1 tablet by mouth two times a day related to hypertension. Hold if the pulse is less than 60 or systolic is less than 100.
Review of Resident #102 Medication Administration Record (MAR) for July 2023 found on July 2, 2023, the staff stopped obtaining the resident's blood pressure but continued the heart rate.
During an interview with the Director of Nursing (DON) on 07/25/23 at 10:20 am, she reviewed the orders and the MAR for July 2023 and confirmed the order was to obtain blood pressure and heart rate prior to the administration of Carvedilol. She confirmed the blood pressure has not been obtained since 07/02/23.
Based on record review, observation and staff interview the facility failed to ensure four (4) of 26 Residents reviewed received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices. A surgical consult was not scheduled for Resident #55 as directed by the nurse practioner, Resident #68's medication was not provided timely, an enteric coated medication was crushed before being administered, and blood pressures were not obtained as ordered by the physician for Resident #102. Resident identifiers: #55, #68, and #102. Facility census: 115.
Findings included:
a) Resident #55
Record review on 07/24/23 found Resident #55 had an ultrasound of her gallbladder on 01/18/23.
The results of this ultrasound found: Gallbladder sludge is noted. No gallbladder wall thickening. No pericholecystic fluid.
The results of the ultrasound were reviewed by the Family Nurse Practioner (FNP) on 01/19/23. The FNP wrote on the consult to get a surgical consult for the abnormal ultrasound with Gallbladder sludge.
At 11:43 AM on 07/24/23, Registered Nurse (RN) # 87 confirmed the consult with a surgeon was never scheduled. She said that possibly the Resident's son who was the Medical Power of Attorney (MPOA) at the time the results were obtained did not want to have the surgical consultation. RN #87 said this can't be confirmed because the MPOA has since passed away. RN #87 further confirmed their was no documentation in the medical record the MPOA did not want to have the consultation. RN #87 stated we have called her sister, the health care surrogate and the sister wants to have a consult so we have scheduled one today.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0924
(Tag F0924)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on observations and staff interviews the facility failed to assure handrail were firmly secured and affixed to the corri...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on observations and staff interviews the facility failed to assure handrail were firmly secured and affixed to the corridor walls. This was a random opportunity for discovery and had the potential to affect more than a limited number of residents residing on North Unit 100 Hall. Facility Census: 115
Findings Included:
a) Handrails
During a tour on 07/24/23 at 1:11 PM this surveyor discovered on 100 Hall the following handrails were not firmly secured and affixed to the corridor walls.
-The handrail between room [ROOM NUMBER] and the chapel door
-Two (2) handrail between the 113 and the chapel door
-The handrail between room [ROOM NUMBER] and 110
-The handrail between room [ROOM NUMBER] and 109
-The handrail between room [ROOM NUMBER] and 107
During an interview 07/24/23 at 1:20 PM, the Administrator acknowledged the rails were not secure and needed repaired.
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Mar 2022
10 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Resident Rights
(Tag F0550)
Could have caused harm · This affected 1 resident
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Based on observation and staff interview the facility failed to ensure the privacy curtain and window blind were closed, when providing pressure ulcer care to a wound on the buttock. This was true f...
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Based on observation and staff interview the facility failed to ensure the privacy curtain and window blind were closed, when providing pressure ulcer care to a wound on the buttock. This was true for one (1) and of four (4) residents reviewed for wound care. Resident identified: #85. Facility census 98.
Findings included:
a) Resident #85
During an observation of wound care on 03/15/22 at 11:58 AM, Registered Nurse (RN) #121 began wound care on the exposed buttock. RN#121 failed to close the privacy curtain between Resident #85 and the roommate (who was in the bed). In addition, RN #121 failed to close the window blinds leaving about a 12 inch gap from the bottom of the blind to the window sill.
On 03/15/22 at 12:15 PM, RN#121 agreed she failed the provide privacy for Resident #85.
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CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0558
(Tag F0558)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on family interview and staff interview the facility failed to ensure reasonable accommodation of needs for Resident #24...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on family interview and staff interview the facility failed to ensure reasonable accommodation of needs for Resident #249 by not providing a chair for this resident to sit in. This was a random opportunity for discovery. Resident Identified: #249. Facility census: 98.
Findings included:
a) Resident #249
On 03/14/22 at 11:35 AM, Resident #249's daughter stated that when her dad first came to the facility, (admitted on [DATE]) he was getting up in the big chair every day. However, when the new roommate was admitted on [DATE], staff have been putting the roommate in the chair. Observation found only one chair in the room. She went on to say her dad has been in the bed every day since the roommate was admitted on [DATE].
Observation on 03/14/22 at 11:40 AM, found Resident #249 was laying in his bed and the roommate was sitting in the reclining chair. The family member was setting in a folding mental chair.
On 03/14/22 at 12:45 AM, the Administrator was informed of the above findings. The administrator said the facility social worker would be going to the room to talk to the family.
On 03/14/22 at 3:30 PM, Social Worker (SW) #109 provided a grievance/concern form for Resident #249 regarding the above findings.
On 03/15/22 at 12:00 PM, Resident #249 was sitting in a chair.
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CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Assessment Accuracy
(Tag F0641)
Could have caused harm · This affected 1 resident
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Based on medical record review and staff interview the facility failed to complete an accurate minimum data set (MDS) assessment for one (1) of twenty-one (21) assessments reviewed during the Long T...
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Based on medical record review and staff interview the facility failed to complete an accurate minimum data set (MDS) assessment for one (1) of twenty-one (21) assessments reviewed during the Long Term Care Survey Process. The MDS for Resident #80 did not accurately reflect the resident's status for oxygen services. Resident identifier: #80 Facility census: 98
Findings included:
a) Resident #80
During a medical record review on 03/15/22, it was discovered the MDS assessment completed on 02/02/22 reflected Section O: Special Treatments did not indicate Resident #80 was receiving oxygen therapy. The current Physician's orders revealed oxygen was being provided at two (2) liters daily since 06/29/21.
An interview with the MDS Coordinator on 03/15/22 at 3:11 PM, verified the MDS assessment did not reflect Resident #80 was receiving oxygen therapy.
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CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0661
(Tag F0661)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on record review and staff interview, the facility failed to provide a discharge summary, communicating necessary inform...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on record review and staff interview, the facility failed to provide a discharge summary, communicating necessary information required for discharge, to the resident/responsible party when the resident was discharged to home. This was true for one (1) of three (3) residents reviewed for the care area of discharge during the long term care survey process. Resident identifier: #99. Facility census: 98.
Findings included:
a) Resident #99
Record review found the resident was admitted to the facility on [DATE]. The resident's care plan reflected the resident was to receive therapy and then return home. On 02/05/22, the resident was discharged home with his family.
On 03/15/22 at 10:24 AM, the Registered Nurse (RN) case manager, RN #86 confirmed no written discharge information, such as a list of the resident's medications, follow-up appointments, or any other information given to the resident or responsible party could be found.
On 03/15/22 at 10:48 AM, the Director of Nursing (DON) said she would look for the discharge summary.
On 03/15/22 at approximately 4:00 PM the above information was discussed with the administrator.
No further information was provided by the close of the survey on 03/16/22.
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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 and staff interview the facility failed to ensure the resident's environment over which it had control was as free from accident hazards as possible. The steam table, used for s...
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Based on observation and staff interview the facility failed to ensure the resident's environment over which it had control was as free from accident hazards as possible. The steam table, used for serving meals, was in operation and was unattended by facility staff. This was a random opportunity for discovery and had the potential to affect a limited number of residents. Facility Census: 98.
Findings included:
a) Steam table
On 03/15/22 at 10:20 AM, observation of the North dining room found the steam table, sitting in the corner of the dining room, was in use and no facility staff were present. The steam table was very hot when touched. The surveyor touched the steam table for about 10 seconds before having to remove her hand. The dials on the steam table were set on the highest level. Steam was rising from the pans containing food placed in the wells of the steam table. The doors to the dining room were wide open allowing access to any resident who wished to enter.
On 03/15/22 at 10:25 AM, Dietary Aide #78 was asked, how long has the steam table been turned on? Dietary Aide #78 stated the steam table is turned on at 5:30 AM and is not shut off until the evening meal is finished.
On 03/15/22 at 10:35 AM, the Maintenance Director (MD) #123 checked the temperature on the steam table with an infrared temperature gun. The temperature was 91 degrees Fahrenheit. MD #123 touched the steam table and said, it is hotter than that. MD #123 obtained another infrared temperature gun and tested the temperature again. At 10:40 AM, the temperature reading was 104 degrees Fahrenheit. The administrator and the Certified Dietary Manager (CDM) #120 were present when the second temperature was obtained. CDM #120 confirmed the steam table is turned on in the morning and is not turned off until after the evening meal.
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CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Incontinence Care
(Tag F0690)
Could have caused harm · This affected 1 resident
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Based on observation and staff interview the facility failed to perform catheter care according to professional standards of practice. This was true for one (1) of one (1) resident observed for cath...
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Based on observation and staff interview the facility failed to perform catheter care according to professional standards of practice. This was true for one (1) of one (1) resident observed for catheter care. Resident identifier: #91. Facility census 98.
Findings included:
a) Resident #91
A review of medical records revealed Resident #91 was recently was treated for a urinary tract infection.
During an observation of catheter care for Resident #91 on 03/16/22 at 9:10 AM, Nurse Aide (NA) #54, failed to use the folding technique while using the same washcloth for catheter care. NA#54 wiped around the base of the penis with the wash cloth. Then without using a clean part of the washcloth or using a clean wash cloth, NA #54 wiped the meatus, without holding the tubing at the meatus, using the same wash cloth. NA#54 wiped one quick pass down the tubing.
On 03/16/22 at 10:10 AM, the Administrator was informed of the above observations.
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CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
Could have caused harm · This affected 1 resident
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Based on observation, staff interview, and record review the facility failed to assure a resident received necessary respiratory care and services in accordance with professional standards of practi...
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Based on observation, staff interview, and record review the facility failed to assure a resident received necessary respiratory care and services in accordance with professional standards of practice. The Resident's humidifier was without humidification during oxygen use. This was a random opportunity for discovery. Resident identifier: #351. Facility Census: 98.
Findings included:
a) Resident #351
On 03/15/22 at 9:28 AM, observation found Resident #351's oxygen was with out humidification during use.
On 03/15/22 at 9:30 AM, Registered Nurse Case Manager (RNCM) #121 confirmed that Resident
#351's oxygen was running at 4L (liters) per face mask and the humidification water bottle was empty. RNCM #121 stated, the oxygen system is changed weekly and dated. The water bottles should be checked by each shift.
On 03/15/22 at 9:35 AM, Licensed Practical Nurse # 34 (LPN) acknowledged it is facility policy to change the oxygen system weekly and check the water used for humidification on each shift.
Facility Policy Labeled Oxygen Therapy, revised on 09/05/19 reads as follows:
.7. Assemble equipment according to resident's needs. Fill humidifier with H2O (water). Humidifier adds water vapor to the dry gas (oxygen) to reduce the drying and irritating effects .
.14. Oxygen rounds will be made by the nurse every shift and PRN (as needed). They will document in the treatment record
On 03/16/22 at 08:59 AM, the Director of Nursing acknowledged the humidification water bottle should be checked by the nurse on each shift.
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CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0921)
Could have caused harm · This affected 1 resident
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Based on observation and staff interview the facility failed to provide a safe and functional environment for residents. The blinds in the room was not able to be closed to provide privacy. This was...
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Based on observation and staff interview the facility failed to provide a safe and functional environment for residents. The blinds in the room was not able to be closed to provide privacy. This was a random opportunity for discovery. Resident Identifier # 1. Facility Census: 98.
Findings Included:
a) Resident #1
On 03/15/22 at 12:10 PM, this surveyor observed Resident #1 sitting in a chair with the window blinds closed. The blind slats were of different lengths and sizes, allowing view from the outside. Resident #1 could not obtain privacy in the room during personal care or rest .
On 03/14/22 at 12:19 PM, Licensed Practical Nurse (LPN) # 34 confirmed the blind slats were of two different lengths allowing view into room from outside even when closed.
On 3/14/22 at 1:10 PM, Maintenance Director # 123 acknowledged the blinds were unable to provide privacy to Resident #1.
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CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0697
(Tag F0697)
Could have caused harm · This affected multiple residents
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Based on record review and staff interview, the facility failed to identify, treat, monitor, and manage the resident's pain to the extent possible in accordance with current professional standards o...
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Based on record review and staff interview, the facility failed to identify, treat, monitor, and manage the resident's pain to the extent possible in accordance with current professional standards of practice. The effectiveness of as needed (PRN) pain medication was not assessed in a timely manner for one (1) of five (5) residents reviewed for unnecessary medications. Resident identifier: #77. Facility census: 98.
a) Resident #77
The facility's policy titled, Pain Management, with implementation date 01/01/22 stated residents' pain management would be reassessed for effectiveness at established intervals.
Review of Resident #77's medical records showed the resident was prescribed Tramadol, a pain medication, 50 mg, every six (6) hours as needed for pain. The resident also had an order for pain assessment every eight (8) hours.
Review of Resident #77's medication administration record (MAR) showed the resident was given Tramadol on 03/09/22 at 10:18 AM for a pain level of seven (7) on a scale from one (1) to ten (10), and nonverbal indications of pain, moaning, and restlessness. On 03/09/22 at 5:08 PM, Resident #77's MAR documented the medication was effective in relieving the resident's pain. According to the MAR, the pain follow-up was scheduled for 03/09/22 at 11:18 AM.
Further review of Resident #77's MAR showed the resident was given Tramadol on 03/10/22 at 9:10 PM for a pain level of 6 and restlessness. On 03/10/22 at 11:45 PM, a pain assessment documented the resident was not having pain. On 03/11/22 at 3:01 AM, Resident #77's MAR documented the medication was effective in relieving the resident's pain. According to the MAR, the pain follow-up was scheduled for 03/10/22 at 10:10 PM.
Further review of Resident #77's MAR showed the resident was given Tramadol on 03/12/22 at 10:41 AM for nonverbal indications of pain, moaning, grimacing, and restlessness. On 03/12/22 at 2:56 PM, a pain assessment documented the resident was not having pain. On 03/12/22 at 2:57 PM, Resident #77's MAR documented the medication was effective in relieving the resident's pain. According to the MAR, the pain follow-up was scheduled for 03/12/22 at 11:41 AM.
Further review of Resident #77's MAR showed the resident was given Tramadol on 03/14/22 at 10:04 AM for a pain level of 8 and nonverbal indications of pain, moaning and guarding. On 03/14/22 at 6:04 PM, a pain assessment documented the resident was not having pain. On 03/14/22 at 6:05 PM, Resident #77's MAR documented the medication was effective in relieving the resident's pain. According to the MAR, the pain follow-up was scheduled for 03/14/22 at 11:04 AM.
During an interview on 03/15/22 at 10:43 AM, the Director of Nursing (DON) confirmed pain was to be reassessed one (1) hour after administration of PRN pain medication, as stated on the MAR. She confirmed reassessment of Resident #77's pain was not documented an hour after PRN Tramadol administration.
No further information was provided through the completion of the survey.
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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
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on observation, staff interview, and record review, the facility failed to establish and maintain an infection preventio...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on observation, staff interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to help prevent the development and transmission of communicable diseases and infections. The facility failed to ensure: proper signage was on the door of a room that was in Transmission Based Precautions (TBP); inappropriate co-horting of a Resident with multidrug-resistant organism (MDRO); and failed to use a barrier while draining a catheter collection bag. In addition, proper infection control measures were not implemented for three (3) out of three (3) residents with dressing change observations. This had the potential to affect more than a limited number of residents residing at the facility. Resident identifiers: #249, #252, #48, #53, #91, #95, #85, and #9. Facility census 98.
Findings included:
a) Signage not on door on TBP
While interviewing a residents family member on 03/14/22 at 12:10 PM in room [ROOM NUMBER], Nurse Aide (NA) #7 came to the doorway and started putting on Personal Protection Equipment (PPE). NA#7 was asked why she was using PPE? At this time, it was pointed out to NA#7 there was no signage on the door indicating the need to wear PPE. NA# 7 was asked what type of PPE was to be used in the room and which of the two (2) residents residing in the room had an infection? NA #7 said, she was not sure and would go ask someone. After waiting for NA #7 return with information for 19 minutes, NA #7 was seen going in another Residents room.
During a brief interview on 03/14/22 at 12:29 PM, Licensed Practical Nurse (LPN) #13 was asked which resident was placed in TBP and what type of infection did the resident have? LPN #13 said she did not know. LPN #13 agreed there was no signage on the door. At this time the facility administrator joined in the conversation and stated the signs may have fallen off, and she would find the Infection Preventionist (IP) and find out.
On 03/14/22 at 12:38 PM, IP stated she was not working when the lab results came back for Resident #252 indicating the resident had a MDRO. However, she instructed the staff to place Resident #252 on contact precautions.
On 03/14/22 at 4:30 PM, the Administrator provided a copy of an inservice educating staff about ensuring signage on the doors are visible for all residents in TBP. This inservice was signed by all present staff.
b) Inappropriate co-horting for Resident #53 with Resident #48 with MRDO
While reviewing medical records for Resident #48, it was found that Resident #48 was positive for Methicillin-resistant Staphylococcus Aureus (MRSA) (this is a MDRO) on 02/28/22. The infection was located at the resident's at the tube feeding site. It was noted in the medical records the wound currently has active drainage.
A review of medical record revealed the (roommate) Resident #53 does not have an infection. The roommate does not have a history of MRSA or any other MDROs.
During an interview on 03/15/22 at 10:08 AM, Infection Preventionist (IP) nurse stated she did not have anyone that had the same MDRO as Resident #48, so she understands that in that case she would co-[NAME] with someone who does not have any MDROs. IP was asked if she has any criteria to follow for this type of co-horting? IP stated Resident #53 did meet the criteria to co-[NAME] with Resident #48.
On 03/15/22 at 10:47 AM, the IP provided the Centers for Disease Control (CDC) guidance that states it is preferred to co-[NAME] with like MDRO's or be in a private room. In addition, information from Association for Professionals in Infection Control and Epidemiology, the IP highlighted the following:
- Co-horting with a patient whose MRSA is unknown or who is negative for MRSA.
If a resident is placed with another resident who is at low risk for acquiring a MRSA infection. This type of placement is based on several factors, including whether the MRSA-positive roommate has:
* Open skin areas
During an interview on 03/16/22 at 8:10 AM, DON was shown documentation that Resident #53 did not meet the criteria to co-[NAME] with anyone with an MDRO because she had skin tears (open wounds that would be entry for infections for MDROs). The DON stated, well if that's the case no one could co-[NAME] because they (residents) all get skin tears.
Review of Resident #48's medical records revealed the following in nursing notes:
-03/04/22 at 11:54 PM, When staff was assisting Resident #53 to bed, they observed a bruise and skin tear to the right elbow. Resident had been up in her wheelchair, wheeling herself around in and out of other rooms. Resident was asked if she hit her elbow on a doorway and she said, yeah probably. Cleaned area and applied TAO (triple-antibiotic ointment) and steri-strips.
-03/05/22 at 7:42 PM, Skin tear and bruise to right elbow remain.
-03/06/22 at 7:41 PM, Bruise and skin tear remain to right elbow.
-03/07/22 at12:08 PM, Resident continues with her skin tear to her right elbow and steri-strips in place.
-03/08/22 at 12:34 PM, Resident has skin tear to her right elbow and has steri-strips in place.
-03/09/22 at 12:33 AM, Skin tear remains on right elbow.
During an interview on 03/16/22 at 8:55 AM, the IP agreed Resident #53 did not meet criteria to co-[NAME] with Resident #48. Stated she was not aware Resident #48 had any skin tears.
c) Failure to use a barrier during catheter care for Resident #91
Observation on 03/16/22 at 9:10 AM, revealed Nurse Aide #5 failed to place a barrier under the collection canister, while emptying the Foley catheter collection bag. After the care was completed, NA#5 admitted to forgetting to use a barrier.
The Administrator was informed of the above information on 03/16/22 at 10:00 AM.
d) Resident #95
During an observation of wound care for Resident #95 on 03/15/22 at 2:45 PM, Registered Nurse (RN)#121, failed to wipe the bed-side-table (which was visibly soiled) prior to placing a barrier on the table. RN #121 took a spray bottle of wound cleanser from the top of the treatment cart and hung it on the outside of her pocket, then placed the wound cleanser on a barrier. After the treatment was completed RN#121 removed the barrier and placed the spray bottle directly on the bed-side-table, before placing the spray bottle on the side of the treatment cart.
On 03/15/22 at 3:01 PM, RN #121 was asked if the spray bottle of wound cleanser was used for multiple residents? RN #121 replied, yes.
e) Resident #85
During an observation on 03/15/22 at 11:58 AM, Registered Nurse (RN)#121, was providing wound care for Resident #85. RN #121 failed to wipe the bed-side-table prior to placing a barrier on the table. RN#121 removed a spray bottle of wound cleanser from the side of the treatment cart and placed it on the barrier. After the care was completed, RN #121 removed the barrier and placed the spray bottle of wound cleanser directly on the bed-side-table, then placed the bottle on top of the treatment cart.
During an interview on 03/15/22 at 3:33 PM, with the Director of Nursing and RN #121, the failure to ensure wound care supplies are used and stored in a safe and sanitary manner was discussed: not cleaning the bed-side-tables prior to placing the barrier on the tables, and using the same bottle of wound cleanser on different residents after placing the spray bottle on multiple uncleaned residents' bed-side-tables, and cross contaminating the treatment cart.
f) Resident #9
On 03/15/22 at 11:11 AM, observation was made of Resident #9's pressure ulcer dressing change to her buttock. The dressing change was performed by Registered Nurse (RN) #121.
RN #121 entered Resident #9's room with the supplies for the dressing change. The RN placed a disposable barrier on the resident's overbed table but did not clean the table first. The RN placed a package with collagen and a package with border foam dressing on the barrier. RN #121 placed a bottle of wound cleanser directly on the resident's overbed table, not on the barrier. The RN also had a package of gauze pads. RN #121 poured some of the gauze pads from the package onto the barrier. The RN then placed the package with the remaining gauze pads directly on the resident's overbed table, not on the barrier.
Following the completion of the dressing change, RN #121 carried out the items that had been brought into Resident #9's room. The RN disposed of the barrier. The RN placed the bottle of wound cleanser in a storage area on the side of the treatment cart. The wound cleanser bottle was not wiped down, despite having been directly on the resident's overbed table. The package of gauze pads was placed on the top of the treatment cart.
During an interview on 03/15/22 at 3:33 PM, RN #121 was informed pathogens could have been spread from the resident's overbed table to the treatment cart by placing the items directly on the table and then returning them to the cart. Using these items for other residents also would place those residents at risk. RN #121 stated she understood.
No further information was provided through the completion of the survey.
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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.
- • 34% turnover. Below West Virginia's 48% average. Good staff retention means consistent care.
Concerns
- • 41 deficiencies on record. Higher than average. Multiple issues found across inspections.
- • Grade C (50/100). Below average facility with significant concerns.
Bottom line: Mixed indicators with Trust Score of 50/100. Visit in person and ask pointed questions.
✓ Report will be sent to your email
About This Facility
What is Princeton Health's CMS Rating?
CMS assigns PRINCETON HEALTH CARE CENTER an overall rating of 2 out of 5 stars, which is considered below average nationally. Within West Virginia, this rating places the facility higher than 0% of the state's 100 nursing homes. A rating at this level reflects concerns identified through health inspections, staffing assessments, or quality measures that families should carefully consider.
How is Princeton Health Staffed?
CMS rates PRINCETON HEALTH CARE CENTER's staffing level at 4 out of 5 stars, which is above average compared to other nursing homes. Staff turnover is 34%, compared to the West Virginia average of 46%. This relatively stable workforce can support continuity of care.
What Have Inspectors Found at Princeton Health?
State health inspectors documented 41 deficiencies at PRINCETON HEALTH CARE CENTER during 2022 to 2024. These included: 41 with potential for harm.
Who Owns and Operates Princeton Health?
PRINCETON HEALTH CARE CENTER is owned by a non-profit organization. Non-profit facilities reinvest revenue into operations rather than distributing to shareholders. The facility operates independently rather than as part of a larger chain. With 120 certified beds and approximately 113 residents (about 94% occupancy), it is a mid-sized facility located in PRINCETON, West Virginia.
How Does Princeton Health Compare to Other West Virginia Nursing Homes?
Compared to the 100 nursing homes in West Virginia, PRINCETON HEALTH CARE CENTER's overall rating (2 stars) is below the state average of 2.7, staff turnover (34%) is significantly lower than the state average of 46%, and health inspection rating (3 stars) is at the national benchmark.
What Should Families Ask When Visiting Princeton Health?
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 Princeton Health Safe?
Based on CMS inspection data, PRINCETON HEALTH CARE 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 2-star overall rating and ranks #100 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 Princeton Health Stick Around?
PRINCETON HEALTH CARE CENTER has a staff turnover rate of 34%, 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 Princeton Health Ever Fined?
PRINCETON HEALTH CARE 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 Princeton Health on Any Federal Watch List?
PRINCETON HEALTH CARE 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.