How many inspection deficiencies does HAMPSHIRE CENTER have?

HAMPSHIRE CENTER has 46 deficiencies from recent inspections. None are at the Immediate Jeopardy level.

What are the staffing levels at HAMPSHIRE CENTER?

HAMPSHIRE CENTER has a three-star staffing rating from CMS with 0.66 RN hours per resident per day. This rating is based on registered nurse (RN), licensed practical nurse (LPN), and nurse aide staffing hours.

Where is HAMPSHIRE CENTER located?

HAMPSHIRE CENTER is located in ROMNEY, WV. It is a Medicare and Medicaid certified skilled nursing facility.

How many beds does HAMPSHIRE CENTER have?

HAMPSHIRE CENTER has 62 certified beds.

Who owns HAMPSHIRE CENTER?

HAMPSHIRE CENTER is a for profit - corporation facility and is part of the GENESIS HEALTHCARE chain.

What questions should families ask when visiting HAMPSHIRE CENTER?

Families visiting HAMPSHIRE CENTER should ask about daily routines, communication with families, how they handle medical emergencies. Also ask to speak with current residents or families, tour during mealtime, and request a copy of the most recent inspection report.

How does HAMPSHIRE CENTER compare to other nursing homes?

HAMPSHIRE CENTER has a 3-star overall rating, which is average compared to other nursing homes in WV. Consider visiting multiple facilities before making a decision.

HAMPSHIRE CENTER

Name: HAMPSHIRE CENTER
Address: 260 SUNRISE BOULEVARD, ROMNEY, WV, 26757, US
Telephone: (304) 822-7527
Rating: 3.0

260 SUNRISE BOULEVARD, ROMNEY, WV 26757 · (304) 822-7527

For profit - Corporation 62 Beds GENESIS HEALTHCARE Data: November 2025

Trust Grade

60/100

#47 of 122 in WV

Share this report:

HAMPSHIRE CENTER nursing home in ROMNEY, WV - Photo 1 of 5

HAMPSHIRE CENTER nursing home in ROMNEY, WV - Photo 2 of 5

Photo by Hampshire Center

HAMPSHIRE CENTER nursing home in ROMNEY, WV - Photo 3 of 5

Photo by Hampshire Center

HAMPSHIRE CENTER nursing home in ROMNEY, WV - Photo 4 of 5

Photo by Hampshire Center

HAMPSHIRE CENTER nursing home in ROMNEY, WV - Photo 5 of 5

1 / 5 photos

Last Inspection: January 2024

Within standard 12-15 month inspection cycle. Federal law requires annual inspections.

Overview

Hampshire Center in Romney, West Virginia has a Trust Grade of C+, indicating it is decent and slightly above average compared to other facilities. It ranks #47 out of 122 in the state, placing it in the top half, and is #1 out of 2 in Hampshire County, meaning it is the best local option. Unfortunately, the facility is currently worsening; the number of issues reported rose significantly from 11 in 2022 to 30 in 2024. Staffing is a relative strength, with a turnover rate of 37%, which is below the state average of 44%, but RN coverage is only average. While there are no fines on record, which is positive, there are concerning incidents such as a lack of privacy during showers, failure to follow physician's orders for wound care, and serving meals at inappropriate temperatures, indicating areas that need improvement. Overall, families should weigh the strengths of staffing and absence of fines against the recent decline in quality and specific care issues.

Trust Score: C+
In West Virginia: #47/122
Safety Record: Low Risk
Inspections: Getting Worse
Staff Stability: 37% turnover. Near West Virginia's 48% average. Typical for the industry.
Penalties: No fines on record. Clean compliance history, better than most West Virginia facilities.
Skilled Nurses: Each resident gets 39 minutes of Registered Nurse (RN) attention daily — about average for West Virginia. RNs are the most trained staff who monitor for health changes.
Violations: 46 deficiencies on record. Higher than average. Multiple issues found across inspections.

★★★☆☆

3.0

Overall Rating

★★★☆☆

3.0

Staff Levels

★★★☆☆

3.0

Care Quality

★★★☆☆

3.0

Inspection Score

↔

Stable

2022: 11 issues

2024: 30 issues

The Good

Full Sprinkler Coverage · Fire safety systems throughout facility
No fines on record
Staff turnover below average (37%)
11 points below West Virginia average of 48%

Facility shows strength in fire safety.

The Bad

3-Star Overall Rating

Near West Virginia average (2.7)

Meets federal standards, typical of most facilities

Staff Turnover: 37%

Near West Virginia avg (46%)

Typical for the industry

Chain: GENESIS HEALTHCARE

Part of a multi-facility chain

Ask about local staffing decisions and management

The Ugly 46 deficiencies on record

Aug 2024 13 deficiencies

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Investigate Abuse (Tag F0610)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, and staff interview, the facility failed to do a complete and thorough investigation on a possible resident to resident altercation resulting in death. This failed practice had the potential to affect more than a limited number of residents. Resident identifiers #63 and #35. Facility Census 62. Findings Included: a) Resident # 63 A record review on 08/13/24 at 9:00 AM, of Resident # 63's E Interact Change in Condition dated 01/20/24 read as follows: Another resident grabbed at this resident's sleeve and this resident lost balance and fell down. Resident landed on buttocks and the staff member caught head in hands before hitting the floor. Four staff members witnessed the fall. Further record review revealed another E Interact Change in Condition form dated 02/14/24 that read as follows: Found resident on floor in room [ROOM NUMBER], blood noted from back of head. Helmet, elbow pads, and hip pads on. 911 called, neck supported by nurse. Helmet removed. Further Record review revealed an Interdisciplinary team (IDT) note that lists staff in attendance and reads as follows: Resident found on floor by staff in room [ROOM NUMBER]. Helmet, elbow pads and hip pads in place as ordered when found. Bleeding noted underneath the helmet. Helmet removed by staff and neck supported by nurse. Blood noted on the floor from the posterior head wound. 911 called and the resident was transported immediately via ambulance to (local hospital named). Resident returned from hospital with a CVA and cerebral hemorrhage diagnosis. Resident has 4 staples to the back of head with minimal bleeding noted. Resident now on comfort care due to decline in condition . No response to stimuli noted. Several interventions were removed from the care plan due to resident state. Most interventions do not apply to resident currently due to recent diagnosis. According to the (5) five day follow up Resident #36 passed away from the head injury on 02/16/24. b) Resident #35 A record review on 08/13/24 at 9:10 AM of Resident #35's E Interact Change in Condition form dated 01/20/24 reads as follows: Resident saw another resident attempting to converse with a third resident. This resident attempted to stop another resident from conversing with the third. She grabbed the sleeve of the resident attempting conversation. That resident lost balance and fell. Four staff members witnessed an altercation. Further record review revealed an E Interact Change in Condition form dated 02/15/24 that reads as follows: Another resident was observed on the floor in Resident #35's room on 02/24/24. Resident #35 originally reported to staff She fell. Later Resident #35 stated to staff I did it, thief [sic] Staff did not witness the incident. Neither resident demonstrates capacity. Other resident was transferred to hospital for evaluation. A review of the (5) five day follow up on the incident Resident # 35 was put on 15 minute checks for 72 hours. c) The investigation A review of the five day followup on 08/13/24 at 12:30 PM, revealed that no staff or residents had been interviewed for the incident resulting in death. During an interview 0n 08/14/24 at 1:00 PM, The Director of Nursing stated, There were no witnesses. The residents shared a bathroom and we are assuming she came in through the bathroom door. Neither resident could tell us what happened. When the surveyor asked why staff was not interviewed, The DON stated, Because no one saw the fall. I was told by the corporate to put the Change in Condition in for (Resident #35 named) just because she had said that and I guess for precaution.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Comprehensive Care Plan (Tag F0656)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review and staff interview, the facility failed to implement an intervention regarding pressure ulcers for Resident #54 and implement an intervention of wearing personal protective equipment (PPE) for Resident #50. This was true for two (2) of 16 residents reviewed during the survey process. Resident Identifiers: #54 and #50. Facility Census: 62. Findings Included: a) Resident #54 On 08/13/24 at 11:00 AM, a record review was completed for Resident #54. The review found the resident was receiving wound care for an unstagable pressure ulcer on the left heel. The care plan was reviewed regarding the wound care and pressure ulcer. The care plan listed an intervention of assist resident in turning and repositioning every 1 (one) hrs (hours) and PRN (as needed). The Director of Nursing (DON) was interviewed regarding this intervention on 08/13/24 at 1:00 PM. At this time, the DON was asked where is the documentation of the one (1) hour turning and repositioning? The DON stated, there is no documentation to verify this intervention was completed. b) Resident #50 On 08/14/24 at 5:07 PM, an observation of Nurse Aide (NA) #71 and NA #17 entering room [ROOM NUMBER] without wearing the appropriate PPE for enhanced barrier precautions for Resident #50 due to an indwelling medical device (feeding tube). At this time, the resident stated, he needed changed. When a resident is under enhanced barrier precautions, the nurse aides should have worn a gown and gloves while performing high contact activities. On 08/14/24 at 5:11 PM, both NA #71 and #17 were asked, Isn't the resident on enhanced barrier precautions? NA #17 stated, no .there isn't a cart in front of his door. Signage was posted on the door stating enhanced barrier precautions were in place. On 08/14/24 at 5:35 PM, the DON was notified. The DON stated, they know there is only one cart on each hallway .they know.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0657 (Tag F0657)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

. Based on record review and staff interview, the facility failed to update a care plan regarding an actual fall for Resident #42. This was true for one (1) of three (3) residents reviewed during the survey process. Resident Identifier: #42. Facility Census: 62. Findings Included: a) Resident #42 On 08/14/24 at 9:20 AM, a record review was completed for Resident #42. The review found the resident had an actual fall on 07/10/24 due to the bathroom floor being slippery from powder which is being used with another resident who shares the bathroom. The care plan was reviewed at this time. The care plan focus area stated, Resident is at risk for falls, R/T (related to) Weakness, Osteoarthritis, Chronic Pain, HTN (hypertension). The need for assistance with ADLs, (activities of daily living) use of meds (medications) that could cause drowsiness/dizziness. On 08/14/24 at 9:48 AM, the Director of Nursing was notified the care plan had not been revised to show an actual fall had occurred on 07/10/24. The DON stated, the care plan has not been revised to show an actual fall.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

ADL Care (Tag F0677)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

. Based on observation, record review, and staff interview, the facility failed to provide Activities of Daily Living (ADL) care to dependent residents. This failed practice was found true for (1) one of (4) four residents reviewed for ADL care during the survey process. Resident identifier #50. Facility Census 62. Findings Included: a) Resident #50 During an Observation on 08/14/24 at 5:00 PM, Resident #50's call light came on. Further observation at 5:10 PM, shows Resident #50's call light continues to be on. During an interview on 08/14/24 at 5:15 PM, Resident #50 stated, I need changed, I feel wet. An observation on 08/14/24 at 5:16 PM, shows Nurse Aide (NA) #71 and NA #17 entering Resident #50's room. The NA's asked Resident #50 what he needed. Resident #50 stated, I want changed NA #17 stated, I'll be back in a few minutes with your tray. The call light was then turned off and NA #71 and #17 walked out of the room. At 5:18 PM, the surveyor intervened and asked NA #71 what Resident #50 needed? NA #71 stated, Oh, I didn't hear what he said, he usually wants coffee. During an interview on 08/14/24 at 5:40PM, The Director of Nursing (DON) stated, They know better than that. The DON confirmed that Resident #50 should have been provided incontinence care when he needed it. A record review on 08/14/24 at 6:00 PM, revealed a care plan that reads as follows: Focus: · Resident requires assistance for ADL care related to CVA with monoplegia, weakness, left BKA, left knee contracture, arthritis, Goal: · Will be limited assist with 2 or more ADLs by next review. Interventions: · Encourage resident participation with ADL care. See ADL flowsheets for current level of support provided. Independent with eating and locomotion. Extensive to dependent with bathing. Extensive with transfers. Limited to extensive with remaining ADLs. Independent to extensive with toileting. Not currently walking. ·Resident has a left knee contracture. · Stand on weaker side of resident (left) when assisting with ADLs or other activities. · Bed rail(s) used as an enabler.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0679 (Tag F0679)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, record review and staff interview, the facility failed to provide an ongoing program of activities to meet the needs and interest of the residents. This was a random opportunity for discovery during the survey process. Resident identifier #36. Facility Census 62. Findings Included: a) Resident #36 An observation on 08/12/24 at 12:20 PM, showed Resident #36 eating her lunch in a common area in front of the nurses station. Further observation showed Resident #36 continuing to sit in the common area in front of the nurse's station with no television and/or music on at 1:30 PM, 1:45 PM, 2:25 PM and 3:00 PM. An observation on 08/13/24 at 8:30AM showed Resident #36 eating her breakfast in a common area in front of the nurses station. Further observation of Resident #36 at 10:00AM revealed Resident #36 crying in the common area in front of the nurses station. No Television/music was on at this time. Resident #36 continues to be in the common area at 11:00 AM and still appears to be upset. Resident #36 was eating her lunch in the common area at 12:25 PM. Further observation on 08/13/24 of Resident # 36 showed her asleep in her wheelchair in the common area in front of the nurses station from 1:30 PM to 3:30 PM A record review on 08/13/24 at 12:00 PM, of Resident #36's activity care plan reads as follows: Focus: Resident exhibits or is at risk for limited and/or meaningful engagement related to: Cognitive loss/dementia. Goal: Resident will increase level of participation in activities as evidenced by: increased socialization, increased verbalization of satisfaction in involvement, increased attendance and participation. Intervention: · ( Resident #36 name ) prefers to be called [NAME]. · Encourage ( Resident #36 name) participation in activity preferences such as church service. · Provide (Resident #36 name) with opportunities for choice during care/activities to provide a sense of control. · Provide and review calendar/daily flow with [NAME]/patient/family to identify interests and preferences. · Invite and assist patient, as needed, to activities of interest. · Establish a relationship with ( Resident # 36 name) using informal conversations and/or small groups to foster resident trust and an environment where resident feels comfortable expressing interests and participating in activity. · Encourage family/friend's support and involvement in facility based activities and opportunities · Provide appropriate cueing through physical prompt, physical assist, verbal direction, etc.) to enable successful participation in activity. · Remiove physical barriers that prevent [NAME] from participating in daily routines and/or preferred activities. Further record review of Resident #36's Minimum Data Set (MDS) section F, with an Assessment Reference Date (ARD) of 03/08/24 was marked it is important to resident to participate in group activities and that it is important for resident to do things with groups of people. A record review of the MDS section F with an ARD of 07/08/24 is marked not assessed for the entire section. A review of Resident #36's activity participation records for the months of 06/2024, 07/2024, and 08/2024 shows there are a lot of A's to show active participation in individual activities Resident #36 is not physically or cognitively able to participate in. Such as the following: Exercise/sports/walking/wheeling. It is also marked individual activity for watching or listening to TV/Movies when surveyors made multiple observations of none of these activities being provided. Further record review of Resident #36's MDS with an ARD of 07/08/24, section C shows a Brief Interview of Mental Status (BIMS) score of 3. Section GG reveals that Resident #36 is not able to propel herself in the wheelchair. During an interview on 08/14/24 at 2:38 PM, the Activity Director (AD) stated, There are days where she (Resident #36), thinks someone is out to get her. Her participation has gone down. I do have her on the forget me not group. But she didn't come today. She confirmed, Resident #36 had been sitting in the common area across from the nurses station for (2) two days.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0688 (Tag F0688)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

. Based on observation, resident interview and staff interview, the facility failed to provide appropriate treatment to prevent further decrease in range-of-motion for Resident #11. This was a random opportunity for discovery. Resident Identifier: #11. Facility Census: 62. Findings Included: a) Resident #11 On 08/14/24 at 3:30 PM, an interview was held with Resident #11. During the interview, Resident #11 stated, I had my shower earlier and they didn't put my splint on my hand (right). On 08/14/24 at 4:00 PM, a record review was completed for Resident #11. The review found a physician's order stating, SoftPro resting hand splint (WHFO) (wrist/hand/finger orthosis) to be applied to right hand in the morning, when patient is in her wheelchair, and to be removed in the evening, at bedtime. Skin checks to be performed pre/post WHFO application two times a day. On 08/14/24 at 5:04 PM, an additional observation of Resident #11 was made. The resident did not have the resting splint on her right hand. On 08/14/24 at 5:07 PM, an interview was held with Nurse Aide (NA) #71. The NA was asked, does the resident normally wear a splint on her right hand? NA #71 stated, she usually doesn't wear one. On 08/14/24 at 5:09 PM, Registered Nurse (RN) #41 confirmed the resident does have a physician's order for the splint to be applied to the right hand. On 08/14/24 at 5:30 PM, the Director of Nursing (DON) was notified. The DON confirmed the resident should be wearing the splint to the right hand to prevent further decrease in range-of-motion.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Accident Prevention (Tag F0689)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

. Based on observation, record review, resident interview and staff interview, the facility failed to ensure the resident environment, over which it has control, was as free from accident hazards as possible. This was a random opportunity for discovery. Resident Identifier: #9. Facility Census: 62. Findings Include: a) Resident #9 On 08/12/24 at 9:00 AM, the initial interview was held with Resident #9. Observations made during the interview, found multiple medications sitting on the over-the-bed table and laying on the resident's bed. Resident #9 was asked, are you allowed to have these medications in your room? The resident responded, it is okay .it is no big deal. On 08/12/24 at 9:28 AM, Registered Nurse (RN) #41 entered into the resident's room. RN #41 was asked, why does the resident have medication laying around his room? RN #41 stated, I don't know why the medication is in here .I didn't know anything about it. On 08/12/24 at 9:40 AM, the Director of Nursing (DON) was interviewed regarding the medication found in Resident #9's room. The DON stated, We don't know what he has .his family brings it in .we offered a lock box but we have to keep a key and (Resident's name) refused . On 08/12/24 at 9:55 AM, the Administrator was interviewed regarding the medication found in the resident's room. The Administrator stated, (Name of Resident) is a difficult resident .he does what he wants .I am banned from his room. The medications found in the resident's room on 08/12/24 at 9:00 AM are as follows: -- One (1) Incruse Ellipta Inhaler --Two (2) Advair Inhalers --Two (2) Mucinex Nasal Sprays --One (1) bottle of Visine Eye Drops --One (1) tube of Absorbine Muscle Rub --One (1) roll on bottle of Biofreeze --One (1) bottle of Liquid Antidiarrheal Medication --One (1) bottle of Gas X After further review of the medical record, the resident did not have a physician's orders for any of the above medications. An interview was held with the DON on 08/13/24 at approximately 1:00 PM. The DON stated, I have talked with the physician and he is not going to give physician's orders for the medication found in the resident's room. The physician feels the resident has enough as needed medication available. The DON was asked, are there any wanderers in the facility? The DON stated, Name of Resident #48. The DON was then asked, do you not feel this is a safety issue? The DON stated, no (the Name of Resident #9) would not allow anyone to take anything out of his room. The DON was then asked, how would a resident who is unable to ambulate stop an ambulatory resident? The DON stated, he would not allow it.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0712 (Tag F0712)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review, resident interview and staff interview, the facility failed to ensure physician's visits were completed every 30 days for the first 90 days for Resident #9. This was a random opportunity for discovery. Resident Identifier: #9. Facility Census: 62. Findings Included: a) Resident #9 On 08/12/24 at 9:00 AM, an interview was held with Resident #9. The resident stated, I want to talk to the physician about certain things and I can never see him .it's usually the nurse practitioner .sometimes it's things I want to discuss with a physician. On 08/12/24 at 11:30 AM, a record review was completed for Resident #9. The findings of the review were unclear as to when the facility physician visited the resident versus the nurse practitioner. The DON was asked for a list of the provider's visits to Resident #9. The resident was admitted to the facility on [DATE]. The physician's visits were as follows: --02/22/23 --03/22/23 --05/25/23 --06/22/23 --09/10/23 --11/26/23 --01/21/24 The physician's visits were reviewed and found the visit in April, 2023 was not completed by the facility physician. On 08/13/24 at approximately 10:00 AM, the Director of Nursing (DON) was asked for a policy relating to when the facility physician should visit the residents. The information provided for the state of [NAME] Virginia stated the following: the initial visit should have a completed H&P (History & Physical) within 5 (five) days prior to admission or within 72 hours following admission; and the follow up visits should be every 30 days for the first 90 days . On 08/13/24 at 2:00 PM, the DON was notified of the missing physician's visits. The DON stated, I didn't realize the resident was not seen by the physician.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Infection Control (Tag F0880)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview and record review the facility failed to provide an effective infection control program which meets current standards of practice. This failed practice was found true for (3) of (3) residents reviewed for infection control practices during the survey process. Resident identifiers #9, #54, and #50. Facility Census 62. Findings included: a) Resident #9 During an observation on 08/12/24 at 9:45 AM, of Resident #9's bathroom revealed (2) two bed pans were in the bathtub, (1) one of the bed pains had small droppings of a brown substance in it and liquid was in the corners. The commode had Urine in it with a black ring around the top of the urine. Mixed vegetables were found on top of the stopper in the sink. During an interview on 08/12/24 at 9:50 AM, Resident #9 stated, They never clean that stuff up. They just come and do it as fast as they can. During an interview on 08/12/24 at 10:00 AM The Director of Nursing (DON) stated, Yes, this shouldn't be like this. I will get it taken care of. b) Resident #54 On 08/14/24 at 10:30 AM, wound care was observed for Resident #54 completed by Registered Nurse (RN) #41. During the wound care, RN #41 would complete hand hygiene but then open the bathroom door with bare hands to retrieve gloves. This happened three (3) times during the wound care observation. The first time was after placing a barrier on the over-the-bed table; the second time was after removing the soiled dressing; and lastly, after cleansing the wound. On 08/14/24 at 9:45 AM, RN #41 was advised of the infection control breach. RN #41 stated, I should have had the gloves available so I wouldn't have had to open the bathroom door. On 08/14/24 at 11:00 AM, the Director of Nursing (DON) and the Administrator were notified. The DON stated, she was very nervous. c) Resident #50 On 08/14/24 at 5:07 PM, an observation of Nurse Aide (NA) #71 and NA #17 entering room [ROOM NUMBER] without wearing the appropriate personal protective equipment (PPE) for enhanced barrier precautions for Resident #50 due to an indwelling medical device (feeding tube). At this time, the resident stated, he needed changed. When a resident is under enhanced barrier precautions, the nurse aides should have worn a gown and gloves while performing high contact activities. On 08/14/24 at 5:11 PM, both NA #71 and #17 were asked, Isn't the resident on enhanced barrier precautions? NA #17 stated, no .there isn't a cart in front of his door. Signage was posted on the door stating enhanced barrier precautions were in place. On 08/14/24 at 5:35 PM, the DON was notified. The DON stated, they know there is only one cart on each hallway .they know.

CONCERN (E) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0583 (Tag F0583)

Could have caused harm · This affected multiple residents

Read full inspector narrative →

. Based on observation, and staff interview, the facility failed to provide privacy to residents when providing assistance for showers. This was a random opportunity for discovery during the Survey process. Resident identifier #8. Facility Census 62. Findings Included: a) Resident #8 An observation on 08/12/24 at 9:45 AM, of the shower room located on hall 200 revealed the shower room had no lock or in use signage. Noticing there was no sign or lock the Surveyor knocked on the door. There was no answer, so the Surveyor entered the shower room. Further observation of the shower room revealed Nurse Aide (NA) #38 standing undressing Resident #8, who only had a brief on at this time. During an interview on 08/12/24 at 9:50 AM, NA #59, Stated, We just usually knock. I agree there isn't much privacy. During an interview on 08/12/24 at 10:00 AM, The Administrator stated, Well, us who work here know when shower time is. We just usually know when it is in use. The Administrator confirmed that there was no lock on the door, or in use signage.

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

Quality of Care (Tag F0684)

Could have caused harm · This affected multiple residents

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, record review and staff interview, the facility failed to follow physician's orders regarding wound care for Resident #9 and #36, follow a physician's order regarding adaptive equipment for Resident #8, and completing an intervention per the physician for a possible resident to resident altercation for Resident #35. This was true for three (3) of 16 residents reviewed during the survey process. Resident Identifiers: #9, #36, #8 and #35. Facility Census: 62. Findings Included: a) Resident #9 On 08/13/24 at 10:30 AM, a record review was completed for Resident #9. The review found physician's orders were not being followed regarding treatments, including wound care. The following physician's orders were not completed on the following dates: --Clotrimazole-Betamethasone External Cream 1-0.05% apply to affected area topically every day shift for itching. --06/20/24 --07/02/24 --07/10/24 --Hydrocortisone External Cream 1% apply to affected areas topically every day and evening shift for itching/rash. --06/20/24 --07/02/24 --07/10/24 Kerlix Gauze Roll Large Miscellaneous apply to peri-anal topically every days shift for surgical wound. Moisten with saline and pack wound. Cover with bordered gauze. --06/20/24 --07/02/24 --07/10/24 Lidocaine External Cream 3% apply to affected area topically every day shift for pain. --06/20/24 --07/02/24 --07/10/24 Triad Hydrophilic Wound Dress External Paste apply to affected areas topically every day shift for wound care. --06/20/24 --07/02/24 --07/10/24 On 08/14/24 at 1:00 PM, the Director of Nursing (DON) was notified. The DON confirmed the treatment orders were not followed. b) Resident #36 An observation on 08/13/24 at 10:30AM, revealed, Resident #36 had a bandage on her left shin dated 08/11/24. A record review on 08/13/24 at 11:00 AM, of Resident #36's orders revealed an order which read as follows: Skin tear: Cleanse left shin with Skintegrity Wound Cleanser and apply Sureprep No-Sting to periwound skin and adhesive contact area. Approximate edges when possible with moistened swab. Apply Optifoam Gentle. Every day shift. The Director of Nursing (DON) confirmed, the bandage was dated for 08/11/24 and had not been changed as ordered on 08/12/24. c) Resident #8 During an observation on 08/12/24 of the noon meal, Resident #8 was eating lunch and had pink liquid in a regular cup. Resident #8's meal ticket read: Provide [NAME] Cup with all meals. During an interview on 08/12/24 at 12:15 PM, NA #12 stated, Usually on the hall if they have that cup they are on their tray. I don't know why they don't do it that way in the dining room. I am really not sure. I am new here. I will get her the cup. She confirmed, Resident #8 did not have the Kennedy cup as ordered. A record review on 08/12/24 at 1:00 PM revealed an order for Resident #8 which read as follows: Kennedy cup with all meals. d) Resident #35 A record review on 08/14/24 at 10:30 AM of Resident # 35's E Interact Change in Condition form dated 02/15/24 revealed, she had a possible altercation with another resident. The (5) five day follow up revealed, she was put on 15 minute checks for 72 hours. Further record review showed, the 15 minute checks were completed on 02/15/24 and 02/16/24 but no 15 minute checks could be found for 02/17/24. On 08/14/24 at 11:00 AM, The DON confirmed, the 15 minute checks for Resident #35 had not been completed for the full 72 hours.

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

Food Safety (Tag F0812)

Could have caused harm · This affected multiple residents

Read full inspector narrative →

. Based on observation and staff interview, the facility failed to serve meals at a palatable temperature. This failed practice was a random opportunity for discovery and had the potential to affect more than a limited number of residents during the survey process. Resident identifiers #54 and #60. Facility Census 62. Findings Included: a) Food temperatures Resident #53 and #60 According to the meal timesheet hall 400 trays were brought out to the hallway at 7:45 AM During an observation on 08/13/24 at 8:00 AM, of hallway 400 it was revealed, Resident #54 and #60 were sitting in the hallway in reclining wheelchairs and their breakfast meal trays were still on the food cart. No staff were noted to be nearby and were down hall 200 passing breakfast trays. Further observation at 8:10AM of hallway 400 showed that Residents #54 and #60's breakfast trays were still on the food cart and no staff were present on the hallway. During an interview on 08/13/24 at 8:25 AM, while Residents #54 and #60's food was still on the meal cart, Nurse Aide (NA) #69 stated, We pass all trays on all halls first and then go back and assist them. During an observation on 08/13/24 at 8:26 AM, The Certified Dietary Manager (CDM) checked the temperature of Resident #54's breakfast tray at the surveyors request. The food temperature was as follows: Puree sausage: 83.3 degrees Fahrenheit (F) Puree pancakes: 90.5 degree F. Oatmeal: 94.1 degrees During an interview on 08/13/24 at 8:30 AM, The CDM stated, Serving temperature should be 145 degrees. I think the danger zone is 41 to 135 degrees. I will get them another tray. A review of Healthcare services Group Policy titled [Food Distrubution} on 08/13/24 at 10:00 AM, number (6) six reads as follows: Proper food handling techniques to prevent contamination and temperature maintenance controls will be used for point-of-service dining. Further policy review of the policy titled {Food: Preparation} Number 11, 12 and 13 reads as follows: 11. When hot pureed, ground or diced food drops into the danger zone (below 135 degrees F.), the mechanically altered food must be reheated to 165 degrees F for 15 seconds if holding for hot service. 12. When reheating foods will be rapidly heated to 165 degree F. for 15 seconds. If the food is not reheated within (2) two hours it must be discarded. 13. All foods will be held at appropriate temperatures, greater than 135 degrees F. (or as state regulation requires) for hot holding, and less than 41 degrees F for cold food holding.

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

Medical Records (Tag F0842)

Could have caused harm · This affected multiple residents

Read full inspector narrative →

. Based on record review and staff interview, the facility failed to provide an accurate and complete record for an acute transfer for Resident #9 and meal intake for Resident #8. This was true for two (2) of 16 residents reviewed during the survey process. Resident Identifiers: #9 and #8. Facility Census: 62. Findings Include: a) Resident #9 On 08/12/24 at 12:00 PM, a record review was completed for Resident #9. The review found the resident had been transferred to an acute care facility on 02/22/24 . The transfer form listed the date as 07/08/23. On 08/12/24 at 12:30 PM, the Director of Nursing was notified of the incorrect transfer date. The DON stated, I will have to look into this. b) Resident #8 During a record review on 08/14/24 at 12:30 PM of Resident #8's meal intake from 06/16/24 to 08/12/24, it revealed that out of a possible 174 meals, 42 of those had no documentation. 0n 08/14/24 at 2:07PM the Nursing Home Administrator confirmed the meal intakes were not documented properly.

Jan 2024 17 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

Read full inspector narrative →

. Based on observation record review and staff interview, the facility failed to ensure residents were treated with dignity and respect. These failed practices were a random opportunity for discovery and were true for Resident #9. Resident identifier: #9. Facility census: 59. Findings included: a) Resident #9 During the interview process of the survey on 01/15/24 at 8:10 AM. Upon entering the room, it was noted the roommate in the bed beside the window was almost finished with his breakfast. His tray was empty except for a fourth of the egg toast sandwich he was eating. While Resident #9 was trying to blindly reach for food on the tray, because the tray was not placed in front of him and was above his eye level. Resident #9 found a prepackaged cup of juice. Resident #9 was observed trying to open it for eight (8) minutes. He tried to push his finger through the top, he tried to bite it open, and then he used a spoon and finally got a hole in the top of it by using the handle of the spoon. Resident #9 drank the juice from the small hole. On 01/15/24 at 8:48 AM, Resident # 9 had managed to move the plate cover enough to get what appeared to be scrambled eggs with his fingers. On 01/15/24 at 8:51 AM, Nurse Aide #75 was asked if Resident #9 was positioned correctly to eat. NA #75 stated, no he was not and walked halfway down the hall to a nurse and another nurse aide standing at the medication cart. Moments later Licensed Practical Nurse (LPN) #3 yelled down the hall towards this surveyor, He's a feeder! NA #75 returned and stated, He is a feeder. NA #75 was asked who was going to help Resident #9 eat. NA# 75 said, NA #7 was the one to feed him as she pointed to the NA standing beside LPN #3. NA #7 came to assist Resident #9 on 01/15/24 at 9:02 AM. NA# 7 stood on the right side of the bed and did not sit down. NA #7 was asked if she would normally sit or stand while assisting this resident. NA #7 replied, There is not a chair in here as you can see. A review of the medical records for Resident #9 found there was not an order for assistance for meals. The care plan read as follows: * Monitor for changes in nutritional status (changes in intake, ability to feed self, unplanned weight loss/gain, abnormal labs) and report to food and nutrition/physician as indicated. On 01/17/24 at 11:09 AM the Director of Nursing (DON) was informed of the above events. The DON stated, the NA's have been re-educated about leaving the tray in the room without setting it up for the resident. The DON provided no more information at the conclusion of this survey. .

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0604 (Tag F0604)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

Based on observation, resident interview, medical record review and staff interview, the facility failed to ensure residents were free from physical restraints and evaluate resident's ability to remove physical restraints easily. This was true for two (2) of two (2) residents reviewed for restraints. Resident Identifier: #51 and #49. Facility census: 59. Findings included: a) Resident #51 Observed Resident #51 up in a Broda wheelchair with a thigh strap restraint in place and buckled in the back of the chair, on 01/15/24 at 9:08 AM. A second observation on 01/16/24 at 8:36 AM found Resident #51 up in chair with thigh strap restraint in place. A review of Resident #51's medical record on 01/16/24 at 10:32 AM found no physician's order for a Broda wheelchair with thigh positioning device/restraint. Continued review of the admission Minimum Data Set (MDS) with an Assessment Reference Date of 11/20/23. Section P, Restraints and Alarms, indicated no physical restraints were used. The Brief Interview for Mental Status (BIMS) scored a 1, which indicated severely impaired cognition. Subsequent review revealed the care plan was not developed for a Broda Wheelchair with thigh strap positioning device/restraint. On 01/16/24 at 12:49 PM during an interview with the Therapy Director they verified Resident #51 could not release the thigh strap device on her own. She stated it latches behind the chair. During an interview, on 01/16/24 at 1:08 PM, the Director of Nursing (DON) stated they do not document every two (2) hours for resident checks because they feel it is in place for a positioning device. She did verify Resident #51 would not be able to release the thigh strap, and it did hold her in the chair to keep her from falling. b) Resident #49 During a facility tour, on 01/15/24 at 10:10 AM and 01/16/24 at 11:45 AM, Resident #49 was sitting in his wheelchair with a tray table over his lap, fully enclosing his body. A review of Resident #49's medical record on 01/15/2024 at 4:57 PM identified Resident #49 lacks decision making capacity with a BIMS of four (4). Resident #49 does not present delusions or hallucinations per MDS with an ARD of 12/1/2023. The resident has a noted impairment on both sides of the upper and lower extremities and requires substantial maximal assistance from a sit to stand position. It is noted he has mild pain which does not interfere in his daily activities. One recent fall on 10/21/23 revealed the resident was found on the floor in his room, with no injuries noted. A review of the Physicians orders identified a tray table to be used while the resident was seated in his wheelchair for positioning purposes as needed. It was also ordered for a bed alarm to be used while resident is in bed to alert staff to the resident attempting to get up unassisted every shift for history of falls prior to admit, check placement and operational function. The progress notes from 05/18/23 stated a significant change due to wheelchair positioning decline and weight gain. A review of the care plan identified Resident #49 was at risk for falls related to (R/T) history of falls, hemiplegia, and hemiparesis from CVA (stroke), poor cognition, anemia, weakness, traumatic brain injury (TBI), lack of coordination, and multiple other conditions with appropriate goals and interventions in place. The comprehensive care plan did not define person centered interventions according to the standards of practice for the use of a physical restraint tray table to be used while the resident is seated in his wheelchair for positioning purposes as needed. During an interview, with the Director of Nursing (DON,) on 01/16/2024 at 11:50 AM, the Director of Nursing asked Resident #49 to demonstrate his ability to remove the tray table from over his lap. Resident #49 was unable to remove the tray table from his lap. The DON acknowledged the care plan did not define and or implement person centered interventions according to the standards of practice for the use of the tray table being a physical restraint while the resident is seated in his wheelchair for positioning purposes. .

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

Read full inspector narrative →

. Based on observation, resident Interview and staff interview, the facility failed to ensure an allegation of neglect was reported when Resident #55 was burned from an e-stim patch. This was a random opportunity for discovery. Resident identifier #55. Facility Census 59. Findings included: a) Resident #55 An observation and interview with Resident #55 on 01/15/24 at 8:39 AM revealed a scabbed area to her right lower leg. She stated, It got burnt from a E-stim patch in therapy that was defaulted. Resident #55's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/04/23 noted the resident had a score of Brief Interview for Mental Status (BIMS) of 15. A BIMS score of 15 indicates the resident is cognitively intact and has capacity. A medical record review found it was void of information from the incident mentioned in the interview. A review of the Physician's Order Summary revealed from: 12/26/23 --Silvadene External Cream 1 % (Silver Sulfadiazine) Apply to right lower leg topically everyday shift for wound for 14 Days cleanse wound, apply Silvadene and optifoam dated 12/26/23. --Silver Sulfadiazine Cream 1 % Apply to right lower leg topically every day and evening shift for burn for 14 Days two times a day dated 11/26/23. A continued review found no evidence on the incident log or the reportable log regarding this burn to Resident #55's leg. An interview on 01/16/24 at 11:20 AM with Team Lead Skin Health Nurse #19, found she failed to do a change in condition or progress note on the burn from therapy on Resident #55's leg area. She stated on 11/26/23 the day Resident #55 brought it to the staff's attention; the right lower leg was just a little red and on the second day it had got a little worse. She stated that she had Silver Sulfadiazine cream ordered on 11/26/23. She verified that no incident report or reportable was completed. She stated, the burn happened in therapy and if more information was needed to contact the Therapy Director. During an interview on 01/16/24 at 11:42 AM, the Director of Therapy stated an as needed (PRN) therapy staff member placed the electrical stimulation (E-Stim) on Resident #55 on a Sunday. She was unsure of the date or the name of the therapy staff member that was working when Resident #55 complained the E-Stim pads burnt her.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Investigate Abuse (Tag F0610)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

. Based on resident interview, staff interview, and operation policy the facility failed to take actions to thoroughly investigate an alleged neglect when Resident #55 received a burn from an e-stim unit. This was a random opportunity for discovery. Resident identifier #55. Facility census: 59. Findings included: a) Resident #55 An observation and interview with Resident #55 on 01/15/24 at 8:39 AM, revealed a scabbed area to her right lower leg. She stated, it got burnt from an E-stim patch in therapy that was defective. Resident #55's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/04/23 noted the resident had a score on the Brief Interview for Mental Status (BIMS) of 15. A BIMS score of 15 indicates the resident is cognitively intact and has capacity. A medical record review found it was void of information from the incident mentioned in the interview. A review of the Physician's Order Summary revealed from: 12/26/23 --Silvadene External Cream 1 % (Silver Sulfadiazine) Apply to right lower leg topically every day shift for wound for 14 Days cleanse wound, apply Silvadene and optifoam dated 12/26/23. --Silver Sulfadiazine Cream 1 % Apply to right lower leg topically every day and evening shift for burn for 14 Days two times a day dated 11/26/23. A continued review found no documentation on the incident log or the reportable log. An Interview 01/16/24 at 11:20 AM with Team Lead Skin Health Nurse #19, found she failed to do a change in condition or progression on the burn from therapy on Resident #55's leg area. She stated on 11/26/23 the day Resident #55 brought it to the staff's attention; the right lower leg was just a little red and on the second day it had got a little worse. She stated, she had Silver Sulfadiazine cream ordered on 11/26/23. She verified that no incident report or reportable was completed. She stated, the burn happened in therapy and if more information was needed speak with the Therapy Director. During an interview on 01/16/24 at 11:42 AM the Director of therapy stated, an as needed (PRN) therapy staff member placed the electrical stimulation (E-Stim) pad on Resident #55 on a Sunday. She was unsure of the date or the name of the therapy staff member that was working when Resident #55 complained the E-Stim pads burnt her.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0645 (Tag F0645)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record reviews and staff interviews, the facility failed to capture diagnoses upon admission and complete an updated Preadmission Screening and Resident Review (PASARR) This was true for three (3) of three (3) residents reviewed for the area of PASARR. Resident identifiers: #112, #51, and #39. Facility census: 59. Findings included: a) Resident #112 During a medical record review on 01/16/24, it was discovered the PASARR was not updated with the admission diagnosis of major depressive disorder. In an interview with the Director of Nursing (DON) on 01/16/24 at 9:37 AM, verified a new PASARR had not been completed to include the admission diagnosis of major depressive disorder. b) Resident #39 On 01/16/24, a record review of the resident's electronic medical record (EMR), the resident's most recent PASARR, dated 08/11/22, indicated no level II was needed. Section lll #30 MI/MR Assessment indicated no diagnosis of Major Depression. The record also revealed the resident had a diagnosis of Major Depression on admission [DATE] but did not receive a new PASARR to address whether or not specialized services were needed. On 01/17/23 at 2:23 PM the Director of Nursing verified Resident #39's PAS did not reveal her diagnosis of Major Depression. She confirmed a new PASARR was not completed. c) Resident #51 On 01/16/24, a record review of the resident's electronic medical record (EMR), the resident's most recent PASARR, dated 08/11/22, indicated no level II was needed. Section lll #30 MI/MR Assessment indicated no diagnosis of Major Depression. The record also revealed the resident had a diagnosis of Major Depression on admission [DATE] but did not receive a new PASARR to address whether or not specialized services were needed. On 01/17/23 at 2:23 PM the Director of Nursing verified, Resident #51's PASARR did not reveal her diagnosis of Major Depression. She confirmed a new PASARR was not completed.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0655 (Tag F0655)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

. Based on record review and staff interview the facility failed to develop a person-centered 48 hour baseline care plan for urinary tract infection (UTI). This was true for one (1) of one (1) reviewed for the care area of UTI during the Long-Term Care Survey Process. Resident identifier: #56. Facility census: 59. Findings included: a) Resident #56 During a medical record review, on 01/17/24, it was discovered the baseline care plan completed within 48 hours of Resident 56's admission did not communicate the admission diagnosis of a UTI. In an interview, on with the Assistant Director of Nursing (ADON) on 01/17/24 at 03:20 PM, they verified the 48 hour baseline care plan did not include the diagnosis of UTI.

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

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, resident interview, record review and staff interview the facility failed to develop or implement a comprehensive person-centered care plan with measurable objectives for each resident. This was true for three (3) of 17 residents reviewed during the Long-Term Care Survey Process. Resident Identifiers: Resident #58, Resident #49, and Resident #40. Facility Census: 59 Findings Include: a) Resident #58 On 01/15/24 at 10:10AM during a tour of the facility, Resident #58 was seen to in a wheelchair with a chair alarm. A review of the medical record on 01/16/24 at 8:54 AM, found Resident # 58 was admitted on [DATE] with a Brief Interview of Mental Status (BIMS) score of 06 and lacked capacity long term. The residents comprehensive care plan review did not identify a person centered comprehensive care plan per the standards of practice for the use of the chair alarm. On 01/16/24 at 11:36AM the Director of Nursing (DON) reviewed the care plan and acknowledged the chair alarm was not included in the person centered comprehensive care plane. The DON acknowledged the use of the chair alarm should be care planned. b) Resident #49 During a facility tour on 01/15/24 at 10:10AM, Resident #49 was observed sitting in his wheelchair with a tray table over his lap fully blocking his ability to stand freely. A review of Resident #49 medical record on 01/15/24 at 4:57 PM, identified Resident #49 did not have capacity with a BIMS of 04. Resident #49 did not present with delusions or hallucinations per Minimum Data Set (MDS) with ARD of 12/1/2023. The resident has a noted impairment on both sides of his upper and lower extremities and requires substantial maximal assistance for sit to stand. It is noted that he has mild pain that does not interfere in his daily activities. One recent fall on 10/21/23 is noted with the resident being found on the floor in his room, with no injuries noted. A review of the Physicians orders identifies a tray table to be used while the resident is seated in his wheelchair for positioning purposes as needed. It is also ordered for a bed alarm to be used while resident is in bed to alert staff that resident is attempting to get up unassisted every shift for history of falls prior to admit, check placement and operational function. The progress note from 5/18/23 states a significant change due to wheelchair positioning decline and weight gain. A review of the person centered comprehensive care plan identifies that he is at risk for falls R/T Hx of falls, hemiplegia and hemiparesis from CVA, poor cognition, anemia, weakness, TBI, lack of coordination, and multiple other conditions with appropriate goals and interventions in place. The person centered comprehensive care plan did not define interventions according to the standards of practice for the use of a physical restraint tray table to be used while the resident is seated in his wheelchair for positioning purposes. During an interview with the Director of Nursing (DON) on 1/16/2024 at 11:50AM the Director of Nursing asked Resident #49 to demonstrate his ability to remove the tray table from over his lap. Resident #49 was unable to remove the tray table from his lap in order for him to be able to stand freely. The DON acknowledged that the care plan did not define and or implement interventions according to the standards of practice for the use of the tray table being a physical restraint. The DON acknowledged that a comprehensive care plan should have been developed according to the standards of practice and include ongoing monitoring and evaluations for the use of the physical restraint. c) Resident #40 During a medical record review on 01/16/24, it was discovered the person-centered care plan had not been developed to include complete hospice interventions. The interventions did not include the Nurse Aide (NA) or their responsibilities. An interview with the Director of Nursing (DON) on 01/16/24 at 11:52 AM verified the NA had not been included as part of the interdisciplinary team providing hospice care and services for Resident #40.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0657 (Tag F0657)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

. Based on record review and staff interview the facility failed to revise the residents care plan in regard to tube feeding. This failed practice was true one (1) out of one (1) reviewed for tube feeding. Resident identifier: #45. Facility census 59. Findings include: a) Resident #45 During the interview process on 01/15/24 at 9:07 AM it was noted a tube feeding pump was at bedside. Record review found the tube feeding had been on hold since 11/15/23. The current care plan still contains the following: *Enteral Feed up/on at 7PM down/off at 7 AM. *Glucerna 1.5 CAL. administer Continuous via Pump 35/ml/hour for 12 hours a day if less than 75% of meals consumed. Interview on 01/17/24 at 2 PM with the Director of Nursing (DON) confirmed the enteral feeding has been on hold since 11/15/23 and agreed the care plan has not been revised to the current plan of care.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0675 (Tag F0675)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

Based on observation and staff interview the facility failed to ensure the resident was correctly positioned to maximize eating abilities. These failed practices were a random opportunity for discovery and was true for Resident #9. Resident Identifier: #9. Facility census 59. Findings included: a) Resident #9 Observation on 01/15/24 at 8:10 AM, found Resident #9 was trying to blindly reach for food on his tray, because his tray was not placed in front of him and was above his eye level. Resident #9 found a prepackaged cup of juice. Resident #9 was observed trying to open it for eight (8) minutes. He tried to push his finger through the top, he tried to bite it open, and then he used a spoon and finally got a hole in the top of it by using the handle of the spoon. Resident #9 drank his juice from the small hole. On 01/15/24 at 8:48 AM, Resident # 9 had managed to move the plate cover enough to get what appeared to be scrambled eggs with his fingers. On 01/15/24 at 8:51 AM, Nurse Aide #75 was asked if Resident #9 was positioned correctly to eat. NA #75 stated no he was not and walked halfway down the hall to a nurse and another nurse aide standing at the medication cart. Moments later Licensed Practical Nurse (LPN) #3 yelled down the hall towards this surveyor, He's a FEEDER! NA #75 returned and stated, he is a feeder. NA #75 was asked who was going to help Resident #9 eat. NA# 75 said NA #7 was the one to feed him as she pointed to the NA standing beside LPN #3. NA #7 came to assist Resident #9 on 01/15/24 at 9:02 AM. NA# 7 stood on the right side of the bed and did not sit down. NA#7 was asked if she would normally sit or stand while assisting this resident. NA#3 replied there is not a chair in here as you can see. A review of the medical records for Resident #9 found there was not an order for assistance for meals. The care plan read as follows: Monitor for changes in nutritional status (changes in intake, ability to feed self, unplanned weight loss/gain, abnormal labs) and report to food and nutrition/physician as indicated. Encourage resident participation with ADL care. See ADL flowsheets for current. level of support provided. Independent with eating. Independent to extensive with bed mobility and locomotion. Limited to extensive with transfers and walking. Extensive to dependent on toileting, hygiene, bathing and dressing. On 01/17/24 at 11:09 AM the Director of Nursing (DON) was informed of the above events. DON said the NAs have been re-educated about leaving the tray in the room without sitting it up for the resident. DON provided no more information at the conclusion of this survey.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

ADL Care (Tag F0677)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

. Based on observation, record review, family interview and staff interview the facility failed to provide Activities of Daily Living (ADL) care for dependent residents in the care area of bathing/showers and assisting during mealtime. This was true for two (2) out of two (2) residents reviewed for ADLs. Resident identifiers: #45, and #9. Facility census 59. Findings Include: a) Resident #45 A medical record review found Resident #45 suffered a Cerebral Infarction, which left her totally dependent for ADL care. During a family phone interview on 01/15/24 at 12:03 PM, with the husband of Resident #45, he stated he often must bush her hair and when she was first admitted he had to cut the hair on the back of her head almost to the scalp because it was so matted up. He also stated she did not have dandruff before coming here. He went on the say many times he felt like his wife had not been showered in a while and hair is rarely washed or brushed. A review of the facility ADL sheet called the, Documentation Survey Report v2, dated for the month of January, had the following information: Bed bath given on the following days. -01/01/24 -01/03/24 -01/05/24 -01/07/24 -01/09/24 -01/14/24 -01/15/24 Showers given on the following days. -01/16/24 On 01/17/24 at 2:20 PM, during an Interview with the Director of Nursing (DON) the comment made by the family member above was shared with the DON. The Facility form called the, Documentation Survey Report v2, dated 01/2024 was also shared with the DON as well. The DON agreed in the last 16 days Resident #45 received one (1) shower on 01/16/24. The DON also agreed Resident #45 should also receive a Bed bath on the days she does not receive a shower. b) Resident #9 Observation on 01/15/24 at 8:10 AM, found Resident #9 was trying to blindly reach for food on his tray, because his tray was not placed in front of him and was above his eye level. Resident #9 found a prepackaged cup of juice. Resident #9 was observed trying to open it for eight (8) minutes. He tried to push his finger through the top, he tried to bite it open, and then he used a spoon and finally got a hole in the top of it by using the handle of the spoon. Resident #9 drank his juice from the small hole. On 01/15/24 at 8:48 AM, Resident # 9 had managed to move the plate cover enough to get what appeared to be scrambled eggs with his fingers. On 01/15/24 at 8:51 AM, Nurse Aide #75 was asked if Resident #9 was positioned correctly to eat. NA #75 stated no he was not and walked halfway down the hall to a nurse and another nurse aide standing at the medication cart. Moments later Licensed Practical Nurse (LPN) #3 yelled down the hall towards this surveyor, He's a FEEDER! NA #75 returned and stated, he is a feeder. NA #75 was asked who was going to help Resident #9 eat. NA# 75 said NA #7 was the one to feed him as she pointed to the NA standing beside LPN #3. NA #7 came to assist Resident #9 on 01/15/24 at 9:02 AM. NA# 7 stood on the right side of the bed and did not sit down. NA#7 was asked if she would normally sit or stand while assisting this resident. NA#7 replied there is not a chair in here as you can see. A review of the medical records for Resident #9 found there was not an order for assistance for meals. The care plan read as follows: Monitor for changes in nutritional status (changes in intake, ability to feed self, unplanned weight loss/gain, abnormal labs) and report to food and nutrition/physician as indicated. Encourage resident participation with ADL care. See ADL flowsheets for current. level of support provided. Independent with eating. Independent to extensive with bed mobility and locomotion. Limited to extensive with transfers and walking. Extensive to dependent on toileting, hygiene, bathing, and dressing. On 01/17/24 at 2:20 PM the Director of Nursing (DON) was informed of the above events. The DON said the NAs have been re-educated about leaving the tray in the room without sitting it up for the resident. The DON provided no more information at the conclusion of this survey.

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

Read full inspector narrative →

. Based on medical record review, resident interview and staff interview, the facility failed to ensure one (1) resident received treatment and care in accordance with professional standards of practice. The facility failed to ensure a change in condition was completed or a skin issue was monitored for progression. This was a random opportunity for discovery. Resident Identifier: Resident #55. Facility Census: 59. Findings Include: a) Resident #55 An observation and interview with Resident #55 on 01/15/24 at 8:39 AM, revealed a scabbed area to her right lower leg. She stated it got burnt from an Electrical Stimulation (E-stim) patch in therapy which was defective. Resident #55's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/04/23 noted the resident had a score on the Brief Interview for Mental Status (BIMS) of 15. A BIMS score of 15 indicates the resident is cognitively intact and has capacity. A medical record review found it was void of information from the incident mentioned in the interview. A review of the Physician's Order Summary revealed from: 11/26/23 --Silvadene External Cream 1 % (Silver Sulfadiazine) Apply to right lower leg topically everyday shift for wound for 14 Days cleanse wound, apply Silvadene and optifoam dated 12/26/23. --Silver Sulfadiazine Cream 1 % Apply to right lower leg topically every day and evening shift for burn for 14 Days two times a day dated 11/26/23. A continued review found no documentation on the incident log or the reportable log. An Interview 01/16/24 at 11:20 AM with Team Lead Skin Health Nurse #19, found she failed to do a change in condition or progression on the burn from therapy on Resident #55's leg area. She stated on 11/26/23 the day Resident #55 brought it to the staff's attention; the right lower leg was just a little red and on the second day it had got a little worse. She stated, she had Silver Sulfadiazine cream ordered on 11/26/23. She verified no incident report or reportable was completed. She stated the burn happened in therapy and if I wanted more information on the incident, I could speak with the Therapy Director. During an interview on 01/16/24 at 11:42 PM the Director of therapy stated an as needed (PRN) therapy staff member placed the E-Stim on Resident #55 on a Sunday. She was unsure of the date or the name of the therapy staff member which was working when resident #55 complained the E-Stim pads burnt her.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Medication Errors (Tag F0758)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, record review and staff interview, the facility failed to use a psychotropic medication to treat a specific, diagnosed, and documented condition. This was found for one (1) of five (5) residents reviewed for unnecessary medications. Resident identifier: #58. Facility Census 59 Findings include: a) Resident #58 A review of the medical record on 01/16/24 at 8:54 AM, found Resident # 58 was admitted to the facility on [DATE] with a Brief Interview of Mentals Status (BIMS) score of six (6) and lacked capacity to make medical decisions. The Minimum Data Set (MDS) with an assessment reference date (ARD) of 10/30/23 identified the resident suffering from disorganized thinking behavior, which fluctuates (comes and goes, changes in severity). Resident #58's diagnosis include: -- Alzheimer's disease -- unspecified dementia in other diseases classified elsewhere, unspecified severity, without behavioral disturbance, -- psychotic disturbance -- mood disturbance, and --anxiety -- cognitive communication deficit With a current medication regimen of quetiapine fumarate, and Haldol injection solution. An MRR recommendation for 12/14/23 to reduce the risk of falls is to decrease Seroquel dosage from 50 mg BID to 25mg am and 50 mg HS. A review of the orders and MAR and Seroquel order identifies the reduction on the order dated 1/10/24. A specific, diagnosed, and documented condition could not be identified in the medical record review for the use of a psychotropic medication treatment. During an interview with the Director of Nursing on 01/16/24 at 12:29PM the Director of Nursing (DON) acknowledged Resident #58 is being prescribed a psychotropic medication for Resident #58's dementia with behaviors. The DON then reviewed the diagnosis listed in the medical record and acknowledged the diagnosis listed is dementia without behavioral disturbance. The DON acknowledged Resident #58 did not have an appropriate diagnosis for the use of the psychotropic medication treatment.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Medical Records (Tag F0842)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

. Based on record review and staff interview the facility failed to have a complete order for hospice services for Resident #40. This was true for one (1) of one (1) resident reviewed for the care area of hospice, during the Long-Term Care Survey Process. Resident #40 did not have a complete order for hospice. Resident identifier: 40. Facility census: 59. Findings included: a) Resident #40 During a medical record review, on 01/16/24, it was discovered the order for hospice services was incomplete. It did not include the phone contact for the hospice service provider. In an interview with the Director of Nursing (DON) on 01/16/24 at 1:30 PM, the DON verified the order for hospice was incomplete. It did not include the phone contact for the hospice provider.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0919 (Tag F0919)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

. Based on observation and staff interview, the facility failed to ensure the call light system device was accessible for a resident while in bed. This was a random opportunity for discovery and was true for Resident #30. Resident identifier: #30 Facility census: 59. Findings included: a) Resident #30 On 1/15/24 at 8:07 AM during a tour of the facility, Resident #30 was seen in his bed with oxygen half off his face and he was very agitated and cursing asking to see a nurse. When asked if he had called for assistance with the use of his call light, he stated it wasn't working. The call light was lying on the floor under his bed at this time. TLSH #19 was asked to come to the room for Resident #30. Team Lead Skin Health (TLSH) #19 confirmed the resident was able to operate the call light and acknowledged Resident #30's call light was lying on the floor, out of the residents reach. TLSH #19 stated Resident #30 was very agitated about some family issues which had recently occurred and because his call light was not working and on the floor. TLSH #19 stated she had called maintenance to come and fix the call light.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Food Safety (Tag F0812)

Could have caused harm · This affected multiple residents

Read full inspector narrative →

. Based on observation and staff interview, the facility failed to maintain the kitchen in a safe and sanitary manner in accordance with professional standards of practice.This had the potential to affect any residents receiving nourishment from the kitchen. Facility census: 59. Findings included: a) Kitchen tour During the kitchen tour on 01/15/24 at 9:13 AM, it was discovered the second-hand washing sink did not have a trash can. The floor under the shelving unit housing the steam table pans was dirty, and the back corner of the walk-in cooler had debris on the floor. An interview with the Dietary Manager on 01/15/24 at 10:25 AM, verified the hand washing sink needed a trash can, the floor beneath the shelving unit needed to be cleaned and the back corner of the walk-in cooler needed to be cleaned.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Infection Control (Tag F0880)

Could have caused harm · This affected multiple residents

Read full inspector narrative →

Based on observation, facility record review, Centers for Disease Control and Prevention (CDC) review, and staff interview the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. These failed practices were discovered during observation of medication administration, and review if the Infection Preventionist surveillance had the potential to affect more than a limited number of residents currently residing in the facility. Resident identifiers: #39, #43, #165, 38, #6, #113, #5, and #112. Facility census 59. Findings included: a) Medication administration a-1) Resident #39 On 01/17/24 at 8:04 AM, Licensed Practical Nurse (LPN) #59 was observed passing medication. The following medication was adminsitered to Resident #39: Abilify 10 mg Aspirin 81 mg Eliquis 5 mg Fluticasone nasal spray Lidocaine patch Methimazole 5mg Prednisolone eye drops LPN#59 failed to use a barrier when she placed the nasal and eye drops on a stack of the residents' personal papers. LPN #59 agreed she should have used a paper towel as a barrier. a-2) Resident #43 Observation of LPN #59 administering medication on 01/17/24 at 8:14 AM, found the following medications were adminsitered to Resident #43: Aspirin 81 mg Baclofen 10 mg Calcium 600 mg Eliquis 5 mg Gabapentin 400 mg Norvasc 5 mg Wellbutrin 100 mg Cymbalta 60 mg Ferrous Sulfate 325 mg Folic acid 1 mg Lasix 20 mg Mobic 7.7 mg K-dur 10mq B- 12 500 mg While popping the medication Wellbutrin out of the blister pack LPN #59 missed the medication cup and the pill landed on the top of the medication cart. LPN #59 picked the pill up with her bare fingers and placed it in the medication cup, then administered it to Resident # 43. LPN #59 agreed she should not have used her bare fingers to pick the pill up off the medication cart. On 01/17/24 at 8:58 AM, thee DON was informed of the above actions of LPN #59 and no further information was provided. b) Failure to place Residents with mulit drug resitant ordganisms (MDROs) in the proper Transmission Based Precautions (TBP) b-1) Resident #165 A review of the monthly infection control line listing revealed on 10/07/23, Resident #165 was listed on the line listing being diagnosed of Discitis (A serious but uncommon medical diagnosis. It is an infection of the intervertebral disc space). Resident #165 was also positive for Methicillin-resistant Staphylococcus aureus (MRSA) (an infection which is caused by a type of staph bacteria that's become resistant to many of the antibiotics.) MRSA can spread by health care workers touching people with unclean hands or people touching unclean surfaces. This MDRO is easily spread in Nursing homes. Resident #165 was receiving Vancomycin at the time. The Infection Preventionist (IP) had wrote Standard precautions on the line listing when asked what type of precautions where used. On 01/17/24 at 11:15 AM the IP was asked why Resident #165 was in standard precautions instead of Contact precautions? The IP stated she made a mistake. b-2) Resident # 38 Resident #38 was diagnosed with MRSA on his right arm on 10/11/23 and was receiving Mupirocin (an antibiotic) and was also placed in Standard precautions. The IP said Resident #38 had multiple abscesses and was not sure all of them had MRSA. On 01/17/24 at 11:15 AM the IP was asked why Resident #38 was in standard precautions instead of Contact precautions? The IP stated she made a mistake. b-3) Resident #5 Resident #5 was diagnosed with a urinary infection which tested positive for extended-spectrum beta-lactamase (ESBL) (this is a MDRO) on 12/04/23 in house acquired, receiving two(2) antibiotics, Bactrim, and Meropenem. Resident #5 was placed in Standard precautions. On 01/17/23 at 11:20 AM IP stated that because Resident #5 had a foley catheter she did not need to be in any precautions other than standard. IP was asked how was it communicated with the staff to use Contact Precautions while caring for the foley catheter for Resident #5, so they did not spread the ESBL to other residents? The IP did not answer. b-4) Resident #6 Resident #6 was diagnosed with MRSA on 12/18/23 to the Right Lower Extremity and was receiving Clindamycin. Resident #6 was placed in Standard Precaution. On 01/17/24 at 11:26 AM the IP stated Resident #6 did not need to be in Contact Precautions because the wound was covered. b-5) Resident #113 Resident #113 was diagnosed with MRSA in the joint of the right knee on 12/19/23 and was placed in Standard Precautions. On 01/17/24 at 11:30 AM the IP said she did not think there was a wound on the right knee. She was asked how was the resident diagnosed with MRSA in the knee joint without a culture of the wound? She was also asked if she looked at the knee herself and she said no. b-6) Resident #112 Resident #112 was diagnosed with C. diff (also known as Clostridioides difficile or C. difficile) is a germ (bacterium) that causes diarrhea and colitis (an inflammation of the colon). C-Diff can be transferred from one person to another. When C. diff germs are outside the body, they become spores. These spores are an inactive form of germ and have a protective coating allowing them to live for months or sometimes years on surfaces and in the soil. The germs become active again when these spores are swallowed and reach the intestines. On 01/17/24 at 11:39 AM, the IP said she must have made a mistake, and she should have placed Resident #112 in Contact Precautions. On 01/17/24 at 2:00 PM the DON was informed of the above information and agreed the Residents were not placed in proper TBP. The CDC recommends contract precautions for MRSA, ESBL, and C-Diff.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Antibiotic Stewardship (Tag F0881)

Could have caused harm · This affected multiple residents

Read full inspector narrative →

. Based on facility record review and staff interview the facility failed to establish an antibiotic stewardship program that includes antibiotic use protocols and a system to monitor antibiotic use. This was true for six (6) out of nine (9) residents reviewed for antibiotic stewardship. Resident identifiers: Resident #9, #23. #4 #34, #113, and #11. Facility census 59. Findings included: a) Resident #9 A review of the line listing found Resident #9 had onset of symptoms of a Urinary Tract Infection (UTI) on 12/29/23. Resident #9 was given an antibiotic named Cipro which started on 01/02/24. There was no resolution date entered. Also, the were no results listed or if a Urinalysis (UA) was completed. Leaving it unclear if the antibiotic given was needed or the correct one for this infection. On 01/17/24 at 11:35 AM the Infection Preventionist (IP) was asked for the UA and the results. IP stated the resident was sent to the ER (a local hospital) and they are unable to get the results. b) Resident #23 A review of the line listing found Resident #23 had onset of symptoms of a Urinary Tract Infection (UTI) on 01/13/24. Resident #23 was given an antibiotic named Macrobid started on 01/13/24. There was no resolution date entered. Also, the were no results listed or if a Urinalysis (UA) was completed. Leaving it unclear if the antibiotic given was needed or the correct one for this infection. On 01/17/24 at 11:45 AM the IP stated she has a hard time getting the lab results for Resident #23. She also stated she was not sure if all the residents mentioned above had UA. c) Resident #4 A review of the line listing found Resident #4 had onset of symptoms of a Urinary Tract Infection (UTI) on 01/14/24. Resident #4 was given an antibiotic named Macrobid started on 01/14/24. There was no resolution date entered. Also, the were no results listed or if a Urinalysis (UA) completed. Leaving it unclear if the antibiotic given was needed or the correct one for this infection. On 01/17/24 at 11:45 AM the IP stated she has a hard time getting the lab results for Resident #4. She also stated she was not sure if all the residents mentioned above had UA. d) Resident #34 A review of the line listing found Resident #34 had onset of symptoms of a Urinary Tract Infection (UTI) on 01/13/24. Resident #34 was given an antibiotic named Cipro on 01/14/24. There was no resolution date entered. Also, the were no results listed or if a Urinalysis (UA) completed. Leaving it unclear if the antibiotic given was needed or the correct one for this infection. On 01/17/24 at 11:45 AM the IP stated she has a hard time getting the lab results for Resident #34. She also stated she was not sure if all the residents mentioned above had UA. e) Resident #113 A review of the line listing found Resident #113 had onset of symptoms of a Urinary Tract Infection (UTI) on 10/01/23. Resident #113 was given an antibiotic named Nitrofurantoin started on 10/01/23. Also, the were no results listed or if a Urinalysis (UA) completed. Leaving it unclear if the antibiotic given was needed or the correct one for this infection. On 01/17/24 at 11:45 AM the IP stated she has a hard time getting the lab results for Resident #113. She also stated she was not sure if all the residents mentioned above had UA. f) Resident #11 A review of the line listing found Resident #11 had onset of symptoms of a Urinary Tract Infection (UTI) on 10/22/23. Resident #11 was given an antibiotic named Azithromycin started on 10/22/23. Also, the were no results listed or if a Urinalysis (UA) completed. Leaving it unclear if the antibiotic given was needed or the correct one for this infection. On 01/17/24 at 11:45 AM the IP stated she has a hard time getting the lab results for Resident #11. She also stated she was not sure if all the residents mentioned above had UA. On 01/17/24 at 2:00 PM the DON was shown the above findings and agreed the information that should have been provided was not there and left it unclear if the resident received the right medications.

Oct 2022 11 deficiencies

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0553 (Tag F0553)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

. Based on record review, resident and staff interview, the facility failed to ensure a resident was included in all aspects of person-centered care planning, which supported the resident's goals, choices, and preferences including, but not limited to, goals related to the their daily routines. This was true for one (1) of 22 residents reviewed for care plan involvement during the survey process. Resident identifier: Resident #15 Census; 62 Findings included: a) Resident #15 An interview, with Resident #15, on 10/03/22 at 9:53 AM, revealed the resident was not aware of the care that had been planned and stated he/she had not been invited to attend any care plan meeting. A record review , showed a Minimum Data Set (MDS), completed 08/08/22, assessing the resident to have a BIMS (Brief Interview for Mental Status) to be at a score of 11, which would indicate mild impairment. Further review of the record showed two (2) care plan meeting notices had been provided to family members on 05/26/22 and 08/25/22, but there was no evidence the resident had been invited to attend or was involved in the process. An interview with the Nurse Educator, on 10/05/22 at 11:56 AM, verified the resident had not been invited to care plan conference, only family, The Nurse Educator stated further, during the interview, the resident should have been invited and stated he/she was the one who had sent out all invitations and did not recall inviting the resident to any meeting. An interview with the Director of Nursing (DON), on 10/05/22 at 12:19 PM. verified the resident should have been invited and there was no evidence she had been included in the care planning process. .

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0554 (Tag F0554)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

. Based on observation, record review, resident and staff interview, the facility failed to ensure when a resident self administered medications, the interdisciplinary team had determined this practice was clinically appropriate. This deficient practice was identified during a random opportunity for discovery when Resident #53 was observed in the resident's room with an inhaler on the bedside table. Resident identifier: Resident #53. Census: 62. Findings included: a) Resident #53 A review of Policy NSG 309 Medications: Self-administration, revision date of 03/01/22, showed if a resident requests to self-administer medications they would be evaluated for safety and appropriateness. If it was determined the resident could self-administer medications, an order would be obtained , self administration and self-storage would be care planned, and capability re-evaluated initially , quarterly and with any change of condition. An observation on 10/03/22 at 10:17 AM, revealed an inhaler laying on the bedside table, in the resident's room, belonging to Resident #53. An interview with Resident #53 on 10/03/22 at 10:17 AM, revealed the resident kept the inhaler at the bedside as a back up inhaler for when he/she became short of breath. A record review showed the latest self-administration of medication assessment , being completed in 2016, which determined the resident was unable to self-administer medications at that time. No further, more recent assessment was identified. Further review of the medical record, showed a current physician's order, dated 09/22/22, for Ventolin 90 mcg inhaler with directions for one (1) puff to be inhaled orally every four (4) hours as needed for shortness of breath or wheezing, A current Physician's order showed the resident may not self administer medications. An interview with the Director of Nursing (DON) and Resident #53, on 10/04/22 at 08:57 AM, revealed Resident #53 stating he/she had kept the inhaler there for some time and wanted it. The DON stated, at this time, the resident would be re-evaluated for self-administration of medications because there was no permission for the resident to self-administer the medication. .

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0561 (Tag F0561)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

. Based on resident interview, record review, and staff interview the facility failed to provide showers according to the residents preferences. This failed practice was true for one (1) of twenty-two (22) sampled residents. Resident Identifier: #26 Facility Census: 62 Findings Included: a) During the initial interview phase of the long term survey process Resident #26 complained of getting bed baths instead of showers as she preferred. According to her care plan, it is important for her to choose between a shower or a bed bath and she prefers a shower. Records indicate that she is schedule for a shower every Monday, Wednesday and Friday. Documentation shows she received seven (7) out of fourteen (14) showers schedule for the last thirty-four (34) days. She received twenty-seven (27) bed baths during this time. This was confirmed with the Director of Nursing during an interview on 10/04/22 at 4:45 PM. .

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

ADL Care (Tag F0677)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, record review and staff interview, the facility failed to assist residents to carry out Activities of Daily living (ADL's) including grooming and eating , when the resident was assessed to require assistance. This was true for one (1) of nine (9) residents reviewed for ADLs during the Long Term Care Survey Process (LTCSP). Resident #50 did not receive assitance with grooming as required. Resident identifier : Resident #50. Census: 62. Findings included: a) Policy review A review of Policy : NSG 200 Activities of Daily Living (ADLs). with a revision date of 06/11/21, showed the facility must provide the necessary care and services when a resident was unable to carry out this function, to ensure a residents ADLs, including grooming and eating, were maintained. Documentation was required every shift when ADL assistance was provided and was to be made in the medical record. b) Resident # 50 An observation of Resident #50, on 10/03/22 at 01:38 PM, revealed the resident to have an excessive amount of facial hair on the chin area. A record review showed a Minimum Data Set (MDS), dated [DATE], which assessed Resident #50 as requiring, under section J. Personal hygiene, to require extensive assistance of two (2) staff members to complete the task of personal hygiene which included grooming. An interview with the Director of Nursing (DON), on 10/04/22 at 12:00 PM, verified the facial hair on Resident #50 had been removed 10/04/22, but added, the resident should have been groomed prior to the observation of 10/03/22, to remove the excess facial hair. The interview on 10/04/22 at 12:00 PM, with the DON, verified there was no documentation noting Resident #50 was offered and/or refused assistance with grooming prior to the 10/04/22 interview. The DON stated further, Resident #50 was assisted several times a week and should have had facial hair removed as needed . .

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Respiratory Care (Tag F0695)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

. Based on observation, record review, ,and staff interview, the facility failed to ensure respiratory care was provided in accordance with professional standards of practice for one (1) of three (3) residents who was reviewed for oxygen therapy. Physician's orders for the oxygen administration flow rate was not followed for Resident #53. Resident identifier: Resident #53. Census: 62 Findings included: a) Resident #53 Review of the Policy, titled : Oxygen Concentrator, revision date of 06/15/22, showed, under section 2. (10), the liter flow would be set per order. A record review, showed a current physician's order, dated 9/22/22, for Resident #53 to receive oxygen at one (1) Liter per minute via Nasal Cannula continuously. An observation was made of the flow rate of oxygen Resident #53 was receiving on 10/04/22 at 09:06 AM, in the presence of Director of Nursing (DON). The DON verified at this time the flow rate was set on three (3) liters per minute, when the order was for the resident to receive one (1) liter of oxygen per minute. .

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0727 (Tag F0727)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

. Based on record review and staff interview, the facility failed to ensure a Registered (RN) was present at the facility for at least eight (8) consecutive hours a day seven (7) days a week. This had the potential to affect a limited number of residents residing at the facility. Facility census: 62. Findings Included: a) Registered Nursing hours During a review on 10/05/22 of the daily nurse staffing hours revealed on 10/02/22 there was no RN scheduled for that date. A review of the payroll time sheet for RN #64, revealed on 10/01/22 clocked in at 10:45 PM and clocked out at 7:30 AM. During an interview on 10/05/22 at 2:37 PM the Scheduling and Payroll Manager #68 stated there was no RN scheduled for Sunday because the RN # 64's name worked Saturday 11 PM to 7:15 AM. She acknowledged it was not 8 consecutive hours on Sunday 10/02/22. .

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Menu Adequacy (Tag F0803)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

. Based on observations, resident interview and staff interview the facility failed to provide menu items according to resident preference and the facility also failed to provide notification of changes of the menu by not noting or updating on the menu and/or residents were not notified of the change, when substituting foods. This had a potential to affect all residents receiving nourishment from the facility kitchen. Resident Identifiers: Resident #13, and Resident # 18. Facility Census: 62 Findings Included: a) Resident #13 During an interview on 10/03/22 at 10:39 AM Resident #13 stated We get a lot of soup and sandwiches, the food is never good. We never receive what we are supposed to. If the menu says chicken noodle soup we get tomato soup. The menu might say hamburger and we get a ham sandwich. During a main dining room observation on 10/03/22 at 12:22 PM the Residents' meal tray tickets stated the following: Harvest Soup Egg salad sandwich lettuce and tomato Watermelon Pasta Salad During an interview on 10/03/22 at 12:53 PM the [NAME] stated there were no tomatoes or lettuce available. Someone marked the beets off the original menu, added pasta salad and the beets arrived on the truck. We used them instead of making pasta salad. We did not inform the Residents of the menu change, we usually don't. b) Resident #18 During an interview on 10/03/22 at 9:58 AM Resident # 18 stated the food needs much improvement, carrots need to be cooked more, and more country foods. I received a frozen muffin a couple days ago, I was supposed to get french toast, that is what the ticket said. But the muffin was frozen, they did not even thaw them. We never receive the food, the paper says they will serve us. c) Observation and Interviews During an observation the breakfast meal trays on 10/04/22 at 8:14 AM, Resident #12's breakfast tray meal ticket stated the following: Orange juice 6 ounces (oz) Cheerios 3/4 cup Banana 1 each Country Biscuit 1 each Sausage Gravy 3 oz Chocolate Milk 8 oz 2% milk 8 oz Coffee 6 oz Yogurt 1 each Resident #12's breakfast tray revealed the following items: Bowl of rice crispies Biscuit with gravy White Milk Coffee During an interview on 10/04/22 at 8:16 AM Nurses Aide #47, acknowledge the breakfast meal ticket did not match what was served on the breakfast tray. Further observations on 10/04/22 of the breakfast meal trays revealed Resident #110's breakfast tray meal ticket stated the following: Oatmeal 1/2 cup Banana 1 each Scrambled Egg 1/4 cup Wheat Toast 1 slice Resident #110's breakfast tray revealed the following items: Bowl of rice crispies a fried egg a piece of toast milk orange juice During an interview on 10/04/22 at 8:20 AM the Director of Nursing acknowledged Resident's #110 and Resident #12's breakfast tray did not match the tray meal ticket. During an interview on 10/04/22 at 8:23 AM The [NAME] and the Dietary Aide stated we are out of cheerios, chocolate milk, yogurt, bananas and all juice except orange juice. That is why they did not receive the items for breakfast. We run out of supplies all the time. We have to substitute a lot, we never have what we need. On 10/04/22 at 8:35 AM the Administrator was notified of the dietary issues. During the follow up dietary visit on 10/04/22 at 11:45 AM revealed the menu read as follows: Grilled Turkey and Swiss Sandwich Snickerdoodle Cookies Garlic Tater Tots The dietary staff were preparing the following: Grilled Ham and Cheese Sandwiches Baked Tater Tots During an interview on 10/04/22 at 11:45 AM the [NAME] stated we can not get Turkey, we substituted for Ham. We did not have Swiss cheese, I used American cheese. We make tater tots, we use garlic on the Tater tots , I use salt. .

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Medical Records (Tag F0842)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

. Based on observation, record review and staff interview the facility failed to accurately document the percentage of meal intake for the Resident. This was true for one (1) of twenty-two (22) records reviewed. Resident Identifier: #30 Facility Census: 62 Findings Included: a) According to Resident #30's care plan she is independent to extensive assistance with eating. The care plan also has interventions for participation in the restorative feeding program twice (2) a day, three (3) times a week as well as monitor intake of all meals. On 10/04/22 this surveyor witnessed Restorative Aid (RA) #9 attempt to feed Resident #30. The Resident would not wake up enough to eat. After attempting to feed the Resident for approximately fifteen (15) minutes the RA took the resident back to her room. The Resident did not eat anything. Restorative Aide #9 did not provide any documentation concerning the lunch meal However, Certified Nurse Aid (CNA) #34 documented that the resident feed herself and ate 100% of the meal. This was incorrect. CNA #34 was not in the dining room during the lunch meal and the Resident did not feed herself, nor did she eat 100% of the meal. This was discussed and confirmed with the Director of Nursing on 10/05/22 at 1:15 PM. The Director of Nursing provided not further information or clarification. .

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0679 (Tag F0679)

Could have caused harm · This affected multiple residents

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, medical record review, resident interview and staff interview, the facility failed to implement an ongoing resident centered activities program designed to meet the interest of and support the physical, mental and psychosocial well-being of each resident. The facility failed to provide activities according to their interest for Resident #47 and Resident #48 and failed to develop a care plan in a timely manner for Resident #110. This practice was found true for three(3) of five (5) Residents reviewed for the Activity Care Area during the Long term care survey process. Resident Identifier: Resident #47, Resident #48 and Resident #110 Facility Census: 62 Findings Included: a) Resident #47 During the initial tour of the facility on 10/03/22 at 10:21 AM observed Resident # 47 laying in the bed, in the dark with the privacy curtain pulled, window blinds closed, and no over bed light on. Resident #47 was holding her bed comforter tag in her hand rubbing it. There was no TV/music or other sensory stimulation provided in the room. Resident is unable to communicate with this surveyor. During another observation on 10/03/22 at 12:45 PM Resident #47 continued to lay in the bed, in the dark with the privacy curtain pulled, window blinds closed, and no over bed light on. Resident #47 was rubbing fingers together and mumbling. There continues to be no sensory stimulation provided in the room. Several observations on 10/04/22 made in the AM revealed Resident # 47 laying in the bed, in the dark with the privacy curtain pulled, window blinds closed, and no over bed light on. There continued to be no sensory stimulation provided in the Resident's room. An observation on 10/04/22 after lunch, Resident #47's blind was open, no other sensory stimulation such as TV or music was provided in the room. An observation on 10/05/22 at 10:45 AM an observation revealed Resident # 47 laying in bed with an over bed light on, the privacy curtain continued to be pulled and blind was closed. Resident had a fitted bed sheet pulled over her rubbing it with her fingers. There was no TV, music or other sensory stimulation provided in her room. A review of Resident #47's medical record review on 10/04/22 at 7:54 PM revealed Resident # 47's Assessment of Daily and Activity Preferences dated 08/31/22 stated the following: Section titled: Staff Assessment of Activity Preferences Resident Prefers checked were listed as follows: -listening to music -doing things with groups of people -participating in religious activities -Comments: Resident enjoy listening to music. Resident enjoys doing things with groups of people such as entertainment. Resident enjoys going outside when weather is nice and she enjoys religious activities. A further medical record review of Resident # 47's medical record on 10/04/22 at 8:04 PM revealed the following care plan: Focus Statement: Resident exhibits or is at risk for limited and/or meaningful engagement related to cognitive loss due to DX: Alzheimer's Disease. This focus statement was initiated on 09/20/19 and revised on 08/31/22. Goals associated with this focus read as follows: Resident # 47's name will demonstrate interest as evidenced by increased attention, smiling, speaking 1-2 words in 1:1 visits. This goal had a target date of 12/15/22 Inventions included: Provide 1:1 visits one to three times a week Assist resident as needed, to activities of interest, such as church service and entertainment. I enjoy watching/listening TV. It is important for me to go outside when the weather is good and enjoy sitting and relaxing. I am of the Protestant faith and would like to participate in religious services. These interventions were added on 09/20/19 with a revision date of 06/18/21. Further review of the Resident #47's medical records revealed a activity participation sheet for October with the following preference and interests marked as participated: -10/03/22: Household chores/care of belongings/parenting/shopping- Independent -10/03/22: Music/Concerts/Live Music/Operas/playing/Singing: Independent -10/03/22: Relaxing/Looking out window/resting/thinking-Independent -10/03/22: Socializating/Socials/Talking on Phone/Visits/Sending Cards-Independent -10/03/22: Spizova Bear: 2A One to One Visit -10/04/22:Household chores/care of belongings/parenting/shopping- Independent -10/04/22: Manicure/Aromatherapy/Massage/Painting Nails/Salon/Spa-Actively Involved -10/04/22: Movies/TV-Independent -10/04/22: Reading/Audio Books-2A One to One Visit During an interview 10/05/22 10:48 AM Nurses Aide #2 stated Resident #47 is a total assist, I try to get her up everyday. She attends some music but yells a lot and they bring her back. She has no visitors, she sits in the hallways when up in the chair. She does better in the afternoon after 12:30 PM. During an interview on 10/05/22 at 10:55 AM the Activity Director (AD) stated Resident #47 watches TV in her room. The staff is socializing with her throughout the day and receives morning visits daily from us. Her participation sheets reflect my assistants' turn on the TV for the resident. The live music is streamed through TV in rooms and in common areas. Her TV is turned on. The household chores documented is Resident #47 normally has a stuffed animal in her hands, so we count that care for her belongings. The documentation of relaxing/looking out the window/resting is she is resting in her bed and she looks out her window. When asked why Resident #47 did not attend the religious service on 10/04/22 at 2:00 pm the AD stated, I am not sure I will have to check with my assistant. The AD acknowledged Resident #47's Activity Assessment and Care Plans revealed the Resident enjoys religious services, music and TV and it is not being provided to the Resident. During the interview this surveyor informed the AD of the above observations of Resident #47 from 10/03/22 to 10/05/22. The AD stated I am so upset, this is so sad we are not providing anything for her. b) Resident # 48 An initial tour of the the facility on 10/03/22 at 11:02 AM revealed Resident #48 was sitting in a wheelchair in the hallway beside the nurses desk. During an interview on 10/03/22 at 11:02 AM Resident #48 stated Do I smell good?, Do I smell good?, I got a shower, I got a shower, and then strolled off in his wheelchair. Further observations on 10/03/22 and 10/04/22 revealed Resident #48 getting up from the wheelchair and chair alarm sounding and the alarm saying Resident's name sit down in your chair and the Resident would sit down. This continues several times throughout the observations. Several staff members would remind him to sit down. Resident would stroll throughout several areas in the facility continuing to try to get up and then sit back down. A review of Resident #48's medical record review on 10/04/22 at 8:30 PM revealed Resident # 48's Recreation Comprehensive assessment dated [DATE] stated the following: -very important to have field and stream magazines -very important to, listen to country music -somewhat important to do things with group of people such as play bingo and go to parties. -very important to watch or listen to TV -very important to go outside to garden, smoke, games, talk, sit, bird watch -somewhat important to participate in religious services. Summary stated .Resident enjoys parties, bingo, exercise and entertainment. Resident is meeting goal, continue with current plan of care. A further medical record review of Resident # 48's chart on 10/04/22 at 8:36 PM revealed the following care plan: Focus Statement: Resident exhibits or is at risk for limited and/or meaningful engagement related to: cognitive deficits due to traumatic brain injury (TBI). This focus statement was initiated on 06/09/22 Goals associated with this focus read as follows: Establish residents desire to increase social particpation and relationships. Date initiated 06/09/22 with a revision date of 09/12/22, target date 12/08/22. Interventions included: .Encourage resident to particpation in activity preference of such as bingo and parties. Invite and assist resident/patient as needed, to activities of interest. Further review of the Resident #48's medical records revealed a activity participation sheet for October and the following preference and interest were marked as participated: -10/03/22 Bingo-Refused -10/03/22 Household Chores/Care of Belongings/Parenting-Independent -10/03/22 Manicures/Aromatherapy/Massage-Active -10/03/22 Movies/TV- Independent -10/03/22 Reading/Audio Books-Independent -10/03/22 Socializing/socials/talking on phone/visits-Independent -10/04/22 Household Chores/Care of Belongings/Parenting-Independent -10/04/22 Movies/TV- Independent -10/04/22 Reading/Audio Books-Independent -10/04/22 Religious Services-Actively Involved -10/04/22 Socializing/socials/talking on phone/visits-Independent During an interview on 10/05/22 at 11:23 AM AD stated Resident # 48 attends exercise, we use a board that has a hammer, he was in construction for one on one visits. He likes bingo and parties. The activity participation sheets reflect he does household belongings which is his hat, he takes care of his hat throughout the day. The TV is documented because he listens to the music streamed through the television in the commons area, which is where he is most of the time Reading is Daily chronicle we deliver daily. We do not receive the field and stream magazine but if I get other fishing magazines. I give them to him. The AD reviewed the September activity participation sheet and stated there is no documentation of participation or that we assisted to attend any religious activities in September. He needs to be more involved in activities and assist him more with activities. c.) Resident #110 A record review for Resident #110 showed the resident was admitted to the facility on [DATE]. The careplan for Resident #110, showed a care plan, dated as complete on 09/29/22,. Further review of the activities approaches to the identified problem or focus area was not specific to the resident preferences and was not complete. The care plan, dated 09/29/22, showed no specific preferences for the resident as evidenced by the following plan in place for implementation: While in the facility, resident/patient states that it is important that s/he has the opportunity to engage in daily routines that are meaningful relative to their preferences. + Encourage and facilitate residents/patients activity preferences (select all that apply per Recreation Assessment) ·It is important for me to choose what clothing to wear. (no response was entered by facility staff. ·It is important for you to know which of my personal belongs I prefer to take care of myself. ·I like to snack between meals and prefer ______________. ·It is important for me to choose my bedtime and I prefer to go to bed (Delete all that do not apply) earlier than PM, between 7-PM, after PM or whenever I want. ·It is important for me to have family or a close friend involved in discussions about my care. (No response was entered by facility staff.) ·I would like a place to lock up things to keep them safe. ___________ (No response entered by facilty staff.) ·I enjoy listening to music and prefer _________ (specify type:, era and ways preferred to listen. ·I enjoy watching/listening TV. (No response was entered by facility staff.) ·It is important for me to go outside when the weather is good and enjoy eating/drinking, playing games or sports, gardening, napping, sitting, smoking, talking/visiting, tanning, walking, bird watching/wildlife observing, working, and/or __________. ·I would benefit from accommodation for hearing loss by using closed caption TV, communication board, placement near speaker/leader, use of amplifiers/headphones, written instructions/gestures and/or others____________. (Delete all that do not apply). ·I would benefit from accommodation for cognitive limitations by using decreased environmental clutter, demonstration, reminders, one-to-one settings, physical prompts, single step activity, small groups, time limited, very limited time, verbal prompts and/or others____________. (Delete all that do not apply). ·I would benefit from accommodation for physical limitations by using demonstration, adaptive materials/equipment, physical prompts and/or others_______. (Delete all that do not apply). ·I would benefit from accommodations for visual impairments by using audio books/books on tape, someone to read to them, large print materials, magnifier/telescope glasses, and/or others____________.(Delete all that do not apply). During an interview on 10/05/22 at 11:02 AM the AD stated I just finished Resident #110's name's care plan, she was admitted on [DATE]. I forgot I had not completed it. The AD acknowledged the care plan was not completed within the 14 days. .

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0725 (Tag F0725)

Could have caused harm · This affected multiple residents

Read full inspector narrative →

Based on record review, resident interview and staff interview, the facility failed to ensure sufficient qualified nursing staff were available at all times to provide nursing and related services to meet the residents' needs safely and in a manner that promoted resident rights, physical, mental and psychosocial well-being in accordance with the facility assessment. This failed practice has the potential to affect more than an isolated number of residents currently resding in the facility. Resident Identifiers: Resident #53. Facility census: 62 Findings Included: a) Resident Council meeting During a resident council meeting held on 10/04/22 at 10:02 AM the following concerns were presented: Confidential interviews with the Resident group found the following concerns related to call lights: -Depends on how many is working how long it takes them to answer the call lights. -There can be one (1) Nurses Aide to a hallway or one (1) to the whole building. -Sometimes we wait up to an hour. -They turn off the call light then you wait a long time before they return if they come back at all. -Sometimes we don't get our shower, they pull the shower aides to the floor to cover the shifts because of the call ins. -Some Residents have gone five (5) days, 15 days, or 10 days without showers. b) Facility Assessment Staffing A review of the Facility Assessment tool dated 05/11/22 found the following. .Staffing Plan 3.2 Based on your residents population and their needs for care and support, describe your general approach to staffing to ensure that you have sufficient staff to meet the needs of the residents at any given time. Staff: Licensed Nurses: Registered Nurse (RN), Licensed Practical Nurse (LPN),Licensed Vocational Nurse (LVN) providing direct care Plan: Based on 60 Census: 1:x 30 LPN and/or RN Day shift, 1:x 30 LPN and/or RN Day shift 1:x 30 LPN and/or RN Evening shift, 1:x 30 LPN and/or RN Evening shift 1:x 30 LPN and/or RN Night shift, 1:x 30 LPN and/or RN Night shift Staff: Direct Care Staff Plan: Based on 60 census 1:x 7.5 Certified Nurse Aide (CNA) Day Shift 1:x 10 Certified Nurse Aide Evening Shift 1:x 20 Certified Nurse Aide Night Shift A review of the facility Daily Nurse Staffing Forms found the following issues: -10/04/22 Facility Census was 62: Night Shift, one (1) LPN a 1:62 ratio instead of the 1:30 ratio needed. -10/03/22 Facility Census was 62: Day Shift, six (6) CNA a 1:10.33 ratio instead of the 1:7.5 ratio and one (1) LPN for a 1:62 ratio instead of the 1:30 ratio needed. -09/28/22 Facility Census was 61: Night Shift, one (1) LPN a 1:61 ratio instead of the 1:30 ratio needed. -09/26/22 Facility Census was 62: Day Shift six (6) CNA a 1:10.33 ratio instead of the 1:7.5 ratio -09/25/22 Facility Census was 62: Night Shift one (1) LPN a 1:62 ratio instead of the 1:30 ratio needed. -09/23/22 Facility Census was 62: Day Shift six (6) CNA a 1:10.33 ratio instead of the 1:7.5 ratio needed. -09/22/22 Facility Census was 62: Evening Shift, one (1) LPN and Night shift one (1) LPNa 1:62 ratio instead of the 1:30 ratio needed on each shift. -09/19/22 Facility Census was 61: Evening Shift one (1) LPN and Night shift one (1) LPN a 1:61 ratio instead of the 1:30 ratio needed on each shift. -09/15/22 Facility Census was 61: Day Shift five (5) CNA1:12.2 ratio instead of the 1:7.5 ratio needed , Evening shift one (1) LPN and Night Shift one (1) LPN a 1:61 ratio instead of the 1:30 ratio needed on each shift. During an interview on 10/05/22 at 2:37 PM the scheduling and Payroll Manager stated I did not know about the facility assessment and what the facility required. We have a lot of call ins and try to fill them. c) Resident #53 During an interview with Resident #53 , on 10/04/22 at 09:06 AM, the resident voiced staffing issues to the Director to Nursing (DON), in the presence of the surveyor. It was learned, Resident #53 wanted to keep an inhaler at the bedside because of the long response time it took for call lights to be answered. Resident #53 stated it may take thirty (30) minutes for someone to respond just to answer the light. Resident #53 added, at times, there was only one aide on the hallway for 16 residents, which made her/him nervous having to wait for an inhaler to be brought to the room, in case the resident experienced shortness of breath and needed a treatment. After the resident interview , on 10/04/22 at 09:06 AM, the DON verified Resident #53 was alert and oriented with a Brief Interview for Mental Status (BIMS) of 15, which indicated there was no impairment with cognition and was a reliable source of information.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Food Safety (Tag F0812)

Could have caused harm · This affected multiple residents

Read full inspector narrative →

. Based on observation, policy review and staff interview the facility failed to store food in accordance with professional standards for food safety. The facility failed to label and date food items that were open and failed to dispose of expired food items. The facility also failed to accurately record dishwasher and resident refrigerator temperature logs. The facility also failed to keep the kitchen equipment sanitary. The facility also failed to have a one (1) inch space between the floor and ice machine drain in the kitchen and nourishment room ice machines. These failed practices had the potential to affect more than a limited number of residents currently receiving nourishment from the facility's kitchen and nourishment room. Facility census: 62. Findings Included: The Food Service Director (FSD) was not present upon entering the facility. The [NAME] was in charge of the kitchen at the time of the initial tour. a) Pantry A review of a facility policy titled Food Storage: Receiving with a revision date of 09/17 found the following. .5. All food will be appropriately labeled and dated either through manufacturer packaging or staff notation. .Guidelines for Labeling and Dating Food labels must include: -the food item name -the date of preparation/receipt/removal from freezer -the use by date as outlined in the attached guidelines The initial tour of the kitchen with the [NAME] beginning on 10/03/22 at 8:55 AM found the following items in the pantry: -An opened bag of flour with no opened date -An opened bag of bread crumbs with no open date -An opened bag of graham cracker crumbs with no open date -A box of 7-opened graham cracker pie crust with no open date The [NAME] confirmed the above items should have been labeled and dated once they were opened. b) Walk- In Refrigerator The initial tour of the kitchen with the [NAME] beginning on 10/03/22 at 8:55 AM, found the following items in the walk in refrigerator: -an open bag of shredded carrots with no open date or use by date (UBD) -an open bag of diced potatoes with no open date or UBD -an open package of yellow cheese with no open date or UBD -an open gallon of mayonnaise with no open date or UBD -an open gallon of thousand island with no open date or UBD -an open gallon of soy sauce with no open date or UBD The cook confirmed the above items should have been labeled and dated once they were opened. These items were discarded at this time. -A pan of scrambled eggs was not covered, labeled or dated. -A pan of individual bowls of watermelon was not covered, labeled or dated. The [NAME] stated the eggs and watermelon are for lunch, we just put them in for awhile. I will get them covered and labeled. c) Walk- in Freezer The initial tour of the kitchen with the [NAME] beginning on 10/03/22 at 8:55 AM, found the following items in the walk in freezer: -a open box of roll dough with no open date or UBD The [NAME] confirmed the above items should have been labeled and dated once they were opened. These items were discarded at this time. d) Spice rack The initial tour of the kitchen with [NAME] beginning on 10/03/22 at 8:55 AM, found the following items in the spice rack: -an open bottle of lemon juice with no open date -an open bottle of vinegar with no open date -an open bottle of oil with no open date The [NAME] confirmed the above items should have been labeled and dated once they were opened. These items were discarded at this time. e) Dish Machine Log A review of a facility policy titled Warewashing with a revision date 09/17 found the following. .Procedures .3. Temperature and/or sanitizer concentration logs will be completed as appropriate An observation on 10/03/22 at 9:05 AM revealed a dishwasher temperature log that was incomplete. Evidence revealed the temperature log was missing documented temperatures for the following dates and times: -On 10/01/22 Breakfast and Lunch was void of temperatures -On 10/02/22 Breakfast and Lunch was void of temperatures -On 10/03/22 Lunch temperature was documented for the lunch: wash:120, rinse 120, PPM 100 and initials: (Intials Redacted to Maintain Privacy). Please note it was not lunch time therefore these temperatures could not have been accurate. The [NAME] acknowledged the temperature log was incomplete and should have been completed daily. Also acknowledged that on 10/03/22 the lunch temperature was not completed at the appropriate time. f) Three compartment sink log An observation on 10/03/22 at 9:05 AM revealed a three compartment sink temperature log that was incomplete. A review of the temperature log revealed temperatures were missing for the following dates and times: -On 10/01/22 Breakfast and Lunch was void temperatures -On 10/02/22 Breakfast and Lunch was void temperatures -On 10/03/22 Lunch temperature was documented for the lunch: wash:120, rinse 120, PPM 100 and initials: (Initial Redacted to Maintain Privacy). Please note it was not lunch time therefore these temperatures could not have been accurate. The [NAME] acknowledged the temperature log was incomplete and should have been completed daily. Also acknowledged that on 10/03/22 the lunch temperature was completed at the appropriate time. g) Walk-in Freezer A review of a facility policy titled Food Storage: Cold Foods with a revision date of 04/18 found the following. .Procedures .4. An accurate thermometer will be kept in each refrigerator and freezer. A written record of daily temperatures will be recorded An observation on 10/03/22 at 9:05 AM revealed a walk-in freezer temperature log that was incomplete. A review of the temperature log revealed temperatures were missing for the following dates and times: -On 10/01/22 AM and PM was void temperatures -On 10/02/22 AM and PM was void temperatures The [NAME] acknowledged the temperature log was incomplete and should have been completed daily. h) Walk-in Refrigerator Log An observation on 10/03/22 at 9:05 AM revealed a walk-in refrigerator temperature log that was incomplete. A review of the temperature log revealed temperatures were missing for the following dates and times: -On 10/01/22 AM and PM was void temperatures -On 10/02/22 AM and PM was void temperatures The [NAME] acknowledged the temperature log was incomplete and should have been completed daily. i) Reach-In Refrigerator Temperature Log An observation on 10/03/22 at 9:05 AM revealed a reach-in refrigerator temperature log that was incomplete. A review of the temperature log revealed temperatures were missing for the following dates and times: -On 10/01/22 AM and PM was void temperatures -On 10/02/22 AM and PM was void temperatures The [NAME] acknowledged the temperature log was incomplete and should have been completed daily. j) Unsanitary equipment During the initial tour of the kitchen with the [NAME] beginning on 10/03/22 at 8:55 AM, an observation of the ceiling vent above the silverware prep table revealed accumulation of dust on the vent. The [NAME] acknowledged the accumulation of dust in the ceiling vent and stated it's cleaned by the maintenance not sure how often. During an interview on 10/04/22 at 12:39 PM the Maintenance Director acknowledged the ceiling vent did need to be cleaned. He stated I will start them on a two week cleaning schedule. k) Kitchen Ice Machine An observation on 10/04/22 at 11:25 AM revealed a ice machine in the kitchen area which did not have a one (1) inch space between drain and floor. During an interview on 10/04/22 at 12:39 PM the Maintenance Director stated I was not aware there was to be a one (1) inch space between the floor and drain. I will fix it now. l) Nourishment Room Ice Machine During the observation of the nourishment room on 10/04/22 at 11:45 AM with the Director of Nursing revealed the ice machine did not have a one (1) inch space between drain and the floor. During an interview on 10/04/22 at 12:39 PM the Maintenance Director stated I was not aware there was to be a one (1) inch space between the floor and drain. I will fix it now. On 10/04/22 at 12:15 PM the Dietary District Manager was informed of all the findings and provided no further information or clarification. .

Jun 2021 5 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

Read full inspector narrative →

. Based on observation and staff interview, the facility failed to treat two (2) of the 15 sample residents in the long-term care survey process with dignity and respect. The facility posted signs above resident beds noting details of personal care. Resident Identifiers: #14 and #16. Facility Census: 54. Findings included: a) Resident #14 On 06/21/21 at 9:29 AM, an observation made in Resident #14's room found a of sign above Resident #14's bed indicating resident needed to drink nectar thick liquids. Additionally, the sign went on to explain how to appropriately thicken liquids: 16 oz. (big white cups) = 3 packs of thickener. 8 oz. (clear cups) = 1 1/2 packs of thickener. The Director of Nursing (DON) acknowledged, during an interview on 06/21/21 at 1:54 PM, facility protocol is not to post clinical care/personal care instructions in a viewable area. The DON stated that possibly speech therapy would have posted the sign and she would address the issue. b) Resident #16 On 06/21/21 at 9:31 AM, an observation made in Resident #16's room found a sign above Resident #16's bed indicating the resident needed to drink nectar thick liquids. Additionally, the sign went on to explain how to appropriately thicken liquids: 16 oz. (big white cups) = 3 packs of thickener. 8 oz. (clear cups) = 1 1/2 packs of thickener. The Director of Nursing (DON) acknowledged, during an interview on 06/21/21 at 1:54 PM, facility protocol is not to post clinical care/personal care instructions in a viewable area. The DON stated that possibly speech therapy would have posted the sign and she would address the issue. .

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0578 (Tag F0578)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

. Based on record review and staff interview, the facility failed to ensure two (2) of fifteen (15) residents reviewed during the long-term care survey process had a Physician Orders for Scope of Treatment (POST) form completed per directions specified by the [NAME] Virginia Center for End-of-Life Care in conjunction with the [NAME] Virginia Health Care Decisions Act (16-30-1). Resident identifiers: #31 and #49 . Facility Census: 54. Findings included: a) Resident #31 A medical record review, on 06/21/21 at 1:04 PM, found a POST form on Resident #31's chart. Section C entitled, Medically Administered Fluids and Nutrition, directed Resident #31 should have IV (intravenous) fluids for a trial period of no longer than _____. The specified time period was left blank and was not completed on the POST form. In 2002, the POST form was incorporated into the [NAME] Virginia Health Care Decisions Act (16-30-25.) POST forms are standardized forms used to reflect orders by a qualified physician for medical treatment of a person in accordance with that person's wishes. The directions for completing the POST form, compiled by the [NAME] Virginia Center for End of Life, require accurately documenting a patient's treatment preferences, which would include accurate documentation of the length of the trial period for IV fluids. During an interview 06/21/21 at 1:50 PM, the Director of Nursing (DON) acknowledged the trial period was not defined and the form should be updated. b) Resident #49 A medical record review, on 06/21/21 at 1:15 PM, found a POST form on Resident #49's chart. Section C entitled, Medically Administered Fluids and Nutrition, directed Resident #49 should have IV (intravenous) fluids for a trial period of no longer than _____. The specified time period was left blank and was not completed on the POST form. In 2002, the POST form was incorporated into the [NAME] Virginia Health Care Decisions Act (16-30-25.) POST forms are standardized forms used to reflect orders by a qualified physician for medical treatment of a person in accordance with that person's wishes. The directions for completing the POST form, compiled by the [NAME] Virginia Center for End of Life, require accurately documenting a patient's treatment preferences, which would include accurate documentation of the length of the trial period for IV fluids. During an interview on 06/22/21 at 8:40 AM, the DON acknowledged the trial period was not defined and the form should be updated. .

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0642 (Tag F0642)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review and staff interview the facility failed to coordinate and complete a Minimum Data Set (MDS) to reflect a resident's status at the time of discharge. The facility failed to record information on the MDS assessment that reflected the resident was discharged . This was true for one (1) of three (3) residents reviewed for discharge. Resident identifier: #1. Facility census: 54. Findings included: a) Resident #1 A record review, on [DATE] at 8:15 AM , revealed two (2) accepted MDS entries. The first MDS was titled Entry dated [DATE] and the second MDS was titled Admissions-None PPS dated [DATE]. Further record review of a progress note dated [DATE] at 6:20 AM, on [DATE] at 8:20 AM, revealed Resident was sent to Hampshire Memorial Hospital ER at 0620 for fall, seizure activity, and cardiac arrest while EMS was here. An interview with the MDS Coordinator (MDSC) #46, on [DATE] at 8:31 AM, revealed I forgot to discharge him The MDSC #46 confirmed, Resident # 1 was sent to the hospital on [DATE] and then expired at the hospital. MDSC #46 stated, I forgot to discharge him when he did not come back. .

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Respiratory Care (Tag F0695)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, resident interview, record review and staff interview the facility failed to provide respiratory care and services that was in accordance with professional standards of practice. The facility failed to store and date a nasal cannula for oxygen, a nebulizer face mask and tracheostomy tubing in accordance with professional standards. The facility failed to ensure a physician order was in place prior to providing oxygen to a resident. The failed practice was true for two (2) of two (2) residents reviewed for respiratory care. Resident identifiers #17 and #3. Facility census: 54. A policy review titled Oxygen: Nasal Cannula with revision date 06/01/21, on 06/22/21 at 10:51 AM, stated replace disposable set-up every seven days. Date and store in treatment bag when not in use. Findings included: a) Resident #17 An observation on 06/21/21 at 11:08 AM, revealed Resident #17 in bed and was receiving oxygen through a nasal cannula at a rate of two (2) liters per minute. An interview with Resident #17, on 06/21/21 at 11:09 AM, revealed, the facility wanted Resident #17 to receive oxygen while in the facility. Resident #17 stated, they want me to wear this oxygen even though I do not wear one at home. A record review, on 06/21/21 at 12:00 PM, revealed, no physician order available for oxygen. An additional observation, on 06/21/21 at 2:15 PM, revealed Resident #17's nasal cannula was stored hanging off the bed and laid in a full trash can with tissues and cups. A nebulizer with facemask also laid directly on top of Resident #17's bedside stand. An interview with Certified Nursing Aide (CNA) #3, on 06/21/21 at 2:20 PM, confirmed the nasal cannula should not have been hanging off the bed and into a dirty trash can. CNA #3 confirmed, the nasal cannula should have been stored in the clean bag hanging off the oxygen concentrator. CNA # 3 stated Resident #17 was administered oxygen since admission on [DATE]. CNA #3 stated the nurse would have to discuss the nebulizer as only the nurses touch the nebulizers. An observation, on 06/21/21 at 2:20 PM, revealed CNA #3 removed the contaminated nasal cannula from the trash can, placed the nasal cannula into the clean bag hanging off the oxygen concentrator and exited Resident #17's room. An additional interview with CNA #3, on 06/21/21 at 2:25 PM, revealed the nasal cannula should have been discarded after being contaminated in the trash can. CNA #3 stated, I just got nervous with Surveyor watching and meant to discard the contaminated nasal cannula but didn't. An interview with Licensed Practical Nurse (LPN) #1, on 06/21/21 at 2:30 PM, revealed the nebulizer mask should not have been stored on Resident # 17's bedside stand without being placed in a bag. LPN #1 confirmed the nebulizer mask should have been placed in a bag and dated for storage. An interview with Registered Nurse (RN) #15, on 06/21/21 at 2:40 PM, revealed there was no physician order for administration of oxygen. RN #15 confirmed there was no active or discontinued order for administration of oxygen for Resident #17. b) Resident #3 During initial tour on 06/21/21 at 10:38 AM, an Easy Air Compressor was discovered to be in use to supply humidified compressed air via Trach Collar to Resident #3. The disposable corrugated tubing and Y-bag (attached to corrugated tubing midway between compressor and resident, used to collect excess moisture) were not labeled and dated as to when they were last changed. The This finding was verified by Registered Nurse (RN) #15. The Y-drain bag was also noted to half full of moisture. While in Resident room, the Resident stated, They told me don't have the tubing for it (Easy Air Compressor). RN #15 stated that central supply does the maintenance for the respiratory equipment. On 06/21/21 at 2:30 PM Central Supply Clerk stated she does not change the corrugated tubing for the Easy Air Compressor for Resident #3, she does not feel comfortable, and a nurse has to do it. The Central Supply Clerk provided visible proof of corrugated tubing within inventory of the facility. At 2:35 PM, RN #15 stated, Yea I guess nursing is the one that changes it, and we should mark it somehow. On 6/21/21 04:01 PM, the Director of Nursing (DON) said she had a call out to (Name of Durable Medical Equipment Company) to inquire for recommendations of changing he corrugated tubing for the O2 compressor. The DON and RN #15 both stated they thought it was last changed when the resident was sent out for transfer on 06/11/21. The DON agreed the maintenance and supply changes for the Easy Air Compressor needed to be documented. On 6/22/21 at 8:50 AM the DON stated, I told you wrong yesterday, it was actually 06/15/21 the last time the tubing was changed on the air compressor, (Administrators first name) found a note for that date where she was transferred and brought back. The DON further stated an order has been added to the treatment administration record for the tubing to be changed weekly. The DON said she had also had a call out to (Name of Respiratory Therapy Service Liaison used by facility) for consult for further guidance on maintenance of the Easy Air Compressor and Oxygen Concentrator when used for traches (tracheostomy's). At 10:22 AM on 06/22/21, the DON provided a policy from (Name of Specialized Respiratory Company) obtained through inquiry from the Respiratory Therapy Service Liaison consult that indicated disposable supplies should be changed out weekly, which would include the corrugated tubing on the Easy Air Compressor. The DON stated that is the guideline they will be following moving forward. Record review indicated an order for O2 (oxygen) 10 liters/minute via tracheostomy collar with humidification every shift. The Resident was a full code with diagnosis of acute respiratory failure with hypercapnia, chronic obstructive pulmonary disease, acute and chronic respiratory with hypoxia, and a history of pneumonia due to pseudomonas. Review of the facility's policy, Respiratory Equipment/Supply Cleaning/Disinfection, revision 06/01/21, stated supply change for oxygen delivery device should be every seven days. .

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Food Safety (Tag F0812)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

. Based on observation and staff interview, the facility failed to store food in accordance with professional standards for food service safety. The facility failed to label and date food items that were open and failed to dispose of expired food items. This failed practice had the potential to affect a limited number of residents who are served food from the kitchen. Facility census: 54. Findings included: a) Initial Tour of Kitchen with Dietary Manager Observations during the initial tour of the kitchen, on 06/21/21 at 8:45 AM, revealed: -One 5 lb. container of cottage cheese. There was no opened date on containter. There was no use by date on containter. There was a Best if used by date of 01/21/21 stamped on container by the manufacturer. The Dietary manager stated: This should have been thrown out and immediately disposed of it. -One 25 lb. bag of Japanese bread crumbs. There was no opened date on bag. There was no use by date on bag. There was a new bag beside it. The Dietary Manager stated: This one should have been thrown away and immediately disposed of it. -19 individual bowls of various cereal covered with plastic lids sitting on a tray. The bowls were not labeled or dated. There was nothing on the tray to signify date the cereal was placed in the bowls. The Dietary Manager explained that the staff set up the evening before for breakfast. The Dietary Manager acknowledged the failure to label food items with a Date Opened and/or Use by Date does not allow the staff to ensure the food is safe for consumption. .

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.
• 37% turnover. Below West Virginia's 48% average. Good staff retention means consistent care.

Concerns

• 46 deficiencies on record. Higher than average. Multiple issues found across inspections.

Bottom line: Mixed indicators with Trust Score of 60/100. Visit in person and ask pointed questions.

Email me this report

About This Facility

What is Hampshire Center's CMS Rating?

CMS assigns HAMPSHIRE CENTER an overall rating of 3 out of 5 stars, which is considered average nationally. Within West Virginia, this rating places the facility higher than 99% of the state's 100 nursing homes. This mid-range rating indicates the facility meets federal standards but may have areas for improvement.

How is Hampshire Center Staffed?

CMS rates HAMPSHIRE CENTER's staffing level at 3 out of 5 stars, which is average compared to other nursing homes. Staff turnover is 37%, compared to the West Virginia average of 46%. This relatively stable workforce can support continuity of care.

What Have Inspectors Found at Hampshire Center?

State health inspectors documented 46 deficiencies at HAMPSHIRE CENTER during 2021 to 2024. These included: 46 with potential for harm.

Who Owns and Operates Hampshire Center?

HAMPSHIRE CENTER is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility is operated by GENESIS HEALTHCARE, a chain that manages multiple nursing homes. With 62 certified beds and approximately 59 residents (about 95% occupancy), it is a smaller facility located in ROMNEY, West Virginia.

How Does Hampshire Center Compare to Other West Virginia Nursing Homes?

Compared to the 100 nursing homes in West Virginia, HAMPSHIRE CENTER's overall rating (3 stars) is above the state average of 2.7, staff turnover (37%) is near the state average of 46%, and health inspection rating (3 stars) is at the national benchmark.

What Should Families Ask When Visiting Hampshire Center?

Based on this facility's data, families visiting should ask: "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" "Can I speak with family members of current residents about their experience?"

Is Hampshire Center Safe?

Based on CMS inspection data, HAMPSHIRE 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 3-star overall rating and ranks #1 of 100 nursing homes in West Virginia. While no facility is perfect, families should still ask about staff-to-resident ratios and recent inspection results during their visit.

Do Nurses at Hampshire Center Stick Around?

HAMPSHIRE CENTER has a staff turnover rate of 37%, 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 Hampshire Center Ever Fined?

HAMPSHIRE 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 Hampshire Center on Any Federal Watch List?

HAMPSHIRE 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.

Facility Details

Beds: 62
Avg. Residents: 59
Occupancy: 96.6%
Ownership: For profit - Corporation
Chain: GENESIS HEALTHCARE
Medicare: Yes
Medicaid: Yes
Sprinklers: Yes

Trust Score Breakdown

Base Score: 50
3-Star Rating: +20
46 Deficiencies: -10
Final Score: 60/100

Nearby Alternatives

HAMPSHIRE MEMORIAL HOSPITAL 2-star

View all in ROMNEY →

Check Bed Availability

Data: CMS Medicare Care Compare

Updated: November 2025

Facility ID: 515176