Does CEDAR RIDGE CENTER have any serious inspection findings?

Yes, CEDAR RIDGE CENTER has 6 Immediate Jeopardy citations on record, which represent the most serious type of deficiency. The facility has 99 total deficiencies from recent inspections.

What are the staffing levels at CEDAR RIDGE CENTER?

CEDAR RIDGE CENTER has a one-star staffing rating from CMS with 0.58 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 CEDAR RIDGE CENTER located?

CEDAR RIDGE CENTER is located in SISSONVILLE, WV. It is a Medicare and Medicaid certified skilled nursing facility.

How many beds does CEDAR RIDGE CENTER have?

CEDAR RIDGE CENTER has 119 certified beds.

Who owns CEDAR RIDGE CENTER?

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

What questions should families ask when visiting CEDAR RIDGE CENTER?

Families visiting CEDAR RIDGE CENTER should ask about what corrective actions were taken after fines, how serious violations have been addressed. Also ask to speak with current residents or families, tour during mealtime, and request a copy of the most recent inspection report.

How does CEDAR RIDGE CENTER compare to other nursing homes?

CEDAR RIDGE CENTER has a 1-star overall rating, which is below average compared to other nursing homes in WV. Families should carefully review inspection findings and consider alternatives.

CEDAR RIDGE CENTER

Q: What is CEDAR RIDGE CENTER's CMS rating?

CEDAR RIDGE CENTER has a one-star overall rating from CMS (Centers for Medicare & Medicaid Services), based on health inspections, staffing levels, and quality measures.

Q: Is CEDAR RIDGE CENTER safe?

CEDAR RIDGE CENTER has documented safety concerns including a substantiated abuse finding on record, 6 immediate jeopardy citations, placement on the CMS Special Focus Facility list. Families should ask about corrective actions taken.

Q: Do nurses at CEDAR RIDGE CENTER stick around?

CEDAR RIDGE CENTER has average staff turnover at 54%, which is typical for the nursing home industry.

Q: Was CEDAR RIDGE CENTER ever fined?

Yes, CEDAR RIDGE CENTER has been fined $108,423 by federal regulators. Fines are issued for serious violations of Medicare and Medicaid requirements.

302 CEDAR RIDGE ROAD, SISSONVILLE, WV 25320 · (304) 984-0046

For profit - Corporation 119 Beds GENESIS HEALTHCARE Data: November 2025 6 Immediate Jeopardy citations

Trust Grade

0/100

#93 of 122 in WV

Share this report:

CEDAR RIDGE CENTER nursing home in SISSONVILLE, WV - Photo 1 of 5

CEDAR RIDGE CENTER nursing home in SISSONVILLE, WV - Photo 2 of 5

Photo by Cedar Ridge Center

CEDAR RIDGE CENTER nursing home in SISSONVILLE, WV - Photo 3 of 5

Photo by Cedar Ridge Center

CEDAR RIDGE CENTER nursing home in SISSONVILLE, WV - Photo 4 of 5

Photo by Cedar Ridge Center

CEDAR RIDGE CENTER nursing home in SISSONVILLE, WV - Photo 5 of 5

1 / 5 photos

Last Inspection: April 2025

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

Overview

Cedar Ridge Center has received a Trust Grade of F, indicating significant concerns and a poor overall rating. They rank #93 out of 122 nursing homes in West Virginia, placing them in the bottom half, and #8 out of 11 in Kanawha County, meaning only a few local options are available that are rated higher. The facility’s situation is worsening, with issues increasing from 8 in 2024 to 24 in 2025. Staffing is rated 1 out of 5 stars, and while turnover is average at 54%, this suggests that many staff members may not stay long enough to build meaningful relationships with residents. Additionally, the center has incurred $108,423 in fines, which is concerning and indicates repeated compliance problems. Critically, recent inspections revealed serious incidents, including a failure to follow proper infection control measures for residents with multidrug-resistant organisms, which could affect all residents. Furthermore, gaps in bed safety resulted in a resident becoming entrapped, creating a serious risk of injury. While there is average RN coverage, which is important for monitoring residents closely, the overall picture presents significant weaknesses that families should consider carefully when choosing this facility for their loved ones.

Trust Score: F
In West Virginia: #93/122
Safety Record: High Risk
Inspections: Getting Worse
Staff Stability: 54% turnover. Above average. Higher turnover means staff may not know residents' routines.
Penalties: $108,423 in fines. Lower than most West Virginia facilities. Relatively clean record.
Skilled Nurses: Each resident gets 34 minutes of Registered Nurse (RN) attention daily — about average for West Virginia. RNs are the most trained staff who monitor for health changes.
Violations: 99 deficiencies on record. Higher than average. Multiple issues found across inspections.

★☆☆☆☆

1.0

Overall Rating

★☆☆☆☆

1.0

Staff Levels

★★☆☆☆

2.0

Care Quality

★☆☆☆☆

1.0

Inspection Score

↔

Stable

2024: 8 issues

2025: 24 issues

The Good

Full Sprinkler Coverage · Fire safety systems throughout facility
No fines on record

Facility shows strength in fire safety.

The Bad

1-Star Overall Rating

Below West Virginia average (2.7)

Significant quality concerns identified by CMS

Staff Turnover: 54%

Near West Virginia avg (46%)

Higher turnover may affect care consistency

Federal Fines: $108,423

Well above median ($33,413)

Significant penalties indicating serious issues

Chain: GENESIS HEALTHCARE

Part of a multi-facility chain

Ask about local staffing decisions and management

The Ugly 99 deficiencies on record

6 life-threatening 2 actual harm

May 2025 2 deficiencies 1 IJ (1 affecting multiple)

CRITICAL (K) 📢 Someone Reported This

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

Immediate Jeopardy (IJ) - the most serious Medicare violation

Accident Prevention (Tag F0689)

Someone could have died · This affected multiple residents

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, the facility failed to ensure Resident #31, #37, #105 and #53 had an accident-free environment. Excessive gaps were found with no gap fillers at the foot of three (3) residents' beds. One (1) resident had his arm entrapped between the mattress and side rail. Excessive gaps in danger zones on a resident bed can lead to serious injuries including death. This created an immediate jeopardy situation that began on 05/13/25 at 10:00 AM and ended on 05/14/25 at 12:00 PM. Resident identifiers: #31, #37, #105 and #53. Facility census: 104. Findings include: a) On 05/13/25 between the hours of 9:30 AM through 10:00 AM, observations of all the beds in the facility revealed that the mattresses had no gap fillers and there were gaps greater than approximately 5 inches in resident beds. This allowed for a space at the foot of the bed that could allow the entrapment of Resident #31, Resident #37, and Resident #53. On 05/13/25 at approximately 11:40 a.m., an interview with the Maintenance Assistant (MA) on 05/13/25 at approximately 11:40 a.m. verified these findings. The facility was notified of the Immediate Jeopardy (IJ) at 12:40 PM on 05/13/25. The facility submitted their first abatement plan of correction (POC) at 1:49 PM on 05/13/25. The state agency requested changes and the second abatement POC was submitted on 05/13/25. The plan of correction was accepted on 05/13/25 at 3:33 PM. The plan of correction stated, Maintenance Director fixed the gap at the foot of beds for Resident #31, #37, and #53 on 05/13/25 and used the bed safety measuring tool to ensure it passed. All residents of the facility have the potential to be affected. The Maintenance Director/designee conducted an audit on 5/13/25 utilizing the bed safety tool to ensure the head/foot of beds passed according to manufacturer guidelines with any corrective action immediately upon discovery. The Director of Nursing (DON)/designee conducted an audit on 5/14/25 of residents beds that require gap filler to ensure it is in place with any corrective action immediately upon discovery. Re-education was provided by the Nursing Home Administrator (NHA) to the maintenance department on 5/13/25 regarding the use of the bed safety measuring device to be used to conduct the inspection as they evaluate gaps and potential entrapment risks between head/foot of beds with a post-test by the NHA/designee prior to the beginning of the next shift to work. New maintenance staff will be provided education, including post-test during orientation by the NHA/designee. Re-education was provided by the DON/designee to all the nursing staff on 5/13/25 regarding residents that require gap fillers on the bed to ensure the placement with a post-test to validate understanding. Any nursing staff not available during this time frame will be provided re-education, including post-test by the DON/designee prior to the beginning of the next shift to work. New nursing staff to be provided education, including post-test during orientation by the DON/designee. The Maintenance Director/Designee will monitor resident beds with any change in bed frame, mattress or bedrail utilizing the bed safety measuring device starting 5/13/25 to ensure the head/foot of beds pass according to manufacturer guidelines daily for 2 weeks including weekends and holidays then 5 times a week for 4 weeks, then 3 times a week for 4 weeks, then randomly thereafter. The DON/designee will monitor residents with gap fillers on bed starting 5/14/25 to ensure the placement of gap filler daily for 2 weeks including weekends and holidays, then 5 times a week for 4 weeks, then 3 times a week for 4 weeks then randomly thereafter. Results of monitors will be reported by the DON/designee monthly to the Quality Improvement Committee (QIC) for any additional follow-up and or in-servicing until the issue is resolved then randomly thereafter as determined by the QIC committee. After observation of the implementation of the abatement POC, the IJ was abated at 12:00 PM on 05/14/25. b) Resident #105 Medical Record review revealed Resident #105 was a [AGE] year-old admitted for long term care. He had the following diagnoses: diabetes, hypokalemia, dementia, dysphagia, thyroid disorder and history of falls. He lacked capacity and had a Brief Interview for Mental Status (BIMS) score of 5. A score of 5 indicated severe cognitive impairment. Medical Record Review (MRR) revealed Resident #105 had a fall on 04/19/25 at 5:10 AM. This fall resulted in an injury to the left arm related to entrapment of the arm between mattress and rail. Nurse Aide #135 was assigned to the resident on 04/19/25. According to Nurse Aide #135's statement the resident was last seen in bed on 04/19/25 between 2:30 AM and 3:00 AM. On 05/14/25 during an interview with the administrator, the administrator stated NA #135 left the facility at 3:03 AM on 04/19/25 without letting her supervising nurse know. Nurse Aide #135 was terminated because of the investigation completed by the facility. Witness statements that were collected by the facility and reviewed by the survey team revealed the resident's bed was at waist level when he was found following the fall. Following the fall Resident #105 was transferred to the Emergency Department (ED) and found to have an arterial tear to the left arm. He received surgical intervention to repair the artery and muscle. Review of the facility's investigation revealed Resident #105 was found on 04/19/25 at 5:10 AM. A statement dated 04/19/25 written by Nurse Aide #64 stated, When I walked into (Resident #105's) room I saw (Resident #105) laying in the floor face down with his left arm stuck between the bed and bed rail. His left arm was extended over his head and his arm was twisted. I ran over to him and tried to remove his arm from the bedrail, but it was so tight I couldn't do it by myself. I yelled for (Licensed Practical Nurse #97) and she came in to help me try to remove his arm from the bed rail again and we were unsuccessful. LPN #97 yelled for (name of staff) who was working on third assignment, and she came in and began to assist us. After a few seconds (name of staff) and I were able to free his arm from the bed. During this time (Nurse Aide #121) came in the room and said she was going to get the lift and lift pad so we could safely get him off of the floor and back into the bed so we could check him out. While we waited on her to get back with the lift and lift pad I was holding (Resident #105's) right hand and (name of staff) was holding his left hand. (name of staff) asked Resident #105 to squeeze her hand with his left hand and he was unable to do so. I asked him to squeeze my hand with his right hand and he successfully did. When we got him out of the floor with the lift we noticed that he had a knot coming from his left armpit. LPN #97 tried to call the doctor who advised her to call 911. I did notice when I first went into his room that his bed was placed way higher than normal. I frequently work second assignment and know he has a tendency to roll out of the bed I make sure his bed is to the floor all the way down. His call light and bed remote were both in the floor. His headboard was placed against the wall with both rails up. I do not remember seeing him have on any anti-slip socks at the time of his fall. We checked his brief once he was in bed and he was dry. A bed safety evaluation was performed on 01/27/25. Review of evaluation revealed Step #5 (Risk Factor Evaluation and #7 (Check for Zones of Entrapment) were not completed. There was no documentation in Step #5 and #7. On 05/13/25 at 5:30 PM the Administrator said after this incident they went through the building and assessed all residents' bed/bed rails for the space between the mattress and the side rail. Observations made by the survey team during the investigation did not reveal any potential entrapment areas between the mattress and side rails.

SERIOUS (G) 📢 Someone Reported This

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

Actual Harm - a resident was hurt due to facility failures

Free from Abuse/Neglect (Tag F0600)

A resident was harmed · 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 provide an environment for residents free from neglect and physical harm for one (1) of four (4). This failed practice caused physical harm to Resident #105. Resident #105 fell out of bed and injured his left arm. The failed practice was determined by the state survey team to have been corrected prior to entrance and will be cited at past non-compliance. Resident identifier: #105. Facility census: 104. Findings include: a) Resident #105 Medical Record review revealed Resident #105 was a [AGE] year old admitted for long term care. He had the following diagnoses: diabetes, hypokalemia, dementia, dysphagia, thyroid disorder and history of falls. He lacked capacity and had a Brief Interview For Mental Status (BIMS) score of 5. A score of 5 indicated severe cognitive impairment. Review of an internal investigation completed by the facility revealed Resident #105 had a fall on 04/19/25. According to the facility's investigation this fall resulted in an injury to the left arm related to entrapment of the arm between mattress and rail. Nurse Aide #135's statement reflected that Resident #105 was last seen in bed on 04/19/25 between 2:30 AM and 3:00 AM. Nurse Aide #135 was assigned to the resident on the night of 04/19/25. Nurse Aide #135 was terminated as a result of the investigation completed by the facility. A review of a statement collected by the facility from Nurse Aide (NA) #64 revealed she clocked in on 04/18/25 at 7:00 PM. NA #64 said that NA #135 left at 3:00 AM. NA #135 advised NA #64 that she had finished her round and that everyone had been checked and changed. According to NA #64, NA #110 was supposed to come in at 3:00 AM but had called in to report he was running late. NA #121 came over from south to help NA #64 deal with the fact that NA #110 had not shown up for work. NA #64, NA #121 completed checks on their respective assigned hallways and then went to cover NA #110's assignment. Review of the facility's investigation revealed Resident #105 was found by NA #64 on 04/19/25 at 5:10 AM. A statement dated 04/19/25 written by Nurse Aide #64 stated, When I walked into (Resident #105's) room I saw (Resident #105) laying in the floor face down with his left arm stuck between the bed and bed rail. His left arm was extended over his head and his arm was twisted. I ran over to him and tried to remove his arm from the bedrail but it was so tight I couldn't do it by myself. I yelled for (Licensed Practical Nurse #97) and she came in to help me try to remove his arm from the bed rail again and we were unsuccessful. LPN #97 yelled for (name of staff) who was working on third assignment, and she came in and began to assist us. After a few seconds (name of staff) and I were able to free his arm from the bed. During this time (Nurse Aide #121) came in the room and said she was going to get the lift and lift pad so we could safely get him off of the floor and back into the bed so we could check him out. While we waited on her to get back with the lift and lift pad I was holding (Resident #105's) right hand and (name of staff) was holding his left hand. (name of staff) asked Resident #105 to squeeze her hand with his left hand and he was unable to do so. I asked him to squeeze my hand with his right hand and he successfully did. When we got him out of the floor with the lift, we noticed that he had a knot coming from his left armpit. LPN #97 tried to call the doctor who advised her to call 911. I did notice when I first went into his room that his bed was placed way higher than normal. I frequently work second assignment and know he has a tendency to roll out of the bed I make sure his bed was to the floor all the way down. His call light and bed remote were both in the floor. His headboard was placed against the wall with both rails up. I do not remember seeing him have on any antislip socks at the time of his fall. We checked his brief once he was in the bed and he was dry. On 05/14/25 during an interview with the administrator, the administrator stated NA #135 left the facility at 3:03 AM on 04/19/25 without letting her supervising nurse know. The Administrator stated during an interview, on 05/14/25, that it was her expectation that all residents were visually observed and provided if care if needed at least every (2) hours. It was confirmed that this resident was not checked on for over two (2) hours. Following the fall Resident #105 was transferred to the Emergency Department and found to have an arterial tear to the left arm. He received surgical intervention to repair the artery and muscle. The resident did not return to the facility. The facility provided a copy of an In-Service Sign-In Sheet dated 04/21/25. The topic and description was Shift to Shift report (walking around) must take place at the end of your shift with the oncoming CNA/Nurse. If you leave the floor for lunch, break or your shift is over you must report to your nurse/supervisor that you are leaving so your assignment can be reallocated to who is covering for you. On 05/14/25 the administrator stated NA #135 left the facility at 3:03 AM on 04/19/25 without letting her supervising nurse know. A review of the facility's investigation revealed Nurse Aide #110 was scheduled to report to work at 3:00 AM on 04/19/25. Investigation revealed that NA #110 had called in to report he would be arriving for work late and later that morning called in to report he would not be there for the entire shift. During an interview on 05/14/25 at approximately 10:35 a.m., the Administrator stated, During our investigation, we discovered the issue and immediately began to correct the issue. We done separate training related to this finding. Education was completed to all NAs by 05/01/25. The facility provided a copy of an In-Service Sign-In Sheet dated 04/21/25. The topic and description was Shift to Shift report (walking around) must take place at the end of your shift with the oncoming CNA/Nurse. If you leave the floor for lunch, break or your shift is over you must report to your nurse/supervisor that you are leaving so your assignment can be reallocated to who is covering for you. The Administrator said after this incident they went through the building and assessed all residents' bed/bed rails for the space between the mattress and the side rail. Observations made by the survey team during the investigation did not reveal any potential entrapment areas between the mattress and side rails. A bed safety evaluation was performed on 01/27/25. Review of evaluation revealed Step #5 (Risk Factor Evaluation and #7 (Check for Zones of Entrapment) were not completed. There was no documentation in Step #5 and #7. A fall risk assessment was completed on 01/28/25. Results of assessment were that Resident #105 was a fall risk and was care planned for fall risks. Documentation review revealed that all NAs were provided education on correct procedure when performing a shift-to-shift report (walking around). Sign-in sheets for the in-service were reviewed and staff interviews with Nurse Aide (NA) #110, #79, #12, and #77 verified training completed. On 05/14/25 at approximately 12:19 p.m., interview with Nurse Aide (NA) #110. The surveyor asked the NA to explain the shift-to-shift report process. NA #110 correctly explained the process. On 05/14/25 at approximately 1:13 p.m., conducted an interview with Nurse Aide (NA) #79. Asked the employee what procedure they would follow if they had to leave or at change of shift. NA #79 stated, I would notify who is in charge and I would give a report to whoever is taking care of my residents. Education was completed and verified by a signature sheet on 04/21/25. On 05/14/25 at approximately 1:41 p.m., the surveyor conducted an interview with Nurse Aide (NA) #12. The surveyor asked the employee what procedure they would follow if they had to leave or at change of shift. NA #12 stated, I would give a report to oncoming CNA and do a walk around. Education was completed and verified by a signature sheet on 04/21/25. On 05/14/25 at approximately 1:47 PM, the surveyor conducted an interview with Nurse Aide (NA) #77. NA #77 was asked what procedure they would follow if they had to leave or at the change of shift. NA #77 stated, I would give report and do a walk around. If I had to leave, I would notify who was in charge. Education was completed and verified by a signature sheet on 04/21/25

Apr 2025 22 deficiencies 2 IJ (1 affecting multiple)

CRITICAL (J) 📢 Someone Reported This

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

Immediate Jeopardy (IJ) - the most serious Medicare violation

Respiratory Care (Tag F0695)

Someone could have died · 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 review, the facility failed to ensure Resident #111 received respiratory care to ensure Resident #111's airway remained intact and was able to be reestablished immediately if the tracheotomy tube would become dislodged. This was true for one (1) resident reviewed for the care area of Respiratory care during the long term care survey process. The facility failed to ensure they had the supplies at bedside to replace Resident #111's tracheotomy canula. The physician orders and Resident #111's care plan dictated the supplies were to be kept at bedside. When the staff was asked were the supplies were to replace the canula were located, it took greater than 15 minutes to find the needed supplies in the supply closet. They were not kept at bedside as directed in the physician order and care plan. The failure to replace Resident #111's tracheotomy cannula timely could result in the immediate loss of a secure airway leading to severe hypoxia, anoxic brain injury, cardiopulmonary arrest and potentially death. Medical literature affirms that timely intervention is critical. Delayed recognition or failure to reestablish the airway with in minutes can cause irreversible harm. The State Agency (SA) determined this failure put Resident #111 in an Immediate Jeopardy (IJ) situation. The facility was notified of the immediate jeopardy at 5:03 PM on 04/15/25. The facility submitted and the SA accepted a plan of correction (POC) at 5:20 PM. After observation of implementation of the POC the IJ was abated at 6:27 PM on 04/15/25. After the IJ was abated and the immediacy was removed, but a deficient practice remained for Resident #97. Resident #97 was ordered to have continuous oxygen but it was not in place. After the abatement the scope and severity was decreased from a J to a D. Resident Identifiers: #111 and #97. Facility Census: 111. Findings Included: a) Resident #111 Resident #111 was admitted to the facility on [DATE]. The resident record contained the following physician orders related to trach care: -- Type of Trach 6.5 size of trach 6 spare trach kept at bedside and ambu bag at bedside. A review of the residents care plan found the following care plan interventions related to the trach included: -- Keep a spare trach/orturator trach kit at bedside. Added to the care plan 03/24/25. -- Type of trach: 6.5 size of trach 6 keep spare trach and ambu bag at beside. Added to the care plan on 03/24/25. Observations of Resident #111 with the Director of Nursing (DON) at approximately 11:45 am found the resident did not have a size six (6) trach at her bed side. She was then asked if she could show the surveyor that she had one in the facility. She summoned the Respiratory Therapist (RT) who looked in the supplies they were unable to locate a size 6. The RT then went to Resident #111's room to see what size trach was currently in place. The RT determined it was a size 7.5 instead of a 6.5. He was then able to locate the size 7 trach kit which would have been the size down. It took greater than 15 minutes to locate the trach kit which according to the physicians orders and care plan should have been located at bed side. He agreed it needed to be at bed side and not in the storage area. An additional interview with the RT, on 04/15/25 at 1:25 PM, confirmed he was one who ordered the wrong size trach. He stated that when she arrived the hospital did not send orders with her regarding the size of her trach. He stated that he looked at it and they are new and have different numbers. He stated that he looked at the chart and made an error when putting in the orders and the care plan. When asked what type of circumstances would cause the trach to dislodge the RT stated, A deep cough moving around just about anything could make it pop out. An interview with Licensed Practical Nurse #60 (LPN), confirmed if the trach would come out he would hold the oxygen over the hole and call a Registered Nurse. He confirmed, he was not allowed to replace the trach. A review of the facility's procedure related to Tracheotomy Tube Change/reinsertation,found primary licensed staff inserts the new tube. The DON indicated this meant an LPN can reinsert the new tube. She stated he knew that so I don't know why he told you that. Further review of the procedure for Tracheotomy Tube Change/reinsertation found the following, .9. Verify size of trach that patient has in place to assure appropriate tube size and type. 10. Verify the two replacement trachs, current size and one size below, are available at bedside along with manual resuscitator . An additional interview with the RT at, 04/15/25 at 2:26 PM, revealed he should have ordered a 6un75H in the trach and she should have had a 5un70h at bedside. He stated that he went by the diameter of 7.5 instead of the size of the trach. However the ordered reflected a 6.5 not the diameter of 7.5. The RT confirmed the residents trach is uncuffed and they are more likely to dislodge. A follow up interview with the DON after the facility's was notified of the IJ confirmed it took greater than 15 minutes to find the correct size trach. She stated, But we was not in an emergency situation. She felt they would have found it quicker had the trach been dislodged however the chaos of any emergency likely would cause further delay. She agreed the spare trach should have been at bedside. b) Facility's Plan of Correction The facility's plan of correction read as follows (typed as written): The Director of Nursing (DON)/designee placed the emergency trach as ordered by the resident's 11 bedside on 4/15/25 @ 500pm. All residents with tracheostomies of the facility have the potential to be affected. As of 4/15/25 no other residents with tracheostomies in the facility at this time. Re-education was provided by the Director of Nursing(DON)/Designee to all licensed nurses starting on 4/15/25 to ensure residents with a tracheostomy tube in place will have a spare tracheostomy tube with obturator of the same manufacturer brand and size currently used AND one size smaller at the bedside. A Post-test to validate understanding. Any licensed nurses not available during this time frame will be provided re-education, including post-test and return demonstration by DON/designee upon the beginning of next shift to work. New Licensed nurses will be provided education, including post-test during orientation by the DON/designee. Annual in-servicing will be provided to licensed nurses regarding the care of indwelling urinary catheters. The Unit Managers (UM)/Designee will conduct observations starting on 4/15/25 to ensure residents with a tracheostomy tube in place will have a spare tracheostomy tube with obturator of the same manufacturer brand and size currently used and one size smaller at the bedside daily across all shifts for 2 weeks including weekends and holidays, then 3 times a week for 2 weeks then randomly thereafter. Results of observations will be reported by the Unit Manager (UM)/designee monthly to the Quality Improvement Committee (QIC) for any additional follow-up and or in-servicing until the issue is resolved, then randomly thereafter as determined by the QIC committee. c) Resident #97 The facility failed to provide oxygen via nasal cannula for Resident #97 who was ordered oxygen continuously. On 04/16/25 at 10:25 AM, the state surveyor observed Resident #97 not wearing his oxygen and the concentrator turned off. Resident #97's physician's order stated, Oxygen at 2 L/min via Nasal Cannula continuously. Licensed Practical Nurse (LPN) #60 confirmed the resident was not wearing his oxygen. LPN #60 placed the resident's nasal cannula, turned the oxygen concentrator on, and changed the the liters to two (2) liters per minute from the setting of three (3) liters per minute. LPN #60 stated, It's supposed to be two (2) liters it was three (3) liters. The resident's oxygen saturation level was 96%.

CRITICAL (K) 📢 Someone Reported This

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

Immediate Jeopardy (IJ) - the most serious Medicare violation

Accident Prevention (Tag F0689)

Someone could have died · This affected multiple residents

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on water temperature measurement and staff interview the facility failed to ensure the resident environment over which it had control was as free from accident hazards as possible. The hot water temperature in the hand washing sink located in the main dining room was at an unsafe temperature for resident use. The water temperature in the hand sink in the main dining room was tested with facility equipment by the facility's maintenance director at approximately 2:30 PM on 04/16/25 the temperature was 139.2 degrees Fahrenheit. The water temperature in the sink in the main dining room at 2:56 PM was obtained in the same manner mentioned above and was 125 degrees Fahrenheit. The state agency (SA) felt this put any resident who was able to wash their hands in this sink at an immediate risk for serious injury and/or death and created an Immediate Jeopardy (IJ) situation. The SA notified the facility of the IJ at 3:56 PM on 04/16/25. The SA accepted the facility's plan of correction (POC) at 4:07 PM on 04/16/25. After staff interviews, reviewing the education and facility water temperature measurements for all resident areas, and observing the water was turned off to the main dining room the SA abated the IJ at 6:12 PM on 04/16/25. This failed practice to effect the following residents who were identified by the facility as the residents who could potentially access the hand sink in the main dining room, #166, #14, #216, #44, #81, #66, #49, #71, #96, #34, #104, #167, #87, #21,#84, #8, #168, #53, #7, 80, #51, #62, #31, #1, #22, #101, #28, #11, #57, #59, #91, #35, #107, #73, #27, #40, #10, #72, #102, #45, #46, #19, #8, #93, #61, #82, #48, #43, #3, #106, #47, #60, #217, #266, #6, #15, #52, #108, #29, #77, #83, #50, #108, #29, #77, #83, #50, #58, #26, #64, #68, #12, #74, #103, #78, #39, #6, #17, #88, and #30. Facility Census: 111. Findings Included: a) On 04/16/25 at approximately 2:20 PM the surveyor noticed a hand sink in the main dining room. Because this hand sink is accessible to residents, the surveyor felt the hot water in the sink The water was hot to the touch. The surveyor could not comfortably keep her hand under the stream without withdrawing due to the risk of burns. The maintenance director was asked to come to the dining room to measure the temperature of the hot water in the hand sink. The water temperature in the hand sink in the main dining room was tested with facility equipment by the facility's maintenance director at approximately 2:30 PM on 04/16/25 the temperature was 139.2 degrees Fahrenheit. The water temperature in the hand sink in the main dining room at 2:56 PM was obtained in the same manner mentioned above and was 125 degrees F. (Please note the maintenance director immediately turned off the hot water to the hand sink after the first measurement at 2:30 PM. He turned the water back on to obtain this measurement.) The maintenance director was asked which tank the hot water to the hand sink came from. He indicated initially it was the same tank that fed the resident rooms and shower rooms. He was then asked to obtain temperatures in the back shower room, which was 98.7 degrees F, and in room [ROOM NUMBER] which was 95.0 degrees F. It was immediately after these readings that the second reading from the hand sink in the main dining room was obtained and was 125 degrees F. An interview with the Maintenance Director at approximately 2:45 PM confirmed he does not routinely check the temperature in the hand sink in the dining room. He indicated that he checks the water temperature in the shower rooms and resident rooms. When asked what tank fed the hand sink in the dining room, he indicated it was the same tank that fed resident areas. However, the water temperatures obtained in the shower room and room [ROOM NUMBER] were both less than 100 degrees Fahrenheit. He stated, I'm going to have to look in the attic to determine what tank this water is coming from. The facility self-identified the following residents were able to wash their hands in the main dining hand sink without the assistance of staff: Resident #166, #14, #216, #44, #81, #66, #49, #71, #96, #34, #104, #167, #87, #21,#84, #8, #168, #53, #7, 80, #51, #62, #31, #1, #22, #101, #28, #11, #57, #59, #91, #35, #107, #73, #27, #40, #10, #72, #102, #45, #46, #19, #8, #93, #61, #82, #48, #43, #3, #106, #47, #60, #217, #266, #6, #15, #52, #108, #29, #77, #83, #50, #108, #29, #77, #83, #50, #58, #26, #64, #68, #12, #74, #103, #78, #39, #6, #17, #88, and #30. According to Table 1 in the Guidance to Surveyors related to comfortable/safe water temperatures, found in Appendix PP of the CMS State Operations Manual, a third (3rd) degree burn can occur at 120 degrees F with an exposure time of five (5) minutes, at 124 degrees F with an exposure time of three (3) minutes, at 127 degrees F with an exposure time of one (1) minute, at 133 degrees F with an exposure time of 15 seconds, and at 140 degrees F with an exposure time of 5 seconds, noting that burns can occur even at water temperatures below that level depending on the exposed individual's condition and the length of exposure. The facility submitted the following plan of correction to the AS (typed as written): F689 The Maintenance Director (MD) turned the water off to the dining room sink on 4/16/25 immediately upon discovery. The Nursing Home Administrator (NHA) posted an out of service sign on the dining room sink on 4/16/25 at 2:45pm. All the residents of the facility have the potential to be affected. The Director of Maintenance/designee completed an audit on 4/16/25 of water temperatures from point of use on each resident room, resident care areas, and shower rooms to ensure water temperature is 110 degrees or below with any corrective action immediately upon discovery. Re-education was provided by the Nursing Home Administrator (NHA) /Designee to all maintenance employees starting on 4/16/25 to ensure water temperatures from point of use in the facility is 110 degrees or below. A Post-test to validate understanding. Any maintenance employees not available during this time frame will be provided re-education, including post-test and return demonstration by DON/designee upon the beginning of next shift to work. New maintenance employees will be provided education, including post-test during orientation by the DON/designee. The Maintenance Director (MD) /Designee will monitor facility water temperatures from point of service on each hallway a random room, resident care areas, and shower rooms starting on 4/16/25 to ensure water temperatures are 110 degrees or below daily across all shifts for 2 weeks including weekends and holidays, then 3 times a week for 2 weeks then randomly thereafter. Results of monitors will be reported by the Unit Manager (UM)/designee monthly to the Quality Improvement Committee (QIC) for any additional follow-up and or in-servicing until the issue is resolved, then randomly thereafter as determined by the QIC committee. An additional interview with the Maintenance Director at Approximately 6:00 PM confirmed the hot water tank which fed the hand sink in the main dining room was tied in with the tank that fed the kitchen. He stated, It would have been hotter because the kitchen water has to be hotter.

SERIOUS (G)

Actual Harm - a resident was hurt due to facility failures

Deficiency F0697 (Tag F0697)

A resident was harmed · This affected 1 resident

Read full inspector narrative →

Based on observation, record review and staff interview, the facility failed to ensure orders and interventions were followed to control pain for Residents #42 and #87. This was true for two (2) of six (6) residents reviewed for pain management during the survey process. Resident identifiers: #42, #87. Facility census: 111. The State Agency (SA) determined physical harm was caused to Resident #42 when the facility failed to check on, and assess, Resident #42 for pain, for approximately 50 minutes, despite him yelling out the entire duration, until surveyor intervention. At which time, it was discovered by Licensed Practical Nurse (LPN) #36, Resident #42 was in pain and requested pain medication. Furthermore, physical harm was determined based upon the review of the Medication Administration Record (MAR), orders, and care plan, which revealed the resident had not gotten the correct dose of pain medication, had not received any nonpharmacological interventions for pain as ordered, and was not receiving interventions for pain management that were in place in his care plan. Findings Include: a) Resident #42 Resident #42 received hospice services due to an end stage diagnosis of History of CVA (cerebrovascular accident). Resident #42 has an order for: Morphine Sulfate (Concentrate) Solution 20 MG/ML. Give 10 mg by mouth every two (2) hours as needed for pain/dyspnena. Give 0.50 ML. Hold for Sedation 0.50 ml, every two hours as needed for pain. At approximately 11:30 AM on 4/13/25, during observations in the North hall of the facility, Resident #42 was observed to be yelling out. Review of the resident's record on 04/13/25, revealed indicators for pain were yelling out, restlessness, tenseness. Resident #42 was observed to be yelling out again at approximately 1:30 PM, 2:40 PM, and 3:08 PM. At approximately 9:05 PM on 4/14/25, Resident #42 was heard yelling out in his room. His door was pulled around, almost shut completely, left barely cracked open. This surveyor stood in front of the resident's door until approximately 9:45 PM. No one entered the room to check on the resident during this time period. All three (3) Nurse Aides (NA), #13, #15, #21, assigned to that side of the facility, walked by and Licensed Practical Nurse (LPN) #36 was on the medication cart in the hallway. At approximately 9:45 PM someone could be heard yelling from inside the room, Please help me. Still, no staff member entered the room to check on the resident. At approximately 9:50 PM, this surveyor told LPN #36 Someone in the room is yelling for help. The LPN stated, He's usually confused, but I'll check on him. Upon entering the room, Resident #42 was still yelling out. LPN #36 asked Resident #42 if he was in pain and he indicated he was. She asked him what he needed, and he held up his index finger and thumb, as if he was holding something between them. The nurse asked Do you need your pain medication? Resident #42 indicated he did. LPN #36 administered the pain medication at approximately 9:55 PM. Approximately 20 minutes later, the resident was found to be calmer and yelling out less. LPN #36 was asked what the resident's indicators of pain were. LPN #36 stated his indicators were yelling out, tenseness, and restlessness. LPN confirmed the resident exhibited all symptoms at this time. LPN was asked how the resident communicated pain, to which she stated he was nonverbal and the staff look for things such as yelling out, tenseness, restlessness. LPN #36 stated at this point, the resident should be assessed for pain. Upon review of the resident's Medication Administration Record (MAR) for the month of April 25, on 04/15/25, it was noted zero (0) nonpharmacological interventions for pain management had been implemented, as the entire month, up to 04/15/25 was empty. It was also noted, from the resident's MAR, he was administered morphine at 8:25 PM on 04/13/25 and did not receive it again until 9:52 PM on 4/14/25, going over 24 hours without receiving it. Review of the narcotic sheet on 04/15/25, for the morphine, indicated on 04/9/25 at 8:45 PM, 0.25 ml of morphine was signed out on the log and administered to the resident. 0.25 was signed out and administered at 5:24 AM on 04/10/25. Resident #42 was given half of his ordered dose at this time, as he had an active order for 0.5 ml of Morphine at the time of administration. Progress notes for those days stated the resident was administered 0.5 ml on both occasions, despite the narcotic log stating 0.25 ml was signed out. Upon review of the resident's care plan, the following interventions were noted regarding pain management: Observe for pain. Attempt non-pharmacologic interventions to alleviate pain and document effectiveness. Administer pain medication as ordered and document effectiveness/side effects. Observe for pain and administer as ordered per MD and position for comfort. Resident and HCS will achieve the highest possible level of peace by the time of death as evidenced by alleviated pain and resident exhibited calmness. Assess for pain, restlessness, agitation, constipation and other symptoms of discomfort. Medicate as ordered and evaluate effectiveness. Provide non-pharmacological approaches to aide in decreasing discomfort. Offer non-pharmacologic interventions prior to PRN pain medication administration. Observe for non-verbal signs/symptoms of pain and medicate as ordered. Observe for nonverbal signs of pain: increase in agitation, grimace, resistance to care. During an interview with the Director of Nursing (DON) on 04/16/25 at approximately 4:00 PM, it was confirmed, based on observations and review of the narcotic log and MAR, Resident #42's care plan was not being implemented regarding his pain management. He had received the incorrect dose of morphine (0.25 ml instead of the prescribed 0.5 ml); He did not receive nonpharmacological interventions for pain management as ordered. The DON also confirmed LPN #36 expressed to her Resident #42 was in pain upon the DON's arrival to the facility at approximately 9:50 PM on 04/14/25, as the nurse told the DON she was preparing to administer the resident's morphine. b) Resident #87 A review of Resident #87's medical record on the morning of 04/16/25 found the resident was ordered Hydrocodone 5-325 by mouth every 6 hours for pain, The medication administration record for the month of 03/2025 and the month of 04/2025 along with the controlled substance log coinciding with these month was requested. Upon review of the MAR and the controlled substance log it was found on 04/06/25 at 6:00 PM the medication was initialed as administered but was not signed out on the controlled substance log. This indicated the medication was not administered because it was not removed from the medication card. This same situation occurred again on 04/13/25 for the 6:00 am dose. This was confirmed with Corporate Registered Nurse (CRN) #132 at 5:00 PM at on 04/16/25.

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 resident interview, the facility failed to ensure Resident #94 was treated in a dignified manner, by allowing him to sit in a soiled brief for an extended period of time. This was a random opportunity for discovery. Resident Identifier: 94. Facility census: 111. Findings included: A) Observation At approximately 9:05 PM on 4/14/25, the call light for Resident #94's room was observed ringing in the North hall of the facility. At approximately 9:16 PM, Resident #94 was observed yelling Hello multiple times from inside his room, but did not receive an answer. During this time, Licensed Practical Nurse (LPN) #36 and Nurse Aide (NA) #21 were on the hallway. LPN #36 was passing medications and NA #21 was observed going back and forth between other resident rooms. At approximately 9:20 PM, NA #21 went to a soiled linen bin outside of Resident #94's room, at which time he yelled , Can I get an aide please? NA #21 placed items into the soiled linen bin, walked down the hallway, and did not acknowledge the resident. At approximately 9:23 PM NA #13 entered the Hallway next to Resident #94's room and answered another resident's call light. At approximately 9:25 PM, LPN #36 answered Resident #94's call light. Upon entering the resident's room she asked Resident #94 what he needed, to which he responded I need changed. LPN #36 stated, I'll find out who your aide is and let them know. LPN #36 proceeded to turn the resident's light off and go back to the medication cart. At approximately 9:33 PM, LPN #36 stated to NA #13 [Resident #94's name] needs changed. NA #13 then stated, I'm on back hallway, I'm just covering this until [NA #15's name] gets back. NA #13 then proceeded to walk past Resident #94's room, did not address the resident, and did not enter the room. When Resident #94 saw the aide walk by, he yelled, Did we find an aide yet? At approximately 9:36 PM, LPN #36 told NA #15, [Resident #94's name) needs help. He needs changed. I told the other aide earlier but she didn ' t change him. NA #15 acknowledged Resident #94's needs and retrieved a cart with meal trays on it and pushed it to the dining room. Upon returning to the hallway at approximately 9:45 PM, NA #15 entered Resident #94's room and provided care. B) Resident Interview Resident #94 has a Brief Interview for Mental Status (BIMS) Score of 15, indicating he is cognitively intact. At approximately 10:00 PM, an interview was conducted with Resident #94 regarding his wait time for care. Resident #94 was asked how long his light had been on. Resident #94 stated Since about nine (9:00) o ' clock, about 40 to 45 minutes. Resident #94 then stated, I know they're understaffed around here and I try to be sympathetic to them because of that. But when they let you lay in your own crap for over 40 minutes, it's really hard to be sympathetic.

CONCERN (D)

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

Grievances (Tag F0585)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

Based on record review and resident interview, the facility failed to ensure the resident's right to voice a grievance to the facility without fear of reprisal for Resident #58. This was a random opportunity for discovery and had the potential to affect more than a limited number of residents. Resident Identifier: #58. Facility Census: 111. Findings included: a) Policy Review The facility's policy and procedure stated, The patient/resident (hereinafter patient) has the right to voice grievances to the Center or other agency or entity that hears grievances without discrimination or reprisal and without fear of discrimination or reprisal. Such grievances include those with respect to care and treatment which has been furnished as well as that which has not been furnished, the behavior of staff and of other patients, and other concerns regarding their Center stay. b) Resident Council A resident Council Meeting was held on 04/14/25 at 02:05 PM. The residents expressed you couldn't voice a concern at times without worrying that someone will get back at them. Several residents reported the staff will argue with you and it depends on the staff. c) Interview with Resident #58 On 04/14/25 at 02:55 PM, after the Resident Council Meeting, Resident #58 reported a couple of nights ago she had waited for one hour and a half for urine to be drained from her bladder by Licensed Practical Nurse (LPN) #35. Resident #58 reported she was in pain to the point of tears and by then she had waited over two hours. The resident went into the hall to find a nurse and two (2) were around the corner. LPN #35 asked the resident what she needed and gave attitude to the resident per Resident #58's report. The resident reported LPN #35 stated, I'll get to you when I get to you. Resident #58 reported LPN #35 came into her room, holding the catheterization kit, and went off on me. The resident stated the nurse said she had not been told by the CNA and the resident reported Nursing Assistant #33 had been told. The resident stated, I admit I was rude, but I was hurting. and I try to give them grace. Resident # 58 reported later that night when she needed changed, Nursing Assistant #33 was rude in the way she talked to me during my care and she snapped at me. The resident reported when she was finished with care, Nursing Assistant #33 said, Okay. I'm done. Bye. Resident #58 gave the state surveyor verbal permission to investigate this incident. d) Interview with Administrator The state surveyor reported Resident #58's allegation to the Administrator on 04/14/25 at 3:10 PM. The Administrator stated, I will report this now. On 04/15/25, the state surveyor reviewed the Facility Reported Incident which was submitted and reported timely to the appropriate entities.

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

Free from Abuse/Neglect (Tag F0600)

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, staff interview and record review, the facility failed to ensure Resident #26 and Resident #70 were not neglected. Resident #70 asked for a snack for over 30 minutes she was eventually given a snack but it was the wrong consistency. The nurse aide then had to take it from her which upset the resident. The facility also failed to give Resident #26 his medication even though it was available in the pyxis machine. This was true for two (2) of seven (7) residents reviewed for the care area of abuse during the long term care survey. Resident Identifiers: #70 and #26. Facility Census: 111. Findings Included: a) Resident #26 An interview with Resident #26 on 04/13/25 at 2:44 PM found the Licensed Practical Nurse's (LPN) often let him run out of medication and he don't get it until it comes in from the pharmacy. When asked if knew what medications he runs out of he stated, I don't know the names of them, but I know one of them was for my restless leg syndrome. He indicated it was miserable with his legs jerking and moving all night. A review of Resident #26's medication administration record (MAR) for 04/2025, on 04/16/25, found the following doses of medication were not checked off to indicate they were administered: -- Gabapentin 600 milligrams by mouth two (2) times a day. Missed on 04/02/25 at 9:00 AM. The doses for 04/02/25 at 9:00 PM and for 04/03/25 at 9:00 am were documented on the controlled substance log but were not documented as administered on the MAR. -- Ropinirole 2 mg take two (2) tablets by mouth two (2) times a day for restless leg syndrome. Missed on 04/03/25 at 10:00 PM. -- Synthroid Oral Tablet 100 mcg take one (1) tablet by mouth one time a day. Missed on 04/03/25 at 6:30 AM. An interview with Registered Nurse (RN) #77, in the afternoon of 04/16/25, confirmed Resident #26 missed doses of his Gabepentin, Synthroid, and Ropinirole. She was asked if these medications were available in the pyxis system. She stated, We can go check. RN #77 checked the pyxis system and confirmed the medications were available and could have been pulled by the on duty nurse but were not. b) Resident #70 On 04/14/25 at 9:05 PM the facility was entered on night shift due to resident complaints of care on the night shift. Upon entrance to the facility Resident #70 was observed sitting in the doorway of the Cafe. The resident was yelling for help and asking for a snack. She later began asking for a specific snack of a peanut butter sandwich. Numerous staff were in the area of the resident and could have easily heard her asking for a snack. This continued until about 9:33 PM when Nurse Aide (NA) #55 walked by and Resident #70 asked her for a peanut butter sandwich. NA #55 then stated to another employee, I think she is puree I will get her an apple sauce or pudding in just one (1) minute. Shortly after this exchange the Resident asked LPN #4 for a peanut butter sandwich. LPN #4 then went to the refrigerator retrieved a sandwich and gave it to Resident #70 (the sandwich was not pureed). As resident #70 was trying to open her sandwich NA #55 reentered the cafe and said she is on a pureed diet she can't have that sandwich she then proceeded to take the sandwich from Resident #70. The resident stated, I want to eat that give it to me. The nurse aide took the sandwich at which time she offered her a pudding or applesauce which the resident turned down she stated, I want a peanut butter sandwich. RN #1 pulled up Resident #70's diet order on her computer at 9:39 PM and confirmed she was on a pureed diet. LPN #4 then stated, I did not know that this is the first time I have had her since she has been back. They did not tell me that in report. Resident #70 was readmitted to the facility on [DATE]. At 9:48 PM, RN #84 approached Resident #70 and asked her what was wrong. Resident #70 stated, I'm unhappy. RN #84 asked her why and she stated, They won't give me a peanut butter sandwich. RN #84 explained she could not have that and then asked her if she would like some chocolate pudding. At 9:58 PM the resident was finally provided with a snack she could eat. These observations were discussed with the Director of Nursing and Nursing Home Administrator prior to the surveyor leaving the facility at 11:30 PM on 04/14/25.

CONCERN (D)

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

Comprehensive Assessments (Tag F0636)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

Based on record review and staff interview, the facility failed to complete a Minimum Data Set (MDS) for Resident #13 upon discharge from the facility. This was true for one (1) of thirty-eight (38) residents. This was a random opportunity for discovery and was true for Resident #13. Resident Identifier: #13. Facility Census : 111. Findings included: a) Resident #13 Resident #13's date of stay was from 10/23/24 through 11/11/24. The following Minimum Data Sets were completed for Medicare: Entry/MDS 3.0, Medicare 5 -Day/MDS 3.0 and admission -None PPS/MDS 3.0. A discharge MDS was not found during the record review. On 04/16/25 at 1:34 PM, the state surveyor interviewed MDS Coordinator #77. MDS Coordinator #77 confirmed a discharge MDS had not been completed. The MDS Coordinator stated, I did miss it. and We will fix it.

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, record review, and staff interview, the facility failed to ensure the care plan was implemented regarding pain management interventions for Resident #42, and regarding tracheostomy care for Resident #111. This was true for two (2) of 38 resident care plans reviewed during the survey process. Resident identifiers: #42, #111. Facility census: 111. Findings included: a) Resident #42 Resident #42 is receiving hospice services due to an end stage diagnosis of History of CVA (cerebrovascular accident). Resident #42 has an order for: Morphine Sulfate (Concentrate) Solution 20 MG/ML. Give 10 mg by mouth every two (2) hours as needed for pain/dyspnena. Give 0.50 ML. Hold for Sedation 0.50 ml, every two hours as needed for pain. At approximately 11:30 AM on 4/13/25, during observations in the North hall of the facility, Resident #42 was observed to be yelling out. Review of the resident's record on 4/13/25, it was noted some indicators for pain were yelling out, restlessness, tenseness. Resident #42 was observed to be yelling out again at approximately 1:30 PM, 2:40 PM, and 3:08 PM. At approximately 9:05 PM on 4/14/25, Resident #42 was heard yelling out in his room. His door was pulled around, almost shut completely, left barely cracked open. This surveyor stood in front of the resident's door until approximately 9:45 PM. No one entered the room to check on the resident during this time period. All three (3) Nurse Aides (NA), #13, #15, #21, assigned to that side of the facility, walked by and Licensed Practical Nurse (LPN) #36 was on the medication cart in the hallway. At approximately 9:45 PM, someone could be heard yelling from inside the room Please help me! Still, no staff member entered the room to check on the resident. At approximately 9:50 PM, this surveyor told LPN #36 Someone in the room is yelling for help. The LPN stated He's usually confused, but I'll check on him. Upon entering the room, Resident #42 was still yelling out. LPN # 36 asked Resident #42 if he was in pain and he indicated he was. She asked him what he needed, and he held up his index finger and thumb, as if he was holding something between them. The nurse asked Do you need your pain medication? Resident #42 indicated he did. LPN #36 administered the pain medication at approximately 9:55 PM. Approximately 20 minutes later, the resident was found to be calmer and yelling out less. LPN #36 was asked what the resident's indicators of pain were. LPN #36 stated his indicators were yelling out, tenseness, and restlessness. LPN confirmed the resident exhibited all symptoms at this time. LPN was asked how the resident communicated pain, to which she stated he was nonverbal and the staff look for things such as yelling out, tenseness, restlessness. LPN #36 stated at this point, the resident should be assessed for pain. Upon review of the resident's Medication Administration Record (MAR) for the month of April 25, on 4/15/25, it was noted zero (0) nonpharmacological interventions for pain management had been implemented, as the entire month, up to 4/15/25 was empty. Review of the narcotic sheet on 4/15/25, for the morphine, indicated on 4/9/25 at 8:45 PM, 0.25 ml of morphine was signed out on the log and administered to the resident. 0.25 was signed out and administered at 5:24 AM on 4/10/25. Resident #42 was given half of his ordered dose at this time, as he had an active order for 0.5 ml of Morphine at the time of administration. Progress for those days state the resident was administered 0.5 ml on both occasions, despite the narcotic log stating 0.25 ml was signed out. Upon review of the resident's care plan, the following interventions were noted regarding pain management: Observe for pain. Attempt non-pharmacologic interventions to alleviate pain and document effectiveness. Administer pain medication as ordered and document effectiveness/side effects. Observe for pain and administer as ordered per MD and position for comfort. Resident and HCS will achieve the highest possible level of peace by the time of death as evidenced by alleviated pain and resident exhibited calmness. Assess for pain, restlessness, agitation, constipation and other symptoms of discomfort. Medicate as ordered and evaluate effectiveness. Provide non-pharmacological approaches to aide in decreasing discomfort. Offer non-pharmacologic interventions prior to PRN pain medication administration. Observe for non-verbal signs/symptoms of pain and medicate as ordered. Observe for nonverbal signs of pain: increase in agitation, grimace, resistance to care. During an interview with the Director of Nursing (DON), on 4/16/25 at approximately 4:00 PM, it was confirmed, based on observations and review of the narcotic log and MAR, Resident #42's care plan was not being implemented regarding his pain management. The DON also confirmed LPN #36 expressed to her Resident #42 was in pain upon the DON's arrival to the facility at approximately 9:50 PM on 4/14/25, as the nurse told the DON she was preparing to administer the resident's morphine. b) Resident #111 A review of Resident #111's medical record found the resident was admitted to the facility on [DATE]. A review of the residents care plan found the following care plan: Focus statement: -- Resident exhibits alteration in respiratory status related to trach. This focus statement was initiated on 03/24/25. Goals Include: Resident will have no sign/symptoms of respiratory infection through next review. This was initiated on 03/24/25 and the target date was 04/07/25. Interventions included but were not limited to: -- Keep a spare trach/orturator trach kit at bedside. Added to the care plan 03/24/25. -- Type of trach: 6.5 size of trach 6 keep spare trach and ambu bag at beside. Added to the care plan on 03/24/25. Observations of Resident #111 with the Director of Nursing (DON) at approximately 11:45 am on 04/15/25 found the resident did not have a size six (6) trach at her bed side. She was then asked if she could show the surveyor that she had one in the facility. She summoned the RT who looked in the supplies they were unable to locate a size 6. He then went to the residents room to see what size trach was currently in place. The RT determined it was a size 7.5 instead of a 6.5. He was then able to locate the size 7 trach kit which would have been the size down. He stated this is what she needs. He agreed it needed to be at bed side and not in the storage area as directed by the care plan.

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, residen interview, staff interview, and facility policy review, the facility failed to assist dependent residents with activities of daily living (ADL's) in accordance with the residents assessed needs for care. This was true for two (2) of five (5) residents reviewed for ADL care.Resident Identifiers: #416 and #85. Facility Census: 111. Findings Included: a) Resident #416 On 04/16/25 at 11:28 AM, a review of Resident #416's toileting / toileting hygiene documentation in November 2024 found: --Day shift- three (3) entries of 97- Not applicable in 30 days. --Evening shift- three (3) entries of 97- Not applicable in 30 days. --Night shift- 12 entries of 97- Not applicable in only 30 days. During an Interview on 04/16/25 at 12:08 PM the Director of Nursing (DON) verified there was no documentation that Resident #416 received Toileting hygiene as needed. b) Resident #87 At approximately, 12:45 PM on 4/13/25, an interview was conducted with Resident #87. During the interview, the resident was asked if he received assistance from the staff with Activities of Daily Living (ADLs), such as bathing/showering. Resident #87 stated, I'm supposed to have them on Monday and Friday, but sometimes they just put them off. They are working short a lot of the time and they tell me they will get it done, but they never do. I usually have bed baths, which is fine, but I haven't had one in a while. I wouldn't mind a shower every now and then either. Upon review of the resident's bathing/showering task history for the last 90 days, it was revealed he did not receive a bed bath or shower on the following days: Friday, 01/24/25 Friday, 01/31/25 Monday, 02/3/25 Friday, 02/14/25 Friday, 02/21/25 Friday, 02/28/25 Monday, 03/3/25 Friday, 03/28/25 Friday, 04/11/25 During an interview with the Director of Nursing (DON), at approximately 4:00 PM on 4/16/25, she confirmed the missing dates for the resident's bathing. The facility did not provide any additional documentation by the end of the survey process.

CONCERN (D) 📢 Someone Reported This

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

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

Quality of Care (Tag F0684)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

Based on record review, observation, staff interview and resident interview, the facility failed to follow a physician's order for no straws for Resident #10 and failed to ensure Resident #26 received medication as ordered. These failed practices had the potential to affect more than a limited number of residents. Resident Identifiers: #10 and #26. Facility Census: 111. Findings included: a) During the initial interview process on 04/14/25 at 11:00 AM, the state surveyor observed a straw in Resident #10's water pitcher. Additional observations with the straw in the resident's water pitcher were completed at 12:16 PM, and 12:40 PM. The resident reported she drinks water out of the pitcher. Review of the resident's eating task found the resident to be set-up to independent for eating. At 12:50 PM, Registered Nurse #69 reported the resident had no straws because they were a high risk for aspiration. The straw was not removed at that time. The straw was observed to be removed from the water pitcher at 1:18 PM. Registered Nurse #69 stated, I know her well. At 01:45 PM, the Director of Nursing (DON) reported the resident does not have a straw because she is an aspiration risk. During a night observation completed by the state surveyor on 04/14/25, Resident #10 had a fresh pitcher of ice and water at bedside with a straw. Registered Nurse #1 at 10:40 PM, reported there was a straw in the resident's water pitcher, but stated, I checked her diet and took it out. Registered Nurse #1 stated, It was in there. On 04/15/25 at 11:59 AM, a phone interview was completed with the Speech-Language Pathologist (SLP). The SLP reported the resident had been NPO and had been upgraded to thin liquids. The SLP reported, the resident strangles pretty bad with a straw. The SLP stated using a straw puts the liquid too far back in the throat. She reported the resident does great from a cup. b) Resident #26 An interview with Resident #26 on 04/13/25 at 2:44 PM, found the Licensed Practical Nurse (LPN) often let him run out of medication and he don't get it until it comes in from the pharmacy. When asked if he knew what medications he runs out of he stated, I don't know the names of them, but I know one of them was for my restless leg syndrome. He indicated it was a miserable night with his legs jerking and moving all night. A review of Resident #26's medication administration record (MAR) for 04/2025 on 04/16/25 found the following doses of medication was not checked off to indicate they were administered: -- Gabapentin 600 milligrams by mouth two (2) times a day. Missed on 04/02/25 at 9:00 AM. The doses for 04/02/25 at 9:00 PM and for 04/03/25 at 9:00 am were documented on the controlled substance log but were not documented as administered on the MAR. -- Ropinirole 2 mg take two (2) tablets by mouth two times a day for restless leg syndrome. Missed on 04/03/25 at 10:00 PM. -- Synthroid Oral Tablet 100 mcg take one (1) tablet by mouth one time a day. Missed on 04/03/25 at 6:30 Am. An interview with Registered Nurse (RN) #77, in the afternoon of 04/16/25, confirmed Resident #26 missed doses of his Gabepentin, Synthroid, and Ropinirole. She was asked if these medications were available in pyxis system. She stated, We can go check. RN #77 checked the pyxis system and confirmed the medications were available and could have been pulled by the on duty nurse but were not.

CONCERN (D)

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

Incontinence Care (Tag F0690)

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, interview, and record review, the facility failed to notify the physician of a newly admitted resident's indwelling catheter, and failed to obtain a physician's order for the care and maintenance of the catheter. In addition, the facility failed to provide the appropriate catheter care to prevent potential Catheter Associated Urinary Tract Infections (CAUTI's). This was true for one (1) of five (5) residents reviewed for catheter care. Resident Identifier: #266. Facility census: 111. Findings Included: a) Resident #266 During an interview on 04/13/25 at approximately 2:14 PM, Resident #266 stated she was looking forward to getting her catheter removed. Upon being asked if the facility provided catheter care, resident stated the staff usually emptied her catheter bag when it filled up. A review of the Minimum Data Set (MDS) data presented to the surveyors upon entry indicated Resident #266 was admitted to the facility on [DATE]. The MDS did not show Resident #266 had an indwelling urinary catheter. A review of Resident #266's records, on 04/14/25 at 9:30 AM, revealed no orders pertaining to a catheter, or catheter related care. On 04/14/25 at approximately 12:15 PM, Licensed Practical Nurse (LPN) #26 confirmed there were no orders entered, and in fact the MDS did not identify the resident had a catheter. During an interview with the Unit Manager (UM) #97 on 04/14/25 at 12:25 PM, UM #97 confirmed there were no physicians' orders for catheter care. A request for the task sheets for catheter care revealed the resident was designated as Independent. No documentation was available confirming the facility had provided catheter care to the resident. During an interview with the Director of Nursing (DON) on 04/14/25 at 1:00 PM, she confirmed no orders had been obtained from the physician for catheter care.

CONCERN (D)

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

Deficiency F0742 (Tag F0742)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

Based upon record review and staff interview, the facility failed to ensure resident received mental health referral and treatment. This was true for 1 (one) of 38 (thirty-eight) residents reviewed during this annual survey process. Resident identifier: #110. Facility census: 111 Findings included: A) Resident #110 A review of Resident #110's medical record found the following: Diagnosis Included: Post traumatic stress disorder Anxiety Disorder Depression A review of the MDS quarterly assessment on 04/03/25, recorded the following: Section D - Mood D0160: Total severity score of 18 D0170 Social Isolation was marked as always feeling lonely or isolated from those around you. Section E - Behavior Verbal behaviors towards others occuring 4 - 5 days per week Section I - Active Diagnoses Psychiatric/Mood Disorder: Anxiety Disorder Depression Post Traumatic Stress Disorder The most recent PASARR: Was completed on 02/04/25 by (Name of Local Hospital) and contained the following: Q23 Medical conditions/symptoms: Mental disorders None Section III: MI/MR Assessment Current diagnosis: None is marked Section IV: Assessment/Plan Suspect patient has underlying dementia now with stroke-likely exacerbated does not have insight to her own medical condition since does not have medical decision-making capacity. Section V: Supplemental Questions Major Mental Illness or suspected mental illness: none Level I (Medical Screen Diagnosis of dementia (Alzheimer's or related condition): box next to question is not checked, indicating the resident does not have this. Resident #110 had the following physician orders: Dental, ophthalmology, podiatry, physiatry, psych,wound Obtain Consult as needed/indicated and treatment for patient health and comfort. No directions specified for order. Other Active 2/5/2025 Resident is not prescribed any anti-psychotic, anti-depressant, or anti-anxiety medications. A review of Resident #110's care plan found the following: Focus area: Resident/patient exhibits or has the potential to demonstrate verbal behaviors related to history of making false accusations regarding staff and other residents relating to this resident's cognitive impairment, confusion, and desire to return home/not be in long-termcare environment. Date initiated: 02/26/25 Interventions included: Evaluate the nature and circumstances (i.e. triggers) of the {verbal behavior} with resident and/or patient reresentative. Evaluate need/provide for Psych/Behavioral Health consultation. The resident's medical record contained a Meditelecare behavior health signed Authorization to Screen, Evaluate & Treat signed by the resident on 2/6/25. The Surveyor requested to see any screenings, evaluations, progress notes on the resident for services provided by Meditelecare. B) Staff interview On 4/16/25, after asking for documentation related to any Meditelecare screenings or visits for the third time, the Director of Nursing stated at 6:02 PM there were no progress notes, evaluations, etc from Meditelecare.

CONCERN (D)

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

Pharmacy Services (Tag F0755)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

Based on record review and staff interview the facility failed to establish a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation; and determine that drug records were in order and that an account of all controlled drugs was maintained and periodically reconciled to enable them to identify and correct any possible drug diversions. There were some discrepancies related to Resident #97's controlled substance log. This was true for one (1) of five (5) residents reviewed for the care area of unnecessary medications. Resident identifier: #97. Facility Census: 111. Findings Include: a) Resident #97 A review of Resident #87's medical record on the morning of 04/16/25 found the resident was ordered Hydrocodone 5-325 by mouth every 6 hours for pain, The medication administration record for the month of 03/2025 and the month of 04/2025 along with the controlled substance log coinciding with these months was requested. Upon review of the MAR and the controlled substance log it was found on 03/21/25, a nurse signed out one (1) dose of the Hydrocodone, but it was not initialed as given on the MAR. Also, between the 6:00 am dose of Hydrocodone on 03/30/325 and the 12:00 PM dose on 03/31/25 two (2) hydrocodone pills were removed and deducted from the count. However, the nurse did not sign, date or time the withdrawals on the controlled substance log as required. This was confirmed with Corporate Registered Nurse (CRN) #132 at 5:00 PM on 04/16/25.

CONCERN (D)

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

Drug Regimen Review (Tag F0756)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

Based on record review, and interview, the facility failed to ensure the attending physician reviewed and acted on the Consulting Pharmacist's recommendations. In addition, the facility failed to ensure that the physician reviewed and documented a response to the recommendations. This was true for five (5) of five (5) residents surveyed. Resident Identifier: Resident #17, # 28, #53, #74 and #87. Facility Census: 111. Findings include: a) Resident #17 On 04/14/25 at 3:11 PM a review of the Consulting Pharmacist's review for Resident #17's medications revealed the following: The Consulting Pharmacist's medication review on 09/20/24 showed the following recommendations: Resident is on Quetiapine 25 MG at bedtime for muscle weakness. This is not an appropriate diagnosis. Recommendation: An antipsychotic medication should be used only for the following conditions/diagnoses. Please check the appropriate indication for this resident: Huntington Disease Mood disorders (e.g. bipolar disorder, severe depression refractory to other therapies and/or with psychotic features) Medical illnesses with psychotic symptoms (e.g. neoplastic disease or delirium) and/or treatment related psychosis or mania (e.g. High dose steroids) Nausea and vomiting associated with cancer or chemotherapy Schizophrenia Schizo-affective disorder Schizophreniform disorder Psychosis in the absence of dementia Tourette's disorder Other Facility failed to ensure that the physician reviewed and responded to the recommendation. DON provided an updated diagnosis dated 04/05/25 which stated - Quetiapine Fumarate Oral tablet 25 MG. Give 0.5 tablet by mouth at bedtime for targeted behaviors - agitation, verbal outbursts. The Consulting Pharmacist's medication review on 10/23/24 revealed the following recommendation: Please update the current antipsychotic order for Quetiapine 12.5 MG at bedtime with a diagnosis and include specific behaviors that can be quantitatively and objectively documented by the nursing staff. The behavior must have the potential to cause danger to themselves and/or others. The facility failed to ensure that the physician reviewed and acted upon the recommendation. The Consulting Pharmacist's medication review on 12/18/24 showed the following recommendation: This resident is on the anticoagulant Rivaroxaban Oral tablet 15 MG. Anticoagulants have an inherent increased risk for bleeding and potential for thromboembolism. Please add order to monitor for signs and symptoms of bleeding and thromboembolism during each nursing shift. Notify prescriber if resident experiences any of the following signs/symptoms of bleeding, dark/discolored urine, black tarry stools. Nose bleeds, vomiting and/or coughing up blood. Signs/symptoms of thromboembolism: Pain or tenderness of upper or lower extremity. Increased warmth, edema and/or erythema of affected extremity. Unexplained shortness of breath. Chest pain, coughing, Hemoptysis, feelings of anxiety or dread. The facility failed to ensure that the physician reviewed and acknowledged the recommendation. b) Resident #28 On 04/14/25 at 3:25 PM a review of the Consulting Pharmacist's review for Resident #28's medications revealed the following: The Consulting Pharmacist's medication review on 12/17/24 showed the following recommendation: The resident is on the anticoagulant Eliquis. Anticoagulants have an inherent increased risk for bleeding and potential for thromboembolism. Please add order to monitor for signs and symptoms of bleeding and thromboembolism during each nursing shift. Notify prescriber if resident experiences any of the following signs/symptoms of bleeding, dark/discolored urine, black tarry stools. Nose bleeds, vomiting and/or coughing up blood. Signs/symptoms of thromboembolism: Pain or tenderness of upper or lower extremity. Increased warmth, edema and/or erythema of affected extremity. Unexplained shortness of breath. Chest pain, coughing, Hemoptysis, feelings of anxiety or dread. The facility failed to ensure that the physician reviewed and acknowledged the recommendation. c) Resident #53 On 04/14/25 at 3:35 PM a review of the Consulting Pharmacist's review for Resident #28's medications revealed the following: The Consulting Pharmacist's medication review on 01/14/25 showed the following recommendation: Please record specific behavior seen and any side effects with use of the psychoactive medication Buspar. If side effects are seen, physician should be notified. Please record behavior even if dose of medication is not given. Add MAR behavior monitoring for Buspar. The facility failed to ensure that physician reviewed and acknowledged recommendations. d) Resident #74 The Consulting Pharmacist's medication review completed on 01/20/25 showed the following recommendation: Please add a behavior monitoring sheet for this resident due to Duloxetine. Record specific behaviors and any side effects noted with use of psychoactive medications given. If side effects are noted, physician should be notified. Record all behaviors noted, even if medication is not given as the intervention. The facility failed to ensure that the physician reviewed and acknowledged the recommendation. During an interview on 04/15/25 at 2:30 PM the Director of Nursing (DON) confirmed that the physician had not signed the Pharmacist's recommendations e) Resident #87 A review of Resident #87's medical record on the morning of 04/16/25 found the pharmacist reviewed the resident's drug regimen in 02/2025 and 01/2025 and made recommendations to the physician and/or Director of Nursing (DON). The recommendations were requested from the facility along with the physicians and/or DON's response. At 5;22 PM on 04/16/25 the Corporate Registered Nurse (CRN) #132 confirmed they could not locate the recommendations nor the physician and/or DON response.

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 →

Based on observation, record review, and staff interview the facility failed to ensure Resident #70's medication regimen was free from unnecessary antipsychotic medications. This was true for one (1) of five (5) residents reviewed for the care area of unnecessary medications during the long-term care survey process. Resident identifiers: #70. Facility's Census: 111. Findings Include: a) Resident #70 On 04/14/25 at 9:05 PM the facility was entered on the night shift due to resident complaints of care on the night shift. Upon entrance to the facility Resident #70 was observed sitting in the doorway of the Cafe, the resident was yelling for help and asking for a snack. She later began asking for a specific snack of a peanut butter sandwich. Numerous staff were in the area and could have easily heard her asking for a snack. This continued until about 9:33 PM when Nurse Aide (NA) #55 walked by and she asked her for a peanut butter sandwich. NA #55 then stated to another employee, I think she is puree I will get her an apple sauce or pudding in just one (1) minute. Shortly after this exchange the Resident asked LPN #4 for a peanut butter sandwich. LPN #4 then went to the refrigerator retrieved a sandwich and gave it to Resident #70 (the sandwich was not pureed) As resident #70 was trying to open her sandwich NA #55 reentered the cafe and said, She is on a pureed diet she can't have that sandwich. NA #55 then proceeded to take the sandwich from Resident #70. The resident stated, I want to eat that. Give it to me. The nurse aide took the sandwich at which time she offered her a pudding or applesauce which the resident turned down she stated, I want a peanut butter sandwich. At 9:48 PM RN #84 approached Resident #70 and asked her what was wrong. Resident #70 stated, I 'm unhappy. RN #84 asked her why and she stated, They won't give me a peanut butter sandwich. RN #84 explained she could not have that and then asked her if she would like some chocolate pudding. At 9:58 PM the resident was finally provided with a snack she could eat. These observations were discussed with the Director of Nursing and Nursing Home Administrator prior to the surveyor leaving the facility at 11:30 PM on 04/14/25. Upon return to the facility's the next morning at 8:30 AM on 04/15/25 Resident #70's medical record was reviewed. This review found Resident #70 was administered a 2.5 milligram (MG) injection of Haldol for agitation on 04/15/25 at 12:30 AM which was one (1) hour after the surveyors left the facility. On 04/15/25 when the Nursing Home Administrator (NHA) was asked why the resident received this medication she provided a report titled, Urgent Care Report. This report indicated at 12:21 am on 04/15/25 the telehealth provider was contacted for the following reason, Agitation Yelling Creaming for help Wide awake despite Seroquel 1000 mg and melatonin. Nursing staff attempted numerous interventions all unsuccessful Further review of the record found no documentation to indicate what interventions nursing staff had attempted to change the resident's behavior prior to medication intervention. The NHA stated, The nurse is going to come in and complete her documentation in regards to this. Later in the afternoon the facility's provided a SBAR communication form. This note had the following regarding Resident #70, Appearance Summarize your observations: Resident yelled out help repeatedly if left alone in room, or cafe by nurses and CNA's. As soon as the nurse and CNA left room resident yelled out for help once again, nurse returned to cafe and assisted resident in finding TV channel they liked. Nurse and resident agreed on a TV channel she liked, as soon as nurse walked away resident started yelling. Resident asked to be taken to her room, toileted, offered food or drink. TV was turned on before CNA and nurse left the room. Resident Yelled again. This form indicated they contacted the provider who ordered a 2.5 mg injection of Haldol. A review of the care plan for Resident #70 found the following: Focus Statement: Resident exhibits verbal behaviors related to pseudobulbar affect. History of verbal outbursts becomes agitated and shouts for help. (First name of Resident #70) frequently call out for help both when assistance is needed and when there is not identifiable immediate need. This behavior may also be do to anxiety This focus statement was added to the care plan on 07/23/24. Goal: The resident will demonstrate effective coping skills related to verbal behavior. Interventions Included: -- 1:1 reassurance time sit with (First name of Resident #70) talk about past employment or other things that are meaningful to her. -- offer resident tablet and head phone, provide resident with pod cast options when resident appears to struggle with mood stability. -- offer resident use of her tablet for personal program viewing with headphones to decrease potential for verbal aggression or yelling out. -- (First name of Resident #70) enjoys watching tv sitting up in her chair. -- Use music therapy via electronic device tablet to help soother and redirect compulsive behaviors. An interview with the Director of Nursing (DON) on the afternoon of 04/15/25 confirmed she was still at the facility when the nurse got the order for Haldol. She indicated that she was on the other side of the facility. She stated when she saw the order come through, she went over to speak with the nurse. She stated, Resident #70's behavior was not much different than it was when the surveyor was in the facility earlier in the night. She agreed, they had not tried all the interventions listed above. She agreed the injection of Haldol should have been a last resort and was not.

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 interview, the facility failed to update orders to discontinue dialysis access care, and monitoring of the dialysis access graft/fistula. In addition, the facility failed to update orders and a care plan when a C-collar was discontinued. Resident Identifiers: #88, and #10. Facility Census: 111. Findings Include; a) Resident #88 During an interview, on 04/15/25 at approximately 1:20 PM, Resident #88 stated the dialysis access in her right upper arm was no longer patent. The resident stated he now had a dialysis catheter in her right upper chest, which was used during hemodialysis treatments. Record review on 04/15/25 at approximately 2:15 PM revealed the following order dated 10/08/24: External hemodialysis catheter 2 lumens (location) right chest wall with transparent dressing. DO NOT Change END caps. Further record review revealed the following orders dated 08/31/24: AV fistula/graft location: right upper extremity Change AV fistula/graft site dressing every Thursday Monitor AV fistula/graft site for S/S infection, edema, bleeding and upon return from dialysis. Notify primary care physician and dialysis unit if there are signs and symptoms of infection If AV fistula/graft site is bleeding apply pressure for 15 minutes and notify MD/Physician extender if bleeding does not stop Auscultate bruit and palpate thrill. Notify physician for absence of bruit/thrill. Every day and night shift. A review of the Treatment Administration Record (TAR) on 04/15/25 at 3:30 PM revealed facility staff continued to monitor the non-patent dialysis access, and document it was working. Monitoring was discontinued after surveyor intervention on 04/15/25 as evidenced by the following documentation: Auscultate bruit and palpate thrill. Notify physician for absence of bruit/thrill. every day and night shift Start Date- 08/31/2024 1900 D/C Date- 04/16/25 1047 Monitor AV fistula/graft site for S/S infection, edema, bleeding and upon return from dialysis. Notify primary care physician and dialysis unit if there are signs and symptoms of infection. If AV fistula/graft site is bleeding apply pressure for 15 minutes and notify MD/Physician extender if bleeding does not stop as needed Start Date- 08/31/2024 1549 D/C Date- 04/16/25 1045 During an interview with Unit Manager (UM) #97 on 04/15/25 at 3:26 PM, UM #97 confirmed the access was still being monitored. She stated she would discontinue the orders for monitoring. b) Resident #10 The facility failed to update orders and care plan for Resident #10's C-collar which was discontinued on 04/09/25 as recorded on the resident's Medication Administration Record (MAR). Resident #10's physician's order stated, Skin integrity checks; monitor c- collar placement and surrounding skin q shift to for skin integrity checks; notify provider for any abnormalities or concerns every day and night shift. The care plan stated: c-collar to be in place to assist with healing and protection as resident will allow. On 04/14/25, nurse's progress note stated, Resident refusing C-Collar. Patches not needed at this time. On 04/15/25 at 12:47 PM, the Director of Nursing confirmed the discharge order for the c-collar and the order for skin checks and care plan were not updated.

CONCERN (E)

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

Deficiency F0576 (Tag F0576)

Could have caused harm · This affected multiple residents

Read full inspector narrative →

Based on record review, staff interview and resident interview, the facility failed to ensure the residents' right to to receive mail on Saturdays was honored. This was a random opportunity for discovery and had the potential to affect more than a limited number of residents. Facility Census: 111. Findings included: a) The facility's policy and procedure stated, The Recreation Director or designee will: .1.2 Ensure that mail is delivered to the person unopened or postmarked (for outgoing mail) within 24 hours, including Saturdays. b) On 04/14/25 at 02:05 PM during the Resident Council Meeting, the residents reported that mail was not delivered on Saturdays. c) On 04/15/25 at 10:13 AM, the Administrator confirmed mail was to be delivered on Saturdays. The Administrator stated, Mail was supposed to be delivered. She reported the two activities directors will begin working the weekends since they had recently had an assistant leave and there are two open positions in that department. The Administrator reported she will educate and begin an audit for the residents to receive mail timely and on Saturdays.

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 F0698 (Tag F0698)

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, interview and record review, the facility failed to follow administration directions for medications prescribed for the control of phosphorous levels for dialysis patients. This was true for 5 of 5 residents on dialysis. Resident Identifiers: Residents #33, #88, #94, #105 and #108. Facility census:111. Findings Include: a) Resident #33 Record review and interview on 04/13/25 at 2:35 PM revealed, Resident #33 is a [AGE] year-old female on hemodialysis diagnosed with the following conditions: Chronic systolic heart failure Chronic respiratory failure with hypoxia Type 2 diabetes mellitus with polyneuropathy End-stage renal disease on hemodialysis Dilated cardiomyopathy History of nicotine dependence Hypertension Morbid obesity Gastroesophageal reflux disease Anemia A review of the resident's medication orders on 04/15/25 at approximately 11:55 AM revealed Resident #33 was prescribed: Renvela Oral Tablet 800 MG (Sevelamer Carbonate). Give 3 tablets by mouth before meals for end stage renal disease Renvela is a medication classified as a phosphate binder. It is designed to be taken three times a day with meals to help control phosphorus levels in the body. By binding to phosphorus in food, Renvela prevents it from being absorbed. Phosphate binders should generally be taken within 5 to 10 minutes before or immediately after meals and snacks. It is important not to take Renvela with other medications; instead, those should be administered at least 1 hour before or 3 hours after taking Renvela. Record review on 04/15/25 at approximately 1:30 PM revealed the resident is scheduled for dialysis on Tuesdays, Thursdays, and Saturdays. The orders state the following: Pick-up time 5:30am Chair time 6:30 am A review of the Medication Administration Record (MAR) for Resident #33 on 04/15/25 at 3:13 PM revealed the administration time for Renvela, was after the resident had left the facility for dialysis on Tuesdays, Thursdays and Saturdays. In addition, Renvela was not administered at meal times as evidenced by the following entries in the MAR: 04/01/24 (Tuesday) 6:30 AM - Renvela 800 MG tablets X 3. 11:30 AM - Renvela 800 MG tablets X 3 4:30 PM - Renvela 800 MG tablets X 3 04/02/25 6:30 AM - Renvela 800 MG tablets X 3. 11:30 AM - Renvela 800 MG tablets X 3 4:30 PM - Renvela 800 MG tablets X 3 04/03/25 (Thursday) 6:30 AM - Renvela 800 MG tablets X 3. 11:30 AM - Renvela 800 MG tablets X 3 4:30 PM - Renvela 800 MG tablets X 3 04/04/25 6:30 AM - Renvela 800 MG tablets X 3. 11:30 AM - Renvela 800 MG tablets X 3 4:30 PM - Renvela 800 MG tablets X 3 04/05/25 (Saturday) 6:30 AM - Renvela 800 MG tablets X 3. 11:30 AM - Renvela 800 MG tablets X 3 4:30 PM - Renvela 800 MG tablets X 3 04/06/25 6:30 AM - Renvela 800 MG tablets X 3. 11:30 AM - Renvela 800 MG tablets X 3 4:30 PM - Renvela 800 MG tablets X 3 04/07/25 6:30 AM - Renvela 800 MG tablets X 3. 11:30 AM - Renvela 800 MG tablets X 3 4:30 PM - Renvela 800 MG tablets X 3 04/08/25 (Tuesday) 6:30 AM - Renvela 800 MG tablets X 3. 11:30 AM - Renvela 800 MG tablets X 3 4:30 PM - Renvela 800 MG tablets X 3 04/09/25 6:30 AM - Renvela 800 MG tablets X 3. 11:30 AM - Renvela 800 MG tablets X 3 4:30 PM - Renvela 800 MG tablets X 3 04/10/25 (Thursday) 6:30 AM - Renvela 800 MG tablets X 3. 11:30 AM - Renvela 800 MG tablets X 3 4:30 PM - Renvela 800 MG tablets X 3 04/11/25 6:30 AM - Renvela 800 MG tablets X 3. 11:30 AM - Renvela 800 MG tablets X 3 4:30 PM - Renvela 800 MG tablets X 3 04/12/25 (Saturday) 6:30 AM - Renvela 800 MG tablets X 3. 11:30 AM - Renvela 800 MG tablets X 3 4:30 PM - Renvela 800 MG tablets X 3 04/13/25 6:30 AM - Renvela 800 MG tablets X 3. 11:30 AM - Renvela 800 MG tablets X 3 4:30 PM - Renvela 800 MG tablets X 3 04/14/25 6:30 AM - Renvela 800 MG tablets X 3. 11:30 AM - Renvela 800 MG tablets X 3 4:30 PM - Renvela 800 MG tablets X 3 04/15/25 (Tuesday) 6:30 AM - Renvela 800 MG tablets X 3. 11:30 AM - Renvela 800 MG tablets X 3 4:30 PM - Renvela 800 MG tablets X 3 During an interview with Unit Manager (UM) #97 on 04/15/25 at 3:25 PM, UM #97 stated the medication was being administered during med pass and not during meal times. An interview with the Director of Nursing (DON) on 04/16/2 at approximately 3:35 PM, confirmed the medication was not being administered with food. b) Resident #88 Record review and interview revealed Resident #88 is a [AGE] year-old female on hemodialysis. Resident was diagnosed with the following conditions: Chronic Kidney Disease Stage 5 Unspecified Hydronephrosis Essential (Primary) Hypertension Other Hyperlipidemia Age-Related cognitive decline Muscle weakness (Generalized) Hypothyroidism (Unspecified) Acquired absence of kidney Hyperkalemia A review of the resident's medication orders on 04/15/25 at approximately 10:55 AM revealed Resident #33 was prescribed: Renvela Oral Tablet 800 MG (Sevelamer Carbonate). Give 2 tablet by mouth three times a day for CKD. To be taken with food/meals. Renvela is a medication classified as a phosphate binder. It is designed to be taken three times a day with meals to help control phosphorus levels in the body. By binding to phosphorus in food, Renvela prevents it from being absorbed. Phosphate binders should generally be taken within 5 to 10 minutes before or immediately after meals and snacks. It is important not to take Renvela with other medications; instead, those should be administered at least 1 hour before or 3 hours after taking Renvela. Record review on 04/15/25 at approximately 12:30 PM revealed the resident is scheduled for dialysis on Mondays, Wednesdays, and Fridays. The orders state the following: Facility to transport Chair time 11:00 am Early lunch meal at 10:00 due to dialysis schedule A review of the Medication Administration Record (MAR) for Resident #33 on 04/15/25 at 3:25 PM revealed the administration time for Renvela, was scheduled to meet the resident's dialysis schedule on Monday's, Wednesday's, and Friday's, however, the medication administration schedule was not adjusted for non-dialysis days, resulting in the medication not being administered with meals as evidenced by the following entries in the MAR: 04/01/24 10:00 AM - Renvela 800 MG tablets X 2. 1:00 PM - Renvela 800 MG tablets X 2 5:00 PM - Renvela 800 MG tablets X 2 04/02/25 (Wednesday) 10:00 AM - Renvela 800 MG tablets X 2. 1:00 PM - Renvela 800 MG tablets X 2 5:00 PM - Renvela 800 MG tablets X 2 04/03/25 10:00 AM - Renvela 800 MG tablets X 2. 1:00 PM - Renvela 800 MG tablets X 2 5:00 PM - Renvela 800 MG tablets X 2 04/04/25 (Friday) 10:00 AM - Renvela 800 MG tablets X 2. 1:00 PM - Renvela 800 MG tablets X 2 5:00 PM - Renvela 800 MG tablets X 2 04/05/25 10:00 AM - Renvela 800 MG tablets X 2. 1:00 PM - Renvela 800 MG tablets X 2 5:00 PM - Renvela 800 MG tablets X 2 04/06/25 10:00 AM - Renvela 800 MG tablets X 2. 1:00 PM - Renvela 800 MG tablets X 2 5:00 PM - Renvela 800 MG tablets X 2 04/07/25 (Monday) 10:00 AM - Renvela 800 MG tablets X 2. 1:00 PM - Renvela 800 MG tablets X 2 5:00 PM - Renvela 800 MG tablets X 2 04/08/25 10:00 AM - Renvela 800 MG tablets X 2. 1:00 PM - Renvela 800 MG tablets X 2 5:00 PM - Renvela 800 MG tablets X 2 04/09/25 (Wednesday) 10:00 AM - Renvela 800 MG tablets X 2. 1:00 PM - Renvela 800 MG tablets X 2 5:00 PM - Renvela 800 MG tablets X 2 04/10/25 10:00 AM - Renvela 800 MG tablets X 2. 1:00 PM - Renvela 800 MG tablets X 2 5:00 PM - Renvela 800 MG tablets X 2 04/11/25 (Friday) 10:00 AM - Renvela 800 MG tablets X 2. 1:00 PM - Renvela 800 MG tablets X 2 5:00 PM - Renvela 800 MG tablets X 2 04/12/25 10:00 AM - Renvela 800 MG tablets X 2. 1:00 PM - Renvela 800 MG tablets X 2 5:00 PM - Renvela 800 MG tablets X 2 04/13/25 10:00 AM - Renvela 800 MG tablets X 2. 1:00 PM - Renvela 800 MG tablets X 2 5:00 PM - Renvela 800 MG tablets X 2 04/14/25 (Monday) 10:00 AM - Renvela 800 MG tablets X 2. 1:00 PM - Renvela 800 MG tablets X 2 5:00 PM - Renvela 800 MG tablets X 2 04/15/25 10:00 AM - Renvela 800 MG tablets X 2. 1:00 PM - Renvela 800 MG tablets X 2 5:00 PM - Renvela 800 MG tablets X 2 On 04/15/25 at 10:58 AM, during medication administration, LPN #26 was observed administering the following medications to Resident #88: Clopidogrel Bisulfate Tablet 75 MG 1 tablet Ferrous Sulfate Oral Tablet 325 (65 Fe) MG 1 tablet Renvela Oral Tablet 800 MG X 2 tablets Sodium Bicarbonate Oral Tablet 650 MG 1 tablet During an interview with UM #97 on 04/15/25 at 11:15 AM, UM #97 stated the medications were being administered during med pass and not during meal times. An interview with the DON on 04/16/2 at approximately 3:35 PM, DON confirmed the medication was not being administered, as prescribed, with food. c) Resident #94 Record review on 04/15/25 at approximately 11:50 AM revealed Resident #94 is a [AGE] year-old male Patient is long-term resident of the facility. Resident is diagnosed with the following: End-stage renal disease on hemodialysis Hepatitis B Heart failure with midrange ejection fraction Anemia Hypertension Hypothyroidism Cerebrovascular accident Presence of AV shunt Chronic back pain Pancytopenia Record review on 04/15/25 at approximately 1:20 PM revealed the resident is scheduled for dialysis on Tuesdays, Thursdays, and Saturdays. The orders state the following: Time for Pick up: 7am Transport to [dialysis] A review of the resident's medication orders on 04/15/25 at approximately 12:53 PM revealed Resident #94 was prescribed the following medication: Velphoro Oral Tablet Chewable 500 MG (Sucroferric Oxyhydroxide - Give 2 tablets by mouth with meals for ESRD (Chew or Crush) Velphoro (sucroferric oxyhydroxide) is a phosphate binder indicated for the control of serum phosphorus levels in patients with chronic kidney disease on dialysis. Velphoro is to be taken with food or meals. Tablets must be chewed or crushed; tablets must not be swallowed whole. A review of the Medication Administration Record (MAR) for Resident #94 on 04/15/25 at approximately 2:13 PM revealed Velphorx was administered after the resident left the facility for dialysis at 7:00 AM on Tuesdays, Thursdays and Saturdays. Furthermore, Velphoro was not given at meal times, as evidenced by the following entries in the MAR: 04/01/24 (Tuesday) 7:30 AM - Velphoro 500 MG tablets X 2 11:30 AM - Velphoro 500 MG tablets X 2 4:30 PM - Velphoro 500 MG tablets X 2 04/02/25 7:30 AM - Velphoro 500 MG tablets X 2 11:30 AM - Velphoro 500 MG tablets X 2 4:30 PM - Velphoro 500 MG tablets X 2 04/03/25 (Thursday) 7:30 AM - Velphoro 500 MG tablets X 2 11:30 AM - Velphoro 500 MG tablets X 2 4:30 PM - Velphoro 500 MG tablets X 2 04/04/25 7:30 AM - Velphoro 500 MG tablets X 2 11:30 AM - Velphoro 500 MG tablets X 2 4:30 PM - Velphoro 500 MG tablets X 2 04/05/25 (Saturday) 7:30 AM - Velphoro 500 MG tablets X 2 11:30 AM - Velphoro 500 MG tablets X 2 4:30 PM - Velphoro 500 MG tablets X 2 04/06/25 7:30 AM - Velphoro 500 MG tablets X 2 11:30 AM - Velphoro 500 MG tablets X 2 4:30 PM - Velphoro 500 MG tablets X 2 04/07/25 7:30 AM - Velphoro 500 MG tablets X 2 11:30 AM - Velphoro 500 MG tablets X 2 4:30 PM - Velphoro 500 MG tablets X 2 04/08/25 (Tuesday) 7:30 AM - Velphoro 500 MG tablets X 2 11:30 AM - Velphoro 500 MG tablets X 2 4:30 PM - Velphoro 500 MG tablets X 2 04/09/25 7:30 AM - Velphoro 500 MG tablets X 2 11:30 AM - Velphoro 500 MG tablets X 2 4:30 PM - Velphoro 500 MG tablets X 2 04/10/25 (Thursday) 7:30 AM - Velphoro 500 MG tablets X 2 11:30 AM - Velphoro 500 MG tablets X 2 4:30 PM - Velphoro 500 MG tablets X 2 04/11/25 7:30 AM - Velphoro 500 MG tablets X 2 11:30 AM - Velphoro 500 MG tablets X 2 4:30 PM - Velphoro 500 MG tablets X 2 04/12/25 (Saturday) 7:30 AM - Velphoro 500 MG tablets X 2 11:30 AM - Velphoro 500 MG tablets X 2 4:30 PM - Velphoro 500 MG tablets X 2 04/13/25 7:30 AM - Velphoro 500 MG tablets X 2 11:30 AM - Velphoro 500 MG tablets X 2 4:30 PM - Velphoro 500 MG tablets X 2 04/14/25 7:30 AM - Velphoro 500 MG tablets X 2 11:30 AM - Velphoro 500 MG tablets X 2 4:30 PM - Velphoro 500 MG tablets X 2 04/15/25 (Tuesday) 7:30 AM - Velphoro 500 MG tablets X 2 11:30 AM - Velphoro 500 MG tablets X 2 4:30 PM - Velphoro 500 MG tablets X 2 During an interview with UM #97 on 04/15/25 at 11:35 AM, UM #97 stated the medication was being administered during med pass and not during meal times. An interview with the DON on 04/16/2 at approximately 3:35 PM, DON confirmed the medication was not being administered, as prescribed, with food. d) Resident #105 A closed record review on 04/15/25 at approximately 4:15 PM revealed Resident #105 was a [AGE] year-old male who was on hemodialysis. Resident was diagnosed with the following diagnoses: Anemia of chronic disease CAD Carotid stenosis Cataracts bilateral CHF Type2 diabetes Diarrhea End-stage renal disease on dialysis Hypertension Hyperkalemia Hyperlipidemia Record review further revealed resident was scheduled for dialysis on Mondays, Wednesdays and Fridays. Dialysis orders specified the following: Pick up 6:30 AM Chair time of 7:00 AM Early breakfast meal at 6:00 am due to dialysis schedule Monday-Wednesday-Friday A review of the resident's medication orders on 04/15/25 at approximately 4:53 PM revealed Resident #105 was prescribed: Calcium Acetate Oral Tablet 667 MG (Calcium Acetate (Phosphate Binder)) Give 2 tablet by mouth with meals for Supplement Calcium Acetate is a phosphate binder used to treat hyperphosphatemia in dialysis patients. It is recommended this medication be taken with meals. Other medications should not be taken with Calcium acetate. They should be taken at least one (1) hour before or three (3) hours after calcium acetate administration. A closed record review of the Medication Administration Record (MAR) for Resident #105 on 04/15/25 at approximately 2:20 PM revealed the administration time for Calcium acetate was after the resident had left the faciity on Mondays, Wednesdays and Fridays. In addition, Calcium acetate was not administered at meal times, as evidenced by the following entries in the MAR: 03/20/25 7:30 AM - Calcium acetate 667 MG tablets X 2. 11:30 AM - Calcium acetate 667 MG tablets X 2 4:30 PM - Calcium acetate 667 MG tablets X 2 03/21/25 (Friday) 7:30 AM - Calcium acetate 667 MG tablets X 2. 11:30 AM - Calcium acetate 667 MG tablets X 2 4:30 PM - Calcium acetate 667 MG tablets X 2 03/22/25 7:30 AM - Calcium acetate 667 MG tablets X 2. 11:30 AM - Calcium acetate 667 MG tablets X 2 4:30 PM - Calcium acetate 667 MG tablets X 2 03/23/25 7:30 AM - Calcium acetate 667 MG tablets X 2. 11:30 AM - Calcium acetate 667 MG tablets X 2 4:30 PM - Calcium acetate 667 MG tablets X 2 03/24/25 (Monday) 7:30 AM - Calcium acetate 667 MG tablets X 2. 11:30 AM - Calcium acetate 667 MG tablets X 2 4:30 PM - Calcium acetate 667 MG tablets X 2 03/25/25 7:30 AM - Calcium acetate 667 MG tablets X 2. 11:30 AM - Calcium acetate 667 MG tablets X 2 4:30 PM - Calcium acetate 667 MG tablets X 2 03/26/25 (Wednesday) 7:30 AM - Calcium acetate 667 MG tablets X 2. 11:30 AM - Calcium acetate 667 MG tablets X 2 4:30 PM - Calcium acetate 667 MG tablets X 2 03/27/25 7:30 AM - Calcium acetate 667 MG tablets X 2. 11:30 AM - Calcium acetate 667 MG tablets X 2 4:30 PM - Calcium acetate 667 MG tablets X 2 During an interview with the DON on 04/16/2 at approximately 3:45 PM, DON confirmed the medication was not being administered, as prescribed, with food. e) Resident #108 During an interview on 04/13/25 at 2:45 PM Resident #105 stated he did not get his phosphate binders with his meals. He stated the medication was dispensed during med pass, with the other medications. Record review on 04/13/25 at approximately 3:20 PM revealed Resident #108 is a [AGE] year-old male with a history of end-stage renal disease on dialysis, He is diagnosed with: End-stage renal disease on hemodialysis Cerebrovascular accident Heart failure Hypertension Hyperlipidemia Depression Chronic venous stasis Cardiomyopathy Record review further revealed resident was scheduled for dialysis on Mondays, Wednesdays and Fridays. Dialysis orders specified the following: Time for Pickup 6:10 AM Chair time 6:50 AM Early breakfast meal at 545 AM due to dialysis schedule A review of the resident's medication orders on 04/13/25 at approximately 3:53 PM revealed Resident #108 was prescribed: Auryxia Oral Tablet 1 GM 210 MG (Fe) (Ferric citrate) - Give 1 tablets by mouth with meals for anemia Auryxia (ferric citrate) is a medication used to manage two conditions: high phosphate levels in the blood (hyperphosphatemia) and iron deficiency anemia (IDA) in individuals with chronic kidney disease (CKD). It works as a phosphate binder, reducing the amount of phosphate absorbed from food, and as an iron supplement. Auryxia should be taken with meals. A review of the Medication Administration Record (MAR) for Resident #108 on 04/13/25 at approximately 3:2 revealed the administration time for Auryxia was after the resident had left the facility for dialysis on Mondays, Wednesdays, and Fridays. In addition, Auryxia was not administered at meal times, as evidenced by the following entries in the MAR: 04/03/25 7:00 AM - Auryxia Oral Tablet 1 GM 210 MG(Fe) (Ferric Citrate) 12:00 PM - Auryxia Oral Tablet 1 GM 210 MG(Fe) (Ferric Citrate) 5:00 PM - Auryxia Oral Tablet 1 GM 210 MG(Fe) (Ferric Citrate) 04/04/25 (Friday) 7:00 AM - Auryxia Oral Tablet 1 GM 210 MG(Fe) (Ferric Citrate) 12:00 PM - Auryxia Oral Tablet 1 GM 210 MG(Fe) (Ferric Citrate) 5:00 PM - Auryxia Oral Tablet 1 GM 210 MG(Fe) (Ferric Citrate) 04/05/25 7:00 AM - Auryxia Oral Tablet 1 GM 210 MG(Fe) (Ferric Citrate) 12:00 PM - Auryxia Oral Tablet 1 GM 210 MG(Fe) (Ferric Citrate) 5:00 PM - Auryxia Oral Tablet 1 GM 210 MG(Fe) (Ferric Citrate) 04/06/25 7:00 AM - Auryxia Oral Tablet 1 GM 210 MG(Fe) (Ferric Citrate) 12:00 PM - Auryxia Oral Tablet 1 GM 210 MG(Fe) (Ferric Citrate) 5:00 PM - Auryxia Oral Tablet 1 GM 210 MG(Fe) (Ferric Citrate) 04/07/25 (Monday) 7:00 AM - Auryxia Oral Tablet 1 GM 210 MG(Fe) (Ferric Citrate) 12:00 PM - Auryxia Oral Tablet 1 GM 210 MG(Fe) (Ferric Citrate) 5:00 PM - Auryxia Oral Tablet 1 GM 210 MG(Fe) (Ferric Citrate) 04/08/25 7:00 AM - Auryxia Oral Tablet 1 GM 210 MG(Fe) (Ferric Citrate) 12:00 PM - Auryxia Oral Tablet 1 GM 210 MG(Fe) (Ferric Citrate) 5:00 PM - Auryxia Oral Tablet 1 GM 210 MG(Fe) (Ferric Citrate) 04/09/25 (Wednesday) 7:00 AM - Auryxia Oral Tablet 1 GM 210 MG(Fe) (Ferric Citrate) 12:00 PM - Auryxia Oral Tablet 1 GM 210 MG(Fe) (Ferric Citrate) 5:00 PM - Auryxia Oral Tablet 1 GM 210 MG(Fe) (Ferric Citrate) 04/10/25 7:00 AM - Auryxia Oral Tablet 1 GM 210 MG(Fe) (Ferric Citrate) 12:00 PM - Aury

CONCERN (E)

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

Menu Adequacy (Tag F0803)

Could have caused harm · This affected multiple residents

Read full inspector narrative →

Based on observation and staff interview the facility failed to ensure each resident received the proper portion size of pork during the evening meal on 04/16/25. This failed practice has the potential to affect more than an isolated number of residents and was random opportunity for discovery found during the completion of the kitchen pathway during the long-term care survey process. Facility Census: 111. Findings Include: On 04/16/25 at 5:32 PM the surveyor was observing meal service from the steam table in the facility's kitchen. [NAME] #130 was serving the food from the steam table. She was observed using tongs to serve the pork. The Director of Operations (DOO) was asked how she was sure the pork she was serving was two ounces (OZ) she stated she should be using a 2 oz scoop and not tongs. She corrected the situation; however, the North Short Hall and the South Short Hall had already been served. A review of the menu found each resident should be served 2 ounces of pork.

CONCERN (E)

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

Deficiency F0809 (Tag F0809)

Could have caused harm · This affected multiple residents

Read full inspector narrative →

Based on observation and staff interview the facility failed to ensure all residents received meals at regular times comparable to normal mealtimes in the community. The lunch meal on 06/04/25 was served 45 minutes late to 19 residents due to the facility running out of prepared food. This was true for Resident #95, #3, #68, #60, #90, #21, #29, #24, #56, #6, #61, #5, #41, #79, #38, #58, #36, #45, and #49. Facility Census: 101 Findings Include: a) An observation of the lunch meal began at 12:00 PM on 06/04/25 found the facility was serving ham, macaroni and cheese and beets as the main meal for the residents. At 1:10 PM [NAME] #1 stated, I ran out of food. I'm going to have to make more. The Corporate Director of Operations then began preparing and directing the staff on what to make to continue to the feed the remaining 18 residents. The Corporate Director of Operations, indicated they did not know what happened. They said they made more than the production sheet called for but was still short on servings. The final resident was served at 1:56 PM on 06/04/25 which was 46 minutes after the facility initially ran out of food.

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 and interview, the facility failed to ensure infection control procedures were adhered to in the residents' shower room. This failed practice had the potential for infection of a limited number of residents. This was true for one (1) of two (2) shower rooms inspected during the survey process. Facility Census: 111. Findings included: a) During an inspection of the male and female shower rooms, accompanied by Licensed Practical Nurse (LPN) #26 on 04/14/25 at approximately 1:20 PM, five bottles of unlabeled shampoo bottles were observed in the male shower room. LPN #26 confirmed the bottles of shampoo were not labeled with any resident names. On 04/14/25 at approximately 2:30 PM, the Director of Nursing (DON) confirmed all unlabeled shampoo bottles had been removed from the shower room.

CONCERN (F) 📢 Someone Reported This

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

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

Deficiency F0725 (Tag F0725)

Could have caused harm · This affected most or all residents

Read full inspector narrative →

Based on observations and resident and staff interviews, the facility failed to deploy sufficient direct care staff to meet the needs of the resident population of the facility. This had the potential to affect all residents residing in the facility. Resident identifiers: #94, #58, #51, #85, #91, and #84. Facility census: 111. Findings include: a) Resident #94 On 04/13/25 at approximately 3:09 PM, an interview was conducted with Resident #94. Resident #94 stated the facility was very understaffed. Resident #94 said, They keep telling me they're hiring people, but no one ever stays. The ones that don't do their job, they keep because they can't keep other people, so they have no choice but to keep them. At approximately 9:05 PM on 4/14/25, the call light for Resident #94's room was observed ringing in the North Hall of the facility. At approximately 9:16 PM, Resident #94 was observed yelling Hello multiple times from inside his room, but did not receive an answer. During this time, Licensed Practical Nurse (LPN) #36 and Nurse Aide (NA) #21 were on the hallway. LPN #36 was passing medications and NA #21 was observed going back and forth between other resident rooms. At approximately 9:20 PM, NA #21 went to a soiled linen bin outside of Resident #94's room, at which time he yelled, Can I get an aide please? NA #21 placed items into the soiled linen bin, walked down the hallway, and did not acknowledge the resident. At approximately 9:23 PM NA #13 entered the Hallway next to Resident #94's room and answered another resident's call light. At approximately 9:25 PM, LPN #36 answered Resident #94's call light. Upon entering the resident's room, she asked Resident #94 what he needed, to which he responded, I need changed. LPN #36 stated, I'll find out who your aide is and let them know. LPN #36 proceeded to turn the resident's light off and go back to the medication cart. At approximately 9:33 PM LPN #36 stated to NA #13 (Resident #94's name) needs changed. NA #13 then stated, I'm on back hallway; I'm just covering this until (NA #15's name) gets back. NA #13 then proceeded to walk past Resident #94's room, did not address the resident, and did not enter the room. When Resident #94 saw the aide walk by, he yelled Did we find an aide yet? At approximately 9:36 PM LPN #36 told NA #15, (Resident #94's name) needs help. He needs changed. I told the other aide earlier, but she didn't change him. NA #15 acknowledged Resident #94's needs and retrieved a cart with meal trays on it and pushed it to the dining room. Upon returning to the hallway at approximately 9:45 PM, NA #15 entered Resident #94's room and provided care. Resident #94 has a Brief Interview for Mental Status (BIMS) Score of 15, indicating he is cognitively intact. At approximately 10:00 PM, an interview was conducted with Resident #94 regarding his wait time for care. Resident #94 was asked how long his light had been on. Resident #94 stated Since about nine (9) o ' clock, about 40 to 45 minutes. Resident #94 then stated I know they ' re understaffed around here and I try to be sympathetic to them because of that. But when they let you lay in your own crap for over 40 minutes, it ' s really hard to be sympathetic. b) Resident #58 At approximately 4:45 PM on 4/16/25, an interview was conducted with Resident #58. Resident #58 stated We wait an hour and a half, sometimes two (2) hours for someone to answer our lights. Sometimes all we might need is water, but it takes them that long just to come see. If it was something simple, they could turn the light off and fix it, but they won ' t. Night shift is the worst. I feel like the response time at night should be faster because people are sleeping. They want us to sleep but if we need changed and can ' t get them to change us, we can ' t sleep. Some of them have attitudes. Some of them are always saying they hate this place and hate it being so understaffed. Sometimes the staff here will voice to us that they are understaffed. That's their explanation as to why they are late. I get straight cathed and I always have to wait. I told a nurse at 3:00 PM that I needed one and I am still waiting. He said he would find a woman to come do it and I am still waiting. If you need food heated it and you ask them to do it, they will you they have to do something else first and then you have to wait a while for them to come back and heat your food up. c) Resident #51 On 04/13/25 at approximately 12:28 PM, Resident #51 stated the following about the facility ' s staffing: Weekends are the worst as far as staffing and wait times. 40 minutes is usually the minimum. They'll come in and say Sorry, we are short, we will be back. They usually tell me what's going on out there. d) Resident #85 At approximately 12:45 PM on 4/13/25, an interview was conducted with Resident #87. During the interview, the resident was asked if he received assistance from the staff with Activities of Daily Living (ADLs), such as bathing. Resident #87 stated I ' m supposed to have them on Monday and Friday, but sometimes they just put them off. They are working short a lot of the time and they tell me they will get it done, but they never do. I usually have bed baths, which is fine, but I haven't had one in a while. I wouldn't mind a shower every now and then, either. Upon review of the resident's bathing task history for the last 90 days, it was revealed he did not receive a bed bath or shower on the following days: Friday 1/24/25 Friday 1/31/25 Monday 2/3/25 Friday 2/14/25 Friday 2/21/25 Friday 2/28/25 Monday 3/3/25 Friday 3/28/25 Friday 4/11/25 During an interview with the Director of Nursing (DON) at approximately 4:00 PM on 4/16/25, she confirmed the missing dates for the resident ' s bathing. The facility did not provide any additional documentation by the end of the survey process. e) Resident #91 On 04/13/25 at approximately 02:36 PM, Resident stated the following about facility staffing in an interview: It takes them an hour to an hour and a half to answer your light when you need help. f) Resident #84 At approximately 10:00 AM on 4/14/25, an interview was conducted with the representative of Resident #84. During the interview, the representative stated when he visits the facility it is hard to find staff when help is needed. He stated Resident #84 ' s room smelled strongly of urine when he visited recently. He stated Resident #84 had soiled her brief and eventually removed it, and staff did not come in to change her or remove the brief from the room, leaving it to smell like urine. He stated I know they are doing the best they can up there with the staff they have, but they need more. That ' s my only complaint is that you can ' t find help when you need it. On 04/14/25 at approximately 2:00PM a Resident Council Meeting was held. During the meeting, the residents brought the following issues forward, related to staffing. -Residents reported a lot of times only one staff person per hall - especially North-short Hall and South-long Hall. -Wait on call lights for one (1) to one (1) and a half hours - sometimes it could take up to 3 hours to get assistance. -One person to 16 rooms at night. -A lot of call offs from staff. -Nurses and CNAs are afraid of how long they will have to stay because of call-offs or not enough staff scheduled. H) Staff interviews At approximately 10:15 PM on 4/14/25 an interview was conducted with Nurse Aide (NA) #21. NA #21 stated there is a call-in problem with some employees. She stated this leaves the staff in a position where someone is working over, and sometimes they can ' t get the shift covered. She states this leaves them working short frequently. She states she feels the residents do not receive the care they need due to staffing issues. At approximately 10:35 on 4/14/25, on the North side of the facility, multiple call lights were observed going off on the long hallway. NA #15 was answering lights in the hallway, and the administrator was observed answering another. Lights continued to go off on the long hallway. At this time, NA #13 and #21 were observed standing in the back, short, hallway, leaned against the wall, talking, not responding to the call lights, despite no call lights ringing on the back, short, hallway.

Aug 2024 4 deficiencies 1 IJ

CRITICAL (J) 📢 Someone Reported This

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

Immediate Jeopardy (IJ) - the most serious Medicare violation

Menu Adequacy (Tag F0803)

Someone could have died · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on staff interview and record review the facility failed to follow the diet order for a resident on a pureed diet. The wrong texture of diet was provided which resulted in a choking incident for Resident #112. This failed practice was found true for (1) of (3) residents reviewed for diet order accuracy during the survey process. Resident identifiers #112. Facility Census 111. The State Agency (SA) determined this placed the resident in a past non-compliance immediate Jeopardy (IJ) situation. Resident #112 was provided regular texture food, which caused her to choke. The resident late died. The SA called the past noncompliance IJ starting on 08/14/24 and ending on 08/22/24. The facility was notified of the IJ at 2:05 PM on 08/26/24. Findings Include: a) Resident #112 A record review on 08/26/24 at 12:05 PM, found Resident #112 was ordered the following diet: Dysphagia pureed texture, thick liquids-nectar consistency. Further record review revealed a care plan which read as follows: Focus: Resident exhibits or is at risk for impaired swallowing related to Parkinson's disease and diagnosis of dysphagia. Has a history of choking. Goals: Resident will not experience further episodes of choking through the next review. The Resident will be free from signs/symptoms of aspiration through the next review. Interventions: - Dependent with all meals. - Obtain swallow study. - Obtain speech evaluation as ordered. - Provide a regular puree consistency diet as ordered. - Provide nectar consistency liquids as orders; grandson is not compliant with thick liquids. - Encourage small sips/bites and cue as needed. - Monitor for signs/symptoms of aspiration such as coughing, watery eyes, choking, moist sounding voice. Further record review revealed a nurses note which read as follows: Date: 08/14/24 Heard resident coughing. Observed resident with blue lips. Patted back to help dislodge resident, then went to Heimlich maneuver times (3) three with no effects. Registered Nurse (RN) attempted heimlich maneuver to no effect. Yelled for help and Licensed Practical Nurse (LPN) came over along with the RN from the South side. Resident is encouraged to cough with little effect. Nasal cannula applied at (2) litters. Emergency Medical Technician (EMT) arrived at this time to take over. Notified the on call nurse, The Director of Nursing (DON) , Hospice, the doctor, and family. b) Hospital A review of the (local hospital named) record from 08/14/24 to 08/15/24 reads as follows: History of present illness: Patient is an [AGE] year old female with past medical history of dysphagia, dementia, and Parkinson's. Resident on a puree diet who presents to the emergency department by Emergency Medical Services (EMS) for chief complaint of suspected food bolus. Per EMS patient is supposed to be on a pureed diet secondary to dysphagia, dementia, and Parkinson's but at Cedar Ridge nursing home the patient was supposedly given a Pinky nail sized piece of pepperoni per EMS. After she was given the piece of pepperoni she was found to be cyanotic with an oxygen saturation in the low 50's thus EMS was called. Patient presented to the emergency department on 15 Liters (L) non-rebreather and otherwise found to be tachypneic at 22 with appropriate oxygen saturation. Patient is a do not resuscitate (DNR)/ Do not incubate (DNI). Per EMS patient is nonverbal at baseline thus not able to provide a review of symptoms. Attestation statement: (Resident # 112 named) [AGE] year old female seen in conjunction with (Doctor named). Patient presented as discussed above. Patient had declined in respiratory status after possible dysphagia/aspiration concerns. Respiratory status appeared to have some improvement but then appeared to decline again. Medical Power of Attorney (MPOA) contacted who wanted to uphold DNR/DNI aside from potential GI procedure indicated. Immediately after phone discussion patient had further respiratory decline despite non-invasive efforts and went into cardiac arrest. Heimlich maneuver without success. Patient again discussed with MPOA who did want to uphold patients wishes of DNR/DNI status. Patient declared deceased at 1:45AM. c) Facility investigation summary A review of the facilities reporting and investigation on 08/26/24 at 1:30 PM, found the following summary of the 5-day follow-up completed on 08/20/24: On 08/14/24 (Resident #112 named) was seated at the nurses' station with Nursing Assistant (NA) #99, NA was feeding resident snacks when she began choking. LPN on duty was seated behind the nurses station and immediately intervened and began emergency interventions. EMS was called and the resident was transferred to the emergency room for further evaluation. This allegation of neglect was reported to the Office of Health Facilities Licensure and Certification (OHFLAC), Adult Protective Services (APS), the Nurse Aide Registry and the Ombudsman, and an investigation was initiated. NA #99 was suspended pending the results of this investigation. Resident is an [AGE] year old female admitted to Cedar Ridge Center for long-term care services. Resident lacks the capacity to make medical decisions and has a Brief Interview for Mental Status (BIMS) score of (7) seven. She has medical diagnosis of Lewy Body Dementia, Parkinson's Disease, Peripheral Vascular Disease, Dysphagia, Hyperlipidemia, and Anxiety. Resident requires assistance with Activities of Daily Living (ADL) and has a history of falling due to poor safety awareness related to her diagnosis. The alleged perpetrator was interviewed regarding this allegation on 08/15/24. NA #99 stated she was sitting with (Resident #112 named) at the nurses' station on the night of 08/14/24 because she was attempting to get out of bed unassisted. NA #99 stated she gave Resident #112 some pudding, but the resident appeared to still be hungry. She stated after the resident ate her pudding; she gave her a small cup of water (around six ounces) to wash down her pudding. Around 30 minutes later, NA #99 then gave the resident a small piece of pepperoni, about the size of her pinky nail, and shortly after the resident began showing signs of choking. No other staff members working on the night of the event witnessed NA #99 feed Resident #112 the pepperoni. However, NA #99 told staff she did after the resident began choking. When questioned as to why she fed the resident off her prescribed diet, NA #99 stated she thought the resident would enjoy having something to eat different from what she was normally served. The only other food resident received on the night of 08/14/24 was her prescribed supplement and the cream out of an oatmeal cream pie which was the correct consistency for her diet. Resident's prescribed diet was a regular dysphagia diet, puree texture and nectar thick liquids. Upon review of the resident's medical record, the diet order was entered correctly and available for direct care staff to see on her [NAME]. NA #99 had education in her employee file regarding proper techniques assisting with dining/feeding residents and performing relief from choking. Resident #112 was transferred to the emergency room (ER) for further evaluation. According to documentation obtained from the ER, the resident initially presented at the ER with appropriate oxygen saturation. Upon presentation, the resident was without respiratory distress , and appeared to be tolerating oral secretions appropriately. She was moved to a room and had an initial episode of retching/coughing and was found to be desatating on a non-rebreather mask. After the doctor contacted resident's MPOA to confirm her DNR status, and MPOA was agreeable to reversing DNI (do not intubate) status if necessary for GI to provide scope to remove foreign body. The GI department at the hospital failed to return the page, and during this time Resident # 112 became bradycardic and lost her pulse. MPOA was again notified and confirmed DNR status and resident was given morphine for comfort until she expired. The DON/designee conducted an audit on 08/15/24 for all residents to ensure diet orders are correct and accurate and attached to the [NAME] with any corrective action immediately upon discovery. The DON/designee conducted an observation round on 08/15/24 for all residents to ensure the correct diet is being served with any corrective action immediately upon discovery. Re-education was provided by the DON/designee to all staff beginning on 08/15/24 to ensure diet orders are followed and the correct diet is being served. The Unit Managers (UM)/designee will monitor starting on 08/15/24 to ensure diet orders are correct and accurate and attached to the [NAME] and the correct diet is being served. As of 08/22/24 all staff had received their education. This allegation of neglect has been substantiated. NA #99 was terminated as a result of the investigation and the Nurse Aide Registry will be notified. d) Implementation of corrective action Review of NA #99 employment history revealed NA #99 was hired on 04/25/24 and terminated on 08/20/24 at the conclusion of the investigation. All employees working the night of 08/14/24 were interviewed and provided a statement. No one working at the time of the incident saw NA #99 give Resident #112 the pepperoni. However; NA # 99 told staff she fed Resident #112 pepperoni. All employees were provided with an in-service and given a post test. All employees' in-service signatures are accounted for. Inservice high points include: 1. A resident is never to be served a food or beverage item that is not consistent with the resident's prescribed diet. 2. Any staff provides any resident with food or beverage should check [NAME] to ensure snack or food item is consistent with residents prescribed diet. 3. Even if the family is non-compliant with prescribed diet; staff must only serve/food beverages consistent with resident's diet. On 08/26/24 surveyors interviewed the following staff about the in-service and what is the appropriate thing to do when it comes to a resident being served the correct diet: Licensed Practical Nurse (LPN) #20 Housekeeper (HK) #84 Nursing Assistant (NA) # 47 NA #14 All staff interviewed stated they were inserviced on following residents diet and they could find the diet on the [NAME].

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 F0687 (Tag F0687)

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 foot care was provided to dependent residents. This deficient practice had the potential to affect one (1) of three (3) residents reviewed for the care area of foot care. Resident identifier: #12. Facility census: 111. Findings include: a) Resident #12 On 07/18/24, The Office of Health Facility Licensure and Certification received that Resident #12's toenails had not been cut since he was admitted to the facility. Review of Resident #12's medical records showed the resident was admitted in February 2024. The resident had a diagnosis of type 2 diabetes mellitus. No nail care was documented in the medical records. On 08/28/24 at 9:08 AM, Resident #12's toenails were observed with assistance from Registered Nurse (RN) #59. They were somewhat long. The left great toe was discolored and was cream and light gray colored. RN #59 stated the podiatry service comes to the building every three (3) months. RN #59 stated Resident #12 would be seen by podiatry on their next visit. Review of the facility's records showed the podiatry service had last provided treatment in June 2024. Resident #12 was not on the list of the residents who received treatment at that time. An email showed the podiatry service would return to the building on 09/09/24-09/10/24. On 06/16/24, Resident #12 was admitted to the hospital due to a urinary tract infection. The discharge summary written on 06/18/24 stated, Son requests referral for patient's L [left] great toe onychomycosis [fungal infection]. The discharge instructions contained instructions to schedule a podiatry appointment within two (2) to four (4) weeks. On 08/29/24 at 12:47 PM, the Administrator stated the resident's representative elected not to receive in-house podiatry services by the facility and that was why the resident was not seen by the podiatry service in June 2024. There was no evidence an external podiatry appointment was scheduled for Resident #12 as instructed in the discharge instructions on 06/18/24. On 08/29/24 at 1:15 PM, Scheduler #70 stated she just made an appointment for Resident #12 to be seen by a podiatrist on 09/18/24.

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 record review, staff interview and observation, the facility failed to provide adequate supervision to residents and to maintain an environment free of accident hazards. This failed practice was found true for (1) one of (1) one resident reviewed for accident hazards during the survey process. Resident identifier: #111. Facility Census 111. Finding Include: a) Resident #111 A review of the facilities reportables, on 08/29/24 at 8:45 AM, revealed a reportable dated 06/28/24 alleging Resident #11 was witnessed drinking from a bottle of wound cleanser which was left on the crash cart. A record review on 08/29/24 at 8:50 AM, revealed a general progress note date 06/28/24 which read as follows: Resident was witnessed drinking from a bottle of wound cleanser; another resident reported to nursing resident had consumed content from a bottle, staff immediately responded; Resident denied pain or distress; no obvious signs of GI discomfort noted upon assessment; resident denied burning or discomfort to mouth; mouth care provided; resident continued to repeat I am o.k.; Resident has impaired cognition related to dementia; Resident wanders related to dementia; provider notified; poison control consulted with recommendation to provide resident with milk and crackers; crackers soften with milk provided to resident; resident tolerated well; CIC initiated for ongoing monitoring of possible reactions; RP notified; care plan reviewed and revised with intervention; offer/assist resident with beverage and assist to common area when all other care needs have been met. Further record review of the Einteract Change in condition forms for Resident # 11 showed no other incidents had occurred in this nature for Resident #111. An observation 08/29/24 at 9:00 AM, found an empty bottle of Dermal Wound Cleanser in residents bedside dresser drawer. An observation 08/29/24 at 9:36 AM, found the empty bottle of Dermal Wound Cleanser remained in resident's bedside dresser drawer. A record review on 08/29/24 at 9:45 AM revealed a care plan with a focus reads as follows: Focus - Resident is at risk for falls and has actual hx of falls with fracture related to Dementia, cognitive loss, lack of safety awareness, abnormalities of gait and mobility, age related physical debility, lack of coordination, wandering, unsteadiness on feet, ambulates independently throughout facility, antidepressant medications, osteoporosis, and overactive bladder During an interview on 08/29/24 at 9:55 AM, The Administrator stated, The department managers do room rounds in the mornings daily to check to make sure everything is locked up and nothing is in residents' room that could be potentially hazardous. Further interview in Resident #111's room The Administrator stated, This should not be in here. I am going to see who is assigned this hallway for room rounds. The Administrator confirmed the empty bottle of wound cleanser was in Resident #111 bedside dresser drawer. A review of the Material Safety Data Sheet (MSDS) reads as follows: Section 4 First Aid Measures Eyes: Thoroughly rinse the affected eye for 15-20 minutes with clean water. If discomfort continues, consult a physician. Skin: If skin irritation develops, discontinue use of the product. If discomfort continues, consult a physician. Inhalation: If respiratory irritation occurs, seek fresh air. Ingestion: The accidental ingestion of the product may necessitate medical attention. In the case of ingestion, dilute with fluids and do not induce vomiting. In the event of an extreme case of ingestion consult a physician or local poison control center.

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 F0700 (Tag F0700)

Could have caused harm · This affected multiple residents

Read full inspector narrative →

. Based on observation, record review, and staff interview, the facility failed to ensure bed rails were implemented within accepted standards of care. Three (3) of three (3) residents reviewed for the care area of bed rails did not have current orders for bed rails. One (1) of three (3) residents reviewed for the care area of bed rails did not have valid informed consent for bed rails. Resident identifiers: #12, #15, #96. Facility census: 111. Findings include: a) Policy and Procedures The facility's policy titled Bed Rails with effective date 07/01/18 and revision date 09/01/22 stated if the Bed Rail Evaluation determines that the patient would benefit from side rails, an order for the bed rails would be obtained from the physician or advanced practice provider (APP). The policy also stated informed consent would be obtained from the resident or, if applicable, the resident representative. b) Resident #12 Based on observation, record review, and staff interview, the facility failed to ensure bed rails were implemented within accepted standards of care. Three (3) of three (3) residents reviewed for the care area of bed rails did not have current orders for bed rails. One (1) of three (3) residents reviewed for the care area of bed rails did not have valid informed consent for bed rails. Resident identifiers: #12, #15, #96. Facility census: 111. Findings include: a) Policy and Procedures The facility's policy titled Bed Rails with effective date 07/01/18 and revision date 09/01/22 stated if the Bed Rail Evaluation determines that the patient would benefit from side rails, an order for the bed rails would be obtained from the physician or advanced practice provider (APP). The policy also stated informed consent would be obtained from the resident or, if applicable, the resident representative. b) Resident #12 On 08/27/24 at 9:45 AM, Resident #12 was observed in a bariatric bed with bilateral quarter bed rails. Resident #12 did not have the capacity to make medical decisions. The resident's medical power of attorney (MPOA) had signed a consent for bed rails on 02/02/24. Resident #12's most recent Bed Rail Evaluation on 07/17/24 showed bed rails were appropriate for the resident. The evaluation indicated bed rails were in use. The resident had been care planned since 03/25/24 for quarter bed rails as an enabler for turning and repositioning. Resident #12 had an order from 03/24/24 through 07/15/24 for quarter bed rails as an enabler for turning and repositioning in bed. The order was rewritten on 08/27/24. On 08/27/24 at 3:19 PM, the Administrator confirmed the resident's bed rail orders were entered today although the bed rails had previously been in use. On 08/28/24 at 9:00 AM, the Administrator stated when Resident #12 was transferred to the hospital in July 2024, bed rail orders were discontinued. The Administrator stated the bed rail orders were not rewritten when the resident returned to the facility. c) Resident #15 On 08/27/24 at 1:45 PM, Resident #15 was observed in bed with bilateral quarter bed rails on the bed. Resident #15 did not have capacity to make medical decisions. The resident's representative gave consent for bed rails on 04/10/24. The most recent bed rail evaluation was performed on 07/13/24 and determined bed rails were appropriate for use. The form indicated side rails were in use. Resident #15 had an order written on 08/27/24 for bilateral quarter bed rails as an enabler for turning and repositioning in bed. The resident was care planned for bed rails on 08/27/24. On 08/28/24 at 9:00 AM, the Administrator stated Resident #15 did not have a previous bed rail order although the bed rails had been in use. She confirmed the resident's bed rail orders were entered on 08/27/24. d) Resident #96 On 08/27/24 at 2:30 PM, Resident #96 was observed in bed with bilateral quarter side rails on his bed. However, he had no order for side rails at this time. Resident #96 had capacity to make medical decisions according to a Physician Determination of Capacity completed 07/31/24. Prior to this, the resident did not have capacity. Review of the resident's medical records showed the resident's previous representative had signed an informed consent for bed rails on 06/02/22. The resident's most recent Bed Rail Evaluation was on 06/03/24. According to the evaluation, bed rails were indicated to aid for independent pressure distribution while in bed, for balance deficit, and to aid in pain relief. Bilateral quarter bed rails were recommended. Review of the resident's orders showed the resident had an order from 10/05/22 through 11/08/23 for quarter bed rails as an enabler for turning and repositioning in bed every day and night shift. He did not have a current order for bed rails. The resident was care planned for bilateral bed rails for turning and repositioning since 12/16/22. On 08/27/24 at 2:50 PM, the Administrator confirmed the resident had bed rails on his bed but no current orders. During an interview on 08/27/24 at 2:45 PM, the Corporate Nurse stated she was auditing bed rails today to ensure orders were written. On 08/28/24 at 9:00 AM, the Administrator stated when Resident #96 was transferred to the hospital in November 2023, bed rail orders were discontinued. The Administrator stated the bed rail orders were not rewritten when the resident returned to the facility. The Administrator also acknowledged informed consent for side rails was needed from the resident since he now had capacity.

Jul 2024 4 deficiencies 2 IJ (1 facility-wide)

CRITICAL (K) 📢 Someone Reported This

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

Immediate Jeopardy (IJ) - the most serious Medicare violation

Deficiency F0760 (Tag F0760)

Someone could have died · This affected multiple residents

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 ensure four (4) residents were free of significant medication errors. On 07/11/24, the facility reported to the Office of Health Facility Licensure and Certification (OHFLAC), Adult Protective Services (APS), and the Ombudsman that Resident #69, Resident #74, Resident #39, and Resident #108 were administered their 8:00 AM medications twice due to incomplete medication administration documentation. The facility developed and implemented a plan of correction on 07/11/24. The state agency investigated the matter on 07/18/24 and determined on 07/11/24 Resident #69, Resident #74, Resident #39, and Resident #108 were in an Immediate Jeopardy situation due to potential adverse consequences from duplicate medication administration. The stage agency reviewed the facility's plan of correction and documentation and determined the Immediate Jeopardy situation had been abated on 07/14/24 when all education with staff was completed. This was prior to the state agency's investigation which made this past non compliance. Resident identifiers: #69, #74, #39, #108. Facility census: 110. Findings included: a) Facility-reported incident and Plan of Correction On 07/11/24, the facility reported to the Office of Health Facility Licensure and Certification (OHFLAC), Adult Protective Services (APS), and the Ombudsman that Resident #69, Resident #74, Resident #39, and Resident #108 were administered their 8:00 AM medications twice due to incomplete medication administration documentation. Both nurses involved were removed from direct care at the time of the allegation and an investigation was initiated. Poison Control was contacted regarding all four (4) residents. Poison Control recommended emergency room evaluation for Resident #39 and Resident #108. Poison control recommended frequent monitoring in the facility for Resident #69 and Resident #74. The facility's plan of correction initiated 07/11/24 was as follows: The licensed nurse conducted a change in condition on 07/11/24 with notification to the medical provider for all four (4) residents who received duplicate medication. The Nurse Practice Educator conducted an audit on 07/11/24 of all licensed nurses' medication administration competencies to ensure all licensed nurses are competent with medication administration within the last 12 months with any correction action immediately upon discovery. The Unit Managers/designee conducted an audit on 07/11/24 for all residents' medication administration records for July 2024 to ensure free from medication errors with any corrective action immediately upon discovery. Re-education was provided by the Director of Nursing (DON)/Designee to all licensed nurses starting on 7/11/24 on safe medication administration practices including verification of correct, patient, drug, route, dose, time, special consideration, and expiration date with a Post-test to validate understanding. Any licensed nurses not available during this time frame will be provided re-education, including post-test and return demonstration by DON/designee prior to the beginning of the next shift to work. New Licensed nurses will be provided education, including post-test during orientation by the DON/designee. Annual in-servicing will be provided to licensed nurses regarding medication administration. The Unit Managers (UM)/Designee will conduct observations starting on 7/12/24 to ensure all licensed nurses are passing medications according to Genesis medication administration policies including verification of right patient, drug, route, dose, time, special considerations, and expiration dates across all shifts for 2 weeks including weekends and holidays, then 5 times a week for 4 weeks, then 3 times a week for 4 weeks, then randomly thereafter. Results of observations will be reported by the Unit Manager (UM)/designee monthly to the Quality Improvement Committee (QIC) for any additional follow-up and or in-servicing until the issue is resolved, then randomly thereafter as determined by the QIC committee. The facility submitted a five (5) day follow-up investigation on 07/16/24 which verified the allegation. The five (5) day follow-up investigation contained the following additional information: Witness statements were obtained and interviews were conducted with the licensed nurses on duty at the time of the med error. It has been determined that LPN [#106] was not familiar with the unit in which she was passing medications, and was unaware there was a 6:00 AM med pass. LPN [#106] was attempting to pass the medications for the 8:00 AM med pass, and when the computer gave her an error message, she proceeded to pre-pull 8:00 AM medications, not realizing that she failed to change the shift time on her MAR to the correct med pass time. This allegation of neglect will be substantiated and reported to the [NAME] Virginia State Board of Examiners for Licensed Practical Nurses. Prior to her return to work, LPN [#106] will receive education on safe administration practices including verification of correct patient, drug, route, dose, time, special considerations, and expiration date with a Post-test to validate understanding. LPN [#106] will receive seven supervised medication passes and be subjected to random monitoring during medication pass. The facility's inservices regarding medication administration and shift reporting were reviewed. The inservice information, sign-in sheets, and post-tests were reviewed. Medications audits performed by the Unit Managers and Director of Nursing were reviewed. Medication administration was observed on the morning of 07/18/24. The nurses performing medication administration, Licensed Practical Nurse (LPN) #28, LPN #62, LPN #42, and LPN #55, were able to correctly answer questions regarding medication administration and documentation. b) Policy and Procedure The facility's policy titled Medication Administration General Guidelines dated January 2024 gave the following procedures: - Medications were to be administered within 60 minutes of scheduled time - The individual who administered the medication dose was to record the administration on the resident's Medication Administration Record (MAR) immediately following the medication being given. In no case should the individual who administered the medications report off-duty without first recording the administration of any medications. c) Resident #69 Resident #69 was a [AGE] year-old man who has resided in the facility since 2022. He did not have capacity to make medical decisions and an Adult Protective Services worker was appointed as his Health Care Representative. According to the resident's Minimum Data Set (MDS) assessment with Assessment Reference Date (ARD) 05/29/24, the resident's Brief Interview for Mental Status (BIMS) score was 9, indicating moderate cognitive decline. The resident had diagnoses of dementia, personality disorder, anxiety disorder, depression, alcohol abuse, congestive heart failure, atrial fibrillation, hyperglycemia, hypertension, and peripheral vascular disease. The following progress note was written by Licensed Practical Nurse (LPN) #105 for Resident #69 on 7/11/2024 at 8:36 AM: This nurse was passing 0800 meds and entered another resident room, resident states she already took 0800 meds. This nurse went to [LPN #106] to ask if she passed 0800 meds to some residents. [LPN #106] states she gave some 0800 meds but is unsure of what [Registered Nurse (RN) #43] gave. This nurse notified [LPN #40], [RN #47]. [LPN #40] is to tell [Nurse Practitioner (NP) #104]. The following late entry note was written by the Director of Nursing (DON) on 7/11/2024 at 11:28AM: Resident received duplicate dosing of a.m. medication; provider notified; poison control consulted; order noted to obtain blood pressure q 1 hour x 4; Resident blood pressures obtained per order; po fluids encouraged and consumed. RP [resident representative] notified of medication error and plan of care. According to the resident's Medication Administration Record (MAR), Resident #69 was scheduled to receive the following medications daily at 8:00 AM: - Amlodipine 5 mg, one (1) time a day for hypertension - Aspirin 81 mg, one time a day for hyperlipidemia - Divalproex sodium, extended-release, 500 mg, one time a day for personality disorder - Eliquis (apixaban) 5 mg, two (2) times a day for atrial fibrillation - Metoprolol extended release, 100 mg, one (1) time a day for hypertension - Seroquel (quetiapine) 25 mg, one (1) time a day for depression Of these medications, the following could have adverse consequences with over dosages: - Amlodipine, which could cause hypotension. - Metoprolol, which could cause hypotension, bradycardia, bronchospasm, and cardiac failure. - Seroquel, which could cause slowed tachycardia, hypotension, heart block, arrhythmias, and drowsiness or sedation. - Eliquis, which could cause risk of bleeding. - Divalproex, which could cause coma, heart block, and somnolence. (Source: medication product label, available on-line from the Food and Drug Administration at www.accessdata.fda.gov.) The following note was written by Nurse Practitioner # 104 on 7/12/2024 at 5:50 PM, [AGE] year-old male with history of dementia, anxiety, depression, personality disorder, chronic systolic heart failure, A-fib [atrial fibrillation], COPD [chronic obstructive pulmonary disease], hyperlipidemia and alcohol abuse. Patient being seen today for follow-up. Per nursing patient received his a.m. medication twice on 7/11/2024 this included aspirin, Seroquel, divalproex sodium, amlodipine and metoprolol. Poison control was notified and gave recommendations to monitor patient in house including vital signs every hour x 4. Patient resting in bed this a.m. He is alert and appropriate. Denies complaints of dizziness, weakness, vertigo, shortness of breath or chest pain. Patient is stable. He has resumed his current medications. On 07/11/24 at 8:27 AM, the resident's blood pressure was 114/66. The resident's blood pressure was monitored hourly for four (4) hours and frequently after that. The resident's blood pressure stayed within normal range. The top number of the blood pressure (systolic) remained over 100. The bottom number of the blood pressure (diastolic) remained over 60. The resident had skilled nursing evaluations performed on 07/12/24, 07/13/24, 07/14/24, and 07/15/24. The resident had no change in vital signs or mental status following the medication error. Resident #69 was interviewed on 07/15/24 at 10:56 AM. He had no complaints about the facility. When specifically asked about medications, the resident had no complaints. d) Resident #74 Resident #74 was a [AGE] year-old who had resided in the facility since 2015. The resident did not have the capacity to make decisions and a family member was the health care surrogate. The resident had diagnoses of dementia, chronic obstructive pulmonary disease, convulsions, cerebrovascular disease, traumatic hemorrhage of cerebrum, hemiplegia/hemiparesis, bipolar affective disease, and anxiety disorder. According to the resident's Minimum Data Set (MDS) assessment with Assessment Reference Date (ARD) 06/11/24, the resident's Brief Interview for Mental Status (BIMS) score was 4, indicating severe cognitive decline. On 07/11/24 at 10:09 AM, an SBAR (Situation, Background, Assessment, and Recommendation) summary for providers was completed for Resident #74. The summary stated, Resident was given a duplicate dose of 8 am medications. Nurse called poison control and DON to make aware of the situation Primary Care Provider Feedback: Primary Care Provider responded with the following feedback: A. Recommendations: Poison control was notified and recommended that patient was stable to monitor at this time. [NP #104] was notified and agreed to monitor resident and not needed to send out at this time. According to the resident's Medication Administration Record (MAR), Resident #74 was scheduled to receive the following medications daily at 8:00 AM: - Acetaminophen, 325 mg, two (2) tablets, every six (6) hours for pain and discomfort - Metamucil fiber, one (1) packet, one time a day for constipation - Paroxetine, 10 mg, one (1) time a day for depression - Potassium chloride, 10 mg, one time a day for hypokalemia - Risperdal (risperidone) 0.5 mg, two (2) times a day for Bipolar - Umeclidinium bromide inhalation, one (1) puff, one (1) time a day for chronic obstructive pulmonary disease - Vitamin D3, 400 units, one (1) time a day for hypovitaminosis D Of these medications, the following could have adverse consequences with over dosages: - Paroxetine, which could cause somnolence, coma, nausea and vomiting, tremor, tachycardia, and confusion. - Potassium chloride, which could cause elevated potassium levels. - Risperdal, which could cause drowsiness or sedation, tachycardia, and hypotension. (Source: medication product label, available on-line from the Food and Drug Administration at www.accessdata.fda.gov.) On 07/12/24 at 6:11 PM, NP #104 wrote the following note: [AGE] year-old male with history of COPD, CVA [cerebral vascular accident], dementia and bipolar disorder. Patient being seen today for follow-up visit. Per nursing patient received his a.m. meds twice yesterday including paroxetine, Risperdal, potassium chloride, and Metamucil. Poison control was notified and patient was monitored in house. Patient resting in bed this a.m. he is alert to person. No acute distress noted. Poor historian due to advanced dementia. The resident had skilled nursing evaluations performed on 07/12/24, 07/13/24, 07/14/24, and 07/15/24. The resident had no change in vital signs or mental status following the medication error. The resident was observed on 07/15/24 at 11:20 AM but was not interviewable. e) Resident #39 Resident #39 was an [AGE] year-old admitted in February 2023. The resident did not have capacity to make decisions due to intracranial hemorrhage and cognitive impairment. A family member was the health care surrogate. According to the resident's Minimum Data Set (MDS) assessment with Assessment Reference Date (ARD) 05/24/24, the resident's Brief Interview for Mental Status (BIMS) score was 13, indicating the resident was cognitively intact. In addition to intracranial hemorrhage, the resident had diagnoses of major depressive disorder, breast cancer, hypertension, and hyperlipidemia. On 07/11/24 at 8:40 AM, an SBAR summary for providers was completed for Resident #39. The summary stated, Resident was given a double dose of her medications. Poison control called. Sending out to ER for evaluation. According to the resident's MAR, the resident was scheduled to receive the following medications daily at 8:00 AM: - amlodipine besylate, 10 mg, one (1) time a day for hypertension - dicyclomine hydrochloride, 10 mg, twice a day for irritable bowel syndrome - exemestane 25 mg, one (1) time a day for breast cancer - letrozole, 2.5 mg, one (1) time a day for breast cancer - propranolol 20 mg, two (2) times a day for hypertension - Wellbutrin (bupropion) 100 mg, one (1) time a day for depression The poison control center provided a toxic substance review to the hospital emergency room. The review stated amlodipine had a low margin for safety and double doses could cause toxicity in patient on multiple cardiac drugs or with brittle cardiac status. Life threatening hypotension (low blood pressure) could occur. Heart block and bradycardia (slow heart rate) were common. Atrioventricular dissociation (a condition in which the atria and the ventricles operate independently from each other) could persist for nine (9) to 48 hours. Pulmonary edema, drowsiness, confusion, and nausea and vomiting could also occur. According to the toxic review, an established toxic dose for bupropion was not established. The following conditions could occur with bupropion overdose: seizures, tremors, agitation, excitement, confusion, tachycardia (increased heart rate), and acute psychotic reactions, including visual hallucinations. Cardiovascular collapse and cardiac arrest could occur with massive overdoses. As for anticholinergics (dicyclomine) the toxic review stated specified toxic doses had not been established. Drowsiness and tachycardia could occur. The toxic review stated beta-blocking agents (propranolol) could cause hypotension (low blood pressure), bradycardia, seizures, and cardiac dysrhythmias. Cardiac conduction disturbances and cardiovascular shock could occur with severe toxicity. The toxic review also stated the amounts of exemestane and Letrozole ingested by the resident were well below toxic range and significant effects were not expected. According to the emergency room records, the resident reported dizziness. Laboratory testing was within normal limits. The resident was discharged to return to the facility on [DATE] at 2:22 PM. The resident had no changes in vital signs or mental status upon return to the facility. On 07/12/24 at 5:34 PM, NP #104 wrote the following note: [AGE] year-old female with history of major depressive disorder, IBS, hypertension, hyperlipidemia, hypothyroidism, nontraumatic intracranial hemorrhage, cerebral edema, and personal history of malignant neoplasm of the breast. Patient being seen today follow-up for ER [emergency room] visit. Patient was sent to [hospital name] 7/11/2024 for medical screening at poison control's recommendation due to accidental drug overdose. Per nursing patient received double her morning meds including: Amlodipine, dicyclomine, letrozole, propranolol, Wellbutrin, and exemestane. Patient sitting up in wheelchair this afternoon. She just returned from having a cataract removed from her left eye. She is alert and oriented. She has no acute complaints of pain or discomfort at this time. The resident had skilled nursing evaluations performed on 07/12/24, 07/13/24, 07/14/24, and 07/15/24. Resident #39 was interviewed on 07/15/24 at 11:30 AM. When asked if she had any problems with the care she received, the resident stated she was given her pills twice on Friday morning. She stated she had to go to the emergency room for evaluation. The resident stated, But I was okay .Those kinds of things happen. f) Resident #108 Resident #108 was a [AGE] year-old who was admitted [DATE]. The resident did not have the capacity to make medical decisions due to cognitive impairment. A family member was health care surrogate for the resident. According to the resident's Minimum Data Set (MDS) assessment with Assessment Reference Date (ARD) 07/02/24, the resident's Brief Interview for Mental Status (BIMS) score was 15, indicating the resident was cognitively intact. The resident had diagnoses of congestive heart failure, atherosclerotic heart disease, Parkinson's Disease, general anxiety disorder, major depressive disorder, and hypertension. On 07/11/24 at 7:00 AM, an SBAR summary for providers was completed for Resident #108. The summary stated, 0800 medications given twice by two separate nurses. poison control notified, physician notified. orders to send resident to ER for evaluation. Resident #108's blood pressure was 91/58 at 7:30 AM on 07/11/24. The resident's most recent recorded blood pressure was 134/78 on 06/04/24. According to Emergency Medical Services (EMS) records, Resident #108 reported feeling tired and dizzy. His blood pressure was noted to be 95-100 systolic, which EMS notes is lower than the resident's baseline blood pressure. The Emergency Medical Technicians inserted an intravenous catheter and began normal saline infusion to increase his blood pressure. According to the resident's Medication Administration Record (MAR), Resident #108 was scheduled to receive the following medications daily at 8:00 AM: - Acetaminophen, 325 mg, two (2) tablets, four (4) times a day for pain - Aspirin, 81 mg, one (1) time a day for coronary artery disease - Carbidopa-Levodopa extended release, 50-200 mg, five (5) times a day for Parkinson's Disease - Carbidopa-Levodopa 25-100 mg, four (4) times a day for Parkinson's Disease - Furosemide 20 mg, one (1) time a day for edema - Isosorbide extended-release tablet, 30 mg, one (1) time a day for hypertension - Paroxetine, 20 mg, one (1) time a day for depression/anxiety - Plavix (clopidogrel) 75 mg, one (1) time a day for coronary artery disease - Sennosides, 8.6 mg, two (2) tablets, one (1) time a day for constipation - Tizanidine, 2 mg, three (3) times a day for muscle relaxant Of these medications, the following could have adverse consequences with over dosages: - Paroxetine, which could cause somulence, coma, nausea and vomiting, tremor, tachycardia, and confusion. - Carbidopa-Levodopa, which could cause heart arrhythmias. - Furosemide, which could cause dehydration, hypotension, and electrolyte imbalances. - Isosorbide, which could cause hypotension, nausea and vomiting, syncope, bradycardia, heart block, coma, and seizures. - Plavix, which could cause increased breathing. - Tizanidine, which could cause hypotension, bradycardia, coma, somnolence, confusion, and respiratory depression. (Source: medication product label, available on-line from the Food and Drug Administration at www.accessdata.fda.gov.) Laboratory testing at the hospital was within normal limits. The resident returned to the facility on [DATE] at 1:57 PM. On 07/12/24 at 5:06 PM, NP #104 wrote the following note: [AGE] year-old male with history of chronic diastolic heart failure, arteriosclerotic heart disease, Parkinson's disease, hypertension and hypothyroidism. Patient being seen today to follow-upfor ER visit. Patient was sent to the ER yesterday 7/11/2024 at [hospital name] for evaluation due to accidental medical overdose after Poison control was consulted and made recommendation. Per nursing patient was given his a.m. medicine x 2 including Zanaflex, Sinemet and isosorbide. Patient was seen and evaluated in ED [emergency department] and later sent back to facility. Patient sitting up in activity room this a.m. He is alert to person/place. Appears at baseline. Patient's vital signs have been monitored. And his regular medication regimen has resumed. The resident had skilled nursing evaluations performed on 07/12/24, 07/13/24, 07/14/24, and 07/15/24. Resident #108 was interviewed on 07/22/24 at 9:45 AM. He had no complaints about the facility. When specifically asked about medications, the resident had no complaints. He acknowledged that he had been evaluated in the emergency room but was unable to provide any additional information about the emergency room visit. g) Staff Interview The Director of Nursing and Administrator were interviewed on 07/15/24 at 3:00 PM. They stated the nurse had given the 8:00 AM medications during the 6:00 AM medications administration pass and had not signed them out as given. Additionally, the nurse had been pulled to another area of the facility and, therefore, had not given report to the on-coming nurse to let her know that medications had been given. The DON stated the nurse had not returned to the facility during the investigation of the incident. If the nurse is permitted to return to the facility after the investigation has concluded, the nurse will have an improvement plan with preceptorship in place. At the time of the Facility Reported Incident investigation on 07/15/24. All staff had been re-educated before their next shift after the incident. Education had begun on 07/11/24 and was completed on 07/14/24.

CRITICAL (L) 📢 Someone Reported This

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

Immediate Jeopardy (IJ) - the most serious Medicare violation

Infection Control (Tag F0880)

Someone could have died · This affected most or all residents

⚠️ Facility-wide issue

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, resident and staff interviews, the facility failed to ensure Enhanced Barrier Precautions (EBP) were followed for residents with Multidrug-resistant Organisms (MDRO's). Resident identifiers: #12, #17 and #72. Facility census: 110. On 07/18/24 at 3:51 PM an immediate jeopardy (IJ) was called at as this failed practice had the potential to affect all residents residing in the facility. Findings included: a) Resident #12 Resident #12 was admitted on [DATE]. Diagnoses included paraplegic, neurogenic bladder with suprapubic catheter, decubitus ulcers, vascular ulcers both heels, chronic kidney disease, and insulin dependent diabetic. admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/11/24 had a Brief Interview of Mental Status (BIMS) with a score of 15. This indicates intact cognition. The resident had the capacity to make medical decisions. On 07/18/24 at 10:55 AM observed two (2) Nurse Aides (NA's) performing direct resident care of changing urine soaked brief and linens wearing only gloves and no gowns. An EBP sign was on the door. When asked if Resident #12 was on EBP, Registered Nurse (RN) #71 responded I don't know, I will go look, and left the room. On 07/18/24 at 11:00 AM an interview with the NA instructor #25 stated that NA #108 was only there to observe the care being provided. NA #66 stated that she was new and had only been here two (2) weeks. Observed RN #71 and NA #108 reenter room wearing gowns and gloves. An interview with Resident #12 at 11:00 AM on 07/18/24 stated that no staff had worn a gown when providing care. b) Resident #72 An additional interview with Resident #72 on 07/18/24 at approximately 1:00 PM stated that no staff had worn a gown when providing care. Record review revealed a history of ESBL and also currently had a Foley Catheter. c) Resident #17 In reviewing residents who had a Foley and residents were to be on contact precautions, found Resident #17 did have a Foley which was not leaking and initially had an EBP sign on the outside of the door. On 07/18/24 at 11:24 AM an interview with NA #15 stated that the Foley was not leaking and had been changed the day before for Resident #17. An EBP sign was posted on the outside of the door and later changed to contact precautions by the IP on 07/18/24 at approximately 2:26 PM. Resident # 17 had wounds that the drainage could not be contained and had MRSA and ESBL in the wounds and was currently being treated with antibiotics. In addition, 49 residents were on Enhanced Barrier Precautions (EBP) were followed for residents with Multidrug-resistant Organisms (MDRO's) including Methicillin-Resistant Staphylococcus Aureus (MRSA), Carbapenem-resistant Enterobacterales (CRE), Vancomycin-resistant Enterococci (VRE), Extended-spectrumbeta-lactamase (ESBL). c) Resident #72 An interview with Resident #12 at 11:00 AM on 07/18/24 stated that no staff had worn a gown when providing care. An additional interview with Resident #72 on 07/18/24 at approximately 1:00 PM stated that no staff had worn a gown when providing care. Record review revealed a history of ESBL and also currently had a Foley Catheter. An interview with the IP and Corporate RN confirmed the staff had not been using EBP as stated in policy on 07/18/24 at 2:29. The IP stated that she had not been the IP but just a few weeks. On 07/18/24 at 3:51 PM an immediate jeopardy (IJ) was called at F880 at an L as this failed practice had the potential to affect all residents residing in the facility. The Plan of Correction (POC) was received on 07/18/24 at 3:54 PM. After consulting with the State Office the POC was approved and agreed to an abatement on 07/18/24 at 4:17 PM. After the abatement, the L was changed to an F as the failed practice had the potential to affect all residents, staff and visitors. The POC was as follows: The Infection Preventionist (IP) provided education to the nursing staff in (on) Resident #12 regarding the use of EBP during high contact resident care activities on 07/18/24. All residents of the facility have the potential to be affected. The Infection Preventionist/designee conducted an observation round on 07/18/24 to ensure nursing staff is donning Personal Protective Equipment (PPE) for residents who are in enhanced barrier precautions with any corrective action immediately upon delivery. All center staff will be reeducated by the Director of Nursing (DON)/designee on 07/18/24 regarding the facility must 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 including nursing staff is donning appropriate PPE for residents who are in enhanced barrier precautions. A posttest completed to validate understanding. All staff not available during this timeframe will be provided reeducation including posttest by the Director of Nursing (DON)/designee prior to the next scheduled shift. New staff will be provided education and posttest during orientation by the Infection Preventionist (IP)/designee. The DON/designee will conduct an observation round starting on 07/18/24 to ensure nursing staff is donning appropriate PPE for residents who are in enhanced barrier precautions daily across all shifts for 2 weeks, including weekends and holidays, then 5 times a week for 4 weeks then 3 times a week for 4 weeks, the randomly thereafter. Results of monitors will be reported by the Nursing Home Administrator/designee to the Quality Improvement Committee (QIC) monthly for any additional follow-up and or in-servicing until the issue is resolved, then randomly thereafter as determined by the Quality Improvement Committee. A review of the facility policy and procedure titled IC308 Enhanced Barrier Precautions with a revision date of 01/08/24. As of July 2022, the Center Disease Control (CDC) targeted MDRO's are defined as pan-resistant organisms, CRE, CR Pseudomonas, CR Acinetobacter baumaii and Candida auris. Additional MDRO's that might be included based on local requirements: MRSA, ESBL, VRE, MDRO-Pseudomonas aeruginosa and drug resistant Streptococcus pneumoiae. In the procedure section titled Enhanced Barrier Precautions with an effective date of 08/01/23 and revision date of 05/01/24. Enhanced barrier: All residents with any of the following: infection or colonization with a targeted MDRO Chronic wounds and/or indwelling medical devices such as central line, urinary catheter, enteral feeding tube regardless of MDRO colonization status. During high contact resident care activities: providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use, central line, urinary catheter, enteral feeding tube . wound care; and skin opening requiring a dressing.

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 F0658 (Tag F0658)

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 services to meet professional standards of care. A medication labeled by the pharmacy to be used for a specific resident was used for another resident. This was a random opportunity for discovery found during medication administration observation. Resident identifiers: #4 and #52. Facility census: 110. Findings included: a) Residents #4 and #52 The facility's policy titled Medication Administration General Guidelines dated January 2024 gave the following procedure: - Medications supplied for one resident are never administered to another resident. On 07/18/24 at 7:38 AM, Licensed Practical Nurse (LPN) #28 was observed administering medications to Resident #4. The resident had an order written on 06/25/24 for Lactulose, 10 grams in 15 milliliters concentration, give 45 ml by mouth two (2) times a day for hyperammonemia (high ammonia level). LPN #28 could not find lactulose for Resident #4. There was an unopened Lactulose bottle with a label for Resident #52. The Lactulose concentration was 10 grams in 15 milliliters. LPN #28 stated Resident #52 was no longer in the facility. LPN #28 stated she could use Resident #52's Lactulose for Resident #4 since the bottle was unopened and Resident #52 was no longer in the facility. She poured the Lactulose from the bottle into a medication cup and administered it to Resident #4. LPN #28 stated a bottle of Resident #4's Lactulose needed reordered from the pharmacy and she did so using the computer. On 07/18/24 at 11:00 AM, the incident was reported to the Administrator, the Director of Nursing (DON), and the Corporate Nurse were notified. They confirmed the facility's policy that medications supplied for one (1) resident are never administered to another resident. No further information was provided through the completion of the investigation.

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 →

Based on record review and staff interview, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice. Physician-ordered medication parameters were not followed. This deficient practice had the potential to affect (1) of four (4) residents reviewed during the investigation. Resident identifier: #39. Facility census: 110. Findings included: a) Resident #39 Resident #39 had the following physician-ordered medication parameters: - Amlodipine besylate, 10 mg, one (1) tablet by mouth one (1) time a day for hypertension. Hold for pulse below 60 or SBP [systolic blood pressure] less than 110 or DBP [diastolic blood pressure] less than 70 and notify provider, ordered on 02/23/23. - Propranolol, 20 mg, one (1) tablet by mouth two (2) times a day for hypertension. Hold for pulse below 60 or SBP less than 110 or DBP less than 70 and notify provider, ordered on 01/08/24. According to the resident's Medication Administration Record (MAR), at the following dates and times, amlodipine besylate was administered despite the resident's vital signs being outside the administration parameters: - 07/02/24 at 8:00 AM, pulse was 59 beats per minute - 07/10/24 at 8:00 AM, diastolic blood pressure was 66 - 07/11/24 at 8:00 AM, diastolic blood pressure was 66 - 07/14/24 at 8:00 AM, diastolic blood pressure was 66 At the following dates and times, propranolol was administered despite the resident's vital signs being outside the administration parameters: - 07/01/24 at 8:00 PM, pulse was 59 beats per minute - 07/02/24 at 8:00 AM, pulse was 59 beats per minute - 07/19/24 at 8:00 PM, diastolic blood pressure was 64 - 07/10/24 at 8:00 AM, diastolic blood pressure was 66 - 07/19/24 at 8:00 PM, diastolic blood pressure was 66 - 07/11/24 at 8:00 AM, diastolic blood pressure was 66 - 07/14/24 at 8:00 AM, diastolic blood pressure was 66 On 07/18/24 at 11:20 AM, the Director of Nursing (DON) confirmed amlodipine and propranolol had been administered to Resident #39 when the parameters indicated the medications should have been held. No further information was provided through the completion of the investigation.

Dec 2023 1 deficiency

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 F0680 (Tag F0680)

Could have caused harm · This affected multiple residents

Read full inspector narrative →

. Based on staff interview and record review, the facility failed to provide a qualified activity professional for recreational services. This failed practice was a random opportunity for discovery and had the potential to affect all residents. Facility census: 110. Findings included: a) Activity Professional On 12/12/2023 at 3:00 PM the appointed Recreation Director (RD) #105 stated she has not had the activity professional qualification course but was set to have it in the upcoming January 2024 class. During an Interview on 12/13/2023 at 10:00 AM the Administrator stated the RD was enrolled into the Modular Education Program for Activity Professionals (MEPAP) course in November 2023 through National Certification Council for Activity Professional (NCCAP). Record review showed a copy of the enrolment email for RD #105 to attend the (MEPAP) course with an enrollment date of 11/03/23. During an interview on 12/13/23 at 11:03 AM Activity Consultant Certified (ACC) #301 Instructor verified the facilities recreation director was enrolled in MEPAP the course starting January 8th, 2024. ACC #301 stated the certification course would take 3 months and would be completed March 8th, 2024. Through staff interview and record review it showed that the facility has not had an Qualified Activity Professional at facility since 08/23/23.

Sept 2023 4 deficiencies

CONCERN (D) 📢 Someone Reported This

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

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

Report Alleged Abuse (Tag F0609)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

. Based on facility policy review, record review and staff interviews, the facility failed to ensure resident to resident altercations were reported to all the proper State Agencies. This is true for four (4) of ten (10) incidents reviewed for resident to resident alterations. Resident Identifiers: Resident #83, Resident #92, Resident #79, Resident #40, Resident #95, Resident #11 and Resident #54. Facility Census: 110. Findings Included: A review of a facility policy titled OPS300 Abuse Prohibition: with a revision date of 10/24/22 read as follows. .Process: .7.4 Report allegations to the appropriate state and local authority(s) involving neglect, exploitation or mistreatment (including injuries of unknown source) suspected criminal activity, and misappropriation of patient property within 24 hours if the event does not result in serious bodily injury. .9. The Administrator or designee will: .9.2 Report findings of all the completed investigations within five (5) working days to the Department of Health using the state on-line reporting system or state approved forms. A review of the facility external abuse reporting requirements with no date read as follows: Type: No Serious Bodily Injury Person Responsible for Reporting to State Agency(ies): Administrator or Director of Nursing When to Report: Immediately but no later than 24 hours after forming the suspicion To Whom to Report: State Survey Agency (SA) Law Enforcement (i.e. police, public safety officers, medical examiners) Adult protective services where state law provides for jurisdiction in long term care facilities. a) Incident occurring 08/04/23 A review of the facility's Reportable log on 09/27/23 at 8:30 AM revealed Resident #83 and Resident #92 were involved in a resident to resident altercation. A risk management note dated 08/04/23 stated Resident #92 was taunting Resident #83 while she was attempting to get ice. Resident #83 smacked Resident #92 across the face. Resident #92 pushed Resident #83 almost knocking her down to the ground. The facility determined the allegations were resident to resident altercation and reported the event to the Ombudsman. The facility did not report the allegation to the State Survey Agency, Law Enforcement and/or Adult Protective Services (APS). During an interview on 09/27/23 at 10:39 AM the Social Worker(SW) #3 stated when a Resident to Resident altercation occurs with no physician interventions, I only report it to the Ombudsman. The SW #3 was asked do you not consider slapping someone or taunting abuse? The SW stated that I don't guess, I just follow what I was taught to do. During an interview on 09/27/23 at 11:43 AM, the SW #3 and the Administrator #119 were presented with the other resident to resident altercations that were reported to the correct agencies that did not have any physician interventions. During an interview on 09/27/23 at 12:00 PM, the Administrator #119 acknowledged the inconsistency of reporting to the correct agencies. b) Incident occurring 07/21/23 A review of the facility's Reportable log on 09/27/23 at 8:37 AM revealed Resident #40 and Resident #95 were involved in a resident to resident altercation. A risk management note dated 07/21/23 stated Resident #40 and Resident #95 were standing at the nurses station yelling at each other. Resident #95 stated you best never call me a Bitch again Resident #95 hit Resident #40 in the chest, Resident #40 started fighting back. The facility determined the allegations were resident to resident altercation and reported the event to the Ombudsman. The facility did not report the allegation to the State Survey Agency, Law Enforcement and/or Adult Protective Services (APS). During an interview on 09/27/23 at 10:39 AM, the SW #3 stated that when a Resident to Resident altercation occurs with no physician interventions, I only report it to the Ombudsman. The SW #3 was asked do you not consider slapping someone or taunting abuse? The SW stated that I don't guess, I just follow what I was taught to do. During an interview on 09/27/23 at 11:43 AM, the SW #3 and the Administrator #119 were presented with the other resident to resident altercations that was reported to the correct agencies that did not have any physician interventions. During an interview on 09/27/23 at 12:00 PM, the Administrator #119 acknowledged the inconsistency of reporting to the correct agencies. c. Incident occurring on 06/15/23 A review of the facility's Reportable log on 09/27/23 at 8:45 AM revealed Resident #11 and Resident #54 were involved in a resident to resident altercation. A risk management note dated 06/15/23 stated Resident #11 slapped Resident #54 on the left arm a couple of times. Resident #54 stated okay that did it then started towards Resident #11. Resident #11 started slapping Resident #54 arm again and grabbing it. Resident #54 was asked if she was hurt Resident #54 stated well it hurts but I am okay I think. Resident #54 was leaving and stated Oh man my arm does hurt. The facility determined the allegations were resident to resident altercation and reported the event to the Ombudsman. The facility did not report the allegation to the State Survey Agency, Law Enforcement and/or Adult Protective Services (APS). During an interview the on 09/27/23 at 10:39 AM, the SW #3 stated that when a Resident to Resident altercation occurs with no physician interventions, I only report it to the Ombudsman. The SW #3 was asked do you not consider slapping someone abuse? The SW stated that I don't guess, I just follow what I was taught to do. During an interview on 09/27/23 at 11:43 AM, the SW #3 and the Administrator #119 were presented with the other resident to resident altercations that was reported to the correct agencies that did not have any physician interventions. During an interview on 09/27/23 at 12:00 PM, the Administrator #119 acknowledged the inconsistency of reporting to the correct agencies. d) Incident Occurring on 05/31/23 A review of the facility's Reportable log on 09/27/23 at 8:53 AM revealed Resident #40 and Resident #79 were involved in a resident to resident altercation. A risk management note dated 05/31/23 stated Resident #40 was asleep on the sofa in the cafe when a female resident tried to wake her up. Resident #40 started screaming at Resident #79 thought that was who woke her up. Resident #40 started punching Resident #79 in the right arm, the right side of his face and kicking him in the right leg. The facility determined the allegations were resident to resident altercation and reported the event to the Ombudsman. The facility did not report the allegation to the State Survey Agency, Law Enforcement and/or Adult Protective Services (APS). During an interview the on 09/27/23 at 10:39 AM, the SW #3 stated that when a Resident to Resident altercation occurs with no physician interventions, I only report it to the Ombudsman. The SW #3 was asked do you not consider hitting an kicking someone abuse? The SW stated that I don't guess, I just follow what I was taught to do. During an interview on 09/27/23 at 11:43 AM, the SW #3 and the Administrator #119 were presented with the other resident to resident altercations that was reported to the correct agencies that did not have any physician interventions. During an interview on 09/27/23 at 12:00 PM the Administrator #119 acknowledged the inconsistency of reporting to the correct agencies

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 record review and staff interviews, the facility failed to ensure one (1) of four (4) residents reviewed, who were unable to carry out activities of daily living, received services to maintain personal hygiene. Resident Identifiers: Resident #105. Facility census: 110. Findings included: a) Resident #105 During a record review on 09/26/23 at 7:30 PM, Resident #105 medical record reviews revealed a showers schedule indicated Resident #105 should receive showers on Mondays, Wednesdays and Saturdays. Further record review revealed Resident #105 received showers on the following days: -09/02/23 -09/06/23 -09/10/23 -09/13/23 -09/16/23 -09/18/23 Bed Bath -09/22/23 Bed Bath This documentation indicated Resident #105 did not receive a shower on the following scheduled days and was coded Not Applicable: -09/04/23 -09/09/23 -09/11/23 -09/18/23 -09/20/23 -09/23/23 -09/25/23 During the record review on 09/26/23 8:02 PM, Medical record review revealed a Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/17/23 revealed the following: Section G, titled Activities of Daily Living Assistance, Section G 0120 titled Bathing A. Bathing: Self Performance coded 3) physical help in part of bathing activity. B. Bathing: Support provided coded 2) one person physical assist. During an interview on 09/27/23 at 10:19 AM, the Director of Nursing (DON) stated that the shower schedule did not start until 09/13/23. I will look for any documentation for Resident #105 not receiving showers for 09/20/23,09/23/23 and 09/25/23. During an interview on 09/27/23 at 11:00 AM, the DON stated I could not find the documentation needed for refusal of showers on 09/20/23 and 09/23/23. The DON presented documentation for 09/25/23 Resident refused a shower but accepted a bed bath.

CONCERN (D) 📢 Someone Reported This

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

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

Quality of Care (Tag F0684)

Could have caused harm · This affected 1 resident

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 ensure residents received treatment and care in accordance with professional standards of practice. Physician-ordered medication parameters were not followed for one (1) of three (3) residents reviewed receiving antihypertensive medications. Resident identifier: #105. Facility census: 110. Findings included: a) Resident #105 Review of Resident #105's physician's orders showed an order written on 09/08/23 for carvedilol 3.125 mg, one (1) tablet by mouth, two (2) times a day, for hypertension, at 8:00 AM and 8:00 PM. The medication was to be held if the resident's blood pressure was less than 110/60 or heart rate below 60. Review of Resident #105 Medication Administration Record (MAR) for September 2023 showed the resident's blood pressure was not recorded on the [DATE]/08/23, 09/09/23, and 09/10/23. According to the MAR, the resident's carvedilol had been administered at 8:00 AM on 09/08/23, at 8:00 AM and 8:00 PM on 09/09/23, and at 8:00 AM and 8:00 PM on 09/10/23. Review of Resident #105's blood pressure documentation in the vital signs portion of the medical record showed the following readings below 110/60: - On 09/09/23 at 9:33 AM, the resident's blood pressure was 102/54. - On 09/09/23 at 9:10 PM, the resident's blood pressure was 104/60. - On 09/10/23 at 9:49 AM, the resident's blood pressure was 98/56. According to the MAR for September 2023, Resident #105 was administered carvedilol on the following four (4) occasions when his blood pressure was lower than 110/60. These occasions were as follows: - 09/11/23 at 8:00 AM, when the resident's blood pressure was 99/56. - 09/18/23 at 8:00 PM, when the resident's blood pressure was 98/63. - 09/22/23 at 8:00 AM, when the resident's blood pressure was 95/60. - 09/25/23 at 8:00 PM, when the resident's blood pressure was 106/62. During an interview on 09/27/23 at 12:00 PM, the Director of Nursing (DON) stated Resident #105's carvedilol should be held if his systolic blood pressure (the top number) was less than 110 or his diastolic blood pressure (the bottom number) was less than 60. She confirmed Resident #105's carvedilol had been administered when it should not have been according to these parameters. .

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 F0804 (Tag F0804)

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 nutritional adequacy by providing inconsistent portions of the food to maintain perimeters of health. This failed practice had the potential to affect all residents currently receiving nourishment from the facility's kitchen. Facility census: 110. Findings included: a) Inconsistent Portions During a tour of the kitchen on 09/26/23 at 12:30 PM with the Director of Dining Services (DDS)#23 revealed the following issues: -During the observation [NAME] #27 was preparing the lunch meal trays from the serving steam table of meatball subs. The meatball subs were getting two (2) meatballs, some three (3), then she was cutting some in half and placing them on the buns. The DDS #23 stated the meatballs are not the 4 ounce size called for on the menu, I think those are bigger, was unable to tell this surveyor how many ounces was being provided to each resident. The menu stated two (2) four (4) ounce meatballs. -Cook #23 was serving french fries with a gloved hand and placing them on the Resident's plate, instead of the appropriate serving size. The DDS #23 stated according to the menu the french fries serving size is one (1) cup The DDS #23 acknowledge she should have used the appropriate one (1) cup serving size. -Cook #23 was serving baked beans with a green scoop, the [NAME] #23 would use a whole scoop and add some more beans, or add two (2) scoops of beans. The DDS #23 stated according to the menu the baked beans serving size is one half (1/2) cup. The DDS acknowledged this were not accurate portions and the residents were not receiving the nutritional value of the meal. The Main Dining Room residents and the first cart containing North Shore trays did not receiving the accurate nutritional value of the meal. The menu provided by the DDS #23 read as follows: -Meatball Sub -Hot Dog on Bun -Baked Beans -Vanilla Ice Cream -French fries The Diet Guide Sheet provided by the DDS #23 read as follows: -Meatball Sub two (2)-four (4) ounce meatballs -Baked Beans half (½) cup -French Fries one (1) cup No other information was provided by the end of the survey.

Sept 2023 1 deficiency

CONCERN (D) 📢 Someone Reported This

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

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

Respiratory Care (Tag F0695)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

Based on record review, observation, staff, and resident interview, the facility failed to ensure Resident #6 was provided with the appropriate supplemental oxygen. This failed practice was true for one (1) of three (3) residents reviewed for oxygen therapy. Resident identifier: #6. Facility census: 118. Findings included: Record review showed an order with start date of 10/31/22 for Oxygen at 2 liters/minute via Nasal Cannula continuous, every day and night shift. On 09/14/23 at observation was made of Resident #6 eating lunch in the dining hall sitting in her wheelchair. Resident #6 was noted not have any supplemental oxygen in use. Resident #6's wheelchair did not have any portable O2 attached for use and no portable tank was located within the dining area belonging to the Resident. Licensed Practical Nurse (LPN) #45 was present in the dining room and verified Resident #6 was not wearing O2. LPN #45 stated, I have never seen [resident's first name] wear O2 while up in her wheelchair, but if the order says continuous then it should be on. Record review showed Resident #6 to have diagnoses of chronic obstructive pulmonary disease, acute and chronic respiratory failure unspecified. Review of the Minimum Data Set (MDS) with a quarterly Assessment Reference Date (ARD) date of 08/14/23 showed Resident #6 to have a Brief Interview of Mental Status (BIMS) score of 15. A score of 13-15 indicates a Resident is cognitively intact. Resident had capacity as of 08/31/22. During an interview on 09/13/23 at 1:30 PM, Resident #6 stated that she has never been offered portable O2 to use while she is up in her wheelchair. The Resident stated that she sometimes gets short of breath after she has been up a while in wheelchair, but just 'copes with it'. Resident #6 stated, Sometimes I come back to my room and use my oxygen in here for a bit until I feel better then head back out. On 09/14/23 at 1:34 PM during an interview, the Director of Nursing (DON) stated Resident #6 likes to be up and moving around. The DON stated she had spoken with the doctor and had the oxygen order changed to as needed (PRN). The DON verified the previous Oxygen order for Resident #6 was for oxygen to be administered continuously, therefore Resident #6 should have been using portable O2 while up in her chair. .

Aug 2023 9 deficiencies

CONCERN (D) 📢 Someone Reported This

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

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

Grievances (Tag F0585)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

Based on review of the facility's grievance concern forms and staff interview, the facility failed to ensure a prompt response to a resident grievance/concern. This was true for one (1) of 35 grievances reviewed. Resident identifier: #106. Facility census: 115. Findings included: a) Resident #106 Review of the grievance/concerns forms on 08/01/23 found the following grievances/concerns made by Resident #106 on 03/20/23: -Resident reports that 2-3 weeks maybe a month, there was a big deal about a Saturday night shower. A nurse asked about why he was washing up in the sink, she asked about his shower. He states he was not asked about a shower. The CNA (certified nurse assistant) told the nurse the resident refused. The resident stated he was never asked. -Several weeks ago, a new catheter was placed and it was bothering the resident. Resident stated it took a few days before they changed it again. -One evening he asked to be changed at 9:30 PM. One girl said she would be back, and she did come back to provide care. A male came in and stated he would be back, he did not come back for 5 hours, the girl already changed him. The male talked on his personal cell phone the whole time he was in there. -The resident stated it did take a while to get him out of bed. The resident said they had excuses or say they are with other people, and it took sometimes a couple hours before they got him up to the chair. He stated that one girl used the I am pregnant excuse and he was not happy about that, that's her problem, not mine. He was told we are out of lift pads. Resident states he is not sure the names of staff members involved and does not have the dates. -He also needed to be back on his prior celexa dosage. He stated, this was the reason for all these complaints and blow ups. He said normally it took the edge off. The description of the action taken is: This nurse spoke with resident regarding showers and bed baths. Resident stated he would prefer bed baths but would like a shower 1 time a month at his request. This has been added to his care plan. At 11:05 AM on 08/01/23, the administrator was asked what the facility did to address all the resident's complaints made on 03/20/23. The only complaint addressed on the grievance/concern form was concerning the resident's bathing activities. An interview with the resident at 12:30 PM on 08/01/23, found the resident had no issues with his bathing activity at this time. He was now receiving his antidepressant. His problem with the catheter had been resolved. He stated the problems with going to bed and getting up continue. Just last night he could not get back to bed until 10:30 PM. At 3:20 PM on 08/01/23, the administrator reviewed the grievance. The administrator confirmed the only grievance addressed on the form was regarding the issue with the shower. In addition, the administrator was advised the resident was still having problems getting up and getting put back to bed. The administrator was unable to provide evidence the resident's grievance/concern documented on 03/20/23 regarding getting up and getting back to bed was addressed.

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 resident interview, staff interview, and record review, the facility failed to ensure one (1) of four (4) residents reviewed, who were unable to carry out activities of daily living, received services to maintain personal hygiene. Resident identifier: #76. Facility census: 115. Findings included: a) Resident #76 During a resident council meeting, requested by the residents, at 10:00 AM on 08/02/23, Resident #76 stated no one would get her up for her showers. She said because no one would get her up, she did not get her showers. She said she had not had a shower for at least a week. She stated, she did not refuse any showers. Record review found the most recent quarterly Minimum Data Set (MDS) with an assessment reference date (ARD) of 06/19/23 found the resident Brief Interview for Mental Status (BIMS) score was 15. A score of 15 was the highest score obtainable and indicated the resident was cognitively intact. At 11:45 AM on 08/02/23, the resident's shower schedule was reviewed in the electronic medical record with the Administrator. Documentation found the resident's last shower was provided on 07/25/23. The resident's shower schedule indicated she should receive showers on Tuesdays and Saturdays. The Administrator confirmed the documentation indicated the resident's last shower was provided eight (8) days ago.

CONCERN (D) 📢 Someone Reported This

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

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

Quality of Care (Tag F0684)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

Based on observation, record review, staff, and resident interview, the facility failed to ensure Resident #100 had diabetic medication available for administration. This failed practice was a random opportunity for discovery and had the potential to only affect a limited number of residents. Resident identifier: #100. Facility census: 115. Findings included: a) Resident council meeting On 08/02/23 at 10:00 AM, the Resident's requested the surveyors attend a special Resident council meeting. During the meeting, Resident #100 said she takes Trulicity and the medication has not been available for the last 2 weeks. Trulicity is a once - weekly injectable prescription medication used to improve blood sugar (glucose.) She says she is supposed to receive an injection every Wednesday, but the nurses just tell her they do not have the medication. b) Medication Review On 08/02/23 at 11:25 AM Licensed Practical Nurse (LPN) #25 was asked to verify Resident #100's Trulicity medication was available for administration at 10:00 PM on 08/02/23. LPN #25 stated the Trulicity was stored in the medication room refrigerator. Observation of Medication Room Refrigerator showed no Trulicity to be available for Resident #100. LPN #25 verified the medication was not there. LPN #25 provided the last order date of the medication was done on 07/05/23. Record review showed an order for Trulicity Subcutaneous Solution Pen-injector 0.75 MG/0.5ML (Dulaglutide). Inject 0.5 ml subcutaneously one time a day every Wednesday for Type 2 Diabetes. During an interview on 08/02/23 at 12:21 PM, the Director of Nursing stated pharmacy only sends one pen at a time that contains a one-time dose. Depending on insurance pharmacy may send three (3) pens or just one (1) pen at a time. The DON stated, Whoever used the last pen should make sure they order the next dose. Resident #100 had capacity and Brief Interview for Mental Status (BIMS) score of 15 as indicated by the significant change Minimum Data Set (MDS) with an assessment reference date (ARD) of 05/19/23.

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

Staffing Information (Tag F0732)

Could have caused harm · This affected multiple residents

Read full inspector narrative →

Based on observation and staff interview, the facility failed to ensure the daily staff posting was correct. This had the potential to affect more than an isolated number of residents. Facility census: 115. Findings included a) Observation of staff posting At 8:13 AM on 08/01/23, observation of the staff posting for 08/01/23 with nurse Aide (NA) #75 on the South hallway found the posting reflected the nursing staff working was: 9.94 NA's, 5 Licensed Practical Nurses, and 4 Registered Nurses. The day shift census was not completed. At 9:30 AM on 08/01/23, the Director of Nursing (DON) confirmed only 9 NA's were working, the facility had a staff member who called in and the staff posting was not updated when the number of nurse aides changed. She confirmed the facility census was 115, which was not documented on the posting form.

CONCERN (E) 📢 Someone Reported This

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

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

Menu Adequacy (Tag F0803)

Could have caused harm · This affected multiple residents

Read full inspector narrative →

Based on observation, staff interview and resident interview, the facility failed to ensure menus were followed. This had the potential to affect more than an isolated number of residents. Facility census: 115. Findings included: a) Observation of the tray line At 8:15 AM on 08/02/23, the cook, Employee #99 was observed serving the morning meal. The food items being served were cereal, oatmeal, eggs, and bread. E #99 was asked if the residents were going to receive any meat with breakfast. E #99 said the regular diets got bacon but the facility ran out of bacon. Employee #99 said, I don't have any sausage because today is food truck day and we ran out of that also. E #99 served the last of the food items on the steam table with the last tray. E #99 was asked, what would happen if residents wanted more food. She stated, I guess I would have to cook some more food. At 8:25 AM on 08/02/23, the cook was informed by a nursing assistant, the facility had a new admission last night - Resident #118 and Resident #118 never received a tray. The Resident was to receive a regular diet. E #99 found a tray of egg bake in the refrigerator. She heated the serving size and placed it on the Resident #118's tray. In addition, she placed some cold cereal and a piece of cinnamon toast on the Resident's tray. The Dietary Manager (DM) #109 was present during the observations. The DM provided a copy of the production count for breakfast, dated 08/02/23, for Breakfast-hot foods. The sheet included: cheddar omelet, fried egg, hard cooked eggs, scrambled eggs, bacon, sausage links or patty, cream of wheat, oatmeal, cinnamon bread, cinnamon toast, wheat and white toast, and brown gravy. The DM said this was what the facility could have cooked but the facility had no bacon, sausage, or cream of wheat. The posted menu for the Residents stated the facility would serve scrambled egg bake, bacon, oatmeal, cinnamon toast, assorted beverages, fruit juice, and milk. During the Resident council meeting at 10:00 AM on 08/02/23, several residents complained food items on the menu were nott available. Residents explained they could choose from a list of what they wanted to eat but half the time the chosen items were not available at the time of service. The residents complained they did not get enough food to eat on their trays. The surveyor asked if they could request more food if they were still hungry. The response was, we are told there isn't any more food left if we ask. The administrator was present during the council meeting and heard the resident comments. The administrator told the surveyor she would address the issues. At 11:45 AM on 08/02/23, the food service district manager, E #119 said the residents who are on a pureed diet do not get any meat for breakfast. When asked why that would be, E #119 said because that was how the menu is written. She said eggs were the protein for the meal.

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 F0925 (Tag F0925)

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, staff interview and resident interview the facility failed to maintain an environment free from flies and gnats. This failed practice was a random opportunity for discovery and had the potential to affect more than a limited number of residents. Resident identifiers: #22, #79, #100, #51. Facility census: 115. Findings included: a) Resident #22 08/01/23 at 10:02 AM Resident #22 asked if the State was going to make them [the facility] do anything about these gnats and flies. Resident #22 stated, If I don't hold my tray [meal tray] down they will carry it off before I get it ate. Resident further stated the flies in his room aggravate him at night while he trying to sleep, landing on his face and nose. Resident said he keeps the air turned up on high, so the flies will not be landing on and around him as much. The Surveyor observed several flies on the resident's over the bed table, with one fly positioned on the resident's drink cup. Resident #22 has capacity and Brief Interview for Mental Status (BIMS) score of 15 reported on the quarterly Minimum Data Set (MDS) dated [DATE]. Highest score obtainable is 15 and indicates the Resident is cognitively intact. b) Resident #79 On 08/03/23 at 11:27 AM, Resident #79 was heard from the hallway cursing loudly about the flies in his room. Resident #79 was attempting to take medications. Resident #79 stated to Licensed Practical Nurse (LPN) #25, These God Damned flies, trying to get in my med cup now, do something about them. Resident #79 informed Surveyor that the flies aggravated him death all the time, and he got no peace from them. At 11:30 AM LPN #25 verified all the flies in the Resident #79's room. LPN #25 stated they fight with the flies every day, and all the Residents are fed up with it. LPN #25 stated, The flies and gnats are even swarming around the medication cart, we spend all day swatting at them. c) Resident #100 During an interview at 11:31 AM, Resident #100 stated, I have green flies in my room, you can't even sleep for them, they crawl on my face. It's ridiculous. Resident #100 had capacity and a Brief Interview for Mental Status (BIMS) score of 15 indicated on the Significant change MDS with an ARD date 05/19/23. d) Dining Room On 08/02/23 at 8:50 AM observation was made of two (2) double shelved carts setting in the in the main dining hall stacked full of dirty meal trays. The meal trays were from 08/01/23 dinner meal. The plates, bowls and cups were uncovered with exposed left-over food and drink. Flies and gnats were heavily swarming around the juice and milk cups, and left-over meatballs on the plates. The Director of Nursing verified the trays and stated one resident likes to keep her tray in her room for longer periods time, however the meals trays should have been covered to prevent drawing further pests. The DON stated they would work on better process for storage. Residents use the main dining hall for eating meals. e) Resident #51 At 8:30 AM on 08/01/23, a fly was buzzing around the Resident's food tray while the Resident was eating in his room. Nurse Aide (NA) #9 was present and said, that fly needs to go. Resident #51 said, flies are always in my room. f) flies in kitchen During a kitchen tour at 8:15 AM on 08/02/23, several flies were in the kitchen around the garbage can. Kitchen employees #99 #95 and #100 observed the flies. On staff member commented, I'm sick of the flies. g) Council Meeting During a meeting, requested by the resident council members, at 10:00 AM on 08/02/23, the residents complained about flies and gnats in the facility. The administrator was present at the meeting and heard the comments made by the residents.

CONCERN (F) 📢 Someone Reported This

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

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

Food Safety (Tag F0812)

Could have caused harm · This affected most or all residents

Read full inspector narrative →

Based on observation and staff interview, the facility failed to ensure food was stored, prepared and distributed in accordance with professional standards for food service safety. This had the potential to affect all Residents at the facility. Facility census: 115. Findings included: a) Observation the the kitchen area At 8:10 AM on 08/02/23 a tour of the kitchen with the Dietary Manager (DM) #109 found the following: Walk in refrigerator - approximately 2 inches from the floor extending upward on the entire length of the outside of the door was a black substance with dirt and debris. The baseboards in the corners of the door had a black substance littered with debris from the floor extending upward about 2 inches from the floor. DM #109 said the door was rusted; however, the baseboards on either side of the door were rubber and had the black substance also. Rags were found stuffed in a hole at the base of the wall in the dish room. The DM said water leaked through the hole in the wall and the rags were to stop the leaking. A metal serving pan was on the floor under the 3 compartment sink. Dirty soapy water was present in the pan. The cook, E #99 said the sink leaked. The DM said someone overfills the sink and water runs out the overflow hole at the top of the sink. The DM's office is inside the kitchen area. Two (2) trash bags of clothing were sitting on the floor in the office as well as a milk crate full of dirty rags. The door to her office was open. The DM said someone left some uniforms for another staff member in the trash bags and she did not know where the dirty used rags came from. At 11:45 AM on 08/02/23, the above observations were shared with the administrator.

CONCERN (F) 📢 Someone Reported This

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

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

Infection Control (Tag F0880)

Could have caused harm · This affected most or all residents

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Hand washing was not provided for residents prior to meals. In addition, a bloody bandage was found on the floor in a resident room. These were random opportunities for discovery and have the potential to affect more than an isolated number of residents who reside at the facility. Facility census: 115. Findings included: a) Observation of the morning meal on 08/01/23 At 8:07 AM on 08/01/23, observation of the morning meal being served on the long hall of the North wing found staff provided no hand hygiene prior to the meal. Nursing assistants (NA's) #75 and #14 as well as Licensed Practical Nurse (LPN) #52 stated they have no means to sanitize the Resident's hands. The staff members stated hand wipes were once on the trays with the meals but the kitchen quit sending wipes. One staff member stated, We were cited for this before and the fix was for the kitchen staff to put individual hand wipes on the trays. They did that for a while and then quit. At 10:15 AM on 08/01/23, the above observation was presented to the Infection Preventionist (IP) #56. IP #56 stated there was a period of time they used the individual wipes but they became hard to get. IP #56 said, We then got the packs of hand wipes and they are supposed to be on the drink carts. The IP said hand hygiene audits are done daily and she isn't aware of any problems. At 3:41 PM on 08/01/23, the above observations were discussed with the administrator. She stated the staff have hand sanitizer available and wipes on the carts she doesn't know why they were not being used. b) room [ROOM NUMBER] At 8:40 AM on 08/02/23, a bloody soiled bandage approximately 4 inches by 4 inches was found on the floor beside bed B in room [ROOM NUMBER]. Nurse Aide (NA) #9 was present in the resident's room feeding breakfast to the Resident. She said she did not know where the bandage came from. She donned a pair of gloves and placed the bandage in the trash can in the resident's room. At approximately 10:00 AM on 08/02/23, the Director of Nursing (DON) said a nurse did a dressing change earlier in the morning and must have dropped the bandage on the floor.

CONCERN (F) 📢 Someone Reported This

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

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

Safe Environment (Tag F0921)

Could have caused harm · This affected most or all residents

Read full inspector narrative →

Based on observation, resident interview, and staff interview, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff and the public. The carpet in the hallways and the activity room was heavily soiled. This had the potential to affect all residents at the facility. Facility census: 115. Findings included: a) Observation of the Carpet At approximately 10:00 AM on 08/01/23, observation of the carpet on North hallway long and short hall and South hallway long hallway with the Environmental Services Director (ESD) #101 found the following: The carpet on the North side of the facility was heavily soiled. Many large black spots, some as big as dinner plates were present on the carpet on the North side of the building. Long streaks of black marks extended the length of the carpet on the hallway. The carpet at the entrances to each resident room was gray in color and heavily stained. The carpeted area around the north nurses was soiled and littered with paper and food debris. The carpet was a black/gray color outside the doorway of the north short hall utility room. The activity room carpet was heavily soiled with a large black spot, bigger than a dinner plate, beside a step on set of scales. Numerous other black/gray spots littered the carpet in the activity room. The carpet at the doorway leading outside to the pavilion was heavily soiled. The carpet on the South side of the building had several small black rings about the size of a saucer. The carpet was heavily soiled outside the doors of the utility rooms on the South side of the facility. ESS #101 said he was new to the facility. ESS #101 said he had discovered the carpet had been cleaned with the wrong cleaning solution for 13 years. ESS #101 said his mission was to get the carpet cleaned and he started last week on the South side of the building. He stated some of the spots would probably never come up. He pulled a pocket knife from his pocket and scraped a red substance from the carpet at the entrance to the double door on the South side. ESS #101 said four (4) of his employees quit about three (3) weeks ago and he was in the process of hiring more staff. He said the long black marks on the carpet were from the wheels of the wheelchairs. He said it was hard to clean when you could not work at night because the carpet machines disturb sleeping residents. ESS #101 said, During the day time, you can't get the carpet dried before someone runs through it again. He said he thought it would be in the best interest of the facility to just tear up the carpet because it was many years old. At 3:10 PM on 08/01/23 the above observations were discussed with the administrator. She stated she was aware the carpet needed cleaned. On the afternoon of 08/01/23, the district manager and ESS #101 were observed cleaning the carpet on the North side of the facility. During the Resident council meeting, requested by the residents, held at 10:00 AM on 08/02/23, the resident's complained about the dirty carpet, at the facility.

Mar 2023 31 deficiencies

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 record review and resident interviews, the facility failed to ensure residents had the right to make choices about aspects of their life in the facility that are significant to the resident for two (2) of five (5) residents reviewed for the category of choices, during the long term care survey. Resident identifier #31 and #20. Census 115. Findings Included: a) Resident #31 On 03/20/23 at 10:58 AM, during a resident interview, Resident #31 stated she does not get enough showers, her family comes in to wash her because she does not get cleaned enough by the staff. Electronic record review of the Bathing Task on 03/21/23, indicated in the last 30 days the resident only received four (4) showers and zero (0) bed baths. The Bathing Task also documented the resident refused eight (8) times. The resident's care plan indicated she requires extensive to total assistance for showers, however it does not indicate her preferences for bathing/showering. In the afternoon of 03/21/23 this information was reviewed with the Infection Preventionist and not further information was provided prior to the end of the survey. b) Resident #20 On 03/20/23 at 10:45 AM during a resident interview, the resident stated, We don't get showers like we are supposed to. The resident stated she was never asked her preferences of bed bath vs shower or how many showers she prefers weekly. Electronic record review on 03/22/2023 of the resident's Bathing Task for the last 30 days, indicated the resident had zero (0) showers, 10 bed baths, and zero (0) refusals. The resident does not have a bathing care plan in place that would indicate her preferences. In the afternoon of 03/21/23 this information was reviewed with the Infection Preventionist and not further information was provided prior to the end of the survey. .

CONCERN (D)

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

Abuse Prevention Policies (Tag F0607)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

Based on resident interview, staff interview and record review the facility failed to implement their abuse and neglect policy. This is true for one (1) of two (2) residents reviewed for abuse. Resident Identifier: #10 Facility Census: 115 Findings Included: a) Resident #10 On 3/20/23 at 2:53 PM, Resident #10 stated she hears staff in the hall way talking about her and laughing at her. She says one staff member is hateful to her and talks mean to her. She was crying while talking to this surveyor and upset because she feels Certified Nurse Aid (CNA) #35 is mean to her and is trying to turn others against her. Resident #10 is unable to care for or protect herself due to physical disabilities. During a record review it was found on 11/08/22 at 4:00 PM a grievance was filed by this Resident against CNA #35 for not being nice to her, and the Resident felt like a prisoner in her room, that her stuff just kept getting pushed further to the side. She states CNA #35 and the room mate were laughing at her and she is turning other CNAs against her. The facility Abuse Prohibition Policy revision date 10/24/22 states .centers prohibit abuse, mistreatment, neglect, misappropriation of resident/patient property, and exploitation for all patients Abuse is defined as .wilful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, injury or mental anguish Verbal Abuse is . any use of oral, written, or gestured language that wilfully includes disparaging and derogatory terms to patients or their families . .if the event the alleged allegations do not involve abuse and do not result in a serious bodily injury, report to the State Survey Agency and adult protective services no later than 24 hours after the allegations are known . During a staff interview with Social Worker #95 on 3/22/23 at 10:09 AM, she agreed the above grievance should have been reported to the appropriate state agencies. She reported this allegation on 3/22/23.

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 resident interview, staff interview and record review the facility failed to report an alleged violation of abuse and/or neglect. This is true for two (2) of two (2) residents reviewed for abuse. Resident Identifier: #10 and #64 Facility Census: 115 Findings Included: a) Resident #10 On 3/20/23 at 2:53 PM Resident #10 stated she hears staff in the hall way talking about her and laughing at her. She says one staff member is hateful to her and talks mean to her. She was crying while talking to this surveyor and upset because she feels Certified Nurse Aid (CNA) #35 is mean to her and is trying to turn others against her. Resident #10 is unable to care for or protect herself due to physical disabilities. During a record review it was found on 11/08/22 at 4:00 PM a grievance was filed by this Resident against CNA #35 for not being nice to her, and the Resident felt like a prisoner in her room, that her stuff just kept getting pushed further to the side. She states CNA #35 and the room mate were laughing at her and CNA #35 is turning other CNAs against her. The facility Abuse Prohibition Policy revision date 10/24/22 states .centers prohibit abuse, mistreatment, neglect, misappropriation of resident/patient property, and exploitation for all patients Abuse is defined as .wilful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, injury or mental anguish Verbal Abuse is . any use of oral, written, or gestured language that wilfully includes disparaging and derogatory terms to patients or their families . During a staff interview with Social Worker #95 on 3/22/23 at 10:09 AM, she agreed the above grievance should have been reported to the appropriate state agencies. She reported the allegations on 03/22/23 after surveyor intervention. b) Resident #64 A review of Resident #64's medical record found the following incident which occurred on 01/01/23. The nursing description of the incident read as follows, Resident came out of her room after being assisted to bed. The resident had blood on her hands. Took her to the bathroom to wash her hands and look for source. Small laceration less than an inch to the left underside of her chin. Pressure applied to stop bleeding. Glue steri strip liquid used once bleeding had stopped. VS (vital signs) obtained. (Name of physician group) notified. Orders obtained to transfer to ER (emergency room). Resident stated, She doesn't know what happened that she, hit my face. A review of the reportable incidents for the month of 01/2023 found no indication this incident had been reported. An interview with Social Worker #14 on 03/22/23 at 3:42 PM confirmed this incident was not reported to appropriate state agencies as required. She stated, we are reporting it now.

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 record review and staff interview the facility failed to do a complete and thorough investigation related to fall resulting in a major injury. This failed practice was true for 0ne (1) out of three (3) reviewed for falls. Resident identified: Resident #51. Facility census 115. Findings included: a) Resident #51 A review of the medical record for Resident #51, found the resident had five fractures on 11/25/22. Resident #51 is 82-years-old, is bed bound (she does not walk or use a wheelchair), and required the use of a mechanical lift for transfers. The following notes were found in the medical record related to Resident #51's injuries and pain: -- Nurse Practitioner (PN)Note dated 11/21/22. Chief complaint: Left hip pain. History of present illness: Seen for complaints of left hip pain. Patient reported this to staff today. She has dementia but able to answer some questions. There have been no falls or injuries per staff. resident points to lateral aspect of left hip and describing pain and difficultly straightening out her leg. Also having pain with movement. She did yell out when being turned in bed. Currently has Acetaminophen 650 mg. twice a day ordered. New order: X-ray of left hip and left femur. -- Nursing Note: Dated 11/21/22: Change of condition: Resident #51 of pain with ROM (Range of Motion) orders for X-ray of left hip and femur. -- Nursing Note: Dated: 11/22/22. Follow-up Left hip and left femur pain. -- Nursing Note: Dated: 11/23/22: Complaint of left hip and left femur pain. Physical behavior directed towards others occur up to five (5) days a week. Rejection of care for five (5) days. --Nursing Note: Dated: 11/24/22: Nurse called in to Resident #51's room due to MPOA (Medical Power of Attorney) having concerns that resident #51 has fallen today going to the shower. It was explained that Resident #51 did not have a shower today and there were no reports of her falling, per staff. Last shower was 11/18/22. -- Nursing Note: Dated: 11/25/22: Son was called. Son stated Resident #51 had reported to him she had fallen after a shower. Reported to son Resident had not been showered since 11/18/22. There were no fall notes at that time or since then. Resident was noted with complaints of pain. NP to reevaluate due to complaints of pain in the sacrum area. -- Nurse Practitioner Note: Dated: 11/25/22. Seen Resident for left hip pain improved but had new complaint of pain of the sacral area. X-ray showed Sacral Fracture. Facility doctor notified and ordered Resident #51 to be sent to a local hospital for MRI (Magnetic Resonance Imaging). The MRI the following fractures: Left Superior Ramus Left Inferior Ramus Left Hemi sacrum. Left Greater Trochanteric Left Intertrochanteric -- Nursing Note: Dated: 11/28/22. Resident had a fall with fractures. Nurse Aide (NA) was transferring Resident #51 from shower chair to bed. NA said Resident started to fall NA and Resident went down to the floor. NA received a final written warning for not reporting a fall immediately. On a facility form titled, APS Mandated Reporting Form the following was written: Date form completed: 11/25/22. Resident told family she had fallen, 11/24/22 Unknown time. Question how long has problem existed? Unknown Resident started complaining of pain on 11/21/22. Contained with the investigation was the following witness statements from staff: -- Witness statements: Dated: 11/27/22. Licensed Practical Nurse #4 wrote: On 11/21/22, Resident complained of left hip and left femur pain with ROM. I completed a Change of Condition. The NP and I went into resident's room to evaluate resident. NP ordered stat X-rays of left hip and left femur. X-ray was obtained and indicated osteoarthritic changes. On 11/22/22 a NA reported Residents roommate reported to her, that a NA dropped Resident #51 during Resident #51's shower day. I reported what the roommate said. At no point in time did any NA report that Resident #51 fell during her shower day. -- Witness statement dated: 11/27/22 Registered Nurse #6 wrote: On November 27th, 2022, I interviewed roommate of Resident related to possible fall. Roommate stated that on the Tuesday before Thanksgiving a little blonde NA attempted to transfer Resident by herself from the shower chair and dropped her on the floor. Roommate stated she thought Resident landed on her bottom but wasn't positive. Stated NA went and got help. She thought it was a nurse because she heard her say, she thought Resident was ok and they put her back to bed. -- Witness statement dated: 11/26/22 NA #121 wrote: Came on shift that night, I do believe this took place Tuesday Nov. 22. Went to change Resident and she yelled out in pain when I tried to turn her to her left side. She was crying. Resident's roommate said the girls that showered her earlier that day dropped her on the floor when trying to get her back in bed. Immediately reported to my shift nurse on the hallway that night. -- Witness statement dated: 11/28/22. NA #100 wrote (typed as written): I did not report it. I felt so bad. I should have reported it when it happened. We both fell. I did get her back in bed. I did not know it was as serve till a week later. It was my second time having her. I am not familiar with her care plan. Was getting her into bed. Had her stand up she lost her balance. I grabbed her we both fell to the ground. That is when I got her into the bed and had help pull her in the bed. I was so scared it happened. I was shaking. On 03/23/23 at 11:24 AM, Social Worked (SW) #95 said she did not include in her investigation Resident # 51 was to be transferred with a lift only which requires two people. The investigation did not include the fact Resident #51 had contratures to the Left knee and the left and right ankle which would make it very difficult and painful for her to stand. The facility also failed to include in their investigations all the missed opportunities to report this accident to obtain medical treatment for Resident #51. It was not reported by the NA #100 when it happened it was 10 days later when she reported it. It was reported to the unit nurse the night after the accident by NA#121. There was not a schedule or assignment sheet included in the investigation, to see who that nurse was It was not reported when the roommate reported the incident to a NA and the NA reported to the nurse on duty. There was not an investigation started when the MPOA reported his mother said she was dropped. On 03/23/23 at 9:10 AM, Director of Nursing (DON) was asked if the facility had determined who the staff were that needed re-education on when to report any and all allegations? DON said she would look for the re-education sign in sheets. At the close of this survey the facility could not provide the documents for NA #100 Receiving a written warning and re-education.

CONCERN (D)

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

Transfer Requirements (Tag F0622)

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 ensure the ombudsman was notified when a resident required transfer to the hospital. This deficient practice had the potential to affect one (1) of five (5) residents reviewed for the care area of hospitalization. Resident identifier: #88. Facility census: 115. Findings included. a) Resident #88 Review of Resident' #88's medical records showed the resident required transfer to the hospital on [DATE]. On 03/22/23 at 10:54 AM, the Director of Admissions provided a list of the residents she had provided to the ombudsman by e-mail at the end of January. The list was of residents who had required transfer to the hospital in the month of January. Resident #88 was not on this list. The Director of Admissions acknowledged Resident #88 was not on this list but should have been. No further information was provided through the completion of the survey.

CONCERN (D)

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 →

Based on resident interview, staff interview, Policy review and record review the facility failed to provide an ongoing resident centered activities program. This was true for two (2) of four (4) residents reviewed for activities. Resident Identifiers: #1 and #17. Facility Census: 115 Findings Included: a) Resident #1 On 3/20/23 at 1:34 PM Resident #1 states there is nothing to do except lay in bed all day. This resident has a Brief Interview for Mental Status (BIMS) of 15 and states I like people. The Resident states she wants to get out and do things with other people, socialize, play Bingo, etc. Record review on 3/22/23 at 10:26 AM of the February and March activity logs shows all her activities have been independent. meaning she has done them alone in her room. Activities of participation shows movies/TV, relaxing/looking out the window/resting/thinking, talking on the phone/sending cards/ mail and walking. On 3/22/23 at 10:28 AM during an interview with the Recreation Director# 54, she confirmed on been the Recreation Director for six (6) weeks, and she is still gathering documentation and information from residents. She will speak to the resident and update her likes/dislikes including the care plan as her preferences may have changed. Record review of the care plan finds Resident #1's interest are as follows: Likes going out to eat and enjoys sitting and talking. Likes to talk with others. Prefers to dine in Dining room, café or her room. Likes to participate in bingo, church, and going out to eat with groups of people. Doing favorite activities: reading the bible/bible lessons, going out to eat, bingo, spending time with family, socials, and watching TV Participating in religious services or practices Encourage and facilitate her activity preferences Provide in room visits and offer supplies. Having reading materials: likes to read bible and work word search books Keeping up with the news: watches the news on TV Likes to do lay down/rest, think, watch TV/movies, herself in her bedroom, common spaces, outdoors Enjoys watching/listening TV. Going outside for fresh air in good weather. It is important for her to vote. The care plan identifies the residents interest but the facility has failed to include this resident in the activities which are important to her. According to the facility Recreation Services Policies and Procedures with a revision date of 4/01/18 the department will create opportunities for each person to have a meaningful life by supporting his/her domains of wellness; identity, growth, autonomy, security, connectedness, meaning, and joy. They will provide an ongoing person-centered recreation program that incorporates the individual's interest hobbies, and cultural preferences which are integral to maintaining and improving a resident's/patient's physical, mental, and psychosocial well being and independence. b) Resident #17 On 3/21/23 at 11:48 AM Resident #17 states he does nothing except lay in his room recently. I love to play Bingo but no one gets me up to go down to play. I use to go to the dining room for meals and they don't get me up for that either. This resident has a Brief Interview for Mental Status (BIMS) of 15 and states I like to get up daily and go out of my room and visit people. Record review on 3/22/23 at 10:26 AM of the February and March activity logs shows all his activities have been independent. meaning he has done them alone in his room. Activities of participation shows cat/mechanical (Resident states he has no idea what that even means), computer/Tablet, current events/news, household chores/movies/TV, relaxing/looking out the window/resting/thinking, talking on the phone/sending cards/ mail. Documentation shows he was at Bingo only three (3) times in two (2) months. On 3/22/23 10:28 AM during an interview with Recreation Director# 54, she stated she has only been there six (6) weeks, and she is still gathering documentation and information from residents. She will speak to the resident and update his likes/dislikes, including the care plan as his preferences may have changed. Record review of the care plan finds Resident #17's interest are as follows: While in the facility, resident/patient states that it is important that she/he has the opportunity to engage in daily routines that are meaningful relative to their preferences. Resident will have opportunities to make decisions choices related to/for self-directed involvement in meaningful activities Encourage and facilitate residents/patients activity preferences (select all that apply per Recreation Assessment) I like to participate with groups of people. It is important for me to have reading materials I enjoy listening to music and prefer country, metal, rock I would like pet visits I like to use a computer, do crosswords/puzzles/games, listen to music, look out the window, lay down/rest, meditate, pray, read, think, watch TV/movies, by myself in my bedroom, common spaces, outdoors I enjoy watching/listening TV. It is important for me to engage in my favorite activities 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. According to the facility Recreation Services Policies and Procedures with a revision date of 4/01/18 the department will create opportunities for each person to have a meaningful life by supporting his/her domains of wellness; identity, growth, autonomy, security, connectedness, meaning, and joy. They will provide an ongoing person-centered recreation program that incorporates the individual's interest hobbies, and cultural preferences which are integral to maintaining and improving a resident's/patient's physical, mental, and psychosocial well being and independence.

CONCERN (D)

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

Deficiency F0743 (Tag F0743)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

The facility failed to address a resident's complaints of increased anger and anxiety for one (1) of five (5) residents reviewed for behavior/mood, in the long term care survey. Resident Identifier #103. Census 115. Findings Included: a) Resident Identifier #103 During a resident interview on 03/20/23 at 11:29 AM, Resident #103 stated he stays angry and feels like he needs something for his nerves. He state he takes something for depression but he needs a nerve pill. He says he does not see anyone for psychological services at this time. A review of Resident #103's record found he has not had any psychological services since 10/10/22. Neither psychological consultation discusses the resident's increased anger or anxiety, only depression. On 03/21/23 at 10:51 AM, an interview with Social Worker (SW) #95 was conducted. SW stated the psychological group consults come to the social workers via email and they print them out. SW #95 stated the social workers keep copies of the consults in a folder and give a copy to medical records to be scanned into the chart under consults. SW #95 says she cannot find any consults in her file for this resident. I don't see where he's seen him recently. He's on the list for next visit but I don't have a date set yet. SW #95 stated the psychological group comes every other week normally or at least monthly. Surveyor requested copies of any psych consults resident has had since he's been at the facility. At 11:15 AM on 03/2/1/23 SW #95 provided copies of two (2) consults with the psychological group dated 09/21/22 and 10/10/22. Record review indicates the resident has nothing ordered for Anxiety, no notes about his increased anger and anxiety, nor any follow up from the psychological group since 10/10/22. The resident does not have an anxiety diagnosis at this time.

CONCERN (D)

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

Deficiency F0745 (Tag F0745)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

The facility failed to ensure their social services provided or arranged consistent psychological intervention for one (1) of five (5) residents reviewed for the category of behavior/mood, in the long term care survey. Resident Identifier: #103. Facility Census: 115. Findings Included: a) Resident Identifier #103 Resident interview on 03/20/2023 at 11:29 AM, found the resident stating he stays angry and feels like he needs something for his nerves. He states he takes something for depression but he needs a nerve pill. He says he does not see anyone for psychological services at this time. A review of Resident #103's medical record on 03/22/22, indicated he has not had any psychological services since 10/10/22. Consults from a psychological group were found for the dates of 09/21/22 and 10/10/22. Neither consult indicates the termination of their services with the resident. Further review of the record found the resident has a history or a suicide attempt. The resident's psychosocial distress care plan indicated behavioral health services will be provided as an intervention. The resident's most recent Minimum Data Set, section D, indicated he had been feeling down and hopeless seven (7) to 11 days in a two (2) week look back period. On 03/21/23 at 10:51 AM, an interview with Social Worker (SW) #95 was conducted. SW stated the psychological group consults come to the social workers via email and they print them out. SW #95 stated the social workers keep copies of the consults in a folder and give a copy to medical records to be scanned into the chart under consults. SW #95 says she cannot find any consults in her file for this resident. I don't see where he's seen him recently. He's on the list for next visit but I don't have a date set yet. SW #95 states that the psychological group comes every other week normally or at least monthly. Surveyor requested copies of any psych consults resident has had since he's been at the facility. At 11:15 AM SW #95 provided copies of two (2) consults with the psychological group dated 09/21/22 and 10/10/22.

CONCERN (D)

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

Drug Regimen Review (Tag F0756)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

Based on record review and staff interview, the facility failed to ensure the drug regimen of each resident was reviewed at least once a month by a licensed pharmacist. This deficient practice has the potential to affect one (1) of five (5) residents reviewed for the care area of unnecessary medications. Resident identifier: #28. Facility census: 115. Findings included: a) Resident #28 Resident #28's medical records contained no documentation the resident's drug regimen was reviewed by a licensed pharmacist during the month of February 2023. During an interview on 03/22/23 at 10:29 AM, the Director of Nursing (DON) stated she was unable to locate any documentation that Resident #28's drug regimen had been reviewed by a licensed pharmacist in February 2023. No further information was provided through the completion of the survey process.

CONCERN (D)

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

Deficiency F0761 (Tag F0761)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

Based on observation, staff interview and record review the facility failed to ensure storage of medications within accepted principles of practice. This was a random opportunity for discovery had the potential to affect a limited number of residents. Residents identifier: Resident #75 and #217. Facility census 115. Findings included: a) Medication Pass observation On 03/21/23 at 8:12 AM, Licensed Practical Nurse (LPN) #94 was present during an observation of the mediation cart on the south end. LPN #94 verified there two (2) medication cups with medication in them in the top drawer. The medication cups had room numbers on them. -- The cup labeled 41-b belonged to Resident #75. This cup contained Gabapentin, Loratadine, Seroquel, Sennoside Docusate, Baproplia, Amitriptyline, Acetaminophen -- The second cup was labeled 39-A, belonging to Resident #217. The cup contained crushed medications the MAR was checked off for the following as being given: Famotidine, Lorazepam, Memantine HCL, Sennosides Docusate, Zonlsamide On 03/21/23 at 8:20 AM, Director of Nursing (DON) was notified of the above findings and provided no further information.

CONCERN (D)

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

Deficiency F0775 (Tag F0775)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

Based on record review and staff interview, the facility failed to have laboratory reports filed in the resident ' s clinical record. This deficient practice had the potential to affect one (1) of five (5) residents reviewed for the care area of unnecessary medications. Resident identifier: #28. Facility census: 115. Findings included: a) Resident #28 Review of Resident #28's physician's orders showed orders for the following laboratory testing every September and March: basic metabolic panel (BMP), thyroid stimulating hormone (TSH), fasting liver panel, and hemoglobin A1C (HbA1C). Results for HbA1C testing in September 2022 were not located in the resident's clinical record. Additionally, Resident #28 had an order for complete blood count (CBC) laboratory testing every March, June, September, and December. Results for CBC testing for December 2022 were not located in the resident's clinical record. On 03/22/23 at 10:40 AM, the Director of Nursing (DON) provided testing reports for Resident #28's HbA1C testing in September 2022 and CBC testing in December 2022. The reports did not have the physician's signature or initial to indicate the test results had been reviewed by the physician. The DON acknowledged she had obtained the laboratory results from the laboratory portal and the results had not been contained in the resident's medical record. No further information was provided through the completion of the survey process.

CONCERN (D)

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

Dental Services (Tag F0791)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, record review and staff interview the facility failed to provide dental care in a timely manner. This was true for one (1) of two (2) residents reviewed for the dental care area. Resident Identifier: #111 Facility Census: 115 Findings Included: a) Resident #111 On 3/20/23 at 1:40 PM, Resident #111 stated to this surveyor he has two (2) rotten teeth which need to be cut out. He states the staff keep just telling him you are on the list. This causes him pain and he takes Tylenol for the pain and it does help. He rates his pain at 2-3 on a scale of 1-10. According to an oral health evaluation completed by the facility on 1/26/23 his natural teeth had four (4) or more decayed or broken teeth/roots. During an interview with the Director of Nursing on 3/21/23 at 11:52 AM, she confirmed he had rotten teeth. He was admitted on [DATE] and the in house dental service had not seen him yet. She does not know when the in house dental service will be there to provide the needed services. She made him an appointment with a local Dentist for 3/27/23, the facility will transport the Resident to the dental appointment .

CONCERN (E)

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

Deficiency F0578 (Tag F0578)

Could have caused harm · This affected multiple residents

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 ensure three (3) of 37 residents reviewed during the long-term care survey process had a the right to request, refuse and or discontinue treatment and to formulate an advanced directive. A Physician Order for Scope of Treatment Form (POST Form) was not completed to Honor a resident's decision to refuse documented, directives of life sustaining wishes. The POST forms were unsigned by the Resident or Medical Power of Attorney (MPOA), A POST form was not updated when a Resident regained capacity. Resident identifiers: Resident #267, #25 and #103. Facility census: 115. Findings Included: a) Resident #267 A medical record review on [DATE] at 2:48 PM found Resident #267's had a POST form with the following directives: --Section A Cardiopulmonary Resuscitation Order. Attempt Resuscitation, including mechanical ventilation, defibrillation, and cardioversion. --Section B Initial Treatment Orders. Full treatments, goal the attempt to sustain life by all medically effective means. --Section D Medically Assistive Nutrition. Provide feeding through new or existing surgically placed tubes. Continued medial recorded review for Resident #267's revealed a State of [NAME] Virginia combined Medical Power of Attorney and Living Will dated [DATE] with the special Directives or limitations on this Power: --If there is no chance of recovery- do not use aggressive treatment. --No feeding tubes. --No breathing tube, Do Not Resuscitate. --No CPR. --No heart Electroshock. --Do not want to be kept alive by artificial or extraordinary means. A subsequent review of Resident #267's active diagnoses revealed, Dementia and Parkinson's Disease. During an interview on [DATE] at the 8:55 AM Director of Nursing (DON) verified there was a difference in the residents documented Living will and the active POST form. On [DATE] at 2:17 PM during an interview the Nurse Practioner #121 stated a new POST form was completed this date with the Residents living will directives. b) Resident Identifier # 25 On [DATE] at 3:22 PM, electronic record review found a Physician's Order of Scope of Treatment (POST) form dated [DATE] which was not signed by the patient or patient's representative under section D. During an interview with the Assistant Director of Nursing (ADON) #92 at 8:32 am on [DATE], the ADON reviewed paper chart and presented the same POST form without a signature. The ADON confirmed it was not signed and stated this is the most current POST form she has for this resident. c) Resident Identifier # 103 Record review on [DATE] revealed a POST form signed by the resident's mother on [DATE]. On [DATE] at 10:07 AM a staff interview with ADON #95 confirmed that the POST form dated [DATE] was the recent POST form they had on file and it was signed by the resident's mother and had not been reviewed or updated with the resident since he had regained capacity. Per Electronic Record review on [DATE], a Physician Determination of Capacity dated [DATE], indicates, .Determination of Capacity: Demonstrates CAPACITY to make medical decisions . This was completed by a physician at the hospital and presented to this facility with his admission records. Further review of the record found another Physician Determination of Capacity dated [DATE] by facility medical director which read, .In my opinion this patient HAS sufficient mental or physical capacity to appreciate the nature and implications of health care decisions . .

CONCERN (E)

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

Safe Environment (Tag F0584)

Could have caused harm · This affected multiple residents

Read full inspector narrative →

Based on Observation, anonymous resident interviews, and Resident council meeting, documentation, and staff interview the facility failed to ensure a safe, clean, comfortable, homelike environment. Water temperatures were at a comfortable temperature, also there were holes in the shower floor, and a black substance on the shower wall. This failed practice has the potential to affect more than isolated number of residents. Facility census 115. Findings included: a) Comfortable water temperature On 03/20/23 at 2:52 PM, there were many residents during the initial interview process who complained about the temperature of the water for showering. These residents said it did not matter what time of day it was at best the water felt lukewarm and on cold days the water feels colder. A Resident council meeting was on held with the residents 03/21/23 at 2:00 PM, there were eight (8) residents in attendance. The residents were very boisterous about the water temperature not being warm enough to be comfortable. During an interview on 03/21/23 at 4:13 PM, Maintenance Director (MD) was asked if there was a problem with the hot water. MD said there are two (2) hot water tanks, one (1) holds 100 gallons and the other one (1) hold 65 gallons. MD was asked if one of the hot water tanks were just for the kitchen, or laundry? MD said both hot water tanks run to the whole facility, none were designated to any one place, both supply water to Kitchen, Laundry, and resident areas. He confirmed the facility runs out of hot water often. On 03/22/23 at 9:25 AM, MD checked the water temperature in the employee bathroom sink after 6 minutes of running the highest temperature was 94 degrees. Research on the amount of hot water used for commercial size dishwasher and washing machine: sources from; maytagcommerciallaundry.com; Appliance Standards Awareness Project, https://appiance-standards.org; Allianceforwaterefficiency.org found the following, The average Commercial Dishwasher uses between 20 to 33 gallons per rack (GPR) (one rack of dishes are loaded into the dishwasher at a time). On 03/23/23 at 9:59 AM, an interview with dietary aide #78 found the dishwasher is used all day and normally we will wash 25-30 rack after each meal. The average commercial washing machine uses 41 gallons of water per load. On 03/23/23 at 10:03 AM, an interview with Manager in training #66 said the laundry staff have washed 10 loads using the large washer so far today. He went on to say by the end of the day normally they do a total of 30 large loads and the small washer has run 3 loads today. On 03/23/23 at 11:00 AM, the Administrator was asked about the water temperatures and the residents complaining about the temperature of the water not being at a comfortable level. The Administrator said she was not aware any of the residents were not happy about the water temperatures. She went on to say one (1) time a resident complained about the temperature, and she had MD go right away and check the temperature and it was within range. Administrator was informed about all of the residents complaining during individual interviews and during resident council meetings. During a look back at previous annual and complaint surveys at the facility it was discovered the facility had received citations about the water being too cold and not comfortable water temperatures before. b) Shower room On 03/22/23 at 9:37 AM, during a tour of the shower room with the MD, the following issues were found : -- There were openings on the floor which enabled water to be able to get under the flooring. MD said the flooring was replaced about three (3) years ago. MD said water most likely does get under the flooring. -- There was also a black substance along the bottom of the shower wall. MD ran his finger over the black substance and got the substance on his finger.

CONCERN (E)

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

Assessment Accuracy (Tag F0641)

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 complete and accurate Minimum Data Set (MDS) assessments for three (3) of 37 residents reviewed in the long-term care survey sample. Resident identifiers: #88, #47, and #103. Facility census: 115. Findings included: a) Resident #88 Resident #88's Minimum Data Set (MDS) assessment with Assessment Reference Date (ARD) 02/23/23 showed the resident had received no antibiotics during the seven (7) day look back period. Review of Resident #88's Medication Administration Record (MAR) for February 2023 showed the resident had received the antibiotic piperacillin/taxobactam intravenously 02/17/23 through 02/22/23. During an interview on 03/22/23 at 10:53 AM, the Clinical Reimbursement Coordinator confirmed Resident #88's MDS assessment with ARD 02/23/23 was incorrect and should have indicated the resident received six (6) days of antibiotic during the look back period. b) Resident # 47 A record review of the quarterly MDS which was completed in February 2023 indicated Resident #47 had not received any dialysis during the look back period. Resident #47's medical recorded indicated the resident went to dialysis on Tuesdays, Thursdays and Saturdays every beginning 01/17/23. An interview with Resident # 47 on 03/20/23 at 10:24 AM confirmed she does in fact go to dialysis on Tuesdays, Thursdays, and Saturdays. On 03/21/23 at 1:12 PM the Coordinator for Clinical Reimbursement confirmed dialysis was not captured on this MDS and should have been. c) Resident Identifier #103 Electronic Medical Record review on 03/21/23 indicated the resident saw a consulting psychological group on 09/21/22 and 10/10/22. Both of these consultation reports stated, .Diagnosis: Depression, Unspecified . These consultation reports were from a Licensed Psychologist. Electronic Medical Record Review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) 03/01/23, section I Depression (not Bipolar) is marked no. On 03/23/23 at 9:59 AM staff interview with MDS Coordinator #90, confirmed they made a mistake on the Quarterly MDS ARD 03/01/2023, Section I. The facility did not capture the resident's diagnosis of depression, unspecified given by Psychologist on 09/21/22. MDS Coordinator #90 to correct this mistake.

CONCERN (E)

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

Comprehensive Care Plan (Tag F0656)

Could have caused harm · This affected multiple residents

Read full inspector narrative →

Based on observation, record review, staff interview, and resident interview the facility failed to develop and or implement a comprehensive care plan for five (5) of 37 sampled residents. Resident Identifiers: #64, #96, #1, #17, and #20. Facility Census: 115. Findings Included: a) Resident #64 An observation of Resident #64 during the noon time meal on 03/20/23 and 03/21/23 found the resident was served her meal in a Styrofoam container and had plastic utensils to eat with. All other residents were not served on Styrofoam. An interview with the Director of Nursing (DON) on 03/23/23 at 8:51 am found Resident #64 is served on Styrofoam with plastic utensils because she has tried to stab the nurses with a fork so they put this intervention in place as a result of the behavior. The DON referred to a physicians order dated 01/31/23 which read as follows, feed assist as resident will allow. Please put meal in Styrofoam. no metal utensils. The DON was asked to review Resident #64's care plan to determine if this intervention had ever been added to the comprehensive care plan. After reading through the care plan the DON stated, It is not on there we will get it added. b) Resident #96 A review of Resident #96's medical record revealed an incident which occurred on 12/26/22. The nursing description of the incident read as follows, CNA reported to the nurse that resident had drank her shampoo and conditioner. About 15 ml combined ingested. Further review of the record found the resident was sent to the emergency room as suggested by poison control. During and interview with the Director of Nursing (DON) at 8:51 am on 03/23/23 she was asked what interventions they put into place to ensure this does not happen again? She reviewed the chart and stated we educated the nursing staff to ensure personal hygiene items are stored appropriately. She was then asked to review the care plan to determine if this intervention was on the care plan. After she reviewed the care plan she confirmed this intervention was not on the care plan and would need to be added. c) Resident #1 On 3/20/23 at 1:34 PM Resident #1 stated there is nothing to do except lay in bed all day. This resident has a Brief Interview for Mental Status (BIMS) of fifteen (15) and states I like people. The Resident states she wants to get out and do things with other people, socialize, play Bingo, etc. Record review on 3/22/23 at 10:26 AM, of the February and March activity logs found all her activities have been independent. meaning she has done them alone in her room. Activities of participation shows movies/TV, relaxing/looking out the window/resting/thinking, talking on the phone/sending cards/ mail and walking. On 3/22/23 10:28 AM , during an interview with Recreation Director# 54, she stated she has only been at the facility six (6) weeks, and she is still gathering documentation and information from residents. She will speak to the resident and update her likes/dislikes. Record review of the care plan finds Resident #1's interest are as follows: - Likes going out to eat and enjoys sitting and talking. - Likes to talk with others. - Prefers to dine in Dining room, café or her room. - Likes to participate in bingo, church, and going out to eat with groups of people. - Doing favorite activities: reading the bible/bible lessons, going out to eat, bingo, spending time with family, socials, and watching TV - Participating in religious services or practices - Encourage and facilitate her activity preferences - Provide in room visits and offer supplies. - Having reading materials: likes to read bible and work word search books - Keeping up with the news: watches the news on TV - Likes to do lay down/rest, think, watch TV/movies, herself in her bedroom, common spaces, outdoors - Enjoys watching/listening TV. - Going outside for fresh air in good weather. - It is important for her to vote. These interests were not represented in the activity participation logs and were not implemented in there residents activity program. According to the facility Recreation Services Policies and Procedures with a revision date of 4/01/18 the department will create opportunities for each person to have a meaningful life by supporting his/her domains of wellness; identity, growth, autonomy, security, connectedness, meaning, and joy. They will provide an ongoing person-centered recreation program that incorporates the individual's interest hobbies, and cultural preferences which are integral to maintaining and improving a resident's/patient's physical, mental, and psychosocial well being and independence. d) Resident #17 On 3/21/23 at 11:48 AM Resident #17 states he does nothing except lay in his room recently. I love to play Bingo but no one gets me up to go down to play. I use to go to the dining room for meals and they don't get me up for that either. This resident has a Brief Interview for Mental Status (BIMS) of fifteen (15) and states I like to get up daily and go out of my room and visit people. Record review on 3/22/23 at 10:26 AM of the February and March activity logs shows all his activities have been independent. meaning he has done them alone in his room. Activities of participation shows cat/mechanical (Resident states he has no idea what that even means), computer/Tablet, current events/news, household chores/movies/TV, relaxing/looking out the window/resting/thinking, talking on the phone/sending cards/ mail. Documentation shows he was at Bingo three (3) times in two (2) months. On 3/22/23 10:28 AM during an interview with Recreation Director# 54, she states she has only been there six (6) weeks, and she is still gathering documentation and information from residents. She will speak to the resident and update his likes/dislikes. An interview with the Director of Nursing on 3/23/23 at 11:25 AM concerning the staff not getting the resident up concluded with her stating she will do an inservice on the topic. Record review of the care plan found Resident #17's interest are as follows: - I like to participate with groups of people. - It is important for me to have reading materials - I enjoy listening to music and prefer country, metal, rock - I would like pet visits - I like to use a computer, do crosswords/puzzles/games, listen to music, look out the window, lay down/rest, meditate, pray, read, think, watch TV/movies, by myself in my bedroom, common spaces, outdoors - I enjoy watching/listening TV. - It is important for me to engage in my favorite activities - 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. The residents likes were on the care plan, but were not implemented by the facility. According to the facility Recreation Services Policies and Procedures with a revision date of 4/01/18 the department will create opportunities for each person to have a meaningful life by supporting his/her domains of wellness; identity, growth, autonomy, security, connectedness, meaning, and joy. They will provide an ongoing person-centered recreation program that incorporates the individual's interest hobbies, and cultural preferences which are integral to maintaining and improving a resident's/patient's physical, mental, and psychosocial well being and independence. e) Resident Identifier #20 On 03/20/2023 at 10:45 AM during a resident interview, the resident stated, We don't get showers like we are supposed to. The resident stated that she was never asked her preferences of bed bath vs shower or how many showers she prefers weekly. Electronic record review on 03/22/2023 of the resident's Bathing Task for the last 30 days, indicated that the resident had zero (0) showers, 10 bed baths, and zero (0) refusals. The resident does not have a bathing care plan in place that would indicate her preferences. This was reviewed with the Assistant Director of Nursing (ADON) on 03/21/23 at 8:32 am with no further information provided.

CONCERN (E)

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

Deficiency F0657 (Tag F0657)

Could have caused harm · This affected multiple residents

Read full inspector narrative →

Based on record review, staff interviews, and resident interviews the facility failed to ensure the timeliness of each resident's person-centered, comprehensive care plan, and to ensure that the comprehensive care plan is reviewed and revised by an interdisciplinary team composed of individuals who have knowledge of the resident and his/her needs, and that each resident and resident representative, if applicable, is involved in developing the care plan and making decisions about his or her care for six (6) of 37 residents in the sample. Resident identifiers #103, #23, #82, #1, #17, and #5. Census 115. Findings Included: a) Resident Identifier #103 Electronic Record review on 03/21/23, revealed a care plan that stated the following: .Resident lacks capacity to make his own medical decisions; mom is HCS (health care surrogate). Resident/Patient or healthcare decision maker shall participate in decisions regarding medical care and treatment x (times) 90 days . On 03/23/23 at 10:15 AM a Staff Interview was conducted with social worker (SW) #95. SW #95 states the resident does not technically have capacity due to only one physician giving him capacity in June of 2022 and she is waiting on the psychologist to see him on his next visit, for the second evaluation to give back his capacity. On 03/23/23 at 10:30 AM an electronic record review of the scanned documents, located two (2) capacity forms, from two (2) different physicians. One (1) dated 06/28/2022 and one (1) dated 10/05/2022, both stating the patient has capacity. Surveyor requested SW #95 print these two (2) capacity forms along with the and the care plan. SW #95 provided copies of both capacity forms and confirmed the care plan incorrectly indicated he lacks capacity and his mother is the HCS. SW #95 acknowledged there wasn't any documentation stating the resident lacks capacity and there were two (2) physicians which indicated he did have capacity. Therefore the care plan is incorrect. b) Resident Identifier #23 Resident interview on 03/20/23 at 11:59 AM, indicated the resident, who has capacity, had never heard of a care plan meeting and stated she had never received an invitation to one. Record review on 03/21/2023, indicated under the documents section there were not any care plan meeting invitations scanned in. The progress notes section of the electronic medical record indicated there weren't any notes regarding a care plan meeting since 07/12/22. On 03/21/2023 at 1:48 PM, staff interview with SW #95, confirmed she does not see a care plan meeting documented since 07/12/22, nor an invitation documented. Surveyor received a copy of the most recent care plan dated 07/12/22. This note did not indicate the resident attended or was invited to her care plan meeting. When SW #95 was asked if there were any meetings held after 07/12/22 and if so, where was the documentation of the meetings she responded I don't know, without any further explanation. SW #95 stated she would be the one responsible to have care plan meetings with this resident. c) Resident #82 During the initial tour of the facility Resident #82 was observed laying in bed in her room. The resident had a television mounted on the wall. There was no remote seen in the residents room, and the residents television was not plugged in. A review of Resident #82 care plan found the following interventions in her regard to her activity preferences: -- Resident likes to watch tv/movies and listen to music. This intervention was last updated on 10/28/22. An interview with the Activities Director at 12:00 pm on 03/23/23, confirmed the resident does like to watch television. She stated, She likes to watched Unsolved Mysteries and the Investigation Discovery (ID) channel. The Activities Director was then asked to accompany this surveyor to Resident #82's room. When in the room the Activities Director confirmed the residents Television was not plugged in and there was no outlet available to plug the television into. She was then asked if Resident #82 had a television remote in her room. She stated after looking in the resident drawers, I do not see one in here. She stated, I am going to have to find out what is going on here. I know she gets mad and throws things. She may have broke it. An additional interview with the Activities Director on 03/22/23 at 1:33 PM found the following. The Activities Director reported she had spoken with three (3) nurses and nurse aides who routinely work with Resident #82 and found she was getting paranoid and scared after watching television. The Activities Director sated, The resident has told them she does not want to watch television anymore. She further stated, When the staff would turn it on her for her the behaviors she exhibited worsened. The Activities Director stated, Her care plan needed revised to reflect these changes. d) Resident #5 A review of the medical records found the facility failed to revise a care plan to indicate the number of times a day Resident # 5 is to be catheterized. Care Plan states twice a day and the order states three times a day, the order for three times a day was wrote on 6/11/2021. On 03/22/23 at 3:41 PM, Director of Nursing (DON) agreed the care plan was not updated to the number of times Resident #5 is to be straight catheterized.

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

ADL Care (Tag F0677)

Could have caused harm · This affected multiple residents

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, and staff interview, the facility failed to provide activities of daily living (ADL's) to maintain good personal hygiene for dependent residents and failed to provide catheterization for a dependent Resident. This is true for three (3) of eight (8) resident reviewed for ADL care. Resident Identifiers: #95, #20, and #5. Facility census: 115. Findings included: a) Resident #95 During an interview on 03/20/23 at 11:19 AM, Resident #95 stated she doesn't get her showers as ordered or her preference. A continued record review of Resident #95's quarterly 02/08/23 Minimum Data Set (MDS), found the resident's brief interview for mental status was fifteen (15) the highest score obtainable. MDS section G (Functional Status) indicates physical help with bathing. MDS Section E (Behaviors) also indicated Resident #95 does not reject care. A review of Resident #95's ADL documentation found, no showers noted on 12/28/22, 01/21/23, 02/12/23 and 03/12/23. On 03/23/23 at 10:03 AM the Infection Preventionist verified Resident #95 did not receive all showers as scheduled. b) Resident #20 On 03/20/2023 at 10:45 AM during a resident interview, the resident stated that, We don't get showers like we are supposed to. The resident stated that she was never asked her preferences of bed bath vs shower or how many showers she prefers weekly. Electronic record review on 03/22/2023 of the resident's Bathing Task for the last 30 days, indicated that the resident had zero (0) showers, 10 bed baths, and zero (0) refusals. The resident does not have a bathing care plan in place that would indicate her preferences. Her Activities of Daily Living (ADL) care plan indicates she requires, .extensive to total assist with dressing, grooming, personal hygiene and bathing . In the afternoon of 03/21/23 this was reviewed with the infection preventionist and no further information was provided. c) Resident #5 On 03/21/23 at 3:25 PM, Resident # 5 asked to speak with this surveyor and the Director of Nursing (DON). Resident # 5 reported she was upset because the nurse who came on shift last night at 10 PM did not catheterize (using a small tube/catheter to empty the bladder of urine) her. Resident # 5 went on to say she was not catheterized until the next morning at 6 AM. Resident # 5 stated it was Registered Nurse (RN) #38 (who is also the facility nurse practice educator). On 03/22/23 at 8:30 AM, the DON was asked about what was done about RN #38 not catheterizing Resident # 5. The DON reported, the nurse she was relieving did not tell her she needed to be catheterized. A review of the medical chart revealed on the TAR (treatment administration record) the task was not checked off and was do to be done at 11:00 PM. The next scheduled time was 6:00 AM and the amount was 500 ML. normally the amount at 6 AM is between 200 to 300 ml. The increase in urine could indicate the resident was not catherized on time. On 03/22/23 at 12:07 PM, the DON was asked if she had looked into why Resident #5 was not straight catheterized on 03/20/23 at 11:00PM. The DON said she would get statements. On 03/22/23 at 3:02 PM, Infection Preventionist (IP) was asked for the statement from the nurses about why Resident #5 was not straight catheterized. IP provided the following witness statements dated 03/23/23. -- Registered Nurse # 38. I was told at 2 AM that resident needed cathed. The nurse Licensed Practical Nurse (LPN)#3 went in to cath and resident stated she wanted to wait until the am cath because the two would be too close together. I was not told when I came in at 11 PM that she needed cathed. -- Witness statement dated: 03/22/23 by LPN #3: Nurse went in residents' room at 1am and told resident she was going to straight cath her. Resident refused, stating it was too close to the next cath time. -- Witness statement dated: 03/22/23 by LPN# 94: I did not cath resident before leaving at 10:30 PM, on Monday 03/20/23. I spoke with resident and told her RN #38 would be in at 11:00 to take over. I did not mark the resident's catheterization off on the TAR. The next text I sent to RN#38 before leaving is below All meds are passed. Charting is in good shape; I'm going to leave keys with LPN#3. -- Witness statement dated: 03/21/23 by Resident #5 taken by Social Worked #14. Social Worker #14 interviewed resident, (named) Resident #5 that stated her nurse (named) LPN #94 left at 10:30 PM on Monday and stated (named) RN #38 the nurse was coming in and straight cath her when she got here. Resident #5 stated she did not get straight cathed until 5:30 AM on Tuesday. Resident #5 stated she used her call light to remind staff she needed straight cathed around 11:30 PM. Stated she told Nurse Aide #93 around 11:30 PM and could not recall who the other Nurse [NAME] was. Social Worker #14 stated Nurse Aide #93 said she did not work Monday night. On 03/23/23 at 2:45 PM Resident #5 stated no one came in and asked me if I wanted straight cathed at 1 or 2 AM. If that would have happened, I would not even be complaining about it, because that would have been on me. On 03/23/23 at 3:10 PM, the IP was informed of the statement made by Resident #5. At this time IP provided an In-service sign-in sheet, dated 03/23/23. Topic and description: When conducting shift to shift report between nurses, you must communicate refusals and the documentation of refusals of care, as well as the risks and benefits associated with the refusal of care. IE: If a resident refuses to be straight cathed, you must document the refusal and that you discussed the risks and benefits (uti, urinary retention, bladder dysfunction/rupture) with the resident. ALWAYS communicate these types of refusals to provide the safest level of care to our residents. There were no signatures on this In-service sheet.

CONCERN (E)

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

Accident Prevention (Tag F0689)

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 and interview the facility failed to ensure the resident environment over which it had control was as free from accident hazards as possible. This was a random opportunity for discovery of the resident smoking area had a help button which was not effective and also had or lightening should the residents go outside after dark. In addition fall precautions were not implemented and the grab bars in resident bathrooms were loose and not properly affixed to the wall. Resident Identifiers: # 67, #52, #42, #40, #61, #76, #23, #89, #95, #60, #103, #56, #24, #69, #63, #84, #9, #97, #41, #417 and #66. Room Identifiers 38 and 44. Facility census: 115. a) Resident smoking area 1) Safety Alarm On 03/21/23 at 12:15 PM two 2 surveyors pushed the help button in the Resident designated smoking area, no staff came to answer the help signal. At 12:42 PM on 03/21/23 the help button was pushed again, no one answered the help signal in the Resident designated smoking area. On 03/21/23 at 12:50 PM the help button was pushed with surveyor present in the Residents designated smoking area, a second surveyor was in the activities room where the inside alarm was located, and a third surveyor was located at the nursing station. No alarm sounded at the nurse station. A light flashed and alarm sounded in activities room one time and stopped. During an Interview on 03/21/23 at 3:29 PM the Activities Director stated that when the help button is pushed in the Residents designated smoking area, that a bell rings at the nursing station and the light flashes from the box plugged in the outlet in the activities room. When she was asked if she heard alarm or saw the flashing light this date, she stated she did not. On 03/21/23 3:29 PM during an Interview the Assistant Director of Nursing (ADON) stated the residents are allowed to go out to the courtyard any time by them self if they have a smoke evaluation. She stated the only alarm from the courtyard was the in the Activities room. The ADON verified that there was an issue with hearing or seeing the alarm, if no staff was present in the activities room. She confirmed that this could be an accident hazard. 2) Lighting On 03/20/23 at 11:20 AM, Resident #95 stated that she is able to go out to smoke independently at any time of the day and night. She continued to say that there isn't very good lighting out in the Resident smoking area after dark. During an interview on 03/21/23 at 3:24 PM the Assistant Director of Nursing verified that the residents are allowed to go out to the courtyard by them self any time, as long as they have a smoking evaluation. On 03/21/23 at 3:39 PM during an Interview with the Activities Director, she stated there were Christmas lights strung around the gazebo in the courtyard to help Residents that go out to smoke at night to see. During an interview 03/21/23 at 3:53 PM the Maintenance Director stated that two (2) of four (4) flood lights work. He continued to say that he was aware that the two (2) didn't work correctly, as they went off during a storm and had not yet been repaired or replaced. b) Resident #51 A review of Resident #51's medical record found they received injuries resulting in the following fractures: Left Superior Ramus Left Inferior Ramus Left Hemi sacrum. Left Greater Trochanteric Left Intertrochanteric The facility staff did not safely transfer Resident #51 in accordance with her care plan and transfer reposition report. Resident #51's medical indicated they were to be transferred via a mechanical lift with a two (2) person physical assist on the following documents: the nursing notes, the [NAME], the care plan, the transfer Repositioning form, and the Physical Therapy report. Resident #51 was unable to stand due to contractures of the left knee, left ankle and right ankle. Resident #51 was also documented as not being able to stand for more than a year and a half. It is unclear on what day this accident actually occurred, as Nurse Aide #100 failed to report the incident. NA #100 stated she tried to stand Resident #51 up to transfer her from a shower chair to the bed alone and without a lift. NA #100 stated the resident lost her balance and both she and Resident #51 fell to the ground. A review of the facilities form Activities of Daily Living (ADL) for Resident #51 found the staff did not always document the mode of transfer. On 11/18/22 at 11:07 and 11:23 AM, code 2,2 was used meaning; Limited assistance: Resident highly involved in activity, one person assist. On 11/25/22 at 11:43 AM, coded 3,3 was used meaning; Extensive assistance-Resident involved in activity, staff provide weight-bearing support. All other days documented from 11/17/22 to 11/30/22 were either blank or coded; 8, 97, meaning activity did not occur. On 03/23/23 at 9:23 AM, the Infection Preventionist said the ADL sheet was very hard to follow and agreed there was many blanks. IP stated Resident #51 is a total dependence- full staff performance for transfers and staff must use two (2) people when using a lift. IP also provided a facility form; Lift Transfer, which states Resident #51 is a Total Lift. c) room [ROOM NUMBER] During and tour while interviewing residents on 03/20/23 at 1:35 PM, It was discovered the handrails in the bathroom for room [ROOM NUMBER] was not firmly secured to the wall. On 03/21/23 at 3:25 PM, Director of Nursing (DON) verified the bathroom handrails were not firmly secured to the wall. d) room [ROOM NUMBER] During and tour while interviewing residents on 03/20/23 at 2:52PM, It was discovered the handrails in the bathroom for room [ROOM NUMBER] was not firmly secured to the wall. On 03/21/23 at 3:25 PM, Director of Nursing (DON) verified the bathroom handrails were not firmly secured to the wall.

CONCERN (E)

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

Respiratory Care (Tag F0695)

Could have caused harm · This affected multiple residents

Read full inspector narrative →

Based on observation, staff interview, record review and Policy and Procedure review the facility failed to provide respiratory care and services within standard principles of practice. This was true for four (4) of four (4) residents reviewed for the care area of respiratory care. Resident Identifiers: #104, #21, #17 and #47. Facility Census: 115 a) Resident #104 On 3/20/23 at 11:10 AM during the initial interview phase of the long term care survey process, it was observed the tubing on his nasal cannula oxygen was dated 3/07/23. This was confirmed with Licensed Practical Nurse #37 on 3/20/23 at 11:12 AM. Record review found the following Physicians order: Order Summary: Oxygen tubing change weekly Label each component with date and initials. According to the facility Oxygen: Nasal Cannula Procedure dated with revision date 6/15/22, #22 states: Replace disposable set-up every seven days. The facility failed to follow their procedure and the Physicians order. b) Resident #21 Observation on 3/20/23 at 11:10 AM found Resident #21's nebulizer mask on her bed. This was confirmed with Licensed Practical Nurse #37 on 3/20/23 at 11:14 AM. The nebulizer mask should be stored in the treatment bag in a sanitary manner when not in use per professional standards of care. c) Resident #17 Observation on 3/20/23 11:24 AM found Resident #17's Trilogy mask on floor by the bedside. This was confirmed with Licensed Practical Nurse #37 on 3/20/23 at 11:25 AM. The trilogy mask should be stored in the treatment bag in a sanitary manner when not in use per professional standards of care. d) Resident #47 During the initial tour on 03/20/23 at 10:40 AM, it was observed a face mask for the BiBAP was sitting on the Bedside table with bags of opened chips and other personal items. Licensed Practical Nurse (LPN) #94 was asked about the mask not being in a bag for storage. LPN #94 agreed the facemask should be in a storage bag. Facility Policy title: PB SH109 Respiratory Equipment and Disinfection and Supply Changes Revision date: 12/06/22 read as follows: .When not in use in patient room store in a treatment bag .

CONCERN (E)

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

Deficiency F0698 (Tag F0698)

Could have caused harm · This affected multiple residents

Read full inspector narrative →

Based on record review, staff interview and resident interview the facility failed to ensure post-dialysis assessments were completed on the Hemodialysis Communication Record. This was true for one (1) out of one (1) reviewed for dialysis. Resident identifier: Resident # 47. Facility census 115. Findings included: a) Resident # 47 During an interview with Resident # 47 on 03/20/23 at 10:24 AM the resident reported she went to dialysis on Tuesdays, Thursdays, and Saturdays. On 03/21/23 at 3:40 PM, the Director of Nursing (DON) was asked for the dialysis communication sheets. A review of the records revealed the forms were incomplete. These forms have three parts to them. The first part (pre dialysis) is to be completed by the facility staff, the second part (this is for the dialysis facility to completed by the dialysis staff) and returned to the facility with the resident. The third part is the post dialysis assessment and should completed by the facility staff. A look back at the Hemodialysis Communication Record starting on 01/24/23 thru 03/21/23 revealed the following: On every form the first section was partially completed. The second and third parts were left blank on On the following days: *01/17/23 * 01/24/23 * 01/26/23 * 01/31/23 * 02/09/23 * 02/14/23 * 02/16/23 * 02/21/23 * 02/28/23 * 03/16/23 * 03/18/23 * 03/21/23 The above findings were verified with the DON on 03/21/23 at 3:45 PM.

CONCERN (E)

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

Deficiency F0726 (Tag F0726)

Could have caused harm · This affected multiple residents

Read full inspector narrative →

Based on record review and staff interview, the facility failed to ensure staff had appropriate competencies and skills sets to perform delegated nursing tasks beyond those taught in their basic educational program. Licensed Practical Nurses were administering intravenous antibiotics and flushes of intravenous lines had not received training on intravenous medications while working at the facility. This deficient practice had the potential to affect one (1) of one (1) residents reviewed for the care area of antibiotic use. Resident identifier: #88. Facility census: 115. Findings included: a) Resident #88 Review of Resident #88's physician's orders showed an order written on 02/17/23 for the antibiotic piperacillin-tazobactam intravenously every eight (8) hours for 31 days for a left medial thigh surgical infection . The resident received the antibiotic through a midline catheter inserted into her right upper arm at the hospital. A heparin lock flush for the midline catheter three (3) times a day and normal saline flush three (3) times a day were also ordered. Resident #88's Medication Administration Record (MAR) showed the following Licensed Practical Nurses (LPNs) had administered the intravenous antibiotics and flushes: #112, #87, #28, #115, #9, #25, #37, #17, #120, and #108. During an interview on 03/21/23 at 2:00 PM, the Infection Preventionist Nurse stated Licensed Practical Nurses (LPN) were permitted to administer intravenous antibiotics, except for the first dose of an antibiotic, after receiving training. A policy titled Infusion Therapy Management with an effective date 10/01/13 and a revision date 03/01/22 was provided. The policy stated, Centers may provide infusion therapy services for patients based on individual patient needs. Infusion therapy is provided by a registered nurse or licensed practical nurse based on scope of practice and state regulations. The policy did not address intravenous medication training for LPNs. The Criteria for Determining Scope of Practice for Licensed Nurses and Guidelines for Determining Acts That May be Delegated or Assigned by Licensed Nurses by the [NAME] Virginia Board of Nurses and The [NAME] Virginia State Board of Examiners for Licensed Practical Nurses, updated October 2019, states as follows: The law in [NAME] Virginia is not specific in that no duties are spelled out as being duties of a licensed practical nurse. The [NAME] Virginia State Board of Examiners for Licensed Practical Nurses can only recommend that licensed practical nurses perform duties and procedures for which training has been provided during the 12 month training program. The administration of I.V. [intravenous] fluids is not a part of the standard curriculum for accredited schools of practical nursing in [NAME] Virginia. However, if written hospital policy permits, additional training has been received and can be verified, providing there is adequate supervision and the licensed practical nurse is willing to accept responsibility, it is not illegal for a licensed practical nurse to perform more difficult procedures, such as administration of I.V. fluids. On 03/22/23 at 1:00 PM, the Infection Preventionist Nurse provided documentation that LPN #28 had received Essentials of Infusion Therapy training on 01/08/23. The Infection Prevention Nurse provided information that LPNs #112 and #108 had passed Infusion Therapy tests and completed Infusion Therapy Skills Self-Assessment check-offs in 2019. LPN #87 had passed an infusion therapy test in 2019. LPN #37 had completed an Infusion Therapy Skills Self-Assessment check-off in 2019. The Infection Preventionist Nurse stated the remaining LPNs, #17, #108, #9, #25, #115 and #120, did not have documentation of intravenous therapy training. Additionally, the Infection Preventionist Nurse stated there were no yearly competencies specifically regarding intravenous therapy for LPNs who had completed training at the facility in 2019. She stated the facility had the started the process of providing intravenous therapy training for LPNs prior to the survey as evidenced by LPN #28's training on 01/08/23. No further information was provided prior to the completion of the survey.

CONCERN (E)

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

Deficiency F0804 (Tag F0804)

Could have caused harm · This affected multiple residents

Read full inspector narrative →

Based on observations, staff interview, and record review, the facility failed to provide each resident food which was palatable. This has the potential to affect all residents who get their nutrition for the kitchen. Facility census: 115. Findings Included: a) Anonymous interviews During Initial tours during the Long Term Care Survey Process (LTCSP) on 03/20/23 multiple Residents throughout the facility verbalized the dislike of the food they receive from the kitchen. The verbalized concerns where the food was not palatable, and the poor quality of the food served. b) Test tray On 03/21/23 at 12:28 PM a surveyor test tray was acquired from the kitchen: --Grilled Cheese was soggy on the one side and crispy on the other. --Tarter Tots had a rubbery texture and had a freezer taste. During an interview on 03/23/23 at 10:30 AM the Corporate Kitchen Account Manager stated they have been trying to give the residents more choices in monthly meals, the daily budget per Resident was recently increased and they change menus every quarter. c) Resident Council A closed Resident Council Meeting was held on 03/21/23 at 2:00 PM. Anonymous residents complained the food was gross and the facility did not know how to cook, examples being extremely thick stew, biscuits that were not done, and frozen green beans. The majority in attendance stated the presentation of the food is not appetizing and the taste of most of the food is not good.

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, staff interview, and equipment manual review the facility failed to store food in the activity's refrigerator and freezer and store food in the resident pantry on south short hall in accordance with professional standards for food service safety related to storage. The facility also failed to keep the ice machine in a safe operating condition. This has the ability to affect all Residents who get their nutrition from the kitchen, and who attends food related activities. Facility Census: 115. Findings included: a) Initial kitchen tour. During the initial kitchen tour on 03/20/23 at 10:54 PM, an observation found an oxygen concentrator stored in the Residents south pantry. During an interview on 03/20/23 at 10:55 AM the Corporate Kitchen Account Manager confirmed medical supplies should not be stored in the Residents food pantry. b) Activities refrigerator On 03/20/23 at 11:40 AM an observation of the Activities refrigerator found the refrigerator temperature log was not completed for the month of March 2023. Continued observation revealed no items in the refrigerator or freezer were labeled or dated. Staff food was also stored in the resident activities refrigerator. During an interview on 03/20/23 at 11:42 AM., the Activities Director confirmed the items were not labeled or dated, staffs food was stored with resident food, and the temperature log for March 2023 was not completed. c) Ice Machine On 03/20/23 at 12:15 pm an observation of the ice machine located in the main dining room found the filter was unhooked from the machine. During an interview and observation on 03/20/23 at 1:33PM the Maintenance director stated the filter is unhooked because the filter is supposed to last six (6) months, but it only lasts one (1) month. The date on the Filter was 12/22 to 6/23. On 03/23/23 a review of the Manitowoc S Model Technician's Handbook found the filter on both sides inlet and outlet page 189 indicated, this filter is very important because the ice machines have a back -flushing action that takes place during every Harvest cycle. A Manitowoc filter drier has high moisture and acid removal capability. On 03/23/23 at 11:38 AM the Infection preventionist Nurse verified the filter was still unhooked.

CONCERN (E)

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, observation and staff interview the facility failed to ensure medical records were complete and accurate. This was true for four (4) of 37 sampled residents. Resident Identifiers: #82, #64, #32 and #21. Facility Census: 115 Findings Included: a) Resident #82 Observations in Resident #82's room on 03/22/23 at 12:00 pm found her 10:00 am snack, a sandwich, was still laying on her bedside table. The sandwich was not eaten. The Activities Director (AD) who was present during the observation placed the sandwich in the trash. A review of Resident #82's medication administration record (MAR) in the afternoon of 03/22/23 found the nurse had documented on the MAR Resident #82 had consumed 50 percent of the sandwich which was discarded by the AD. At 2:00 PM on 03/22/23 the infection preventonist (IP) was asked to review the MAR and confirmed 50 percent was documented as consumed of Resident #82's 10:00 am nourishment. The IP and surveyor then confirmed with the AD the sandwich was not consumed at all and she had thrown the entire sandwich in the trash at 12:00 PM because it had all ready sat out for two (2) hours. b) Resident #64 An observation on 03/21/23 at 11:00 am, found Resident #64 had taken one bite out of a fudge round which was laying on her over the bed table. The fudge round was labeled with the residents name and the label indicated it was her 10:00 am nourishment. At 3:22 pm on 03/21/23 the fudge round was still observed laying on the over the bed table with only one bite taken from it. An interview with Licensed Practical Nurse (LPN) #115 at 3:34 PM on 03/21/23 confirmed she had documented on the medication administration record (MAR) Resident #64 had eaten 100 percent of her 10:00 am nourishment. The surveyor then requested LPN #115 to accompany her to Resident #64's room at which time the fudge round with one bite removed was shown to LPN #115. At this time LPN #115 stated, I asked the girls and they told me she ate all of it, but obviously she had not. c) Resident #32 Review of Resident #32's medical records found the following weights: - 3/10/2023, 110.6 Lbs (pounds) - 2/10/2023, 110.2 Lbs - 1/10/2023, 110.2 Lbs - 12/10/2022, 111.4 Lbs - 11/8/2022, 115.8 Lbs - 10/10/2022, 112.3 Lbs - 9/5/2022, 112.6 Lbs - 8/29/2022, 112.6 Lbs - 7/20/2022, 113.2 Lbs - 7/7/2022, 112.4 Lbs - 6/15/2022, 125.0 Lbs - 5/12/2022, 115.6 Lbs - 4/20/2022, 112.8 Lbs - 3/15/2022, 115.8 Lbs - 2/8/2022, 113.4 Lbs - 1/11/2022, 112.6 Lbs - 12/9/2021, 111.6 Lbs - 11/10/2021, 113.0 Lbs - 10/19/2021, 116.2 Lbs - 10/13/2021, 113.4 Lbs - 10/8/2021, 111.8 Lbs - 10/5/2021, 113.0 Lbs On 07/7/22, the Registered Dietician (RD) completed a nutritional assessment. The RD stated the resident had a 10.1% weight loss in one month. The RD stated RD questions validity of 6/15 weight at this time. During an interview at 03/23/23 at 9:33 AM, the Infection Preventonist stated the weight obtained for Resident #32 on 06/15/23 should have been struck out in the medical records when it was determined to be erroneous by the RD. d) Resident #21 On 3/20/23 at 2:58 PM during record review for Resident #21, it was noted the facility failed to provide a complete order for Hospice care. The order read: Hospice services in place. The order failed to provide the name of the Hospice organization and the contact information for the Hospice Agency. On 3/22/23 at 11:21 AM, during an interview with the Director of Nursing, it was confirmed the order should have read: Hospice services in place with (name of Hospice organization, address and phone number).

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, record review, and staff interview, the facility failed to establish and maintain an infection prevention and control program designed to help prevent the development and transmission of communicable diseases and infections. Gloves were not worn for eye drop administration to Resident #19. Residents #64 and #100 were found to have wheelchair cushions that could not be properly cleaned. Personal Protective Equipment for Resident #19 was found to be improperly discarded. These were random opportunities for discovery and had the potential to affect more than a limited number of residents. Resident identifiers: #19, #64, #100, #19. Facility census: 115. Findings included: a) Resident #19 The facility's procedure titled Medication Administration: Eye (Drops and Ointments) with an effective date 06/01/96 and revision date 06/01/21 stated nurses were to put on gloves before administration of eye drops or ointments. On 03/21/23 at 8:45 AM, medication administration to Resident #19 by Licensed Practical Nurse (LPN) #54 was observed. Resident #19 was ordered several oral medications and Cyclosporine eye drops in both eyes. LPN #54 entered Resident #19's room and gave the resident her oral medications. LPN #54 then administered Resident #19's eye drops. LPN #54 did not don gloves to administer the eye drops. Following the medication administration, LPN #54 stated no one had told her to wear gloves for eye drop administration. b) Resident #64 An observation of Resident #64's wheelchair on 03/20/23 at 10:55 am found a cushion on her chair that was just bare foam. The foam is porous and can not be cleaned properly to prevent the spread of infection. An interview and observation with the Infection Preventionist on 03/20/23 at 12:00 pm confirmed Resident #64's wheel chair cushion did not have a cover on it. She agreed the bare foam was porous and was not able to be cleaned to prevent the spread of disease and infection. c) Resident #100 An observation of Resident #100's wheelchair on 03/20/23 found the cushion was not covered. This cushion was a gel cushion but had a porous bottom. An interview and observation with the Infection Preventionist on 03/02/23 at 12:00 pm confirmed Resident #100's cushion was uncovered. The Infection Preventionist agreed the cushion could not be cleaned properly. d) PPE improperly discarded On 03/21/23 at 1:02 PM an observation of a used Isolation gown on the bed, and dirty linens spilling out of a trash bag laying on the floor in Resident #19's room. Continued observation found an Enhanced Barrier Precaution Sign hanging on the door. During an interview on 03/21/23 at 1:15 PM the Infection Preventionist stated that the items should have been bagged up and taken to the soiled utility immediately after care was provided.

CONCERN (E)

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

Safe Environment (Tag F0921)

Could have caused harm · This affected multiple residents

Read full inspector narrative →

Based on observation and staff interview the facility failed to ensure a safe, functional, sanitary, comfortable environment. A black substance was bleeding through the dining room floor. This was a random opportunity for discovery. Facility census: 115. Findings Included: On 03/20/23 at 10:30 AM an Observation of a black substance bleeding through the dining room entrance floor, around the door facings, through a seam running through the dining room floor and various other places on the floor. During an interview on 03/20/23 at 1:56 PM the Maintenance Director, verified that there is a black substance bleeding through the flooring in the dining are. He stated that the black substance was present when he started at the facility, and he has tried to remove it without success. An interview with the infection Preventionist on 03/23/23 at 1:33 PM, confirmed the black substance has been bleeding through the dining area floor for a long time. She stated the facility has tried various cleaning techniques to remove the substance including scrubbing and deep cleaning.

CONCERN (F)

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

Garbage Disposal (Tag F0814)

Could have caused harm · This affected most or all residents

Read full inspector narrative →

Based on observation and staff interview the facility failed to store garbage and refuse in a proper manner. The dumpster area was polluted with garbage and used medical supplies. This has the potential to affect all residents that reside in the facility. Facility census: 115. Findings included: a) Dumpster area An observation on 03/21/23 found the dumpster area was polluted with garbage and used medical supplies. On 03/21/23 at 10:50 AM during an Interview with the Maintenance Director , he stated the trash has been out around the dumpster for years. He continued to say it is because the staff leave the lid /doors open on the dumpster and the animals get in the dumpster and drag it out.

CONCERN (F)

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

Deficiency F0847 (Tag F0847)

Could have caused harm · This affected most or all residents

Read full inspector narrative →

The facility failed to ensure the person who was explaining the binding arbitration agreement to the residents and the residents representatives understood the agreement and was able to explain the agreement correctly. The admission coordinator was not aware the binding arbitration agreement waived the residents right to a trail by a judge and jury. This failed practice has the potential to affect every resident currently residing in the facility. Facility Census: 115. Findings Included: a) A review of the binding arbitration agreement found the following: .THIS AGREEMENT WAIVES THE RIGHT TO TRAIL BY JURY. PLEASE READ CAREFULLY BEFORE SIGNING. 1. Arbitration. Arbitration is an alternative means of resolving a dispute without involving the courts. The parties agree Arbitration is a property right. In using Arbitration, the dispute is heard and decided by one or more neutral individuals called Arbitrator. The dispute will not be heard or decided by a jury. You have the right to be represented by a lawyer in Arbitration. Arbitrators can award the same damages and other individualized relief a court can award. This agreement waives your right to trail in court by judge or jury. Arbitration is a complete substitute for trail by judge or jury. An arbitrator is specially trained and neutral third party who bears and resolves a dispute between others by arbitration pursuant to applicable law and the terms of this Agreement. During the entrance conference the Nursing Home Administrator (NHA) identified the person responsible for explaining the arbitration agreement as the Admissions Coordinator. On 03/23/23 at 9:58 am an interview with the Admissions Coordinator confirmed she explains the arbitration agreement to residents and/or responsible parties. She indicated she reviews the agreement with them verbally and also give them a copy to read. When asked if the arbitration agreement waives the resident and/or family's right to a trail by jury and judge she stated, No it does not. She stated, If they can not reach a decision with the arbitrator then it will go to trail by judge or jury. She stated, I think it just waives their right for right now they can still go to a judge and jury after arbitration. When the first paragraph of the arbitration agreement was read to the admissions coordinator she stated, I did not know that. I will make sure that is explained moving forward.

CONCERN (F)

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

QAPI Program (Tag F0867)

Could have caused harm · This affected most or all residents

Read full inspector narrative →

Based on observation, record review, and staff interview, the Quality Assessment and Assurance Committee failed to correct quality deficiencies of which it was aware. This deficient practice had the potential to affect all residents residing in the facility. Resident census: 115. Findings included: a) Cross reference F 584 b) Cross reference F 804 c) Cross reference F 814 d) Interview with Administrator During an interview on 03/23/23 at 11:24 AM, the Administrator stated she had received a complaint regarding the water temperatures in the facility. The Administrator stated the water temperatures had been checked following the complaint and was within acceptable limits. The Administrator also stated the facility had been working on improving the food served to the residents. Interventions implemented included interviews with residents and families, training for kitchen staff, and having staff taste test the food being served. The Administrator stated she believed the food had improved. During the interview, the Administrator also stated the facility had been aware of the trash scattered on the ground around the outdoor waste receptacle. She stated the facility was planning on picking up the trash when the weather improved.

CONCERN (F)

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

Deficiency F0868 (Tag F0868)

Could have caused harm · This affected most or all residents

Read full inspector narrative →

Based on record review and staff interview, the facility failed to ensure meaningful participation by the Medical Director in the Quality Assessment and Assurance (QAA) Committee. The Medical Director or designee did not attend quarterly QAA meetings. This failed practice had the potential to affect all residents residing in the facility. Facility census: 115. Findings included: a) Quality Assessment and Assurance Committee meetings During an interview 03/23/23 at 10:03 AM, the Administrator stated the Quality Assessment and Assurance (QAA) Committee meets every month. Sign-in sheets were reviewed for the last year. For the QAA Committee meetings held on 06/22/22, 07/27/22, 08/22/22, and 09/22/22, there was no evidence the Medical Director or designee had attended these meetings. The Administrator confirmed there was no evidence that the Medical Director or designee had attended QAA Committee meetings at least quarterly.

Feb 2022 21 deficiencies

CONCERN (D)

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

Grievances (Tag F0585)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

. Based on interview and record review the facility failed to making prompt efforts to resolve a grievance and to keep the resident notified of progress toward resolution. This is true for two (2) of three (3) reviewed during the Long-Term Care Survey Process (LTCSP). Resident identifiers: #1 and #33. Facility census: 113. Findings Included: a) Resident #1 On 01/31/22 at 12:52 PM during an interview with Resident #1 stated that he doesn't have any pants to wear. He stated that he was missing several pairs of pants that was reported missing a couple months ago. Resident #1 stated that nothing was ever done about the missing items. 02/01/22 a record review of missing items /grievances revealed Resident #1 reported six (6) pairs of socks, a black jogging outfit, three (3) pairs of pants, and a [NAME] Virginia shirt missing on 11/11/21. Subsequent review of the Follow up report revealed Informed residents' family, they can replace items and provide a receipt to the facility for reimbursement. A continued record review of Resident #1's Significant Change 10/12/21 Minimum Data Set (MDS), found the resident's brief interview for mental status was fifteen (15) the highest score obtainable. Resident #1 has capacity. During an interview with the Social Services Director (SSD) on 02/1/22 at 2:10 pm, she stated that she didn't think the family brought the items in and the facility hasn't reimbursed them for the missing items. On 02/02/22 at 1:19 PM an interview with Administrator confirmed, the missing items should have been followed up on and replaced. b) Resident #33 01/31/22 at 1:28 PM during an interview Resident #33 she reported missing four (4) bras that the facility hasn't done anything about. She stated she reported them about three (3) months ago. They haven't refunded the money for the Bras. She stated her sister had to bring her a bra so she would have one to wear when she went out. 02/01/22 a record review of missing items /grievances revealed Resident #33 reported three (3) white sports bra's and one (1) brown sport bra missing on 11/11/21. Subsequent review of the Follow up report revealed Informed residents' family, they can replace items and provide a receipt to the facility for reimbursement. A continued record review of Resident #33's Quarterly on 11/02/21 Minimum Data Set (MDS), found the resident's brief interview for mental status was fifteen (15) the highest score obtainable. Resident #33 has capacity. During an interview with the Social Services Director (SSD) on 02/1/22 at 2:10 pm, she stated that she though the family brought her a bra, but she didn't think the facility had reimbursed them for the missing items. On 02/02/22 at 1:19 PM an interview with Administrator confirmed, the missing items should have been followed up on and replaced. No further information was provided prior to the end of the survey on 02/06/22 at 11:30 AM. .

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 record review and staff interview, the facility failed to ensure a resident fall resulting in serious bodily injury was reported in a timely fashion to the state survey agency. This was true for one (1) of three (3) residents reviewed for falls in the long-term care process. Resident identifier: #107. Facility census: 113. Findings included: a) Resident #107 An electronic health record review was completed on 02/01/22 at 7:30 PM. Resident #107 experienced a fall on 08/05/21 and was transferred to the emergency room (ER) for treatment. LPN #78 documented, on 8/5/2021 at 8:00 PM, that Resident #107 had returned to facility. Additionally, it was documented, Report from ER showed Proximal Humerus Fracture. Splint applied to right arm. Circulation monitored. Resident to follow up with Ortho (orthopedics). Review of the August 2021 Reportables Log revealed the facility had not reported the fall with serious bodily injury within two (2) hours after having knowledge of the injury. During an interview on 02/02/22 at 11:43 AM, the Director of Nursing (DON) acknowledged the incident was not reported until 08/06/21 at 12:07 PM and the two (2) hour reporting requirement had not been met. .

CONCERN (D)

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

Transfer Notice (Tag F0623)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review and staff interview, the facility failed to provide evidence a resident's representative was provided a written Notice of Transfer for an acute hospital transfer/discharge on [DATE]. This was true for one (1) of three (3) hospital transfers reviewed during the long-term care process. This had the potential to affect a limited number of residents in the facility. Resident identifier: #3. Facility census: 113. Findings included: a) Resident #3 A medical record review was completed on 02/01/22 at 8:06 AM. There was no evidence the facility had provided a written Notice of Transfer/Discharge to Resident #3 or their representative for an acute hospital transfer/discharge on [DATE]. On 02/02/22 at 12:30 PM, the Director of Nursing (DON) acknowledged the facility was unable to provide evidence the facility provided a written Notice of Transfer/Discharge for Resident #3's acute hospital transfer on 01/08/22. .

CONCERN (D)

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

Assessment Accuracy (Tag F0641)

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 interview, the facility failed to ensure one (1) of twenty-three (23) residents reviewed during the Long - Term Care Survey Process had an accurate Minimum Data Set (MDS). Resident #90's MDS did not reflect the resident was receiving dialysis services. Resident identifier: #90. Facility census: 113. Findings included: a) Resident 90 On 01/31/22 at 11:37 AM, the resident said she has been receiving dialysis for the past 2 years and was receiving services upon admission to the facility. The resident said her dialysis days are Tuesday, Thursday, and Saturday. The resident was admitted to the facility on [DATE]. Review of the most recent care plan confirmed the resident was receiving outpatient dialysis services on Tuesday, Thursday, and Saturday. Review of the most recent MDS with an assessment reference date (ARD) of 12/23/21 found the MDS did not reflect the resident was receiving dialysis services. On 02/02/22 at 9:23 AM, the MDS coordinator #80 said she made a mistake on the most recent MDS and did not code the resident as receiving dialysis services. MDS #80 said it was coded correctly on all the previous MDS's but this one was just missed. MDS #80 said she would do a correction MDS immediately. On 02/02/22 at 1:41 PM, the administrator was advised of the incorrect MDS. No further information was provided by the close of the 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 and interview, the facility failed to ensure residents who are unable to carry out activities of daily living received the necessary services to maintain good grooming, and personal hygiene. Resident identifier #105. Facility census 113 Findings included: a) Resident #105 On 1/31/22 at 11:55 AM, Resident #105 stated she hasn't had a shower for two weeks. On 02/01/22 at 12:15 PM, record review revealed Resident #105 has showers scheduled every Tuesday and Friday on day shift. Review of the care plan confirms Resident is extensive up to total assistance with bathing. Further record documentation confirms she received two showers during the entire month of January, 2022. e) Resident #74 On 01/31/22 at 11:30 AM, Resident #74 was observed in the hallway with an abundant amount of facial hair. CNA #100 confirmed the presence of the facial hair on Resident #74 and stated, We have to help her with shaving. She cannot do it independently. A record review, on 02/01/22 at 7:05 AM, revealed the following documented details regarding ADL care provided to Resident #74 categorized as Personal Hygiene, defined as how resident maintains personal hygiene, including combing hair, brushing teeth, shaving, applying makeup, washing/drying face and hands. 01/28/22 1:43 AM Extensive one (1) person physical assist 7:23 AM Total one (1) person physical assist 8:10 PM Extensive one (1) person physical assist 01/29/22 1:24 AM Extensive one (1) person physical assist 9:30 AM Extensive one (1) person physical assist 01/30/22 12:19 AM Total one (1) person physical assist 12:13 PM Extensive one (1) person physical assist 4:51 PM Extensive one (1) person physical assist 01/31/22 9:23 AM Total one (1) person physical assist 5:59 PM Total one (1) person physical assist During an interview on 02/01/22 at 1:37 PM, the Director of Nursing (DON) reviewed the above-mentioned documentation regarding ADL care provided to Resident #74 over a four (4) day period. The DON stated it would be her expectation that Resident #74 NOT have facial hair after reviewing the care documented. The DON reviewed Resident #74's care plan but did not find any evidence the resident was combative with care or had a history of refusing assistance with shaving. c) Resident #1 During an Interview with Resident #1 on 01/31/22 at 12:52 PM he revealed that he does not get his showers per scheduled. Medical record review revealed, Resident #1's shower schedule and preference is two (2) times weekly. A continued record review of Resident #1's Significant Change 01/04/22 Minimum Data Set (MDS), found the resident's brief interview for mental status was fifteen (15) the highest score obtainable. MDS section G (Functional Status) indicates physical help with bathing. MDS Section E (Behaviors) also indicated Resident #1 does not reject care. A review of Resident #1's Care Plan revealed, Focus: --Resident requires assistants with Activities of Daily Living (ADLs) care in bathing, grooming, hygiene, dressing, eating, bed mobility, transfers, locomotion, and toileting related to recent hospitalization. Goal: --Resident will improve current level of function in Bathing, grooming, personal hygiene by next review as evidence by improved ADL score. Interventions: --Total assist with bathing. A continued review of Resident #1s ADL documentation found: One (1) Shower documented given on 12/09/21 for the month of December 2021. One (1) Refusal noted 12/30/21 No showers were documented for the month of January 2022. Bed Baths noted in December 2021 and January 2022. On 02/02/22 at 11:04 PM the Director of Nursing (DON) verified Resident #1 did not receive showers as scheduled. d) Resident #39 On 01/31/22 at 12:52 PM Resident #1 stated that she doesn't get her showers as ordered or her preference. A continued record review of Resident #39's quarterly 11/09/21 Minimum Data Set (MDS), found the resident's brief interview for mental status was fifteen (15) the highest score obtainable. MDS section G (Functional Status) indicates physical help with bathing. MDS Section E (Behaviors) also indicated Resident #1 does not reject care. A review of Resident #39's ADL documentation found, only three (3) showers noted in 30 days on 1/08/22, 1/18/22, 1/21/22. On 02/02/22 at 11:04 PM the Director of Nursing (DON) verified Resident #39 did not receive showers as scheduled. Based on observation, record review and interview, the facility failed to ensure residents who are unable to carry out activities of daily living received the necessary services to maintain good grooming, and personal hygiene. Residents #91, #1, #39, and #105 did not consistently receive showers per the shower schedule and personal requests. Resident #74 did not have facial hair removed. Resident identifiers: #91, #105, #1, #39, and #74. Facility census: 113. Findings included: a) Resident #9 On 01/31/22 at 11:03 AM, the resident said, I have scheduled days for my showers but I am not getting them. I would like to have one today. On 02/01/22 at 7:56 AM, record review found the Resident has only received three (3) showers in the last 30 days: 01/3/22, 01/17/22, and 01/24/22. Review of the care plan found the following focus: Resident/Patient requires assistance for ADL (activities of daily living) care in: bathing, grooming, personal hygiene, dressing, bed mobility, transfer, locomotion, toileting) related to: s/p CVA (cerebrovascular accident) with left sided hemiparesis, generalized weakness, impaired balance, and difficulty walking. Date Initiated: 08/08/2018 Interventions related to bathing included: - Provide extensive assistance with personal hygiene Date Initiated: 01/15/2021 - Provide up to extensive assist for bathing Date Initiated: 01/15/2021 On 02/01/22 at 1:15 PM, the Director of Nursing (DON) said all residents are scheduled two (2) showers a week but we give bed baths. The DON reviewed the response history for this resident and confirmed the documentation revealed the resident had only three (3) showers in the month of January. The resident did refuse a shower on 01/07/22 according to the documentation. The DON said the resident should be fine with having a bed bath. The DON confirmed the resident's shower days were Mondays and Fridays. When told the resident said he wanted (2) showers a week with bed baths in between, the DON was asked to accompany the surveyor to the residents room to inquire about his desires for showers/bed baths. On 02/01/22 at 1:17 PM, the resident said he wanted two (2) showers a week. Bed baths in between were OK but he did not always want bed baths. The DON asked the resident if he had requested a shower. The resident said, yes he did but he was told there were problems with the hot water so he couldn't get a shower. He said he asked yesterday, 01/31/22 for a shower which he still has not received. The DON confirmed the resident has capacity and is oriented. She said she would have someone shower him today. Review of the last Minimum Data Set, a quarterly with a reference assessment date of 12/23/21, found the resident scored a 15 on the Brief Interview for Mental Status (BIMS.) A score of 15 indicates the resident is cognitively intact. The resident should have been offered a shower on 01/03/22, 01/07/22, 01/10/22, 01/14/22, 01/17/22, 01/21/22, 01/24/22, 01/28/22, and 01/31/22. The resident received a shower on 01/03/22, 01/17/22 and 01/24/22. He refused a shower on 01/07/22. The resident had not received a shower for 7 days at the time of the interview on 01/31/22. On 02/02/22 at 1:44 PM, the above information was discussed with the administrator. No further information was provided by the close of the survey.

CONCERN (D)

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, interview, and record review, the facility failed to ensure ensure a resident with contractures of both hands had interventions in place to prevent further decline. This was true for one (1) of one (1) resident reviewed for the care area of range of motion during the long-term care survey process. Resident identifier: #73. Facility census: 113. Findings included: a) Resident #73 Observation of the resident at 01/31/22 11:43 AM, found her right and left hands were closed in what appeared to be a contracture. No devices were present to prevent further decline. The resident was unable to be interviewed. Review of the medical record on 02/01/22 at 08:16 AM, found the most recent Minimum Data Set (MDS) a quarterly, with an Assessment Reference Date (ARD) of 12/08/21 found the resident was coded as having contractures on both hands. A significant change MDS with an ARD of 09/10/21 also coded the resident as having contractures on both hands. The prior MDS, a significant change, with an ARD of 06/03/21 found no contractures were present. Therefore, the contractures developed sometime between 06/03/21 and 09/10/21. Reviewed current physician orders found no orders for any devices for contracture prevention. Review of the current care plan found no interventions for the contractures of both hands. On 02/01/22 at 12:17 PM, the Director of the therapy company, Employee #41 said the resident was picked up for services on 09/02/21 for evaluation. E #41 said a carrot was recommended for use to the left hand. The Resident was discharged from services on 10/01/21. On 02/01/22 at 3:57 PM, Employee #80 the minimum data set coordinator, confirmed there were no orders and no care plan to address any contractures. E #80 said the resident has a carrot in her room because I've seen it in there. The surveyor and E #80 observed the resident in bed in her room. A carrot was found on the right side of the resident under her bed covers. When E #80 attempted to place the carrot in the palm of the resident's left hand, the resident cried out, My God I can't hold on to that, my God no no. On 02/01/22 at 4:07 PM, the Director of Nursing (DON) confirmed the resident should have had a physician's order for a carrot to be placed in the left hand. The DON was asked if there was any documentation to verify the carrot had been placed in the resident's left had after therapy recommendation on 10/01/21? The DON said there was no place to document usage but staff must have been trying to use it or it would not have been in the resident's bed. When asked if there were any treatments in place for the right hand, the DON replied, no. The DON said she was writing an order and nursing assistants would be able to document usage from now on. At 4:40 PM on 02/01/22, the DON provided an order for a carrot to be used in the left hand. On at breakfast and remove at lunch as the resident will allow. She said no treatment is ordered at this time for the right hand. On 02/02/22 at 1:45 PM, the administrator was advised of the above findings. No further evidence was provided by the close of the survey. .

CONCERN (D)

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 and staff Interview, the facility failed to ensure that facility was free from accident hazards over which it had control. An Intravenous (IV) Line Supply cart, in the hallway across from the Cafe, was left unlocked and unattended allowing access to its contents by residents and unauthorized persons. This was a random opportunity for discovery and had the potential to affect more than a limited number of residents. Facility Census: 113. Findings included: a) IV Line Supply Cart Observation on 02/01/22 at 12:10 PM, found an unlocked and unattended IV Line Supply Cart in the activity hallway across from the Cafe. An interview with RN #37, on 02/01/22 at 12:14 PM, confirmed the cart was unlocked. RN #37 stated, It is supposed to be locked. They just pulled something out of there and forgot to lock it. RN #37 described the contents of the cart as filtered needles, sterile caps, sterile central line trays, and other supplies dedicated to intravenous treatment. RN #37 confirmed nurses are trained to follow facility policy to secure the iv line supply cart before leaving the area. .

CONCERN (D)

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

Tube Feeding (Tag F0693)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

. Based on record review and interview the facility failed to ensure a resident received enteral feeding tube care and services to prevent complications. The failed practice was true for one (1) of two (2) residents reviewed for tube feedings. Resident identifier: #51. Facility census: 113. Findings included: a) Cleaning Care Review of Resident #51's medical record showed a physician order dated 10/24/21 that stated, Enternal Feed: Cleanse site daily with soap and water. every day shift. The treatment Administration Record (TAR) for the month of January 2022, showed three (3) missed daily treatments. The TAR showed Resident #51 did not get the feeding tube site cleaned daily for the dates of: 01/19/22 01/20/22 01/28/22 An interview, on 02/02/22 at 9:20 AM, with Director of Nursing (DON) verified the feeding tube site was not cleaned on the dates of 01/19/22, 01/20/22 and 01/28/22 and stated the treatments were missed. b) Unnecessary Treatment Review of Resident #51's medical record showed a physician order dated 10/24/21 that stated, Check for residual every day and night shift If 500 ML or over, hold feeding for one hour and recheck. If residual is 250 ML or over (upon recheck) hold feeding, notify physician and document amount in ml. Review of Resident #51's Medication Administration Record (MAR) for October 2021 through January 2022 showed Resident #51's last feeding of Nutren was completed on 10/13/21 and discontinued on 10/20/21. The feeding tube continued to be checked for residual daily through 02/02/22. An interview, on 02/02/22 at 10:05 AM, with Director of Nursing (DON) stated that checking for residual in the feeding tube was not necessary when feeding was discontinued. DON stated that the physician order for residual checks should have been discontinued back in October 2021 when Resident #51's feedings were discontinued. .

CONCERN (D)

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

Deficiency F0697 (Tag F0697)

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 accurately assess for pain and provide pain medication to a Resident for pain management. This was true for one (1) of one (1) residents reviewed for pain. Resident identifier #111. Facility census: 113. Findings included: a) Resident #111 An interview, on 01/31/22 at 11:35 AM, with Resident #111 stated, the facility sometimes administers pain medication and other times not. Resident #111 stated she had pain all the time because of the inconsistency of pain medication. Medical Record review of Resident #111's physician order dated 06/28/21 stated, Norco Tablet 10-325 MG (Hydrocodone-Acetaminophen) Give 1 tablet by mouth every 6 hours as needed for pain related to PAIN, UNSPECIFIED (R52) Not to exceed 3 grams of acetaminophen in 24 hours. A second physician order date 08/22/21 stated, PAIN MONITOR (Able To Communicate)Are you free of pain or hurting? Additional medical record review of resident #111's December 2021 and January 2022 Medication Administration Record (MAR) showed yes and no answers on the MAR with Norco adminstered inconsitently for both yes and no answers. An interview with Director of Nursing (DON), on 02/01/22 at 3:30 PM, stated the MAR should be marked yes if pain free and no if in pain or hurting. An interview with Assistant Director of Nursing (ADON), on 02/01/22 at 3:40 PM, stated the MAR should be marked yes if in pain and no if not in pain. An interview with Licensed Practical Nurse (LPN) #78, on 02/01/22 at 3:42 PM, stated the MAR should be marked yes if free of pain and no if in pain or hurting. Medical Record review of Resident #111's Pain Level Summaries for December 2021 and January 2022 revealed the following pain levels: 12/15/2021- pain level of ten (10) 12/20/2021- pain level of eight (8) 12/20/2021- pain level of nine (9) 12/26/2021- pain level of nine (9) 12/26/2021- pain level of nine (9) 01/07/2022- pain level of nine (9) 01/07/2022- pain level of eight (8) 01/20/2022- pain level of eight (8) 01/20/2022- pain level of seven (7) 01/20/2022- pain level of seven (7) 01/25/2022- pain level of seven (7) 01/25/2022- pain level of eight (8) Additional record review of Resident #111's Medication Administration record (MAR) for December 2021 and January 2022 revealed the following dates Resident #111 was not administered Norco when pain level summary verified pain was present: 12/15/21 12/20/21 12/26/21 01/07/22 01/20/22 01/25/22 An interview, on 02/02/22 at 10:10 AM, with DON stated if the MAR stated yes then the Resident was not in pain. DON reviewed pain level summaries for December 2021 and January 2022 and stated Resident #111 had pain all day on 12/15/21, 12/20/21, 12/26/21, 01/07/22, 01/20/22 and 01/25/22 and verified with the MAR that Resident #111 was not provided Norco when pain was present. DON stated when a resident has a pain level of seven (7) or above Norco should be administered. DON stated that when Resident #111 was in pain Norco should have been administered. .

CONCERN (D)

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

Deficiency F0698 (Tag F0698)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

. Based on interview, record review and observation, the facility failed to ensure one (1) of one (1) resident reviewed for dialysis care received services consistent with the professional standards of care for a resident receiving outpatient hemodialysis services. Ongoing communication and collaboration with the dialysis center was not always present before and after dialysis treatments. Interventions for monitoring dialysis care at the facility were incomplete. In addition, the resident was not identified on the Minimum Data Set (MDS) as receiving outpatient dialysis services. Resident identifier: #90. Facility census: 113. Findings included: a) Facility policy for dialysis Review of the facility's policy for Dialysis: Hemodialysis (HD) Provided by a Certified Dialysis Facility directs: Ongoing assessment of the patient's condition and monitoring for complications before and after HD treatments received at a certified dialysis facility Ongoing assessment and oversight of the patient before and after HD treatments, including monitoring for complications, implementing appropriate interventions, and using appropriate infection control practices . b) Resident #90 Record review found the Resident receives hemodialysis services on Tuesday, Thursday, and Saturday at a local outpatient center. On 02/02/22 at 9:23 AM, an interview with the Minimum Data Set (MDS) coordinator confirmed the resident's most recent MDS with a reference assessment date of 12/23/21 did not code the resident as receiving dialysis. The facility communicates the resident's care and treatment with the dialysis center via a. Hemodialysis Communication Recording, form with each dialysis treatment. The facility completes the record prior to hemodialysis treatment. Information on the record requires the facility to complete the following: Any problems with the access site, blood pressure, temperature, pulse, AV shunt only indicating a + or a - sign for bruit and thrill, time of last meal, diet and patient's general condition. After the treatment the dialysis center completes the following: Any problems with the access site, blood pressure, temperature, pulse, AV shunt only with + or - for bruit and thrill, pre and post dialysis weight, medications given during hemodialysis, and new orders / significant change in condition during hemodialysis, and any post dialysis complications. Review of the communication records for the month of January and February 2022 were reviewed with the Director of Nursing (DON) on 02/02/22 at 9:56 AM. The DON confirmed the following after review: On the following dates there was no communication records between the facility and the dialysis center: 01/06/22 01/13/22 01/18/22 01/20/22 01/29/22. On 01/11/22 the dialysis center completed only the pre and post weight. On 02/01/22 the dialysis center did not complete any information. At 11:02 AM on 02/22/21 the DON returned with a nurses note written at 10:52 AM on 02/22/21 which said the facility spoke to the dialysis center and the dialysis center said the resident refused to go to dialysis on 01/20/22 and 01/29/22. The facility had no records indicating the resident was offered and refused to go to dialysis on 01/20/22 and 01/29/22. On 01/08/22 a nurses note was written indicating the resident refused dialysis treatment due to the cold weather. At approximately 11:20 AM on 02/22/21 the surveyor and the DON spoke with the resident. The resident said she remembered refusing one time to go for treatment because it was really cold outside. She said she did not remember refusing two other treatments but maybe she did. The resident said the dialysis facility uses the perma cath to the right chest for dialysis treatment. She said the AV fistula to the left arm is, Not ripe yet. She said she needed to go back to see the physician about getting something done with AV fistula to the left arm. Review of the resident's most recent care plan found the following focus: Resident has diagnosis of end stage renal disease on dialysis and is at risk for complications related to hemodialysis. Perma cath to right chest and AV fistula to left arm. Interventions included: Monitor dialysis access for +bruit / +thrill as ordered left antecubital. Observe skin condition around catheter insertion site right chest. The only order on the Treatment Administration Record (TAR) was: Monitor hemodialysis site for signs/symptoms of complications (e.g. bleeding, swelling, pain, drainage, odor, hardness or redness at site). Notify the physician and dialysis center immediately with any urgent problems. Everyday and night shift, start date 06/29/21. On 02/02/22 at 12:30 PM, the DON returned with an order to monitor dialysis access for +bruit / +thrill left antecubital every shift every day and night shift. The DON confirmed the facility never had an order to monitor the left antecubital dialysis site prior to today. On 02/02/22 at 1:41 PM, the administrator was advised of the above findings. On 02/02/22, the DON returned with an order dated 02/02/22 at 2:02, Made a call to (Name of Hospital) vascular center to inquire about an appointment that needed rescheduled. The appointment was originally scheduled for 09/08/21 and resident did not go. It was then rescheduled for 12/01/21 and resident refused to go also. Appointment has now been rescheduled for 04/15/22 for testing and 04/27/22 to see (Name of Physician) . .

CONCERN (D)

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

Pharmacy Services (Tag F0755)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

. Based on observation the facility failed to remain in compliance with acceptable labeling requirements regarding expired medications located in the medication storage rooms. This was true for two of two medication storage rooms. Facility census: 113 Findings included: The following items were found to be expired. On 2/02/22 at 9:00 AM The North Medication room observation found five bottles of Vitamin E 90 milligram had expired in 1/22. All expired items were verified and given to the Unit Manager #86 on 2/2/22 at 9:25 AM. On 2/02/22 at 9:30 AM The South Medication room observation found eleven (11) individual heparin 5 milligram syringes had expired on 6-30-21. All expired items were verified and given to the Unit Manager #37 on 2/2/22 at 10 AM. .

CONCERN (D)

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

Deficiency F0761 (Tag F0761)

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 the facility failed to remain in compliance with acceptable labeling requirements regarding expired supplies located in the medication storage room. This was true for two of two medication storage rooms. Facility census 113. Findings included: The following items were found to be expired. On [DATE] at 9:00 AM the North Medication room observation found twelve (12) individual 28 french foley urine catheters' had expired on 8-28-21. Four individual hypodermoclysis kits had expired on [DATE]. All expired items were verfied and given to the Unit Manager #86 on [DATE] at 9:25 AM On [DATE] at 9:30 AM the South Medication room observation found the following to be expired: Lab vacutainer blood collection tubes: 100 blue tubes expired 9-30-21 100 blue tubes expired 1-31-22 100 red tubes expired 7-31-21 100 red tubes expired 8-31-21 100 green tubes expired 8-31-21 25 green tubes expired 11-30-21 One individual 24 gauge IV catheter expired 4-21 Two individual 20 gauge IV catheter expired 2-20 One individual care fusion female luer lock cap expired 6-13-21 One individual care fusion female luer lock cap expired 3-9-21 All expired items were verified and given to the Unit Manager #37 on [DATE] at 10 AM. .

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 →

. b) Resident #39 During an Interview on 01/31/22 at 1:14 PM. Resident #39 stated the facility runs out of food all the time and must send us whatever they have. She stated that she never gets what's on the menu. A medical record review for Resident #39 revealed, a diet order for a Consistent Carbohydrate diet. A review of the facility menu on 02/02/22 for a consistent carbohydrate breakfast menu was juice, bacon & cheddar omelet, wheat toast, diet jelly, margarine, peach garnish, Milk. An observation on 02/02/22 at 8:15 AM of Resident #39's breakfast meal found a small scoop of scrambled eggs, wheat toast, diet jelly, margarine, cheerios and milk. During an interview on 02/02/22 at 8:24 AM with Dietary Assistant #65, she stated that they did not serve the bacon cheddar omelets as on the menu, because they did not have the items to make the omelets. Based on observation, interview, and record review, the facility failed to ensure menus were developed and prepared to meet resident choices and nutritional needs. This was true for two (2) of ten (10) residents reviewed for the care area of food. Resident identifiers: #90 and #39. Facility census: 113. Findings included: a) Resident #90 On 01/31/22 at 11:35 AM, the resident said she didn't like the food at the facility. When asked if she could get a substitute, the resident said all I get is cottage cheese and a peanut butter and jelly sandwich. I don't like those things. I would like to have some fruit and a snack that I could eat. I never get bacon and I really like bacon. Record review found the resident is receiving dialysis and is on a consistent carbohydrate diet. Observation of the residents morning meal on 02/01/22 at 7:50 AM found the resident had a tray ticket on her tray indicating she was to receive a carbohydrate diet. The tray ticket said the resident was to receive a bacon, cheddar omelet. Instead the resident had scrambled eggs. The resident was to have peaches which were not present. Yogurt was also listed but the resident had a bowl of a yellow colored thick substance instead. The resident said she had no idea what was in that bowl. On 02/02/22 at 8:00 AM, the assistant dietary manager (ADM) #65 was asked to come to the resident's room. The ADM said the facility did not have any yogurt so pudding was served. In addition, the ADM said staff must have forgot the peaches. The resident did not have the omelet because the facility had no bacon. The ADM said the resident should have had a cheese omelet. She confirmed the resident had scrambled eggs, hot cereal, pudding and toast. The resident said she did not like hot cereal and did not want it. At 1:42 PM on 02/02/22, the administrator was advised of the above observations. No further information was provided at the close of the survey. .

CONCERN (D)

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

Deficiency F0804 (Tag F0804)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on numerous anonymous interviews during initial tour, observation, food tray temps and staff interview the facility failed to provide food to residents that was at appetizing temperatures. The failed practice had the potential to affect a limited number of residents. Facility census: 113. Findings included: a) Food Temperature checks Numerous, anonymous resident interviews during initial tour, on 01/31/22 at 11:00 AM, revealed the hot food was usually cold and the cold food was warm. An observation of the food tray cart on South Long Hall, on 02/01/22 at 12:10 PM, showed two (2) food trays that sat on top of the food tray cart. A food tray temperature check of room [ROOM NUMBER] A, on 02/01/22 at 12:20 PM, revealed the following food temperatures: Fish- 110 degrees Tater Tots- 103 degrees Pears- 59 degrees A second food tray temperature check of room [ROOM NUMBER] A, on 02/01/22 at 12:23 PM, revealed the following food temperatures: Pureed Bread- 111 Pureed Chicken- 115 Mashed Potatoes- 121 Peaches- 59 An interview with Assistant Kitchen Manager (AKM) #65, on 02/01/22 at 12:25 PM, confirmed the food temperatures were not within the appropriate parameters for serving. .

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 a resident room was adequately equipped to allow the resident to call for staff assistance. This was a random opportunity for discovery. Resident identifier: #10. Facility census: 113. Findings included: a) Resident #10 On 01/31/22 at 3:20 PM, observation found a room was made for Resident #10 in the library of the facility as the resident was in isolation for COVID - 19. Nursing assistant #83, the resident's NA, was observed leaving the resident's room. NA #83 confirmed the resident did not have a means to call for help. She said at one time he had a bell to ring but it is gone now. NA #20 was also at the resident's room and she said the resident had a call bell. The surveyor asked if she could go in the room and verify the resident had a means to call for staff assistance if needed. While waiting for NA #20 to exit the resident's room the administrator and a corporate nurse appeared in the hallway to see what the surveyor wanted. NA #20 exited the resident's room and confirmed the resident did not have a means to call for staff assistance with the administrator and corporate nurse present. .

CONCERN (E)

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

Safe Environment (Tag F0584)

Could have caused harm · This affected multiple residents

Read full inspector narrative →

. Based on observation, resident interview, and staff interview, the facility failed to ensure the residents environment over which the facility has control was homelike. Residents did not receive desired showers because water temperatures in the shower rooms were uncomfortable. This was a random opportunity for discovery and had the potential to affect all residents at the facility. Facility census: 113. Findings included a) Resident interviews Anonymous interviews with several residents found they had not received showers because the water in the shower room was too cold. Some residents said staff told them a hot water tank was broken. Residents estimated the temperature had been cold for about 3 - 4 weeks. b) Observations in the shower rooms At 2:30 PM on 02/01/22, two (2) surveyors observed the men's and women's shower rooms. Both shower rooms had numerous pieces of resident equipment stored in them: shower chairs, bedside commodes, etc. There was no moisture on any of the walls on the shower stalls, no moisture on the floor, no moisture on the shower equipment and no moisture on any of the cloth shower curtains. The shower rooms were clean. There was no evidence any showers had been given recently as one would expect to find some evidence of moisture on the equipment, walls, floors or curtains. Registered Nurse (RN) #16 observed the shower rooms and confirmed there was no evidence of any moisture on the walls, floors, curtains, shower equipment, or curtains. In addition RN #16 observed a daily shower cleaning schedule attached to a clip board noting the shower rooms had not been cleaned daily as directed on the cleaning log. The men's shower room had not been cleaned since 01/28/22. The women's shower room had not been cleaned since 12/01/22. RN #16 confirmed this is the shower area used by all residents in semi-private rooms. She stated the private rooms have a shower. c) Water Temperatures At 2:40 PM on 02/01/22, the maintenance supervisor (MS) #57 observed the women's shower room and confirmed there was no evidence of moisture on the walls, floor, shower curtains, and equipment. The temperature of the water was obtained by MS #57 with the facility's thermometer: After running the water for at least five minutes, the water was 91 degrees. After running the water for several more minutes the temperature only reached 96.6 degrees. At 2:50 on 02/01/22, the maintenance supervisor obtained the temperature in the men's shower room. The temperature reached 94.5 degrees then dropped to 94.1 degrees, then dropped again to 91.8 degrees after several minutes of running the water. MS #57 said if I turn up the water temperature, the water is too hot in other areas of the facility. He stated, It was like that when I got here and it has been like that for a long time. d) Staff interviews Nursing assistants #83 and #44 said residents have complained about the water temperatures in the shower room for a least a couple of weeks. Licensed Practical Nurse (LPN) #32 stated residents have complained about water temperatures. Registered Nurse (RN) #16 confirmed residents have complained about water temperatures. At 3:17 PM on 02/01/22, the administrator was advised of the water temperatures obtained by MS #57 in the shower rooms, residents complaints and staff interviews. No further information was provided before the close of the survey. .

CONCERN (E)

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

Comprehensive Care Plan (Tag F0656)

Could have caused harm · This affected multiple residents

Read full inspector narrative →

. d) Resident #1 A record review revealed an order for Resident #1 (R #1) revealed an order: Cleanse sacrum with wound cleanser, pat dry, apply sure prep to peri wound, apply pluragel to wound bed, cover with allevyn dressing every day and as needed, every day shift for unstageable pressure injury, with a start date 01/15/22. --01/26/22, Was not signed off on the Treatment Administration Log (TAR) --01/29/22, Was not signed off on the Treatment Administration Log (TAR) --01/30/22, Was not signed off on the Treatment Administration Log (TAR) --01/31/22, Was not signed off on the Treatment Administration Log (TAR) Continued review of Resident #1's Medical record found the order: Blue heel elevation to be in place as accountable to resident, monitor every shift for placement. Every day and night shift for prevention. --01/14/22, was not signed off on day shift on the Treatment Administration Log (TAR) --01/18/22, was not signed off on night shift on the Treatment Administration Log (TAR) --01/23/22, was not signed off on night shift on the Treatment Administration Log (TAR) --01/26/22, was not signed off on day shift on the Treatment Administration Log (TAR) --01/29/22, was not signed off on night shift on the Treatment Administration Log (TAR) --01/30/22, was not signed off on day shift on the Treatment Administration Log (TAR) --01/30/22, was not signed off on night shift on the Treatment Administration Log (TAR) --01/31/22, was not signed off on day shift on the Treatment Administration Log (TAR) Subsequent review of the Resident #1's care plan revealed a focus/problem: Resident at risk for skin breakdown has history of skin tears, has multiple pressure areas, and bruising. The goal associated with this problem: Healing goal The resident 's wound /skin impairment will heal as evidence by decreased size, absence of erythema and drainage and /or presence of granulation by next review. Interventions included: Provide wound treatment as ordered. e) Resident #45 On observation on 01/31/22 at 12:59 PM found an old dressing on Resident #45's left heal. A medical record review for Resident #45 revealed an order: Cleanse area to left heal with wound cleanser, pat dry, apply sure prep and cover with allevyn. Change every Monday, Wednesday, Friday, and as needed for a deep tissue injury. --01/07/22, was not signed off on the Treatment Administration Log (TAR) --01/24/22, was not signed off on the Treatment Administration Log (TAR) --01/28/22, was not signed off on the Treatment Administration Log (TAR) Continued review of Resident #1's Medical record found the order: Cleanse coccyx with hydrating cleansing foam, pat dry, apply Z-guard every shift and as needed for preventive measures. --01/07/22, was not signed off on day shift on the Treatment Administration Log (TAR) --01/07/22, was not signed off on night shift on the Treatment Administration Log (TAR) --01/14/22, was not signed off on night shift on the Treatment Administration Log (TAR) --01/16/22, was not signed off on day shift on the Treatment Administration Log (TAR) --01/16/22, was not signed off on night shift on the Treatment Administration Log (TAR) --01/24/22, was not signed off on day shift on the Treatment Administration Log (TAR) --01/24/22, was not signed off on night shift on the Treatment Administration Log (TAR) --01/25/22, was not signed off on day shift on the Treatment Administration Log (TAR) --01/26/22, was not signed off on day shift on the Treatment Administration Log (TAR) --01/29/22, was not signed off on day shift on the Treatment Administration Log (TAR) --01/29/22, was not signed off on night shift on the Treatment Administration Log (TAR) --01/30/22, was not signed off on day shift on the Treatment Administration Log (TAR) --01/30/22, was not signed off on night shift on the Treatment Administration Log (TAR) Subsequent review of the Resident #1's care plan revealed a focus/problem: Resident at risk for skin breakdown related to history of skin tears, bruising, right lateral malleolus unstageable and Deep tissue injury to left heal. The goal associated with this problem: Healing goal The resident 's wounds will heal as evidence by decreased size, absence of erythema and drainage and /or presence of granulation by next review. Interventions included: Provide wound treatment as ordered. During an interview on 02/02/22 at 11:05 AM with the Director of Nursing (DON), verified the treatments were not completed as ordered for Residents #1 and #45 and the care plan was not being followed for pressure area care. f) Resident #39 During an interview on 01/31/22 at 1:16 PM with Resident #39, she stated that she had areas on her legs and her right foot. She stated that they don't do her treatments every day. Observation on 1/31/22 at 1:20 PM, Found no dressings to Resident 39's lower extremities. A medical record review for Resident #39 revealed an order: Cleanse 1st digit of right foot with wound cleanser, pat dry, apply Maxorb AG , cover with non-adherent foam pad and wrap with kerlix for venous ulcers. --01/15/22, was not signed off on day shift on the Treatment Administration Log (TAR) --01/16/22, was not signed off on day shift on the Treatment Administration Log (TAR) --01/24/22, was not signed off on day shift on the Treatment Administration Log (TAR) --01/25/22, was not signed off on day shift on the Treatment Administration Log (TAR) --01/26/22, was not signed off on day shift on the Treatment Administration Log (TAR) --01/29/22, was not signed off on day shift on the Treatment Administration Log (TAR) --01/30/22, was not signed off on day shift on the Treatment Administration Log (TAR) Continued review of Resident #39's Medical record found the order: Cleanse left lower extremity with wound cleanser, pat dry, wrap with calazime wrap, kling and coban every Monday, Wednesday, and Friday and as needed. --01/07/22, was not signed off on day shift on the Treatment Administration Log (TAR) --01/24/22, was not signed off on night shift on the Treatment Administration Log (TAR) --01/26/22, was not signed off on night shift on the Treatment Administration Log (TAR) Subsequent review of the Resident #1's care plan revealed a focus/problem: Resident at risk for skin breakdown related to decrease in mobility, DM type two, has amputation of left great toe, and left second toe, history of venous ulcers, diabetic ulcers and dry skin. The goal associated with this problem: Healing goal The resident will not show any signs of new skin breakdown through next review. Interventions included: Provide wound treatment as ordered. During an interview on 02/02/22 at 11:05 AM with the Director of Nursing (DON), verified the treatments were not completed as ordered and the care plan was not being followed for Residents #39. Based on record review, observation, and interview, the facility failed to ensure six (6) of 27 residents reviewed during the long term care survey had a person-centered comprehensive care plan developed and implemented to meet his / her other preferences and goals, and address the resident's medical, physical, mental, and psychosocial needs. Resident identifiers: #48, #73, #49, #1, #45, and #39. Facility census: 113. Findings included: a) Resident #48 On 01/31/22 at 11:55 AM, the resident said no one was treating and wrapping her legs that had sores because she was a diabetic. The resident pulled back the covers exposing the left and right lower legs. Both legs were wrapped with dressings from the knees to the ankles. The dressings on both the left and right legs were dated 01/23/22 with the initials of the nurse completing the treatment- CD. The resident said her legs were to be dressed daily. On 01/31/22 at 12:00 PM, the residents nurse was in the hallway with the medication cart. Registered Nurse #16 was asked about the residents treatments to the left and right lower extremities. RN #16 said the resident has an order for daily treatments and as need treatments (PRN.) RN #16 accompanied the surveyor to the resident's room and observed the dressing to both the left and right lower legs. RN #16 confirmed both dressings were dated 01/23/22. When asked whose initials were CD, she replied those are my initials and added she doesn't work every day. Record review on 02/01/22 10:23 AM, found an order to Cleanse RLE (right lower extremity) with wound cleanser, pat dry. Apply A&D ointment, cover with a non-adherent pad and wrap in kerlix. Change Q (every) Day and PRN (as needed.) ordered on 1/14/22. The same order was written for the LLE (left lower extremity.) The diagnosis associated with the treatments was, venous ulcers to right and left lower extremities. Review of the treatment administration record (TAR) found seven (7) days when treatments were missed just since 1/14/22: --01/14/22 --01/16/22 --01/24/22 --01/25/22 --01/26/22 --01/29/22 --01/30/22 On 01/27/22 and 01/28/22 the TAR noted the same nurse, RN #16 initialed she had completed the treatments, yet the date on tape on the bandages on both the left and right leg was dated 01/23/22 and both treatments had this same nurses initials. A prudent person could conclude treatments were not completed on 01/27/22 and 01/28/22. 02/01/22 at 12:58 PM, the director of nursing (DON) reviewed the TAR with the surveyor and concluded treatments were not provided as ordered on 01/14/22, 01/16/22, 01/24/22, 01/25/22, 01/26/22, 01/29/22, and 01/30/22. The DON could not explain why the TAR indicated treatments were completed on 01/27/22 and 01/28/22 when the bandages were dated 01/23/22. Therefore, treatments could not have been completed on nine (9) of the seventeen (17) days ordered. On 02/01/22 at 3:23 PM, the above observations and conversations were discussed with the administrator. No further information was presented by the close of the survey. Review of the care plan on 02/03/22 at 10:50 AM, with the Minimum Data Set coordinator Employee #80 confirmed the resident's care plan to provide wound treatment to the venous ulcers was not completed as directed. b) Resident #73 Observation of the resident at 01/31/22 11:43 AM, found her right and left hands were closed in what appeared to be a contracture. No devices were present to prevent further decline. The resident was unable to be interviewed. Review of the medical record on 02/01/22 at 08:16 AM, found the most recent Minimum Data Set (MDS) a quarterly, with an Assessment Reference Date (ARD) of 12/08/21 found the resident was coded as having contractures on both hands. A significant change MDS with an ARD of 09/10/21 also coded the resident as having contractures on both hands. The prior MDS, a significant change, with an ARD of 06/03/21 found no contractures were present. Therefore, the contractures developed sometime between 06/03/21 and 09/10/21. Reviewed current physician orders found no orders for any devices for contracture prevention. Review of the current care plan found no interventions for the contractures of both hands. On 02/01/22 at 12:17 PM, the Director of the therapy company, Employee #41 said the resident was picked up for services on 09/02/21 for evaluation. E #41 said a carrot was recommended for use to the left hand. The Resident was discharged from services on 10/01/21. On 02/01/22 at 3:57 PM, Employee #80 the minimum data set coordinator, confirmed there were no orders and no care plan to address any contractures although the MDS confirmed the resident had contractures. She said she must have forgot to develop a care plan. E #80 said the resident has a carrot in her room because I've seen it in there. The surveyor and E #80 observed the resident in bed in her room. A carrot was found on the right side of the resident under her bed covers. When E #80 attempted to place the carrot in the palm of the resident's left hand, the resident cried out, My God I can't hold on to that, my God no no. On 02/01/22 at 4:07 PM, the Director of Nursing (DON) confirmed the resident should have had a physician's order for a carrot to be placed in the left hand. The DON was asked if there was any documentation to verify the carrot had been placed in the resident's left had after therapy recommendation on 10/01/21? The DON said there was no place to document usage but staff must have been trying to use it or it would not have been in the resident's bed. When asked if there were any treatments in place for the right hand, the DON replied, no. The DON said she was writing an order and nursing assistants would be able to document usage from now on. At 4:40 PM on 02/01/22, the DON provided an order for a carrot to be used in the left hand. On at breakfast and remove at lunch as the resident will allow. She said no treatment is ordered at this time for the right hand. On 02/02/22 at 1:45 PM, the administrator was advised of the above findings. No further evidence was provided by the close of the survey. c) Resident #49 On 01/31/22 at 12:59 PM, the resident said, I don't get my treatments to my pressure ulcer every day like ordered. The resident said the facility hired they hired 2 treatment nurses, a husband - and - wife team. When they have to push the medication cart, I don't get my treatments. Record review on 02/01/22 at 9:02 AM, found the resident has a Stage 4 pressure ulcer on the sacrum. Review of the treatment administration record (TAR) found an order for: Cleanse sacrum with saline wound cleanser, pat dry, pack wound with Maxorb AG Rope, apply skin prep to peri wound, cover with foam dressing BID (two times a day) and PRN (as needed) every day and night shift for Stage 4 pressure ulcer. The order was dated 12/22/21. Thirteen (13) treatments were not provided in January 2022: night shift treatment on 01/07/22 night shift treatment on 01/09/22 night shift treatment on 01/14/22 day shift treatment on 01/15/22 day and night shift treatments on 01/16/22 day and night shift treatment on 01/24/22 day shift treatment on 01/25/22 days and night shift treatments on 01/29/22 day and night shift treatments on 01/30/22 On 02/01/22 at 1:13 PM, the Director of Nursing (DON) confirmed the treatments on the above 13 occasions on the TAR were not initialed by a nurse indicating completion. The DON said the treatment nurses do not work on weekends and it is the responsibility of the nurse to provide treatments as it is the duty of any nurse assigned to the resident to complete treatments as directed. Review of the current care plan found a care plan, revised on 12/02/21 addressing the Stage 4 pressure area to the sacrum. The goal associated with the pressure ulcer was: The resident's wound to sacrum is a non healing wound; no worsening or signs and symptoms of worsening in 90 days. Interventions included: Provide wound treatment as ordered. On 02/01/22 at 1:13 PM, the DON confirmed the care plan was not implemented to provide treatment to the pressure area on the sacrum. .

CONCERN (E)

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

Quality of Care (Tag F0684)

Could have caused harm · This affected multiple residents

Read full inspector narrative →

. Based on observation, resident interview, record review, policy review, and staff interview, the facility to ensure one (1) resident received neurological (neuro) checks after a fall with injury to the head and failed to ensure three (3) residents received treatments for non-pressure related skin conditions. This was true for one (1) of three (3) residents reviewed for falls and for three (3) of four (4) residents reviewed for skin conditions, non-pressure related. Resident Identifiers: #107, #48, #101, and #39. Facility census: 113. Findings included: a) Facility Policy Review of the facility's policy entitled Falls Management, with a revision date of 06/01/21, instructed perform neurological evaluation for all unwitnessed falls and witnessed falls with injury to the head or face. b) Resident #107 An electronic health record review was completed on 02/01/22 at 7:30 PM. Resident #107 experienced a fall on 08/05/21 at 1:31 PM. LPN #86 documented resident fell and hit her head on the nurses station and Resident has hematoma to left forehead. There was no documented evidence reflecting a neurological evaluation was performed or neurological checks were initiated for resident. Resident #107 was transferred to the emergency room (ER) for treatment. LPN #78 documented, on 8/5/2021 at 8:00 PM, that Resident #107 had returned to facility. During an interview on 02/02/22 at 11:43 AM, the Director of Nursing (DON) acknowledged the nursing staff failed to perform a neurological evaluation and neurological checks, noting the focus had been on Resident #107 sustaining a fracture to her arm. e) Resident #39 During an interview on 01/31/22 at 1:16 PM with Resident #39, she stated that she had areas on her legs and her right foot. She stated that they don't do her treatments every day. Observation on 1/31/22 at 1:20 PM, Found no dressings to Resident 39's lower extremities. A medical record review for Resident #39 revealed an order: Cleanse 1st digit of right foot with wound cleanser, pat dry, apply Maxorb AG , cover with non-adherent foam pad and wrap with kerlix for venous ulcers. --01/15/22, was not signed off on day shift on the Treatment Administration Log (TAR) --01/16/22, was not signed off on day shift on the Treatment Administration Log (TAR) --01/24/22, was not signed off on day shift on the Treatment Administration Log (TAR) --01/25/22, was not signed off on day shift on the Treatment Administration Log (TAR) --01/26/22, was not signed off on day shift on the Treatment Administration Log (TAR) --01/29/22, was not signed off on day shift on the Treatment Administration Log (TAR) --01/30/22, was not signed off on day shift on the Treatment Administration Log (TAR) Continued review of Resident #39's Medical record found the order: Cleanse left lower extremity with wound cleanser, pat dry, wrap with calazime wrap, kling and coban every Monday, Wednesday, and Friday and as needed. --01/07/22, was not signed off on day shift on the Treatment Administration Log (TAR) --01/24/22, was not signed off on night shift on the Treatment Administration Log (TAR) --01/26/22, was not signed off on night shift on the Treatment Administration Log (TAR) During an interview on 02/02/22 at 11:05 AM with the Director of Nursing (DON), verified the treatments were not completed as ordered for Residents #39. c) Resident #48 On 01/31/22 at 11:55 AM, the resident said no one was treating and wrapping her legs that had sores because she was a diabetic. The resident pulled back the covers exposing the left and right lower legs. Both legs were wrapped with dressings from the knees to the ankles. The dressings on both the left and right legs were dated 01/23/22 with the initials of the nurse completing the treatment- CD. The resident said her legs were to be dressed daily. On 01/31/22 at 12:00 PM, the residents nurse was in the hallway with the medication cart. Registered Nurse #16 was asked about the residents treatments to the left and right lower extremities. RN #16 said the resident has an order for daily treatments and as need treatments (PRN.) RN #16 accompanied the surveyor to the resident's room and observed the dressing to both the left and right lower legs. RN #16 confirmed both dressings were dated 01/23/22. When asked whose initials were CD, she replied those are my initials and added she doesn't work every day. Record review on 02/01/22 10:23 AM, found an order to Cleanse RLE (right lower extremity) with wound cleanser, pat dry. Apply A&D ointment, cover with a non-adherent pad and wrap in kerlix. Change Q (every) Day and PRN (as needed.) ordered on 1/14/22. The same order was written for the LLE (left lower extremity.) The diagnosis associated with the treatments was, venous ulcers to right and left lower extremities. Review of the treatment administration record (TAR) found seven (7) days when treatments were missed just since 1/14/22: 01/14/22 01/16/22 01/24/22 01/25/22 01/26/22 01/29/22 01/30/22 On 01/27/22 and 01/28/22 the TAR noted the same nurse, RN #16 initialed she had completed the treatments, yet the date on tape on the bandages on both the left and right leg was dated 01/23/22 and both treatments had this same nurses initials-CD. A prudent person could conclude treatments were not completed on 01/27/22 and 01/28/22. 02/01/22 at 12:58 PM, the director of nursing (DON) reviewed the TAR with the surveyor and concluded treatments were not provided as ordered on 01/14/22, 01/16/22, 01/24/22, 01/25/22, 01/26/22, 01/29/22, and 01/30/22. The DON could not explain why the TAR indicated treatments were completed on 01/27/22 and 01/28/22 when the bandages were dated 01/23/22. Therefore, treatments could not have been completed on nine (9) of the seventeen (17) days ordered. On 02/01/22 at 3:23 PM, the above observations and conversations were discussed with the administrator. No further information was presented by the close of the survey. d) Resident #101 Review of the medical record found the resident had orders to cleanse skin tears on the RFA (right frontoanterior) and LFA (left frontoanterior) with wound cleanser, pat dry, apply sureprep to wound edges, and cover with dry dressing. Change every 7 days and PRN (an needed) until healed. A one time order to treat the LFA was written on 01/11/22. A second order was written on 01/18/22 to complete every 7 days. A treatment was provided on 01/18/22. The next treatment needed was 01/25/22. This treatment was not completed. On 01/11/22 a PRN order was written to cleanse ST #1 to RFA with wound cleanser, pat dry, apply sureprep to wound edges, and cover with dry dressing. Change every 7 days and PRN until healed. The resident never had any PRN treatment to ST #1 to RFA. On 01/18/22 a second order was written to cleanse ST #1 to RFA with wound cleanser, pat dry, apply sureprep to wound edges, and cover with dry dressing. Change every 7 days and PRN until resolved. This treatment was provided on 01/18/22. The next treatment was due on 01/25/22 and was never provided. On 01/11/22 an order was written for a PRN treatment to ST #2 to RFA with wound cleanser, pat dry, apply sureprep to wound edges, and cover with dry dressing. Change every 7 days and PRN until resolved. No treatments were ever provided for this order. On 01/18/22 a second order for ST #2 to RFA was written to cleanse with wound cleanser, pat dry, apply sureprep to wound edges, and cover with dry dressing. Change every 7 days and PRN until resolved. A treatment was provided on 01/18/22. The next treatment due was 01/25/22. This treatment was never provided. On 02/02/22 at 10:48 AM, the DON confirmed treatments were not completed as ordered. No further information was provided by the close of the survey. .

CONCERN (E)

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

Pressure Ulcer Prevention (Tag F0686)

Could have caused harm · This affected multiple residents

Read full inspector narrative →

. Based on observation, record review, and staff interview the facility failed to implement physician orders for treatments to promote the healing of pressure areas. This was true for three (3) of four (4) residents reviewed for pressure areas. Resident identifiers #1, #45 and #49. Facility census 113. a) Resident #1 During an interview on 01/31/22 at 12:48 PM with Resident #1, he stated that he has an area on his bottom that would not heal. A medical record review for Resident #1 revealed an order: Cleanse sacrum with wound cleanser, pat dry, apply sure prep to peri wound, apply pluragel to wound bed, cover with allevyn dressing every day and as needed, every day shift for unstageable pressure injury, with a start date 01/15/22. --01/26/22, Was not signed off on the Treatment Administration Log (TAR) --01/29/22, Was not signed off on the Treatment Administration Log (TAR) --01/30/22, Was not signed off on the Treatment Administration Log (TAR) --01/31/22, Was not signed off on the Treatment Administration Log (TAR) Continued review of Resident #1's Medical record found the order: Blue heel elevation to be in place as accountable to resident, monitor every shift for placement. Every day and night shift for prevention. --01/14/22, was not signed off on day shift on the Treatment Administration Log (TAR) --01/18/22, was not signed off on night shift on the Treatment Administration Log (TAR) --01/23/22, was not signed off on night shift on the Treatment Administration Log (TAR) --01/26/22, was not signed off on day shift on the Treatment Administration Log (TAR) --01/29/22, was not signed off on night shift on the Treatment Administration Log (TAR) --01/30/22, was not signed off on day shift on the Treatment Administration Log (TAR) --01/30/22, was not signed off on night shift on the Treatment Administration Log (TAR) --01/31/22, was not signed off on day shift on the Treatment Administration Log (TAR) b) Resident #45 On observation on 01/31/22 at 12:59 PM found an old dressing on Resident #45's left heal. A medical record review for Resident #45 revealed an order: Cleanse area to left heal with wound cleanser, pat dry, apply sure prep and cover with allevyn. Change every Monday, Wednesday, Friday, and as needed for a deep tissue injury. --01/07/22, was not signed off on the Treatment Administration Log (TAR) --01/24/22, was not signed off on the Treatment Administration Log (TAR) --01/28/22, was not signed off on the Treatment Administration Log (TAR) Continued review of Resident #1's Medical record found the order: Cleanse coccyx with hydrating cleansing foam, pat dry, apply Z-guard every shift and as needed for preventive measures. --01/07/22, was not signed off on day shift on the Treatment Administration Log (TAR) --01/07/22, was not signed off on night shift on the Treatment Administration Log (TAR) --01/14/22, was not signed off on night shift on the Treatment Administration Log (TAR) --01/16/22, was not signed off on day shift on the Treatment Administration Log (TAR) --01/16/22, was not signed off on night shift on the Treatment Administration Log (TAR) --01/24/22, was not signed off on day shift on the Treatment Administration Log (TAR) --01/24/22, was not signed off on night shift on the Treatment Administration Log (TAR) --01/25/22, was not signed off on day shift on the Treatment Administration Log (TAR) --01/26/22, was not signed off on day shift on the Treatment Administration Log (TAR) --01/29/22, was not signed off on day shift on the Treatment Administration Log (TAR) --01/29/22, was not signed off on night shift on the Treatment Administration Log (TAR) --01/30/22, was not signed off on day shift on the Treatment Administration Log (TAR) --01/30/22, was not signed off on night shift on the Treatment Administration Log (TAR) During an interview on 02/02/22 at 11:05 AM with the Director of Nursing (DON), verified the treatments were not completed as ordered for Residents #1 and #45. c) Resident #49 On 01/31/22 at 12:59 PM, the resident said, I don't get my treatments to my pressure ulcer every day like ordered. The resident said the facility hired they hired 2 treatment nurses, a husband - and - wife team. When they have to push the medication cart, I don't get my treatments. Record review on 02/01/22 at 9:02 AM, found the resident has a Stage 4 pressure ulcer on the sacrum. Review of the treatment administration record (TAR) found an order for: Cleanse sacrum with saline wound cleanser, pat dry, pack wound with Maxorb AG Rope, apply skin prep to peri wound, cover with foam dressing BID (two times a day) and PRN (as needed) every day and night shift for Stage 4 pressure ulcer. The order was dated 12/22/21. Thirteen (13) treatments were not provided in January 2022: night shift treatment on 01/07/22 night shift treatment on 01/09/22 night shift treatment on 01/14/22 day shift treatment on 01/15/22 day and night shift treatments on 01/16/22 day and night shift treatment on 01/24/22 day shift treatment on 01/25/22 days and night shift treatments on 01/29/22 day and night shift treatments on 01/30/22 On 02/01/22 at 1:13 PM, the Director of Nursing (DON) confirmed the treatments on the above 13 occasions on the TAR were not initialed by a nurse indicating completion. The DON said the treatment nurses do not work on weekends and it is the responsibility of the nurse to provide treatments as it is the duty of any nurse assigned to the resident to complete treatments as directed. .

CONCERN (E)

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

Respiratory Care (Tag F0695)

Could have caused harm · This affected multiple residents

Read full inspector narrative →

. Based on observation, medical record review, and interview, the facility failed to deliver respiratory care services consistent with professional standards of practice. This includes not following the Physicians order for the appropriate liters of oxygen provided, not supplying the appropriate oxygen mask, not storing oxygen supplies properly and not changing and dating the oxygen tubing as per the policy and procedure. This is based on five (5) of five (5) residents reviewed during the survey process. Resident identifiers: #1, #32, #51, #415 and #416. Facility census: 113 Findings included: a) Resident #416 On 1/31/22 at 11:13 AM based on observation Resident #416s' oxygen tubing for her nasal canula was found to have no date on it. This was confirmed with Licensed Practical Nurse (LPN) #58 on 1/31/22 at 11:15 AM. Per Policy and Procedure the oxygen tubing and storage containers for all respiratory supplies are to be changed weekly and dated on the change out date. b) Resident #415 On 1/31/22 at 11:20 AM based on observation Resident #415s' oxygen tubing for his nasal canula was found to have no date on it and the oxygen tubing was on the floor. This was confirmed with Licensed Practical Nurse (LPN) #58 on 1/31/22 at 11:30 AM. Per Policy and Procedure the oxygen tubing and storage containers for all respiratory supplies are to be changed weekly and dated on the change out date and to be stored in a storage bag when not in use. c) Resident #32 On 1/31/22 at 11:10 AM based on observation Resident #32 has a trilogy at bedside. The Resident states she uses it at night. The tubing was dated 12-1-21 and the tubing was on the floor. This was confirmed with Licensed Practical Nurse (LPN) #58 on 1/31/22 at 11:10 AM. The Resident has a medical diagnosis of acute and chronic respiratory failure. Per Policy and Procedure the oxygen tubing and storage containers for all respiratory supplies are to be changed weekly and dated on the change out date and to be stored in a storage bag when not in use. d) Resident #1 An observation on 01/31/22 at 12:49 PM found, Resident #1's continuous positive airway pressure (CPAP) machine mask and tubing was laying on the bed side stand without being placed in a protective bag. On 02/01/22 3:20 PM a second observation CPAP face mask laying on nightstand without a protective cover. An interview on 03/08/21 at 02:58 PM with License Practical Nurse (LPN) #32- confirmed that Resident #1's CPAP mask should be placed in a protective bag when not in use. e) Resident #51 An interview, on 01/31/22 at 12:06 PM, Resident #51 stated the oxygen was suppose to be on four (4) liters. An observation, on 01/31/22 at 12:06 PM, showed Resident #51's oxygen concentrator was set at two (2) liters per minute. Review of Resident #51's medical record showed a physician order dated 01/28/22 that stated, O2 via N/C @ 3 liters PRN for shortness of breath. An interview, on 02/02/22 at 8:20 AM, with Registered Nurse (RN) #37 verified Resident # 51's oxygen concentrator was set at two (2) liters and was wrong per physician order. .

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 →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . d) Resident #10's Room (Facility's Common Room turned into a COVID-19 Positive Room) On 02/01/22 at 1:00 PM, Surveyor observed Activities Worker #112 enter Resident #10's COVID-19 positive isolation room wearing the appropriate PPE. Surveyor then observed Activities Worker #112 exit Resident #10's room with PPE still on. Activities Worker #112 then removed her gloves, placed them in the designated trash bin outside of resident's room, doffed her gown, and placed it in the designated dirty gowns bin outside of resident's room. An interview with Activities Worker #112 at 1:08 PM, revealed she always doffs her PPE in the hallway. Activities Worker #112 stated that is what staff is supposed to do, as the trash bin and dirty gowns bin were outside of the resident's room. c) Laundry Room Record review of the facility's policy titled, Infection Control Policies and Procedure, revision date 06/07/21, showed that staff are to use a facemask / respirators and eye protection while in the center. An observation on 02/02/22 at 9:10 AM found, housekeeper #72 folding clothes in the clean area of the laundry room without wearing Personal Protective Equipment (PPE) During an Interview on 02/02/22 at 9:10 PM with Housekeeper #72 she stated that she does not wear a mask or face shield in the clean side of laundry. She stated she only wears PPE on the dirty side. On 02/02/22 at 9:15 AM Health Care Services #43 entered the laundry area and ask E#72 to don her mask and face shield. During an Interview on 02/02/22 at 9:38 AM with the Infection Preventionist, she verified housekeeper #72 should always have a mask and face shield on while working. Based on observation, staff interview and policy review the facility failed to practice safe donning and doffing procedures of personal protective equipment (PPE) when entering and exiting Covid positive Resident rooms and common areas. These were random opportunities for discoveries. The failed practice had the potential to affect more than unlimited number of residents. Room identifier: #42, laundry room, and Resident #10's common room. Facility census: 113. Findings included: Record review of the facility's policy titled, IC 300 Airborne Infection Isolation Precautions, revised on 11/15/21, showed before exiting room, remove and bag PPE and perform hand hygiene. a) room [ROOM NUMBER] (first incident) An observation, on 02/01/22 at 12:30 PM, showed room [ROOM NUMBER] identified as a Covid positive room with isolation precaution signs and a zippered door barrier. Nurse Aid (NA) #8 was observed exiting room [ROOM NUMBER] with personal protective equipment (PPE) on and doffed the PPE in the hallway of South long hall. South long hall contained both Covid positive resident rooms and non-Covid positive resident rooms. An interview, on 02/01/22 at 12:32 PM, NA #8 stated, I always doff in the hallway because if I take the PPE off in the room before coming out then I will expose my clothes. b) room [ROOM NUMBER] (second incident) An observation, on 02/01/22 at 12:50 PM, showed room [ROOM NUMBER] identified as a Covid positive room with isolation precaution signs and a zippered door barrier. Licensed Practical Nurse (LPN) #78 donned gown by putting the gown over both arms and entered room [ROOM NUMBER] without tying the back of the neck or back area of the gown. An interview, on 02/01/22 at 12:52 PM, with LPN #78, stated the inability to physically tie the back of gown and that the gowns available are too small. .

Understanding Severity Codes (click to expand)

Life-Threatening (Immediate Jeopardy)

J - Isolated K - Pattern L - Widespread

Actual Harm

G - Isolated H - Pattern I - Widespread

Potential for Harm

D - Isolated E - Pattern F - Widespread

No Harm (Minor)

A - Isolated B - Pattern C - Widespread

Questions to Ask on Your Visit

"What changes have you made since the serious inspection findings?"
"What safeguards are in place to prevent abuse and neglect?"
"Can I speak with families of current residents?"
"What's your RN coverage like on weekends and overnight?"

Our Honest Assessment

Strengths

• Licensed and certified facility. Meets minimum state requirements.

Concerns

• Multiple safety concerns identified: Federal abuse finding, 6 life-threatening violation(s), Special Focus Facility, 2 harm violation(s), $108,423 in fines. Review inspection reports carefully.
• 99 deficiencies on record, including 6 critical (life-threatening) violations. These warrant careful review before choosing this facility.
• $108,423 in fines. Extremely high, among the most fined facilities in West Virginia. Major compliance failures.
• Grade F (0/100). Below average facility with significant concerns.

Bottom line: This facility has a substantiated abuse finding. Extreme caution advised. Explore alternatives.

Email me this report

About This Facility

What is Cedar Ridge Center's CMS Rating?

CMS assigns CEDAR RIDGE CENTER an overall rating of 1 out of 5 stars, which is considered much below average nationally. Within West Virginia, this rating places the facility higher than 0% of the state's 100 nursing homes. A rating at this level reflects concerns identified through health inspections, staffing assessments, or quality measures that families should carefully consider.

How is Cedar Ridge Center Staffed?

CMS rates CEDAR RIDGE CENTER's staffing level at 1 out of 5 stars, which is much below average compared to other nursing homes. Staff turnover is 54%, compared to the West Virginia average of 46%.

What Have Inspectors Found at Cedar Ridge Center?

State health inspectors documented 99 deficiencies at CEDAR RIDGE CENTER during 2022 to 2025. These included: 6 Immediate Jeopardy (the most serious level, indicating potential for serious harm or death), 2 that caused actual resident harm, and 91 with potential for harm. Immediate Jeopardy findings are rare and represent the most serious regulatory concerns. They require immediate corrective action.

Who Owns and Operates Cedar Ridge Center?

CEDAR RIDGE 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 119 certified beds and approximately 106 residents (about 89% occupancy), it is a mid-sized facility located in SISSONVILLE, West Virginia.

How Does Cedar Ridge Center Compare to Other West Virginia Nursing Homes?

Compared to the 100 nursing homes in West Virginia, CEDAR RIDGE CENTER's overall rating (1 stars) is below the state average of 2.7, staff turnover (54%) is near the state average of 46%, and health inspection rating (1 stars) is much below the national benchmark.

What Should Families Ask When Visiting Cedar Ridge Center?

Based on this facility's data, families visiting should ask: "What changes have been made since the serious inspection findings, and how are you preventing similar issues?" "What safeguards and monitoring systems are in place to protect residents from abuse or neglect?" "Can you walk me through typical staffing levels on day, evening, and night shifts?" "Can I visit during a mealtime to observe dining assistance and food quality?" These questions are particularly relevant given the facility's Immediate Jeopardy citations, the substantiated abuse finding on record, and the below-average staffing rating.

Is Cedar Ridge Center Safe?

Based on CMS inspection data, CEDAR RIDGE CENTER has documented safety concerns. The facility has 1 substantiated abuse finding (meaning confirmed case of resident harm by staff or other residents). Inspectors have issued 6 Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death). The facility is currently on the Special Focus Facility watch list (a federal program monitoring the lowest-performing 1% of nursing homes nationwide). The facility has a 1-star overall rating and ranks #100 of 100 nursing homes in West Virginia. Families considering this facility should ask detailed questions about what corrective actions have been taken since these incidents.

Do Nurses at Cedar Ridge Center Stick Around?

CEDAR RIDGE CENTER has a staff turnover rate of 54%, which is 7 percentage points above the West Virginia average of 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 Cedar Ridge Center Ever Fined?

CEDAR RIDGE CENTER has been fined $108,423 across 3 penalty actions. This is 3.2x the West Virginia average of $34,163. Fines at this level are uncommon and typically indicate a pattern of serious deficiencies, repeated violations, or failure to correct problems promptly. CMS reserves penalties of this magnitude for facilities that pose significant, documented risk to resident health or safety. Families should request specific documentation of what issues led to these fines and what systemic changes have been implemented.

Is Cedar Ridge Center on Any Federal Watch List?

CEDAR RIDGE CENTER is currently an SFF Candidate, meaning CMS has identified it as potentially qualifying for the Special Focus Facility watch list. SFF Candidates have a history of serious deficiencies but haven't yet reached the threshold for full SFF designation. The facility is being monitored more closely — if problems continue, it may be added to the official watch list. Families should ask what the facility is doing to address the issues that led to this status.

Facility Details

Beds: 119
Avg. Residents: 106
Occupancy: 89.3%
Ownership: For profit - Corporation
Chain: GENESIS HEALTHCARE
Medicare: Yes
Medicaid: Yes
Sprinklers: Yes

Trust Score Breakdown

Base Score: 50
1-Star Rating: +0
6 Immediate Jeopardy citations: -72
2 Actual Harm citations: -10
99 Deficiencies: -10
Fines ($108,423): -15
Abuse Finding: -15
Special Focus Facility: -20
Final Score: 0/100

Nearby Alternatives

THOMAS HOSPITALS SKILLED NURSI... 5-star MEADOWBROOK ACRES 4-star VALLEY CENTER 4-star

View all in SISSONVILLE →

Check Bed Availability

Data: CMS Medicare Care Compare

Updated: November 2025

Facility ID: 515087