WAYNE HEALTHCARE CENTER
For profit - Corporation
60 Beds
COMMUNICARE HEALTH
Data: November 2025
Trust Grade
80/100
#12 of 122 in WV
Last Inspection: March 2025
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
Wayne Healthcare Center in Wayne, West Virginia, has a Trust Grade of B+, indicating that it is above average and recommended for families considering care options. Ranked #12 out of 122 facilities in the state, it is in the top half, and it is the only nursing home in Wayne County. The facility is improving, with the number of issues decreasing from 14 in 2024 to 7 in 2025. Staffing is average with a 3/5 star rating and a turnover rate of 35%, which is lower than the state average of 44%, suggesting that staff members are relatively stable. While the facility has no fines on record, which is a positive sign, there have been some concerning incidents. For example, chocolate milk was found past its expiration date, and a bedpan was left on the bathroom floor for multiple observations, raising sanitation concerns. Additionally, there were issues with maintaining accurate medical records for several residents. Overall, Wayne Healthcare Center has both strengths and weaknesses, making it essential for families to weigh these factors in their decision-making process.
- Trust Score
- B+
- In West Virginia
- #12/122
- Safety Record
- Low Risk
- Inspections
- Getting Better
- Staff Stability ○ Average
- 35% turnover. Near West Virginia's 48% average. Typical for the industry.
- Penalties ✓ Good
- No fines on record. Clean compliance history, better than most West Virginia facilities.
- Skilled Nurses ✓ Good
- Each resident gets 42 minutes of Registered Nurse (RN) attention daily — more than average for West Virginia. RNs are trained to catch health problems early.
- Violations ⚠ Watch
- 35 deficiencies on record. Higher than average. Multiple issues found across inspections.
80/100
Top 9%
No red flags
14 → 7 violations
★★★★★
5.0
Overall Rating
★★★☆☆
3.0
Staff Levels
★★★★★
5.0
Care Quality
★★★★☆
4.0
Inspection Score
↔
Stable
2024: 14 issues
2025: 7 issues
The Good
-
5-Star Quality Measures · Strong clinical quality outcomes
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
-
Staff turnover below average (35%)
13 points below West Virginia average of 48%
Facility shows strength in quality measures, fire safety.
The Bad
Staff Turnover: 35%
11pts below West Virginia avg (46%)
Typical for the industry
Chain: COMMUNICARE HEALTH
Part of a multi-facility chain
Ask about local staffing decisions and management
The Ugly 35 deficiencies on record
Mar 2025
7 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Notification of Changes
(Tag F0580)
Could have caused harm · This affected 1 resident
Based on document review and staff interview, the facility failed to notify the family of one (1) of seven (7) residents that the resident had sustained a fall and was transferred to the hospital. Res...
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Based on document review and staff interview, the facility failed to notify the family of one (1) of seven (7) residents that the resident had sustained a fall and was transferred to the hospital. Resident identifier: #111. Facility census: 59.
Findings include:
a) Resident #111
On 03/26/25 at approximately 3:55 p.m., upon review of the resident's change of condition form, it is documented resident own poa (power of attorney). The surveyor could not locate in the electronic medical record where family emergency contact was contacted regarding the resident's serious accident and transfer to the hospital.
b) On 03/27/25 at approximately 11:02 a.m., interview with employee #55 the employee verified that there was no documentation that family was notified regarding the significant change in the resident's condition. This was also acknowledged by the facility's Administrator upon exit on 03/27/25 at approximately 4:15 p.m.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Transfer Notice
(Tag F0623)
Could have caused harm · This affected 1 resident
Based on record review and staff interview, the facility failed to notify the State Ombudsman of an acute care transfer for Resident #23. This was true for one (1) of three (3) residents reviewed unde...
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Based on record review and staff interview, the facility failed to notify the State Ombudsman of an acute care transfer for Resident #23. This was true for one (1) of three (3) residents reviewed under the care area of hospitalizations. Resident Identifier: #23. Facility Census: 59.
Findings Include:
a) Resident #23
On 03/26/25 at 10:22 AM, an initial interview was held with Resident #23. Resident #23 stated, I've had to go to the hospital, I was pretty sick. A record review was completed on 03/26/25 at 1:30 PM. The review found the resident had been sent to an acute care facility on 08/14/24 for an abnormal abdominal x-ray.
On 03/26/25 at 6:05 PM, an interview was held with the Administrator. The Administrator confirmed the State Ombudsman was not notified of the resident's transfer. The Administrator stated, we don't have the Ombudsman notification for 08/14/24.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to develop the care plan, which included all diagnoses for Resid...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to develop the care plan, which included all diagnoses for Resident #57. This was true for one (1) of five (5) residents reviewed under the care area of unnecessary medications. Resident identifier: #57. Facility census: 59.
Findings include:
a) Resident #57
On 03/26/25 at 2:52 PM, a record review was completed for Resident #57. The resident was admitted to the facility on [DATE]. The review found the care plan did not include all diagnoses for Resident #57. The following diagnoses were not included:
--generalized muscle weakness
--difficulty in walking, not elsewhere classified
--dysphagia, oral phase
--personal history of transient ischemic attach (TIA)
--cerebral infarction without residual deficits (CVA)
--essential (primary) hypertension (HTN)
--hyperlipidemia, unspecified (HLD)
--type 2 diabetes mellitus with diabetic neuropathy, unspecified (DM)
--hypothyroidism, unspecified
--benign prostatic hyperplasia without lower urinary tract symptoms (BPH)
--generalized anxiety disorder (GAD)
--gastro-esophageal reflux disease without esophagitis (GERD)
--acquired absence of the left leg above the knee (AKA)
On 03/27/25 at 9:20 AM, an interview was held with Minimum Data Set (MDS) Registered Nurse (RN) #14. The MDS RN #14 stated, the care plan is in progress .I haven't updated it yet.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0657
(Tag F0657)
Could have caused harm · This affected 1 resident
b) Resident #13
Review of Resident #13's comprehensive care plan showed the following focus, The resident is at risk for pain/discomfort r/t [related to] history of left femur fracture repair s/p [st...
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b) Resident #13
Review of Resident #13's comprehensive care plan showed the following focus, The resident is at risk for pain/discomfort r/t [related to] history of left femur fracture repair s/p [status post] ORIF [open reduction internal fixation], rheumatoid arthritis, muscle spasms, diabetic neuropathy, restless leg syndrome, edema, PVD [peripheral vascular disease].
The following intervention was initiated on 09/26/24, Provide medication, Ultram, per orders. Monitor for s/sx [signs and symptoms] of side effects. Evaluate effectiveness of medication.
Review of Resident #13's physicians' orders showed the resident was currently receiving gabapentin twice a day for nerve pain and Tylenol three (3) times a day for pain. The resident had received Ultram as needed from 09/25/24 through 10/09/24 and Ultram two (2) times a day from 02/03/25 through 02/17/25.
On 03/26/25 at 5:04 PM, Registered Nurse (RN) #14 confirmed Resident #13's comprehensive care plan had not been revised when the resident's Ultram for pain had been discontinued.
No further information was provided through the completion of the survey.
Based on record review and staff interview, the facility failed to revise care plans for Resident #12, related to isolation precautions and Resident #13, related to pain medication. This was true for two (2) of 23 resident care plans reviewed during the survey process. Resident identifiers: #12, #13. Facility census: 59.
Findings include:
A) Resident #12
During review of Resident #12's care plan on 03/26/25, it was noted the resident was recently discharged from the hospital on IV vancomycin, after being diagnosed with Methicillin-resistant Staphylococcus aureus (MRSA) and a Urinary Tract Infection due to Extended Spectrum Beta-Lactamases (ESBL). The resident was placed on isolation precautions upon return from the hospital, however, the resident's care plan was not revised to reflect those isolation precautions.
At approximately 2:50 PM on 3/27/2025, the isolation precautions omission was acknowledged by Electronic Health Records Coordinator Licensed Practical Nurse (EHCLPN) #55 and MDS Registered Nurse (MDSRN) #14. MDS RN #14 stated, I guess it just hadn't found its way into the care plan yet, but I will put it in there now.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
Based on record Review and Staff interview, the facility failed to ensure treatment and care was provided in a timely manner for a resident with a fall with major injury for 1 out of 7 residents revie...
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Based on record Review and Staff interview, the facility failed to ensure treatment and care was provided in a timely manner for a resident with a fall with major injury for 1 out of 7 residents reviewed for falls. Resident identifier: #27. Facility Census: 59.
Findings included:
a) Resident #27
On 12/30/24, the resident had an unwitnessed fall. The incident note on 12/30/24 at 10:20 AM stated, This UCN (Unit Charge Nurse) noted resident laying on the floor in hallway by window sitting on bottom with leg extended in front of him. Resident stated, I think I broke my hip. Assess resident no signs of injury at this time. After getting resident back into wheelchair, resident denies pain with ROM. The Progress Note stated, the Nurse Practitioner was contacted and new orders were obtained for x-ray of the right hip and pelvis. No complaints of pain at this time were documented and the Power of Attorney was notified.
On 12/31/2024 at 6:07 PM, x-ray of right hip and pelvis was completed.
On 01/01/2025 at 5:36 AM, the nurse's progress note stated that x-ray results were not obtained on this shift.
On 01/01/2025 at 2:20 PM, Lab/Radiology results were obtained per the nurse's progress note.
On 01/01/2025 at 3:58 PM, the nursing progress report stated an x-ray was completed with a diagnosis of right hip fracture and possible right occult fracture. Physician recommendation was to transfer to the emergency room for evaluation.
On 03/26/25 at 05:56 PM the Director of Nursing (DON) was interviewed concerning the amount of time it usually takes for an x-ray to be ordered, and results obtained. The DON reported that the physician was contacted for an unwitnessed fall. If a stat x-ray is ordered, it usually takes between eight (8) to twelve (12) hours to get the x-ray completed and they call the doctor to see if they want the resident to be sent out. The DON reported it usually takes about an hour to obtain the results.
On 03/27/25 at 09:55 AM, the surveyor reviewed and confirmed a delay in treatment with the DON concerning Resident #27. The DON stated, I think he was one that didn't complain of pain.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
Based on 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 transmi...
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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. The facility failed to follow accepted procedures for transmission-based precautions. These were random opportunities for discovery. Resident identifiers: #26 and #22. Facility census: 59.
Findings included:
a) Resident #26
The facility's policy titled, Enhanced Barrier Precautions, with approval effective date 04/01/25, stated that, for residents in enhanced barrier precautions, a sign would be posted on the resident's door to indicate enhanced barrier precautions were required.
Review of Resident #26's physicians' orders showed the resident had the following order written on 03/18/25, Enhanced barrier precautions related to: dressing. When dressing/bathing, showering/transferring in room or therapy gym/personal hygiene, changing linen, providing hygiene, changing briefs or assisting with toileting.
The resident also had an order written on 03/14/25 to cleanse pressure wound to outer great left toe with wound cleanser, dry, and apply calcium alginate to wound bed and cover with bordered gauze dressing daily.
During an observation on 03/26/25 at 10:54 AM, there were no indications the resident required enhanced barrier precautions. The resident's door did not have a sign to indicate enhanced barrier precautions were required for the resident.
On 03/26/25 at 12:02 PM, the Assistant Director of Nursing confirmed Resident #26 was in enhanced barrier precautions due to a dressing but did not have signage to indicate she required enhanced barrier precautions on her door.
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.
b) Resident #22
On 03/26/25 at 12:31 PM, Registered Nurse (RN) #68 was observed taking a meal tray into Resident #22, who was under contact precautions for Extended Spectrum Beta-Lactamese (ESBL) in the urine. ESBL is a multi-drug resistant organism (MDRO). Contact precautions are implemented to prevent the spread of infections that can be transmitted through direct and indirect contact with a resident and their environment.
The Signage, provided by the Centers for Disease Control and Prevention (CDC), is to indicate the resident is on contact precautions. The signage was hanging on the door to the resident's room. The signage states, STOP CONTACT PRECAUTIONS EVERYONE MUST: Clean their hands, including before entering and when leaving the room. PROVIDERS AND STAFF MUST ALSO: Put on gloves before room entry. Discard gloves before room exit. Put on gown before room entry. Discard gown before room exit. Do not wear the same gown and gloves for the care of more than one person. Use dedicated or disposable equipment. Clean and disinfect reusable equipment before use on another person. (Typed as written.)
On 03/26/25 at 1:41 PM, Unit Manager (UM) #55 was notified and confirmed the resident was on contact precautions and RN #68 should have worn PPE upon entering the resident's room.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Medical Records
(Tag F0842)
Could have caused harm · This affected multiple residents
Based on record review and staff interview, the facility failed to ensure a complete and accurate medical record for Resident #23's date of an acute care transfer, the indication of a medication for R...
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Based on record review and staff interview, the facility failed to ensure a complete and accurate medical record for Resident #23's date of an acute care transfer, the indication of a medication for Resident #3 and pressure ulcer staging for Resident #12. This was true for three (3) of 23 residents reviewed during the survey process. Resident Identifiers: #23, #3 and #12. Facility Census: 59.
Findings Include:
a) Resident #23
On 03/26/25 at 10:22 AM, an initial interview was held with Resident #23. Resident #23 stated, I had to go to the hospital .I was so sick.
The record review found the resident had been transferred to an acute care facility on 12/04/24 due to an abnormal abdominal x-ray. The date documented on the transfer form was 08/14/24. Upon further review, the fax confirmation sheet had the date circled with a notation stating wrong date. (Typed as written.)
On 03/26/25 at 6:05 PM, the Administrator confirmed the date on the transfer form was incorrect.
b) Resident #3
On 03/27/25 at 10:00 AM, a record review was completed for Resident #3. The review found the resident was prescribed Melatonin 3 (three) mg (milligram) 2 (two) tablets by mouth at bedtime for inability to fall asleep. (Typed as written.)
On 03/27/25 at 10:20 AM, the Unit Manager (UM) #55 was notified of the incorrect indication for the medication. The UM #55 confirmed the indication for the medication was incorrect.
c) Resident #12
Upon review of Resident #12's nursing admission assessment, the resident was noted to have a stage three (3) pressure wound upon admission to the facility. However, upon review of the dietary nutritional assessment, completed by the Registered Dietitian (RD), the wound was noted to be stage one (1). In a subsequent progress note, the RD noted the wound was a stage three (3).
This inaccuracy was acknowledged by Electronic Health Records Coordinator Licensed Practical Nurse (EHCLPN) #55 at approximately 2:50 PM on 03/27/25.
May 2024
14 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Resident Rights
(Tag F0550)
Could have caused harm · This affected 1 resident
.
Based on resident observation, resident interview, and staff interview the facility failed to ensure Resident #54 was treated with dignity and respect. This was true for one (1) of seven (7) residen...
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.
Based on resident observation, resident interview, and staff interview the facility failed to ensure Resident #54 was treated with dignity and respect. This was true for one (1) of seven (7) residents reviewed for the care area of dignity during the long term care survey process. Resident identifier: #54. Facility census: 60.
Findings include :
A) Resident #54
On 4/29/24 at 1:44 PM, Resident #54 was observed with long chin hairs which needed to be removed. An interview with Resident #54 on 4/30/24 at 4:10 PM, confirmed she did not like having chin hair and she would like it removed.
The Director of Nursing was present during the resident interview and agreed her chin hair needed removed. She stated she would do that now.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0552
(Tag F0552)
Could have caused harm · This affected 1 resident
.
Based on record review and staff interview the facility failed to inform the resident or resident representative, in advance, by the physician or other practitioner or professional, of the risks and...
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.
Based on record review and staff interview the facility failed to inform the resident or resident representative, in advance, by the physician or other practitioner or professional, of the risks and benefits of the proposed use of an antipsychotic medication. This was true for one (1) of five (5) sampled residents in the long term survey process. Resident identifier: #36. Facility census: 60
Findings include:
a) Resident #36
On 05/01/24 at 12:42 PM, a review of Resident #36's medical record noted Resident #36 was receiving an antipsychotic medication Rispirdone which was ordered 03/07/24. Upon further review it was noted there was no documentation education related to the risks and benefits of the antipsychotic medication was provided to Resident #36's healthcare decision maker prior to the resident being started on the medication.
On 05/01/24 at approximately 2:00 PM, an interview was conducted with the Director of Nursing who acknowledged the education related to the risks and benefits of the use of the antipsychotic medication was not completed prior to the medication being started.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0582
(Tag F0582)
Could have caused harm · This affected 1 resident
.
Based on record review and staff interview the facility failed to issue a beneficiary notification within appropriate time frames. This was true for one (1) of three (3) residents reviewed for benef...
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.
Based on record review and staff interview the facility failed to issue a beneficiary notification within appropriate time frames. This was true for one (1) of three (3) residents reviewed for beneficiary notifications during the long term care survey process. Resident identifier # 111. Facility Census 60.
Findings include:
A) Resident #111
A review of Resident #111's medical record on 05/01/24 found her last covered day of Medicare services was 12/14/23. A review of her notice of medicare non-coverage (nomnc) Centers for Medicare and Medicaid Services (CMS) form 10123 found it was issued to the responsible party on 12/14/23. The form indicated the appeal needed to be filed on 12/13/23 which was one day before the responsible party was notified. This made the appeal process inaccessible to the residents responsible party.
An interview with the Nursing Home Administrator on 05/01/24 at 10:30 AM, confirmed Resident # 111's NOMNC was not issued two (2) days prior to her last covered day as required.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on observations and staff interviews the facility failed to ensure the residents were provided a safe, functional, sanit...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on observations and staff interviews the facility failed to ensure the residents were provided a safe, functional, sanitary, and comfortable homelike environment. This was evident by soiled equipment, holes in walls and a dirty bathroom. These were random opportunities of discovery during the long term care survey process and had the potential to affect a limited number of residents. Resident Room Identifiers: room [ROOM NUMBER]A, Room # A14B, and Room #B14. Census: 60.
Findings Include:
a) room [ROOM NUMBER]A
On 04/29/24 at 12:37 PM, during a tour of the facility, room [ROOM NUMBER]A was identified to have a piece of equipment in the bathroom which appeared to be soiled on the platform where you would place your feet to stand.
On 04/29/24 at 12:40 PM, during an interview with Licensed Practical Nurse (LPN) # 45 and LPN #65, the equipment was identified to be a turn and positioning device the resident stands on to be assisted to turn. LPN #45 stated the platform to stand on was filthy. Neither LPN #45 nor LPN #65 were aware of what the cleaning requirements were for this equipment.
On 04/30/24 at 11:50 AM, during an interview with the Administrator, the Policies and Standard Procedures for Infection Control Practices for Maintenance Department, Category noted to be Nursing, was provided. It was identified under the Procedures outlined in Section V. Maintenance and repair of equipment used for resident care that the equipment will be cleaned by staff or housekeeping for visible contaminated blood or other body fluids. The Administrator acknowledged the equipment was not properly cleaned and sanitary for the residents use.
b) Room A14-B
During an observation on 04/29/24 at 11:23 AM, two holes in the wall were observed behind the B bed in room [ROOM NUMBER] on the A-wing, The holes were observed on each side of the over the bead light.
A Staff interview on 04/30/24 at 4:20 PM, with the Administrator confirmed the over head light had been replaced and the holes from the previous light remained in the wall. I will have these fixed as soon as possible, thank you.
c) B14
On 04/29/24 at 12:24 PM, the bathroom for room B14 was observed and a brown substance was smeared on the floor by the toilet. An additional observation of the bathroom for room B14 was made on 04/29/24 at 11:30 AM, found the same brown substance on the floor.
On 04/30/24 at 11:40 AM, the director of plant maintenance confirmed the floor needed cleaned. He indicated the room should be cleaned daily.
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
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on record review and staff interview, the facility failed to ensure Resident #30 was free from abuse which includes free...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on record review and staff interview, the facility failed to ensure Resident #30 was free from abuse which includes freedom from resident to resident altercations and #16 was free from inappropriate language from a staff member. This is true for two (2) of two (2) residents reviewed during the survey.
This will be cited as past non compliance because the facility identified what had happened and took immediate steps to correct the failure to ensure it does not reoccur. All components of the of plan of correction were completed prior to this survey beginning.
This did occur and because Resident #30 did not have the cognitive ability to indicate how this affected her the reasonable person standard was applied. A reasonable person would suffer psychosocial harm from being hit by another resident residing in the same facility as her therefore this will be cited as actual harm at past non compliance for Resident #30. Resident #16 voiced to staff that hearing the nurse aide using profanity about caring for her made her upset also resulting in actual harm for Resident #16. Resident Identifier: #30 and #16. Facility Census: 195.
Findings Include:
a) Resident #30
On 04/30/24 at 11:00 AM, a record review was completed for Resident #30. The record review found a documented incident which occurred on 03/28/24 at 3:00 PM. A witnessed allegation of Resident #57 hitting Resident #30 in the left eye was reported by the Activities Director #54. This was also witnessed by two (2) guests.
Resident #30 was admitted to the facility on [DATE]. The resident had the following diagnoses:
- Alzheimer's disease with late onset
- Dementia in other diseases classified elsewhere, unspecified severity, with other behavioral disturbances
- Hypertensive chronic kidney disease with Stage 1 through stage 4 chronic kidney disease or unspecified kidney disease
- Chronic kidney disease, Stage 4 (Severe)
- Anemia in Chronic Kidney disease
- Primary generalize osteoarthritis
- Essential primary hypertension
- Atherosclerotic heart disease of native coronary artery without angina pextoris
- Type 2 diabetes mellitus with diabetic chronic kidney disease
- Iron deficiency anemia secondary to blood loss (chronic)
- Other seasonal allergic rhinitis
- Vitamin D deficiency, unspecified
- Major Depressive Disorder, Recurrent, moderate.
- Insomnia due to medical condition
- Generalize anxiety disorder.
- Muscle weakness (generalized)
- History of falling
- Type 2 diabetes mellitus with hyperglycemia
- Dysphagia, oral phase
- Personal history of COVID-19
- Hypotension, unspecified
- Personal history of (healed traumatic fracture of the right hip
- Slow transit constipation
The Quarterly Minimum Data Set (MDS) dated [DATE] was reviewed on 04/30/24 at 12:30 PM. The Brief Interview of Mental Status (BIMS), found under section C, a score of -04- (four), which indicates moderate cognitive impairment. The resident does not have capacity according to the Physicians Determination of Capacity form dated 03/02/23 and has a resident representative in place.
On 04/30/24 at 01:45 PM, a review of the facility reportable was completed. The review found a reportable dated 03/28/24. The incident took place on 03/28/24 at approximately 3:00 PM. The allegation was Resident #57 hit Resident #30 in the left eye. The incident was reported to the Physician by the Activities Director #54 who witnessed the incident. The reportable was faxed to all appropriate state agencies.
The investigation started immediately on 03/28/24. A written statement was obtained from the Activity Director #54 who states she was talking to (Resident #57) concerning his eye and (Resident #30) pointed at him and he hit her in the left eye. There were two (2) guest that also witnessed the incident. Their statements were #1 he was talking and just hit her in the face, witness #2 it looked like an accident, he went to push away her hand and accidentally hit her in the face.
The Activities Director #54 immediately separated the residents and summoned the Physician which was in house and was instructed to place a cold compress on her eye. Resident #57 was placed on one on one (1:1) until he was able to be transferred to a local hospital for evaluation. He has since been discharged from the facility.
The alleged perpetrator, Resident #57 has the following medical diagnosis:
- Epilepsy, unspecified, not intractable, without status epileptics.
- Anoxic brain damage, not elsewhere classified.
- Difficulty walking
- Muscle weakness (generalized)
- Unspecified mood (affective) disorder
- Impulse disorder
- Intermittent explosive disorder
- Asthma
- Non surgical orthopedic/musculoskeltal
- Essential hypertension
- Unilateral primary osteoarthritis, right hip
- Type 2 diabetes without complications
- Bipolar disorder
- Moderate intellectual disabilities
- Unspecified hearing loss, bilateral
- Mixed hyperlipidenia
- Presence of artificial right eye
- Pain in right knee
Resident #57's Quarterly Minimum Data Set (MDS) dated [DATE] was reviewed on 04/30/24 at 12:40 PM. The Brief Interview of Mental Status (BIMS), found under section C, a score of 12 (twelve), which indicates moderately cognitive impairment. The resident does not have capacity according to the Physicians Determination of Capacity form dated 02/20/23 and has a resident representative in place.
On 04/30/24 at approximately 3:30 PM, the Administrator provided a copy of the Abuse Abatement Plan dated 03/2/24. The Abatement Plan states the following:
Resident's Head to toe assessment completed 03/28/24
Resident's Pain assessment complete. 03/28/24
Resident's MD (medical doctor) and RP (resident representative) notification of incident. 03/28/24
Resident Social services referral. 03/28/24
Care plan reviewed- 04/30/24
All agencies and police notified of incident. 03/28/24
Identification of Others:
All competent residents in the facility were interviewed for any concerns of being safe or if their needs were being met. No residents voiced any concerns of their safety or of their needs not being met. Head to toe skin assessments were conducted on residents residing in the facility who are unable to be interviewed. No additional residents were identified to have any unknown skin issues.
A further review of Resident #30's record indicated a head to toe assessment and a pain assessment were completed on 03/28/24. Based on the residents mental status the facility was able to confirm the witnessed incident at the time of the incident. The completed assessments by nursing staff documented no indication the resident had any physical injuries and the resident did not have any signs or symptoms to indicate pain. There were continued skin assessments completed weekly since the incident. The Resident is scheduled Tylenol 650 mg twice a day for osteoarthritis pain. She has denied pain since the incident. Pain assessments are completed twice a day and a pain observation tool was completed on 03/28/24 based on the incident.
An interview was conducted on 05/02/24 at 11:15 AM with the Administrator and the Director of Nursing (DON). Both the Administrator and the DON confirmed the incident which involved Resident #30 did happen as reported. The Administrator, also stated Resident #57 has been discharged from this facility to a more suitable facility for his mental capacity.
b) Resident #16
On 04/29/24 at 11:00 AM, a record review was completed for Resident #16. The record review found an allegation of the resident hearing a Certified Nursing Assistant (CNA) use profanity in front of Resident #16 and stating CNA #83 doesn't want to care for Resident #16.
On 04/29/24 at 10:30 AM, a review of the facility reportable's was completed. The review found a reportable dated 02/19/24 by the administrator. The incident took place on 02/18/24 . The allegation was CNA #83 stated, , If I knew how much fucking work (he) had to do, he wouldn't have taken this fucking job. Resident #16 heard the statement be made in the doorway of Resident #16's room. Resident #16 reported this to staff stating CNA #83 uses profanity often and I don't care for it and do not want him caring for her. The report was faxed to all appropriate state agencies and investigation started.
The CNA #83 was placed on unpaid suspension following the incident on 02/18/24. Multiple witness statements were obtained by other staff members regarding the incident from 02/18/2024 through 02/21/24. The witness statements reviewed stated CNA #83 did say what he said in front of Resident #16.
The five (5) day follow up investigation was submitted by SSD #84 on 02/23/24 Allegation of abuse (verbal and psychosocial) made by the resident to the nurse Conclusion it was determined the resident overheard CNA using profanity, which was validated by staff members who also heard the profanity. The statement made by CNA #83 left the resident upset and no longer wanting CNA #83 caring for them.
CNA #83 agreed making the statement, however stated he did not use profanity. CNA #83 states he knew this interview was coming and he would no longer be working at the facility he resigned.
SSD #84 concluded an investigation stating Resident #16 was not continuing to be in psychological distress knowing CNA #83 no longer works at this Long-Term Care Facility.
On 02/21/24 CNA #83 resigned during investigation of verbal abuse by using profanity in front of Resident #16 when contacted about the investigation his response was I have been waiting for this call and didn't come into work anyway because I am quitting down there.
Upon being hired to this facility CNA #83 had completed Elder Abuse: The Elder Justice Act training, Preventing, Recognizing, and Reporting Abuse training on 02/07/24.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Assessment Accuracy
(Tag F0641)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on medical record review and staff interviews the facility failed to accurately encode the residents Minimum Data Set (M...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on medical record review and staff interviews the facility failed to accurately encode the residents Minimum Data Set (MDS) upon discharge. This was true for one (1) of two (2) resident discharges reviewed during the long term care survey process. Resident Identifier: Resident #59. Facility Census: 60.
Findings Include:
a) Resident #59
On 4/30/24 at 6:45 PM during a medical record review for Resident #59, there were no notes identified for the anticipated discharge of Resident #59 prior to the discharge occuring on 03/21/24. A review of the miscellaneous documents identified the Notice of Medicare Non-Coverage that was verbally reviewed with Resident #59's son on 03/15/24. Upon further review of the residents record, the Discharge summary dated [DATE] was completed by all required departments. The discharge summary did include but was not limited to the notification of the need to follow up with attending physician in 2 weeks, medication list, and the discharge goals of St Mary's home health.
On 04/30/24 at 10:40 AM, during an interview with Unit Manager Licensed Practical Nurse (UM LPN) #65, she stated that the MDS Coordinator was currently off but she remembered that the residents son had worked with the staff on the discharge process but then he had came to get her one day before the date they had originally planned for. She stated she felt it had to do with financial issues. She further stated she felt that because he came before the planned date is why it was marked as unplanned.
On 04/30/24 at 11:38 AM, during an interview with Regional Director of Finance # 82, she confirmed the cut letter and provided the letter of determination that Resident #59 had won her appeal dated 03/18/24. She further stated that there was nothing financially in the system that would indicate the discharge to be due to financial reasons.
On 04/30/24 at approximately 11:45 AM, during an interview with the Administrator, he agreed that everything identified in regards to this discharge indicates that the discharge was planned and the MDS was not encoded correctly.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
PASARR Coordination
(Tag F0644)
Could have caused harm · This affected 1 resident
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Based on record review and staff interview the facility failed to ensure a resident's Preadmission Screening and Resident Review (PASARR) reflected the diagnoses sheet for a newly diagnosed mental i...
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Based on record review and staff interview the facility failed to ensure a resident's Preadmission Screening and Resident Review (PASARR) reflected the diagnoses sheet for a newly diagnosed mental illness. This was true for three (3) of four (4) residents reviewed for the PASARR care area. Resident Identifiers: #26, #41, and #52 Facility Census: 60
Findings Include:
(a) Resident #26
During a record review on 04/29/24, Resident #26 medical record review revealed admitting diagnosis for 09/08/22 (admission date) included the following:
-Schizoaffective disorder
According to the Diagnosis Report provided by the facility the following diagnoses were added during Resident #26 stay. A review of the PASAAR submitted 03/01/23, there was no new PASARR submitted to reflect this admitting medical diagnosis (Schizoaffective disorder) or the following new diagnosis of:
- Major Depressive Disorder 07/13/23
- Mild cognitive impairment of uncertain or unknown etiology 02/06/23
- Delusional Disorder 11/20/22
- Paranoid Personality Disorder 11/20/22
- Bipolar Disorder (history of) 10/20/22
In an interview with the Director of Nursing on 04/30/24 at 3:36 PM, it was verified the new diagnoses were not submitted on a PASARR.
b) Resident #41
On 04/30/24 at 11:00 AM, a review of Resident #41's medical record noted a new diagnosis of bi-polar disorder was added on 09/15/20. Resident #44's Preadmission Screening and Resident Review form (PASARR) was last completed on 08/28/20. No level II was needed.
On 04/30/24 at 11:15 AM, an interview was conducted with the Director of Nursing who acknowledged the facility failed to resubmit a new PASARR to the state-designated mental health authority promptly when Resident #41 was diagnosed with a change in his mental status.
c) Resident #52
During a record review on 04/30/24 at 2:04 PM, it was found Resident #52 was diagnosed with Major Depressive disorder on 06/06/23.
Further record review revealed Resident # 52's last Preadmission Screening and Resident Review (PASSAR) was completed on 01/20/23, and a diagnosis of Major Depressive disorder was not indicated.
During an interview on 05/01/24 at 12:30PM, with the Director of Nursing (DON), she confirmed a new PASSAR had not been completed for Resident #52.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0645
(Tag F0645)
Could have caused harm · This affected 1 resident
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Based on record review and staff interview the facility failed to ensure a resident's Preadmission Screening and Resident Review (PASARR) reflected the diagnoses sheet for pre admission diagnoses. T...
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Based on record review and staff interview the facility failed to ensure a resident's Preadmission Screening and Resident Review (PASARR) reflected the diagnoses sheet for pre admission diagnoses. This was true for two (2) of four (4) residents reviewed for the PASARR care area. Resident Identifiers: #26, #14, Facility Census: #60
Findings Include:
(a) Resident #26
During a record review on 04/29/24, Resident #26 medical record revealed admitting diagnosis for 09/08/22 (admission date) included the following:
-Schizoaffective disorder
According to the Diagnosis Report provided by the facility and the PASARR submitted 03/01/23 the PASARR did not reflect this admitting medical diagnosis.
In an interview with the Director of Nursing on 04/30/24 at 03:36 PM, it was verified the PASAAR should have reflected the Schizoaffective disorder upon the admission date of 09/08/22.
(b) Resident #14
During a record review on 04/29/24, Resident #14's medical record revealed an admitting diagnosis for 05/25/23 (admission date) included the following:
- Bipolar Disorder
- Mild Cognitive Impairment of Uncertain or Unknown Etiology
According to the Diagnosis Report provided by the facility and the PASARR submitted 05/23/23 by a local hospital, the PASARR did not reflect these admitting medical diagnosis.
In an interview with the Director of Nursing on 04/30/24 at 03:36 PM, it was verified the PASAAR should have reflected the Bipolar Disorder and Mild Cognitive Impairment of Uncertain or Unknown Etiology upon the admission date of 05/25/23.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
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Based on record review and staff interview the facility failed to develop and implement the individualized comprehensive care plan for bowel and bladder continence. This was true for one (1) of two ...
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Based on record review and staff interview the facility failed to develop and implement the individualized comprehensive care plan for bowel and bladder continence. This was true for one (1) of two (2) residents reviewed for the care area of bowel and bladder continence during the long term survey process. Resident Identifiers: Resident #2. Facility Census: 60.
Findings Included:
a) Resident #2
On 04/30/24 at 11:20 AM, a record review of Resident #2's medical record revealed a diagnosis of urinary incontinence. Upon further record review it was noted a Urinary Incontinence Assessment was completed dated 12/22/23 noting Resident #2 was functioning incontinent requiring a toileting program titled Check and Change. During a review of Resident #2's current care plan, it was identified the facility failed to develop or implement an individualized comprehensive care plan for this diagnosis.
During an interview with the Director of Nursing on 05/01/24 at approximately 9:30 AM, the Director of Nursing acknowledged Resident #2 had not been care planned for her urinary incontinence diagnosis as she should have been.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
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Based on observation, resident interview, staff interview, and record review the facility failed to provide care and services in accordance with professional standards of practice by not providing t...
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Based on observation, resident interview, staff interview, and record review the facility failed to provide care and services in accordance with professional standards of practice by not providing timely medical treatment for a foot injury. This was true for one (1) of 29 sampled residents reviewed during the long term care survey process. Resident identifier #52. Facility Census 60.
Findings Include:
a) Resident # 52
During an interview on 04/29/24 at 1:02 PM, Resident #52 who has a Brief Interview for Mental Status (BIMS) of (8) eight stated, I fell in January at my house and came here due to a broken hip. Yesterday my walker fell on the other foot, it hurt. Now I can't walk on either side. I told the nurse and she looked at it when it happened, but no one has done anything since.
An observation on 04/29/24 at 1:03 PM, of Resident #52's right foot revealed dark purple and red bruising on her right big toe and of the toe beside it. The bruising also went down the side and top of her foot.
During an interview on 04/29/24 at 1:10 PM, Licensed Practical Nurse (LPN) # 80 stated, I did not work over here yesterday. She has not said anything to me about it today.
During an interview on 04/29/24 at 1:13 PM with the Assistant Director of Nursing (ADON), while she was observing Resident # 52's right foot, stated, Yes, we definitely need to get that x-rayed. (Resident # 52 named), do not get up and walk by yourself until we get this x-rayed.
A review on 04/29/21 at 1:30 PM, of Resident # 52's medical record revealed that no notes, or incident reports had been charted for Resident # 52 concerning the incident involving the right foot.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Staffing Information
(Tag F0732)
Could have caused harm · This affected multiple residents
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Based on observation and staff interview, the facility failed to ensure the Daily Staffing Posting information was accurate and current with the actual direct care hours and the identified direct ca...
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Based on observation and staff interview, the facility failed to ensure the Daily Staffing Posting information was accurate and current with the actual direct care hours and the identified direct care staff. This was true for four (4) of five (5) Daily Staffing Posting forms reviewed during the long term care survey process. This had the potential to affect more than a limited number of residents. Days Identified: 04/04/24; 04/05/24; 04/12/24 and 04/18/24. Facility Census: 60.
Findings include:
a) Inaccuracy of actual direct care hours.
On 04/30/24 at 9:30 PM, during a review of 04/04/24, 04/05/24, 04/12/24 and 04/18/24 the total direct care hours posted were compared to the Actual Hours for Direct Care Staff Report document for 04/01/24- 04/30/24 calculations. The following inaccuracies were identified.
* 04/04/24 - the Daily Staffing Posting form identified the direct care hours to be 176 hours. The Actual Hours for Direct Care Staff document identified the direct care hours to be 147.50. An inaccuracy of 28.5 hours.
*04/05/24 - the Daily Staffing Posting form identified the direct care hours to be 172 hours. The Actual Hours for Direct Care Staff document identified the direct care hours to be 152.25. An inaccuracy of 19.75 hours.
*04/12/24 - the Daily Staffing Posting form identified the direct care hours to be 172.5 hours. The Actual Hours for Direct Care Staff document identified the direct care hours to be 169.75. An inaccuracy of 2.75 hours.
*04/18/24 - the Daily Staffing Posting form identified the direct care hours to be 183.5 hours. The Actual Hours for Direct Care Staff document identified the direct care hours to be 174.50. An inaccuracy of 8.75 hours.
On 05/01/24 at approximately 11:15 AM during an interview with the Administrator, he agreed the hours identified on the Daily Staffing Posting were more than the actual reported hours worked.
b) Inaccuracy of direct care staffing hours.
On 04/30/24 at 09:30 PM, during a review of 04/04/24, 04/05/24, 04/12/24 and 04/18/24 the staff category and total direct care hours posted were reviewed. The following inaccuracies were identified.
* 04/04/24 - the Daily Staffing Posting of direct care staffing care hours identified the Registered Nurse Director of Nursing (RN DON) eight (8) hours and two (2) Registered Nurse (RN) with Administrative Duties 16 hours as direct care hours.
* 04/05/24 - the Daily Staffing Posting of direct care staffing care hours identified the Registered Nurse Director of Nursing (RN DON) eight (8) hours and two (2) Registered Nurse (RN) with Administrative Duties 16 hours as direct care hours.
* 04/12/24 - the Daily Staffing Posting of direct care staffing care hours identified the Registered Nurse Director of Nursing (RN DON) eight (8) hours and two (2) Registered Nurse (RN) with Administrative Duties eight 16 as direct care hours.
* 04/18/24 - the Daily Staffing Posting of direct care staffing care hours identified the Registered Nurse Director of Nursing (RN DON) eight (8) hours and two (2) Registered Nurse (RN) with Administrative Duties 16 hours as direct care hours.
On 05/01/24 at approximately 11:15 AM during an interview with the Administrator, he stated the RN DON hours and the RN's with Administrative hours were on the Daily Staffing Posting form because they do sometimes assist throughout their shift with the daily care of the residents. With a review of the Labor Classification/ Job Title section of the Centers for Medicare & Medicaid Services- Electronic Staffing Data Submission- Payroll-Based Journal- Long-Term Care Facility- Policy Manual Version 2.6 with the Administrator. This section defines that the Labor Classification/Job Title Reporting shall be based on the employee's primary role and their official categorical title. It is understood that most roles have a variety of non-primary duties that are conducted throughout the day (e.g., helping out others when needed). Facilities shall still report just the total hours of that employee based on their primary role. CMS recognizes that staff may completely shift primary roles in a given day. For example, a nurse who spends the first four hours of a shift as the unit manager, and the last four hours of a shift as a floor nurse. In these cases, facilities can change the designated job title and report four hours as a nurse with administrative duties, and four hours as a nurse (without administrative duties). The Administrator acknowledged the RN DON hours and the RN's with administrative duties hours should not had been included on the Daily Staffing Posting for direct care staff.
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CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0921)
Could have caused harm · This affected multiple residents
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Based on observations, family interview and staff interview the facility failed to ensure the residents were provided a safe, functional, sanitary, and comfortable environment for residents, staff a...
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Based on observations, family interview and staff interview the facility failed to ensure the residents were provided a safe, functional, sanitary, and comfortable environment for residents, staff and the public. The facility failed to place chairs in the residents rooms for the resident and/or visitors to utilize. This was a random opportunity of discovery during the long term care survey process and had the potential to affect a limited number of residents. Resident Identifier: Resident #12. Census: 60.
Findings Include:
a) Resident #12
On 04/29/24 at 12:56 PM, during an interview with Resident #12, his brother was observed to be sitting half way on the rooms packaged terminal air conditioner (PTAC) unit beside Resident #12's bedside. Resident #12's brother stated, the room never had a chair in it but sometimes he is able to get a fold-up chair if there are any available.
On 04/30/24 at 4:10 PM, during an interview with the Administrator, he stated, many rooms does not have chairs and he will replace them. He further acknowledged the rooms should have chairs for residents and visitors to have a functional comfortable homelike environment.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected most or all residents
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Based on observation, policy review, and staff interview the facility failed to store, and serve food in accordance with professional standards by keeping chocolate milk beyond its expiration date, ...
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Based on observation, policy review, and staff interview the facility failed to store, and serve food in accordance with professional standards by keeping chocolate milk beyond its expiration date, and by not ensuring all staff were wearing hairnets during the Long-Term Care Survey Process. This failed practice had the potential to affect all resident currently resding in the facility. Facility Census 60.
Findings Include:
a) Chocolate milk
During the initial tour of the kitchen on 04/29/24 at 11:00 AM, ia gallon of chocolate milk was found in the reach-in-refrigerator with approximately 1/4th of the gallon of chocolate milk left in the jug. The expiration on the jug of chocolate milk was 04/26/24.
A review of the facilities policy number 019, titled, { Food Storage: Cold Foods}, under policy statements reads as follows:
Typed as written
All time/temperature control for safety (TCS) foods, frozen, and refrigerated, will be appropriately stored in accordance with guidelines of the FDA food code.
The Dietary Corporate Manager (DCM), confirmed that the chocolate milk was out of date.
b) Employee #61
During the initial tour of the facility's kitchen on 04/29/24 at 11:00 AM, it was found Employee # 61 was washing and putting up dishes and did not have a hairnet on.
The DCM confirmed that employee # 61 was not wearing a hairnet.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on observation, record review, and staff interview the facility failed to ensure a clean, sanitary environment by leavin...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on observation, record review, and staff interview the facility failed to ensure a clean, sanitary environment by leaving a bedpan in the floor on the A-Hall room [ROOM NUMBER] restroom, and following policy to test yearly for Legionellosis. This failed practice had the potential to affect more than a minimal number of residents in the facility. Facility Census: 60
Findings Include:
a) Bepan left in floor
Observation on 04/29/24 at 11:28 AM, revealed an uncovered bedpan in bathroom floor.
A second observation on 04/29/24 at 1:17 PM showed the bedpan remained on the floor in the bathroom.
On 04/30/24 at 9:00 AM, a third observation with the facility Administrator who confirmed the bedpan still remained in the bathroom floor in room A13.
b) Water Management/Legionella Plan
Legionellosis refers to two clinically and epidemiologically distinct illnesses: Legionnaires disease, which is typically characterized by fever, myalgia, cough, and clinical or radiographic pneumonia and Pontiac fever, a milder illness without pneumonia (e.g., fever and muscle aches). Legionellosis is caused by Legionella bacteria
Review of the facility Water Management plan/Legionella Plan on 05/01/24 at 12:35 PM, revealed the last Legionellosis test was done on 9/14/22.
Further record review of the Policies and standard procedures showed in Policy #: IC:- on page 8
to read Water testing will be performed on an Annual basis and the results of the test to be recorded in the facilities Water Management/Legionella Plan.
During a staff interview on 05/01/24 at 1:00 PM with the Administrator confirmed the policy for water testing was not followed and the facility had not had a Lefionella test since 09/14/22.
Nov 2022
14 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Grievances
(Tag F0585)
Could have caused harm · This affected 1 resident
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Based on record review, resident council minutes review and staff interview, the facility failed to ensure Grievance/Complaint forms were completed accurately for Residents #17 and Resident #264. Th...
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Based on record review, resident council minutes review and staff interview, the facility failed to ensure Grievance/Complaint forms were completed accurately for Residents #17 and Resident #264. This was a random opportunity of discovery. Resident identifiers: #17 and #264. Facility census: 55
Findings Included:
a) Resident #17
During a review of the grievance/complaint forms on 11/09/22 at 8:30 AM revealed Resident #17's Grievance/Complaint form dated 04/14/22 from her representative stated Mom's lunch yesterday was cold when I came in to feed her.
Section titled Documentation of facility follow-up had no follow-up information by the dietary department.
Section titled Resolution of Grievance/Complaint was void of the Administrator's signature and date.
During an interview on 11/09/22 at 11:46 AM, the Social Service Supervisor #81 acknowledged Resident #17's Grievance/Complaint form section facility follow-up was incomplete by the Dietary Department and the Administrator section was void of a signature and date.
b) Resident #264
During a review of the grievance/complaint forms on 11/09/22 at 8:30 AM revealed Resident #264's Grievance/Complaint form dated 04/08/22 from her representative stated Meals are not low sodium.
Section titled Documentation of facility follow-up had no follow-up information by the Dietary Department.
Section titled resolution of Grievance/Complaint was void of the Administrator's signature and date.
During an interview on 11/09/22 at 11:46 AM the Social Service Supervisor #81 acknowledged Resident #264's Grievance/Complaint form section facility follow-up was incomplete by the Dietary Department and the Administrator section was void of a signature and date
c) Resident Council meeting
During the Resident Council meeting held on 11/09/22 at 10:35 AM the following concern was presented: sometimes the food is cold, there was not a specific meal or date just randomly.
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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
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on resident interview, record review, and staff interview, the facility failed to implement the abuse/neglect policy for...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on resident interview, record review, and staff interview, the facility failed to implement the abuse/neglect policy for an alleged allegation of neglect. This was true for one (1) of two (2) residents reviewed for abuse. Residents identifier: Resident #208. Facility census 55.
Findings included:
a) Resident #208
Resident #208 was discharged on 09/27/22. After discharge he proceeded to file a complaint of neglect with Adult Protective Services (APS) and the Veterans Administration (VA). APS relayed this information to the facility Social Worker #81 (SW) via email on 10/04/22 at 11:09 AM. SW #81 also states the [NAME] Virginia Department of Health and Human Resources (WVDHHR) APS representative came to the facility on [DATE] and held a meeting at the facility with the SW #81. The SW states she has no documentation of the meeting.
Social Worker #81 failed to report a report with the Office of Health Facility Licensure and Certification (OHFLAC) and she did not thoroughly investigate the allegation. She stated in her reply email to the VA: Findings: Allegations were unsubstantiated. No corrective action plan is needed at this time. However, there were no witness statements collected.
The facilities Operations Policy on Freedom from Abuse, Neglect and Exploitation dated 7/19/21 states All alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, must be reported to the Executive Director of the facility and to other officials (including to the State Survey Agency and Adult Protection Services) immediately, but: 1) Not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury or; 2) Not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury.
The facility failed to follow the above policy. The allegation should have been reported 24 hours after receiving the email from the APS representative on 10/04/22.
This was confirmed with SW #81 and the Administrator on 11/09/22 at 2:20 PM. The Administrator then filed the neglect complaint with OHFLAC on 11/09/22 at 2:47 PM.
Resident #208 has capacity per the Physicians Determination of capacity dated 9/15/22.
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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
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on Resident interview, record review, and staff interview, the facility failed to report an alleged violation of abuse. ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on Resident interview, record review, and staff interview, the facility failed to report an alleged violation of abuse. This was true for two out two reviewed for abuse. Resident identifier: #208
Findings included:
b) Resident #208
Resident #208 was discharged on 9/27/22. After discharge he proceeded to file a complaint of neglect with Adult Protective Services (APS) and the Veterans Administration (VA). APS relayed this information to Social Worker #81 (SW) via email on 10/04/22 at 11:09 AM. SW #81 also states the [NAME] Virginia Department of Health and Human Resources (WVDHHR) APS representative came to the facility on [DATE] and held a meeting at the facility with the SW #81. The SW states she has no documentation of the meeting.
Social Worker #81 failed to report this to the Office of Health Facility Licensure and Certification (OHFLAC) and she did not thoroughly investigate the allegation. She stated in her reply email to the VA: Findings: Allegations were unsubstantiated. No corrective action plan is needed at this time. However, there were no witness statements collected.
The facilities Operations Policy on Freedom from Abuse, Neglect and Exploitation dated 7/19/21 states All alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, must be reported to the Executive Director of the facility and to other officials (including to the State Survey Agency and Adult Protection Services) immediately, but: 1) Not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury or; 2) Not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury.
The allegation should have been reported 24 hours after receiving the email from the APS representative on 10/04/22.
This was confirmed with SW #81 and the Administrator on 11/09/22 at 2:20 PM. The Administrator then filed the neglect complaint with OHFLAC on 11/09/22 at 2:47 PM.
Resident #208 has capacity per the Physicians Determination of capacity dated 9/15/22.
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CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Investigate Abuse
(Tag F0610)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on Resident interview, record review, and staff interview, the facility failed to investigate an alleged violation of ab...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on Resident interview, record review, and staff interview, the facility failed to investigate an alleged violation of abuse. This was true for two out two reviewed for abuse. Resident identifiers: #208
Findings included:
b) Resident #208
Resident #208 was discharged on 9/27/22. After discharge he proceeded to file a complaint of neglect with Adult Protective Services (APS) and the Veterans Administration (VA). APS relayed this information to Social Worker #81 (SW) via email on 10/04/22 at 11:09 AM. SW #81 also states the [NAME] Virginia Department of Health and Human Resources (WVDHHR) APS representative came to the facility on [DATE] and held a meeting at the facility with the SW #81. The SW states she has no documentation of the meeting.
Social Worker #81 failed to report this to the Office of Health Facility Licensure and Certification (OHFLAC) and she did not thoroughly investigate the allegation. She stated in her reply email to the VA: Findings: Allegations were unsubstantiated. No corrective action plan is needed at this time. However, there were no witness statements collected. SW #81 states she spoke with three (3) residents and several aides and nurses
The facilities Operations Policy on Freedom from Abuse, Neglect and Exploitation dated 7/19/21 states All alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, must be reported to the Executive Director of the facility and to other officials (including to the State Survey Agency and Adult Protection Services) immediately, but: 1) Not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury or; 2) Not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury.
The allegation should have been reported 24 hours after receiving the email from the APS representative on 10/04/22 and an investigation completed with written statements, documentation and followup events.
This was confirmed with SW #81 and the Administrator on 11/09/22 at 2:20 PM. The Administrator then filed the neglect complaint with OHFLAC on 11/09/22 at 2:47 PM.
Resident #208 has capacity per the Physicians Determination of capacity dated 9/15/22.
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CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Assessment Accuracy
(Tag F0641)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on observation, medical record review, and staff interview, the facility failed to accurately complete a Minimum Data Se...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on observation, medical record review, and staff interview, the facility failed to accurately complete a Minimum Data Set (MDS) assessments for three (3) of fifteen (15) residents reviewed during the Long-Term Care Survey (LTCSP). Resident identifier: #22 and #32. Facility census: 55.
Findings Included:
a) Resident #22
Review of the Annual Minimum Data Set 3.0 on 11/07/22 with Assessment Reference Dates (ARD) of 10/05/22 revealed the following: Section O, titled Special Treatment, Procedures and Programs, Section Respiratory Treatments C. Oxygen was not coded.
MDS RAI version 3.0 manual coding instructions for O0100C, Oxygen therapy (typed as written)
Code continuous or intermittent oxygen administered via mask, cannula, etc., delivered to a resident to relieve hypoxia in this item.
A review of Resident #22's medical record on 11/07/22 revealed a physician order dated 09/18/22: oxygen: deliver oxygen as needed (PRN) at two (2) liters/minute via nasal cannula. Obtain Oxygen Saturation (O2) every shift on room air and PRN every shift
During an interview on 11/08/22 at 9:53 AM the Administrator acknowledged that the oxygen was coded incorrectly and stated a modification was being submitted now.
b) Resident #32
A review of medical records revealed Resident #32 was admitted on [DATE].
During an interview on 11/07/22 at 12:42 PM, Resident # 32 said she has sores on her legs.
A review of MDS revealed in the section M 1030, number of venous and arterial ulcers was marked 0.
The admission assessment of evaluations dated 09/08/22 by Licensed Practical Nurse (LPN) #53 found it was documented as having vascular wound to right lower extremity. Measurements/characteristics:
Length 6.5 cm
Width 13 cm
Depth 0.2 cm.
Additional wound information:
Wound bed is red and beefy, moderate amount of blood-tinged drainage, pungent odor noted but subsides when wound is cleansed.
The seconded wound evaluation dated 09/08/22 by LPN #53 found Left Lower Extremity (LLE).
Wound measurements/characteristics:
Length 3 cm
Width 5 cm
Depth 0.2 cm
Additional wound information:
Wound bed is red and beefy, moderate amount of blood-tinged drainage, pungent odor noted but subsides when wound is cleansed.
The seconded wound evaluation dated 09/08/22 by LPN #53 found Left Lower Extremity (LLE).
Wound measurements/characteristics:
Length 3 cm
Width 4.5 cm
Depth 0.2 cm
Additional wound information:
Wound bed is red and beefy, moderate amount of blood-tinged drainage, pungent odor noted but subsides when wound is cleansed.
On 11/09/22 at 9:31 AM, the above findings were verified with RN #3.
An observation on 11/09/22 at 2:08 PM, with Registered Nurse (RN) #3 of wound care for Resident #32 revealed there were six (6) venous ulcers wounds on the left lower leg and two (2) nearly connecting on the lower right leg.
On 09/09/22 at 4:58 PM, Director of Nursing was informed of the above and agreed the MDS was incorrect.
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CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on record review and staff interview, the facility failed to develop a person-centered care plan in the care areas of ps...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on record review and staff interview, the facility failed to develop a person-centered care plan in the care areas of psychosocial well-being and for rehabilitation services to encourage the resident to get out of bed two (2) to three (3) times a week. This failed practice had the potential to affect a limited number of residents who currently reside at the facility and was true for one (1) out of 15 residents reviewed for care plans. Resident Identifiers: Resident #32. Facility census 55.
Findings included:
a) Resident #32
During an interview on [DATE] at 12:56 PM, with Resident #32, she became very upset and crying states she hears the staff talking about her daughter. Resident #32 said it is humiliating and it is all lies, because her daughter would have never done anything to hurt her dad, me or her brother. She said my daughter was doing the best she could. Resident #32 went on to say her husband died, but it was not my daughter's fault.
Resident #32 was asked if she talked anyone at the facility about this? Resident #32 said she did tell the staff she wanted to speak to a higher up person. That is when a Social Worker (SW) came and talked to her. Resident #32 said she reported her concerns to the SW and told the SW how upset she was.
Resident #32 said it is so heartbreaking to her, because her husband is gone, she does not know where her daughter is or how she is doing. She said she was concerned about her disabled son too. on top of being placed here and removed from my home.
A review of the nursing notes, facilities reportable and grievance concern files did not find any information about the above.
On [DATE] at 8:29 AM, Social Services #81 was interviewed. The conversation stated out by stating the name of Resident #32. That is when SS #81 began talking about the daughter of Resident #32 getting arrested for abuse/neglect while being the caregivers for her deceased father, (that was found dead on the sofa) by the police, Resident #32 and her son were hospitalized for septic infections.
The SS#81 was asked about not finding any type of notes or anything about seeing Resident and talking to her and seeing her upset.
SS#81 stated yes, she did talk to Resident #32 about that. However, she like everyone else does make mistakes and may not have made a formal form about it.
During a brief interview on [DATE] at 3:10 PM, Resident #32 was very tearful and crying feels like the staff are whispering behind her back about her daughter. She again talked about her concern for her daughter
During a interview on [DATE] at 8:47 AM, SS#81 returned to say she did not complete the proper form, but had notes about the interaction in a notebook. SS #81 was asked if Resident #32 was emotional and upset when she was talking to her. SS #81 stated yes.
During an interview on [DATE] at 9:16 AM SS #81 stated Resident # 32 is emotional a lot and was surprised to know on her mood and behavior sheets were marked NO since admission for being tearful.
During an interview on [DATE] at 9:20 AM Director of Nursing (DON) was not aware the Nurse Aides were marking Resident # 32 no for tearfulness. DON also was not aware if Resident # 32 was receiving care for mental health but agreed she could benefit emotionally and may benefit from those services.
A review of the care plan for Resident #32 revealed there was not anything in the care plan about the traumatic events that caused Resident #32 to be in the facility.
This was verified by Administrator on [DATE] at 9:57 AM and was corrected at that time by Administrator.
Review of mood and behavior sheets were marked NO for being tearful from admission to current. However, in Physical Therapy notes on [DATE] reports Resident # 32 being tearful and reporting this to social services.
On [DATE] at 9:34 AM, Administrator stated she overheard the conversations about Resident #32 and is calling to get Resident # 32 setup with a mental health provider, after verifying Resident #32 was not currently receiving any mental health services.
During an interview on [DATE] at 2:48 PM, with Nurse Aide (NA) #27 was asked if she normally provides care for Resident #32. NA #27 said yes. NA #27 was asked if she has ever seen Resident #32 emotional, crying, or upset. NA #27 stated yes, she has seen her crying several times. NA #27 then was asked why she did not never document a that in response to the question about mood.
On the facility form titled, (name of facility) Documentation Survey Report, dated: September, October, and [DATE].
Mood indicators: Below are a list of choices and the number used to code mood.
* 1-Negative statements
*2-Repetitive questions
*3-Repetitive verbalization
*4-Persistent anger with staff or others
*5-Self depreciation
^6- Unrealistic fears
*7-Recurrent statements that something terrible is about to happen
*8-Repetitive health complaints
*9-Repetitive anxious
*10-Unpleasant mood in morning
*11-Insomnia change in usual sleep pattern
*12-Sad, pained, worried, facial expressions
*13-Cry, tearfulness,
*14-Repetitive physical movements
*15-Withdrawal from activities of interest
*16- Reduced social interaction
*17-Patient did not have any mood
Review of records revealed number 17 was coded three (3) to four (4) times a day from [DATE] to [DATE] and no other coded numbers were used.
On [DATE] at 4:00 PM, Administrator was informed of the above information.
b) Resident #32 (Getting resident out of bed)
During an interview on [DATE] at 1:11 PM, supposed to get rehab and she has not had any in a long time. They do not get me up in my chair when I ask. I'm told they must ask Physical Therapy (PT).
During an interview on [DATE] at 11:48 AM, Physical Therapist #48 said Resident # 32 was dropped from Occupation Therapy (OT) because she would not predicate. PT #48 was asked what the date was she was dropped. She answered [DATE] and nursing was educated on Out of Bed, on [DATE]. Recommend Resident get up out of bed least 2-3 times a week. Issued resident a reclining wheelchair with elevating leg rest and a cushion.
The above recommendation could not be found on the current care plan.
On [DATE] at 12:33 PM, Director of nursing verified it was not care planned for staff to get Resident #32 out of the bed two (2) to three (3) times a week.
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CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0679
(Tag F0679)
Could have caused harm · This affected 1 resident
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Based on observation, record review, staff interview and resident interview, the facility failed to implement an ongoing resident centered activities program designed to meet the interest of and sup...
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Based on observation, record review, staff interview and resident interview, the facility failed to implement an ongoing resident centered activities program designed to meet the interest of and support the physical, mental and psychosocial well-being of each resident. This facility failed to provided evening group activities and provide Resident #14 with 1:1 visits/social visits. This failed practice had the potential to affect a limited number of residents that reside at the facility. Resident Identifier: Resident #14. Facility Census: 55
Findings Included:
a) Resident #14
During an interview on 11/07/22 at 2:20 PM Resident #14 stated I don't participate in the group activities, they never have anything that I would enjoy. I never see anyone from activities they don't visit, no one visits. Some of the staff peek their heads around the curtain when they change my roommate but not often.
A review of Resident #14 medical records on 11/09/22 revealed an Activities Progress Note dated 10/26/22 stating He is on 1-1 visits with staff at least two (2) times weekly and just enjoys talking to them.
A further review of the medical record revealed Activity monthly participation record for 10/22. The documentation revealed Resident #14 only received one (1) visit weekly by the activity staff.
During an interview on 11/09/22 at 2:15 PM the Activity Supervisor(AS) #51 stated Resident #14 receives one to one (1:1) visits two (2) times a week and is involved in a sensory group weekly.
During his 1:1 he enjoys just talking and I put him and his roommate in the sensory group together so both would benefit from the stimulation.
The AS #51 acknowledged Resident #14 is not provided enough activities to meet his psychosocial well-being.
b) Resident Council Meeting
During the Resident Council Meeting held on 11/09/22 at 10:08 AM the Residents as a group were asked the question, How is the group activity? The following concerns were voiced:
-There is no evening activities
-Nothing going on after 3:00
-We just go back to room after dinner
-We go to bed it's the only choice we have
- I would go to church or bingo or something if we had something in the evenings
-I am so bored after dinner I watch TV and just fall asleep
A review of the monthly Activity Calendar from 06/22 to 11/22 revealed the only evening group activity occurs with a local church group on the following days:
-11/28/22 at 6:30 PM
-10/24/22 at 6:30 PM
-09/26/22 at 6:30 PM
-08/29/22 at 6:30 PM
-07/25/22 at 6:30 PM
-06/27/22 at 6:30 PM
During an interview on 11/09/22 at 2:15 the AS #51 stated we do an evening activity cart daily, we go room to room. The cart has books, coloring sheets, puzzles, word searches and crosswords. I am trying to get more groups to come in. I will change the schedule and start having the staff do the group activities instead of the activity cart.
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CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0692
(Tag F0692)
Could have caused harm · This affected 1 resident
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Based on observation, resident interview, staff interview and medical record review the facility failed to ensure Resident #14 maintained acceptable parameters of nutritional status. This failed pra...
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Based on observation, resident interview, staff interview and medical record review the facility failed to ensure Resident #14 maintained acceptable parameters of nutritional status. This failed practice was true for one (1) of nine (9) residents reviewed for nutrition during the Long-Term Care Survey Process. Resident Identifier #14. Facility Census 55.
Findings Included:
a) Resident #14
During an interview on 11/07/22 at 2:20 PM Resident # 14 stated the food is always cold, I am supposed to receive double portions. I have received them one time. I have lost weight. I am a big man. I was 270 pounds before I got sent to the hospital. I am very hungry all the time. You get snacks if you ask the right person, at the right time.
During a medical record review on 11/07/22 at 2:15 PM revealed Resident #14 on 05/29/2022, the resident weighed 178 lbs. On 11/01/2022, the resident weighed 158 pounds which is a -11.24 % Loss.
During dining observation on 11/08/22 12:10 PM Resident # 14 received a lunch meal in his room. Resident # 14 meal ticket stated roast beef, sweet potatoes special instructions: double portions with all meals.
During an interview on 11/08/22 at 12:10 PM Nurses Aide (NA) #27 acknowledge Resident # 14 received a regular portion of meal; one (1) roll, one (1) cookie, one (1) slice of bread with a scoop of roast beef and gravy, a small portion of mixed vegetables, and a small portion of sweet potatoes.
During an interview on 11/08/22 at 12:14 PM the Dietary Manager (DM) acknowledged Resident # 14 did not receive double portions with the lunch meal. The DM stated I think they have missed it today.
Resident # 14 interrupted the DM and stated I have only received double portions once since I have had them ordered. I have pictures of all my meals and notes on my meal tickets if you would like to see them.
A review of Resident #14 medical records on 11/08/22 reveled a physician order dated 09/28/22: Consistent Carbohydrates diet Regular texture, Regular Consistency, Resident requests double portions with all meals.
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CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
Could have caused harm · This affected 1 resident
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Based on observation, medical record review and staff interview the facility failed to provide necessary respiratory care and services. This was true for one (1) of one (1) resident reviewed for res...
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Based on observation, medical record review and staff interview the facility failed to provide necessary respiratory care and services. This was true for one (1) of one (1) resident reviewed for respiratory care areas during the Long-Term Care Survey Process. Resident #22 was observed not receiving oxygen therapy at the prescribed rate. Resident identifier: Resident #22. Facility census: 55.
Findings Included:
a) Resident #22
During the initial tour of the facility on 11/07/22 at 1:49 PM Resident #22 oxygen flow rate was at three (3) liter/minute (l/m) via nasal cannula.
During a review of Resident #22's medical record on 11/07/22 at 2:00 PM revealed a physician order dated 09/18/22: Oxygen: Deliver oxygen as needed (PRN) at two (2) l/m via nasal cannula.
On 11/07/22 at 2:16 PM the Director of Nursing acknowledged Resident #22 was receiving the oxygen via nasal cannula at three (3) l/min. After review of Resident #22's orders verified the physician orders for oxygen was two (2) l/m.
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CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0745
(Tag F0745)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on Resident interview, record review, and staff interview the facility failed to provide medically related social servic...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on Resident interview, record review, and staff interview the facility failed to provide medically related social services to attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident. This failed practice was a random opportunity for discovery and has the potential to affect a limited number of residents that currently reside in the facility. The failed practice was not providing mental health services for a resident who was emotionally upset due to traumatic events that led up to being removed from her home and the loss of a spouse in addition her caregiver/daughter getting arrested. Resident identifiers: # 32. Facility census 55.
Findings included:
a) Resident #32
During an interview on [DATE] at 12:56 PM, with Resident #32, she became very upset and crying states she hears the staff talking about her daughter. Resident #32 said it is hamulating and it is all lies, because her daughter would have never done anything to hurt her dad, me or her brother. She said my daughter was doing the best she could. Resident #32 went on to say her husband died, but it was not my daughter's fault.
Resident #32 was asked if she talked anyone at the facility about this? Resident #32 said she did tell the staff she wanted to speak to a higher up person. That is when a social worker came and talked to her. Resident #32 said she reported her concerns to the social worker and told the social work how upset she was.
Resident #32 said it is so heartbreaking to her, because her husband is gone, she does not know where her daughter is or how she is doing. She said she was concerned about her disabled son too. on top of being placed here and removed from my home.
A review of the nursing notes, facilities reportable and grievance concern files did not find any information about the above.
On [DATE] at 8:29 AM, Social Services #81 was interviewed. The conversation stated out by stating the name of Resident #32. That is when SS #81 began talking about the daughter of Resident #32 getting arrested for abuse/neglect while being the caregivers for her deceased father, (that was found dead on the sofa) by the police, Resident #32 and her son were hospitalized for septic infections.
The SS#81 was asked about not finding any type of notes or anything about seeing Resident and talking to her and seeing her upset.
SS#81 stated yes, she did talk to Resident #32 about that. However, she like everyone else does make mistakes and may not have made a formal form about it.
During a brief interview on [DATE] at 3:10 PM, Resident #32 was very tearful and crying feels like the staff are whispering behind her back about her daughter. She again talked about her concern for her daughter
During a interview on [DATE] at 8:47 AM, SS#81 returned to say she did not complete the proper form, but had notes about the interaction in a notebook. SS #81 was asked if Resident #32 was emotional and upset when she was talking to her. SS #81 stated yes.
During an interview on [DATE] at 9:16 AM SS #81 stated Resident # 32 is emotional a lot and was surprised to know on her mood and behavior sheets were marked NO since admission for being tearful.
During an interview on [DATE] at 9:20 AM Director of Nursing (DON) was not aware the Nurse Aides were marking Resident # 32 no for tearfulness. DON also was not aware if Resident # 32 was receiving care for mental health but agreed she could benefit emotionally and may benefit from those services.
A review of the care plan for Resident #32 revealed there was not anything in the care plan about the traumatic events that caused Resident #32 to be in the facility.
This was verified by Administrator on [DATE] at 9:57 AM and was corrected at that time by Administrator.
Review of mood and behavior sheets were marked NO for being tearful from admission to current. However, in Physical Therapy notes on [DATE] reports Resident # 32 being tearful and reporting this to social services.
On [DATE] at 9:34 AM, Administrator stated she overheard the conversations about Resident #32 and is calling to get Resident # 32 setup with a mental health provider, after verifying Resident #32 was not currently receiving any mental health services.
During an interview on [DATE] at 2:48 PM, with Nurse Aide (NA) #27 was asked if she normally provides care for Resident #32. NA #27 said yes. NA #27 was asked if she has ever seen Resident #32 emotional, crying, or upset. NA #27 stated yes, she has seen her crying several times. NA #27 then was asked why she did not never document a that in response to the question about mood.
On the facility form titled, (name of facility) Documentation Survey Report, dated: September, October, and [DATE].
Mood indicators: Below are a list of choices and the number used to code mood.
* 1-Negative statements
*2-Repetitive questions
*3-Repetitive verbalization
*4-Persistent anger with staff or others
*5-Self depreciation
^6- Unrealistic fears
*7-Reocurrent statements that something terrible is about to happen
*8-Repetitive health complaints
*9-Repetitive anxious
*10-Unpleasant mood in morning
*11-Insomnia change in usual sleep pattern
*12-Sad, pained, worried, facial expressions
*13-Cry, tearfulness,
*14-Repetitive physical movements
*15-Withdrawl from activities of interest
*16- Reduced social interaction
*17-Patient did not have any mood
Review of records revealed number 17 was coded three (3) to four (4) times a day from [DATE] to [DATE] and no other coded numbers were used.
On [DATE] at 4:00 PM, Administrator was informed of the above information.
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CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0808
(Tag F0808)
Could have caused harm · This affected 1 resident
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Based on observation, resident interview, medical record review and staff interview the facility failed to provide a resident with a prescribed therapeutic diet to maintain nutritional status. This ...
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Based on observation, resident interview, medical record review and staff interview the facility failed to provide a resident with a prescribed therapeutic diet to maintain nutritional status. This is true for one (1) of one (1) reviewed for nutritional care area during the Long-Term Care Survey Process. Resident Identifier: Resident #14. Facility Census: 55
Findings Included:
a) Resident #14
During an interview on 11/07/22 at 2:20 PM Resident # 14 stated I am supposed to receive double portions. I have received them one time. I have lost weight. I am a big man. I was 270 pounds before I got sent to the hospital. I am very hungry all the time. You get snacks if you ask the right person, at the right time.
During a medical record review on 11/07/22 at 2:15 PM revealed Resident #14 on 05/29/2022, the resident weighed 178 lbs. On 11/01/2022, the resident weighed 158 pounds which is a -11.24 % Loss.
During a dining observation on 11/08/22 12:10 PM Resident # 14 received a lunch meal in his room. Resident # 14 meal ticket stated roast beef, sweet potatoes special instructions: double portions with all meals.
During an interview on 11/08/22 at 12:10 PM Nurses Aide (NA) #27 acknowledge Resident # 14 received a regular portion of meal; one (1) roll, one (1) cookie, one (1) slice of bread with a scoop of roast beef and gravy, a small portion of mixed vegetables, and a small portion of sweet potatoes.
During an interview on 11/08/22 at 12:14 PM the Dietary Manager (DM) acknowledged Resident # 14 did not receive double portions with the lunch meal. The DM stated I think they have missed it today.
Resident # 14 interrupted the DM and stated I have only received double portions once since I have had them ordered. I have pictures of all my meals and notes on my meal tickets if you would like to see them.
A review of Resident #14 medical records on 11/08/22 reveled a physician order dated 09/28/22: Consistent Carbohydrates diet Regular texture, Regular Consistency, Resident requests double portions with all meals.
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CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0825
(Tag F0825)
Could have caused harm · This affected 1 resident
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Based on resident interview, record review, and staff interview the facility failed to specialize rehabilitative services such as physical therapy. This failed practice was true for one (1) out of o...
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Based on resident interview, record review, and staff interview the facility failed to specialize rehabilitative services such as physical therapy. This failed practice was true for one (1) out of one (1) for rehab and restorative. Resident identiers: Resident #32. Facility census: 55.
Findings included:
a) Resident #32
During an interview on 11/07/22 at 1:11 PM, supposed to get rehab and she has not had any in a long time. They do not get me up in my chair when I ask. I'm told they must ask Physical Therapy (PT).
On 11/08/22 at 12:29 PM, PT #48 was asked about the physician order for Resident # 32 dated 10/24/22 it revealed Resident # 32 was the receive PT 2-3 times a week. BUE/BLE strengthening.
PT #48 said Resident # 32 was dropped from Occupation Therapy (OT) because she would not predicate. PT #48 was asked what the date was she was dropped. She answered 10/07/22.
During an interview on 11/08/22 at 12:53 PM, PT #48 was asked about the physician order on 10/24/22 she stated she had no records of ever receiving that order. PT #48 stated that maybe the nurses already know how she is and did not send the order to PT. PT #48 was asked if that was normal practice for nursing to decide if someone should get PT over a physician's order, or should PT evaluate all residents that have an order from a physician. PT #48 stated, of course she would follow the physician's order if she would have known about it.
During an interview on 11/09/22 at 9:58 AM, Director of Nursing confirmed that the physicians order for PT dated 10/24/22 was not entered into the system.
During a brief interview with Resident #32 on 11/09/22 at 2:56 PM, said she was so happy she had PT today.
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CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Medical Records
(Tag F0842)
Could have caused harm · This affected 1 resident
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Based on medical record review and staff interview the facility failed to ensure a complete and accurate medical record. The facility failed to ensure the Physician Orders for Scope of Treatment (PO...
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Based on medical record review and staff interview the facility failed to ensure a complete and accurate medical record. The facility failed to ensure the Physician Orders for Scope of Treatment (POST) forms were completed per directions specified by the [NAME] Virginia Center for End of Life Care. This is true for two (2) of fifteen (15) reviewed for the Long-Term Care Survey Process. Resident Identifiers: Resident # 48 and Resident #7. Facility Census: 55
Findings Included:
Using the POST Form Guidance for Health Care Professional 2021 Edition
Section E Signature Section: If the incapacitated patient ' s MPOA representative or health care surrogate is unavailable at the time of form completion, this section can be signed by two witnesses for verbal confirmation of agreement from the patient ' s MPOA representative or health care surrogate. The form should be signed at the earliest available opportunity.
Section F Health Care Provider: Failure to print their name or provide a license number may result in the WV e-Directive Registry being unable to verify the provider ' s information, thus preventing the form from being available through the Registry.
a) Resident #48
During a medical record review on 11/07/22 at 3:54 PM revealed Resident # 48's POST form dated 09/02/22 Section E: Signature Patient Medical Power of Attorney (MPOA) representative stated verbal with only one (1) witness signature.
Section F Signature: Health Care Provider, license/cert number section was void.
During an interview on 11/08/22 at 10:09 AM Social Service Supervisor(SSS) #81 stated on the date Resident # 48 was admitted the MPOA had COVID and was unable to sign the POST form, I did a verbal consent over the phone.
The SSS acknowledged the POST form was void of two witness signatures for verbal consent. Also acknowledged Section F was void the Health Care Provider License number.
b) Resident #7
During a medical record review on 11/07/22 at 3:36 PM revealed Resident #7's POST form dated 09/20/22 Section E: Signature Patient Medical Power of Attorney (MPOA) representative stated verbal with only one (1) witness signature.
Section F Signature: Health Care Provider, license/cert number section was void.
During an interview on 11/08/22 at 10:09 AM Social Service Supervisor(SSS) #81 acknowledged the POST form was void of two witness signatures for verbal consent. Also acknowledged Section F was void the Health Care Provider License number
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CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected multiple residents
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Based on observation, policy review and staff interview the facility failed to store food in accordance with professional standards for food safety. The facility failed to label and date food items ...
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Based on observation, policy review and staff interview the facility failed to store food in accordance with professional standards for food safety. The facility failed to label and date food items that were open and failed to dispose of expired food items. This failed practice had the potential to more than a limited number of residents currently receiving nourishment from the facility's kitchen and the nourishment room. Facility Census: 55
Findings Included:
a) Walk-in Refrigerator
An initial tour of the kitchen with the Dietary Manager (DM) beginning on 11/07/22 at 11:43 AM, the walk-in refrigerator the following items were found:
-two (2) gallon jars of dill spears with no open date
-a bottle of ketchup with no open date
-a gallon of ranch dressing with no open date
The Dietary Manager acknowledged the failure to label food items with a Date Opened and/or Use by Date. Also indicated the item needed to be discarded because they were out of date or not dated.
b) Walk-in Freezer
An initial tour of the kitchen with the Dietary Manager (DM) beginning on 11/07/22 at 11:43 AM, the walk-in freezer the following items were found:
-an opened bag of cauliflower with no open date
-an opened bag of peas with no open date
-an open bag of diced potatoes with no open date
-an open bag of French fries with no open date
The Dietary Manager acknowledged the failure to label food items with a Date Opened and/or Use by Date. Also indicated the item needed to be discarded because they were out of date or not dated.
c) Reach-In Refrigerator
An initial tour of the kitchen with the Dietary Manager (DM) beginning on 11/07/22 at 11:43 AM, the reach-in refrigerator the following items were found:
-a pitcher of unsweetened tea with use by date (UBD) of 11/05
-an opened bottle of Thicken-n-Easy Tea with no opened date
-an opened bottle of Thicken-n-Easy Orange Juice with no open date
The Dietary Manager acknowledged the failure to label food items with a Date Opened and/or Use by Date. Also indicated the item needed to be discarded because they were out of date or not dated.
d) The Pantry
An initial tour of the kitchen with the Dietary Manager (DM) beginning on 11/07/22 at 11:43 AM, the pantry the following items were found:
-an open container of peanut butter with no open date
-During an interview with the DM stated the spices are not marked with a open date we go by the date received on the label. The spices are good for two (2) years.
-an opened bottle of Ground glove with a received date of 12/13/19
-an opened bottle of Ground Ginger with a received date of 10/02/19
-an opened bottle of Crushed Red Pepper with a received date of 06/05/20
-an opened bottle of Celery Salt with a received date of 04/23/20
-an opened bottle of Celery Salt with a received date of 06/17/19
-an opened bottle of Dill Weed with a received date of 05/28/20
-an opened bottle of Spanish Paprika unable to read label of received date
-an opened bottle of Ground Cumin with a received date of 01/27/20
-an opened bottle of Poultry Seasoning with a received date of 10/29/20
-an opened bottle of Parsley Flakes with no date
-an opened bottle of Ground oregano with no date
-an opened bottle of Ground Red Pepper with no date
- a plastic container of elbow macaroni with no label or date
The Dietary Manager acknowledged the failure to label food items with a Date Opened and/or Use by Date. Also indicated the item needed to be discarded because they were out of date or not dated.
e) The Nourishment Room
During the tour of the nourishment room on 11/08/22 at 10:02 AM the refrigerator following item was found.
-an open container of pimento spread with an opened date of 10/25/22
The Dietary Manager acknowledged the failure to label food items with a Date Opened and/or Use by Date. Also indicated the item needed to be discarded because they were out of date or not dated.
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Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated
K - Pattern
L - Widespread
Actual Harm
G - Isolated
H - Pattern
I - Widespread
Potential for Harm
D - Isolated
E - Pattern
F - Widespread
No Harm (Minor)
A - Isolated
B - Pattern
C - Widespread
Questions to Ask on Your Visit
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • Grade B+ (80/100). Above average facility, better than most options in West Virginia.
- • No major safety red flags. No abuse findings, life-threatening violations, or SFF status.
- • No fines on record. Clean compliance history, better than most West Virginia facilities.
- • 35% turnover. Below West Virginia's 48% average. Good staff retention means consistent care.
Concerns
- • 35 deficiencies on record. Higher than average. Multiple issues found across inspections.
Bottom line: Generally positive indicators. Standard due diligence and a personal visit recommended.
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About This Facility
What is Wayne Healthcare Center's CMS Rating?
CMS assigns WAYNE HEALTHCARE CENTER an overall rating of 5 out of 5 stars, which is considered much above average nationally. Within West Virginia, this rating places the facility higher than 99% of the state's 100 nursing homes. This rating reflects solid performance across the metrics CMS uses to evaluate nursing home quality.
How is Wayne Healthcare Center Staffed?
CMS rates WAYNE HEALTHCARE CENTER's staffing level at 3 out of 5 stars, which is average compared to other nursing homes. Staff turnover is 35%, compared to the West Virginia average of 46%. This relatively stable workforce can support continuity of care.
What Have Inspectors Found at Wayne Healthcare Center?
State health inspectors documented 35 deficiencies at WAYNE HEALTHCARE CENTER during 2022 to 2025. These included: 35 with potential for harm.
Who Owns and Operates Wayne Healthcare Center?
WAYNE HEALTHCARE CENTER is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility is operated by COMMUNICARE HEALTH, a chain that manages multiple nursing homes. With 60 certified beds and approximately 58 residents (about 97% occupancy), it is a smaller facility located in WAYNE, West Virginia.
How Does Wayne Healthcare Center Compare to Other West Virginia Nursing Homes?
Compared to the 100 nursing homes in West Virginia, WAYNE HEALTHCARE CENTER's overall rating (5 stars) is above the state average of 2.7, staff turnover (35%) is significantly lower than the state average of 46%, and health inspection rating (4 stars) is above the national benchmark.
What Should Families Ask When Visiting Wayne Healthcare Center?
Based on this facility's data, families visiting should ask: "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" "Can I speak with family members of current residents about their experience?"
Is Wayne Healthcare Center Safe?
Based on CMS inspection data, WAYNE HEALTHCARE CENTER has a clean safety record: no substantiated abuse findings (meaning no confirmed cases of resident harm), no Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death), and is not on the Special Focus Facility watch list (a federal program monitoring the lowest-performing 1% of nursing homes). The facility has a 5-star overall rating and ranks #1 of 100 nursing homes in West Virginia. While no facility is perfect, families should still ask about staff-to-resident ratios and recent inspection results during their visit.
Do Nurses at Wayne Healthcare Center Stick Around?
WAYNE HEALTHCARE CENTER has a staff turnover rate of 35%, which is about average for West Virginia nursing homes (state average: 46%). Moderate turnover is common in nursing homes, but families should still ask about staff tenure and how the facility maintains care continuity when employees leave.
Was Wayne Healthcare Center Ever Fined?
WAYNE HEALTHCARE CENTER has no federal fines on record. CMS issues fines when nursing homes fail to meet care standards or don't correct problems found during inspections. The absence of fines suggests the facility has either maintained compliance or corrected any issues before penalties were assessed. This is a positive indicator, though families should still review recent inspection reports for the full picture.
Is Wayne Healthcare Center on Any Federal Watch List?
WAYNE HEALTHCARE CENTER is not on any federal watch list. The most significant is the Special Focus Facility (SFF) program, which identifies the bottom 1% of nursing homes nationally based on persistent, serious quality problems. Not being on this list means the facility has avoided the pattern of deficiencies that triggers enhanced federal oversight. This is a positive indicator, though families should still review the facility's inspection history directly.