TRINITY HEALTH CARE OF MINGO
For profit - Corporation
90 Beds
Independent
Data: November 2025
Trust Grade
50/100
#59 of 122 in WV
Photo by Trinity Healthcare Services of Mingo
Last Inspection: August 2025
Inspected within the last 6 months. Data reflects current conditions.
Overview
Trinity Health Care of Mingo has a Trust Grade of C, which means it is average and ranks in the middle of the pack among nursing homes. It is ranked #59 out of 122 facilities in West Virginia, placing it in the top half, and it is the only option in Mingo County. The facility is showing improvement, with issues decreasing from 8 in 2024 to 7 in 2025. Staffing is a strong point, with a rating of 4 out of 5 stars and a turnover rate of 33%, which is better than the state average. However, there are concerns regarding RN coverage, as it has less than 95% of facilities, and the facility has faced $25,237 in fines, which is average but indicates some compliance issues. Specific incidents from inspections include a serious case where a resident suffered a fractured hip and a subdural hematoma due to neglect, highlighting a lack of supervision. Additionally, there were concerns that residents' care plans did not reflect their preferences for activities, suggesting a gap in personalized care. Overall, while there are notable strengths in staffing and improvement trends, the facility needs to address serious care and compliance issues to ensure resident safety and satisfaction.
- Trust Score
- C
- In West Virginia
- #59/122
- Safety Record
- Moderate
- Inspections
- Getting Better
- Staff Stability ○ Average
- 33% turnover. Near West Virginia's 48% average. Typical for the industry.
- Penalties ✓ Good
- $25,237 in fines. Lower than most West Virginia facilities. Relatively clean record.
- Skilled Nurses ○ Average
- Each resident gets 30 minutes of Registered Nurse (RN) attention daily — about average for West Virginia. RNs are the most trained staff who monitor for health changes.
- Violations ⚠ Watch
- 30 deficiencies on record. Higher than average. Multiple issues found across inspections.
50/100
Top 48%
Needs review
8 → 7 violations
★★★☆☆
3.0
Overall Rating
★★★★☆
4.0
Staff Levels
★☆☆☆☆
1.0
Care Quality
★★★★☆
4.0
Inspection Score
↔
Stable
2024: 8 issues
2025: 7 issues
The Good
-
4-Star Staffing Rating · Above-average nurse staffing levels
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
-
Staff turnover below average (33%)
15 points below West Virginia average of 48%
Facility shows strength in staffing levels, fire safety.
The Bad
3-Star Overall Rating
Near West Virginia average (2.7)
Meets federal standards, typical of most facilities
Staff Turnover: 33%
13pts below West Virginia avg (46%)
Typical for the industry
Federal Fines: $25,237
Below median ($33,413)
Moderate penalties - review what triggered them
The Ugly 30 deficiencies on record
1 actual harm
Aug 2025
7 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Assessment Accuracy
(Tag F0641)
Could have caused harm · This affected 1 resident
Based on record review and staff interview, the facility failed to ensure a complete and accurate Minimum Data (MDS) assessment in the area of hospice. This deficient practice had the potential to aff...
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Based on record review and staff interview, the facility failed to ensure a complete and accurate Minimum Data (MDS) assessment in the area of hospice. This deficient practice had the potential to affect one (1) of one (1) residents reviewed for the care area of hospice. Resident Identifiers: #62. Facility Census: 82.Findings included:a) Resident #62 Review of Resident #62's physician's orders showed an order written on 03/14/25 for Hospice Care, Do Not Resuscitate, Comfort Treatments. Review of Resident #62's comprehensive care plan confirmed the resident was receiving hospice services. Resident #62's quarterly Minimum Data Set (MDS) assessment with Assessment Reference Date (ARD) 05/01/25 documented the resident was receiving hospice services. Resident #62's quarterly MDS with ARD 07/17/25 documented the resident was not receiving hospice services. On 08/26/25 at 3:33 PM, the Director of Nursing (DON) confirmed Resident #62's MDS with ARD 07/17/25 was incorrect and should have indicated the resident was receiving hospice services. The DON stated she corrected the MDS.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0679
(Tag F0679)
Could have caused harm · This affected 1 resident
Based on record review, staff interview, and policy review, the facility failed to ensure that a comprehensive activities assessment was completed for one (1) of two (2) residents (Resident #8) review...
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Based on record review, staff interview, and policy review, the facility failed to ensure that a comprehensive activities assessment was completed for one (1) of two (2) residents (Resident #8) reviewed for activities during the long-term care survey. Facility census: 82. Resident identifier: #8 Findings Include:a) Resident #8The facility's policy titled Timeframe for Completion of Activities Assessment on New Admissions states: An initial activities interest screening shall be completed by Activities staff or designee within 72 hours of admission to identify immediate preferences and needs. A full Activities Assessment, consistent with the Minimum Data Set (MDS) and facility policy, shall be completed within 14 calendar days of admission. The Activities Assessment will be used to develop an individualized Activity Care Plan. completed and entered in the resident's comprehensive care plan within 7 days after completion of the MDS assessment reference date, per CMS guidelines.On 08/27/25 at 12:30 PM, record review revealed that Resident #8 had an Activity evaluation opened on 04/21/25; however, the evaluation was incomplete, remained in progress, and was not signed.Further review revealed no evidence of an initial activities interest screening within 72 hours of admission or a comprehensive activities assessment within 14 days, as required by facility policy and federal regulation.During an interview conducted on 08/27/25 at 12:45 PM, the Activities Director (AD) stated: I'm not sure how that happened, it was not completed, and I will go do that right now, confirming the assessment had not been completed since the resident's admission.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
Based on observation, record review, and staff interview the facility failed to ensure hazardous chemicals were stored and used safely, creating a potential chemical exposure hazard for residents resi...
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Based on observation, record review, and staff interview the facility failed to ensure hazardous chemicals were stored and used safely, creating a potential chemical exposure hazard for residents residing in the long-term care facility, this was a random opportunity for discovery. Facility Census: 82. Findings include:a) On 08/25/25 at 11:25 AM, the NA (Nurse Aide) cart was observed to contain a container of Sumer Sani-Cloth Germicidal Wipes.During an interview on 08/25/25 at 11:30 AM, the Infection Preventionist (IP Nurse #81) stated, These aint suppose to be on the NA cart, we use these to wipe equipment down after use like, the lifts, glucose machines, vitals machines, I'll educate staff now, and removed the wipes from the cart. confirming they should not be accessable to residents expecially residents who does not have capacity.Recoird Review completed on 08/25/25 at 12:12 PM of the Safety Data Sheet (SDS) revealed the following hazards:Causes serious eye irritationMay cause drowsiness or dizzinessFlammable liquid and vaporMay be harmful if swallowed or inhaled
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
Could have caused harm · This affected 1 resident
Based on observation, record review, and staff interview, the facility failed to provide respiratory services in accordance with professional standards of practice. For one (1) of one (1) residents re...
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Based on observation, record review, and staff interview, the facility failed to provide respiratory services in accordance with professional standards of practice. For one (1) of one (1) residents reviewed for the care area of respiratory care, the supplemental oxygen flow rate was not set to the rate ordered by the physician. Resident Identifier: #74. Facility Census: 82.Findings included: a) Resident #74 Review of Resident #74's physician's orders showed an order written on 08/01/25 for oxygen at 3 liters per minute (LPM) via nasal cannula per concentrator as needed for chronic obstructive pulmonary disorder (COPD). An observation on 08/25/25 at 1:05 PM showed the resident was in bed with oxygen 1.5 LPM infusing via nasal cannula. An observation on 08/26/25 at 9:35 AM showed the resident was in bed with oxygen 2 LPM infusing via nasal cannula. An observation on 08/27/25 at 10:35 AM showed the resident was in bed with oxygen 2 LPM infusing via nasal cannula. This was confirmed by the Director of Nursing (DON). The DON increased the resident's oxygen to 3 LPM in accordance with the physician's order.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Dental Services
(Tag F0791)
Could have caused harm · This affected 1 resident
Based on observation, record review, resident interview, and staff interview, the facility failed to obtain dental services to meet the resident's needs. This deficient practice had the potential to a...
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Based on observation, record review, resident interview, and staff interview, the facility failed to obtain dental services to meet the resident's needs. This deficient practice had the potential to affect one (1) of one (1) residents reviewed for the dental care area. Resident identifier: #5. Facility census: 82.Findings included:a) Resident #5 During an interview on 08/25/25 at 1:58 PM, Resident #5 stated she needed to have a tooth pulled, but she wasn't sure if the extraction had been scheduled. She had an obviously carious front tooth. The resident stated she was beginning to have twinges of pain in the front tooth. Review of Resident #5's medical records showed a consultation report from a dentist dated 12/06/24. The dentist recommended extraction of her remaining maxillary (upper jaw) teeth. A referral was to be made to an oral surgery clinic. The resident's annual Minimum Data Set (MDS) assessment with Assessment Reference Date (ARD) contained the following note in the Care Area Assessment (CAA) process: Resident has natural teeth; she has some missing teeth and potential caries. Dental exam performed at [Dental Clinic] on 12/6/24; resident referred to [Oral Surgery Clinic] for surgical extraction of remaining maxillary dentition #6-#12 and we are awaiting appointment date and time. Resident currently denies oral/tooth pain.On 08/27/25 at 2:18 PM, the Director of Nursing (DON) and Assistant Director of Nursing (ADON) #57 confirmed Resident #5 had not had the dental extractions recommended by the dentist on 12/06/24. They contacted the oral surgery clinic, who provided them with documentation regarding a referral made on 04/22/25. The oral surgery clinic stated they had left messages with the resident's daughter twice. The oral surgery clinic also stated the surgeon who was to perform the surgery had since left the clinic. ADON #57 stated the oral surgery clinic was asked to call the facility to schedule an appointment for tooth extraction.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0810
(Tag F0810)
Could have caused harm · This affected 1 resident
Based on observation, record review, and staff interview, the facility failed to provide physician-ordered adaptive eating devices for one (1) of two (2) residents reviewed for the care area of nutrit...
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Based on observation, record review, and staff interview, the facility failed to provide physician-ordered adaptive eating devices for one (1) of two (2) residents reviewed for the care area of nutrition. Resident identifier: #48. Facility census: 82. Findings included: a) Resident #48 Review of Resident #48's physician's orders showed the following orders: NAS (no added salt) and LCS (low concentrated sugar) diet, pureed texture, honey thick consistency Cup with lid d/t [due to] aspiration precaution. No straws d/t (due to) aspiration precautions. All these orders were written on 07/11/25. On 08/27/25 at 11:18 AM, Nurse Aide (NA) #14 was observed setting up Resident #48's lunch tray on his overbed table while the resident was in bed. The resident had a carton of honey thickened beverage with a straw in it. Resident #48's tray ticket stated, No straws. NA #14 confirmed Resident #48 was to have no straws according to his tray ticket. NA #14 removed the straw from the beverage carton and obtained a lidded cup from the kitchen for the resident's beverage. On 08/27/25, the Director of Nursing confirmed Resident #48 was not using straws due to aspiration precautions.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected multiple residents
Based on record review and staff interviews the facility failed to ensure the comprehensive care plan in the area for dental services for resident #5 and activity preferences for Resident's #8 and #50...
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Based on record review and staff interviews the facility failed to ensure the comprehensive care plan in the area for dental services for resident #5 and activity preferences for Resident's #8 and #50 were developed. This was found true for three (3) of 25 residents' care plans reviewed during the long-term care survey process. Resident identifiers #8, #50, and #5 Facility Census: 82
a) Resident #8
During record review on 08/27/25 at approximately 2:00 PM of Resident #8's section F of the Minimum Data Set (MDS) revealed the resident enjoys Music, Pets, Religious activities and doing things with groups of people.
Further record review of resident #8's personalized care plan interventions revealed the following interventions;
Staff will assist her to/from group activities as needed
Staff will give her verbal praise for her attendance in any group activity
Staff will invite/encourage her to attend group activities of her choice.
Staff will post a monthly activity calendar in her room for her review.
Music, Pets, religious activities, which were activities she enjoys doin were not in Resident #8's care plan.
An interview with the Activity Director on 08/27/25 at 2:30 PM who stated I'll be right back, let me fix that now. Confirming the residents preferences for activities should have been in the care plan.
b) Resident # 50
During record review on 08/26/25 3:30 PM of resident #50's most recent activity evaluation revealed they enjoy Religious/spiritual; activities, parties, music, radio, and watching TV.
Further record review of Resident #50's care plan revealed the following interventions;
Staff will assist her to and from group activities for choice
Staff will thank her for allowing them to visit her
Staff will turn on television on for audible stimulation
Staff will visit her room and attempt simple short conversations.
Nothing in the residents person centered care plan mentions resident #50's preferences for religious/spiritual activities, music/radio, or that the facility provides residents with a monthly activity program calendar.
The activity Director confirmed the care plan as missing resident preferences on 08/28/25 at 2:30 PM
c) Resident #5
During an interview on 08/25/25 at 1:58 PM, Resident #5 stated she needed to have a tooth pulled, but she wasn't sure if the extraction had been scheduled. She had an obviously carious front tooth. The resident stated she was beginning to have twinges of pain in the front tooth.
Review of Resident #5's medical records showed a consultation report from a dentist dated 12/06/24. The dentist recommended extraction of her remaining maxillary (upper jaw) teeth.
The resident's annual Minimum Data Set (MDS) assessment with Assessment Reference Date (ARD) contained the following notes in the Care Area Assessment (CAA) process: Resident has natural teeth; she has some missing teeth and potential caries. Dental exam performed at [Dental Clinic] on 12/6/24; resident referred to [Oral Surgery Clinic] for surgical extraction of remaining maxillary dentition #6-#12 and we are awaiting appointment date and time. Resident currently denies oral/tooth pain .Dental care to be addressed with interventions to ensure resident receives proper dental/oral hygiene and dental care at outside facilities, as well as observation for any oral pain or difficulties with chewing/swallowing.
Review of Resident #5's comprehensive care plan did not show a focus related to dental status. The resident's Activities of Daily living focus contained an intervention to perform oral care every shift.
On 08/27/2025 at 11:12 AM, Assistant Director of Nursing (ADON) #57 confirmed Resident #5 was not care planned for dental issues. She stated she would revise the resident's care plan.
Mar 2024
1 deficiency
1 Harm
SERIOUS
(G)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Actual Harm - a resident was hurt due to facility failures
Free from Abuse/Neglect
(Tag F0600)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on review record, staff interviews, reportable's (immediate and five (5) day), and staff education, time line of the inc...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on review record, staff interviews, reportable's (immediate and five (5) day), and staff education, time line of the incident and plan of correction, the facility failed to ensure a resident was protected from neglect. Resident #42 sustained a fractured hip and a subdural hematoma from an unwitnessed event. The resident was sent to a local hospital where the subdural hematoma had ceased and the hip was repaired. This caused physical harm to the resident and will be cited a G at F600. Resident identifier: #42 Facility census: 81.
Findings included:
a) Resident #42
Resident #42 was originally admitted on [DATE]. Diagnoses included Alzheimer's disease, history of falling, left artificial hip joint, hypertension, heart failure, adult failure to thrive, and Dementia severe with agitation.
An annual Minimum Data Set (MDS) with Assessment Reference Date (ARD) 01/16/24 had a Brief Interview of Mental Status (BIMS) of 3. The BIMS score of three (3) indicates severe cognitive impairment.
A review of the 5-day PPS MDS with an ARD of 02/22/24 found that the resident was dependent for toileting, shower/bath, maximum assistance for dressing, sit to lying; partial to moderate assistance lying to sitting, sit to stand, chair/bed to chair, toileting; walking not attempted due to medical condition or safety. Uses a wheelchair for transportation and wheeling self around facility.
On 03/12/24 at 9:01 AM a review of the reportable for Resident #42 was conducted. Adult Protective Services (APS) was notified on 03/02/24 and referral was not assigned for investigation. OHFLAC and Ombudsman were notified on 03/02/24 and the five (5) day follow up was completed on 03/06/24.
Another immediate reporting was completed on 03/06/24 when after the five (5) day followup found possible neglect. This was reported to OHFLAC, Ombudsman, APS and the Nurse Aide Registry. A
five (5) day followup was again completed on 03/11/24.
An incident report was completed on 03/02/24 at 7:15 AM. A review of reportable folder found statements from Nurse Aides (NA) and Licensed Practical Nurse (LPN).
NA #26 made the following statement on 03/02/24 (typed as written)
I (name redacted),took care of (resident first name) the night of March 1, 2024. That night me and my partner took her to bed and changed her and she was fine. Then at 3am we did another check and we put hipster's and pants on her up above her knees. She was being hateful and we left them up above her knees but did not fall on us at all. Then at 5am we did another bed check she was fine she aslrp but we checked her and she was dried so we left her alone and went and change the other resident in her room. but she was fine we seen nothing wrong with her and no places on her. She still didn't fall on us that time either.
A telephone interview with NA #26 conducted on 03/02/24 at 7:58 PM revealed NA #26 confirmed her statement as read to her. She confirmed that the hipsters were half way down thigh . wasn't all the way up. NA #26 confirmed she had education regarding abuse and neglect and hipsters.
NA #61
NA #61 made the following statement on 03/02/24 (typed as written)
On my shift on March 1st, I took care of (resident name redacted). She stayed up late. I changed her and put her in bed. I checked on her through the night, I did not change her every bed check because she wasn't wet, but I was in there to check on her room mate. But around 3 something in the morning I did change her because she was wet. I did not notice anything out of the ordinary she was the same combated resident. She was saying a few foul words and smacking but she was changed anyways, I did not fight with her to get her pants up, I left them half up, I come back to do my last check in there, changed her room mate and checked (resident first name redacted) after, and she was dry so I did not wake (resident name redacted) up I left her alone. But Resident did not show any signs out of the ordinary or I would have reported to the nurse.
A telephone interview with NA #61 conducted on 03/02/24 at 7:58 PM until 8:12 PM revealed NA #61 confirmed her statement as read to her. When asked what the difference was in her first and second statement, she stated that she was nervous and scared when she made first statement of having left hipsters and pants half way down the residents legs. Stated that she changed Resident #42 around 3-4 AM and her hipsters were wet and changed. As the resident was fighting being changed, the pants were not put on. NA #61 stated that she placed the pants on the end of the bed.
NA # 91
NA #91 made the following statement on 03/02/24 (typed as written)
When I came up the hall I saw (resident name redacted) legs up in the air. Another CNA #129 was already in the room I walked in to see if she needed help and I notices (resident first name redacted) hipsters were down to her knees I walked on side of the bed to help the CNA try to get (resident first name redacted) dressed when I looked down at (resident first name redacted) I noticed a big bruise on side of her head. CNA # 129 went and got nurse immediately we than stalted [sic] dressing (resident name redacted) and saw blood on her arm from skin tear After taking off her shirt we saw a big Bruise on her shoulder [sic] me and (CNA first name redacted) #62 help (resident first name redacted) up into her wheelchair We notice she couldn ' t[sic] stand good.
A telephone interview with NA #91 conducted on 03/02/24 at 11:14 PM revealed NA #91 confirmed her statement as read to her. She stated that Resident #24 was agitated and wanted to get up. When ask if she thought the resident could get herself up said I don't know. She comment that her pants were folded up at the foot of the bed which she though was strange as the resident always complains about being cold and had on no pants.
NA #62
NA #62 made the following statement on 03/02/24 (typed as written)
Was taking a resident up hall when CNA #91 yelled at me for help resident was unable to stand I went in to help and me (NA #62) and CNA discovered bruise on side (right) of head and found bruise on shoulder (right) and discovered blood on sheets and found skin tear on right elbow. Then the nurse came in.
A telephone interview with NA #62 conducted on 03/02/24 at 11:08 PM revealed NA #62 confirmed her statement as read to her. In addition she stated she was standing on the other side of the bed and the resident was in no pain. She did not notice any red marks on hips.
NA #129
NA #129 made the following statement on 03/02/24 (typed as written).
I was in a resident room when I heard (resident name redacted) call out for help. I went into (resident name redacted) room, and was standing at foot of bed; and asked her what she needed about that time (CNA name redacted) #91 walked to (resident's name redacted) bedside and noticed a bruise on (resident first name redacted) head. I left to go get the nurse on duty. When we the nurse and I returned CNA first name redacted) #91 noticed blood on (residents name redacted) sheet, her hipsters was at her knees. We found a pair of pants and shirt lying on floor in front of her closet.
A telephone interview with NA #129 conducted on 03/02/24 at 7:58 PM revealed NA #26 confirmed her statement as read to her.
Timeline from facility
On March 2, 2024
- Nurse was notified by incoming day shift CNA's on residents condition
- All parties at this time as made aware and paper work initiated to turned into APS, OHFLAC, and Ombudsman immediately.
- Administrator watched the cameras that day with nothing suspicious noted or reported at that time.
6:46 AM CNA (#129 an #91) in the room this is the original finding of injuries
6:48 AM CNA #129 went to get the nurse
6:49 AM Nurse (LPN #11) enters the room
6:53 AM Nurse (LPN #85)s enters the room
7:20 AM Paper work initiated
7:50 AM Ambulance arrives
On March 6, 2024 in person interviews with CNA's #91, #62, and #129 was completed by the Administrator, Social Worker, Medical Records, LPN, Assistant Director of Nursing (ADON) and the interim Director of Nursing (DON).
Statements were received by CNA's #61 and #26.
Discovered at this time that the hipsters and pants were left down around the residents knees. Social Worker turned in immediately to CNA Board, APS, OHFLAC and Ombudsman.
On 03/06/24 education on the importance of hipster use and all protective devices began and disciplinary action taken by the CNA Supervisor for CNA's #61 and #26. The education included all NA's except one (1). No information was available as to who conducted the inservice.
An additional education on hipsters on the evening of 03/06/24 was held by the DON, and the Administrator on the importance of these (hipsters) being in place.
Because we had not received the statements until this time, we had no reason to believe that this was an abuse or neglect situation.
On 03/06/24 monitoring of all aides began by supervisors. As of 03/06/24 audits began on residents with hipsters. Spot checks performed on both day and night shift by the supervisor on shift.
Audits remain ongoing at this time .
Abuse and Neglect In Service conducted by Social Worker for CNA's #61 and #26 on 03/06/24. The facility provided evidence of an inservice on abuse and neglect given by the NHA and DON on 02/07/24 for all employees. In addition, an inservice regarding reporting of alleged violations was held on 02/26/24 by the NHA and DON which was attended by all staff from all departments.
On March 6, 2024
- Five day followup turned in.
- At this time it was substantiated as neglect due to reviewing the statements.
- Spoke with the two (2) aides #61 and #26 letting the know that it had been substantiated and was turned into appropriate agencies.
- Counseled again and informed them that the monitoring by supervisor would continue and any further finding would result in termination.
On March 13, 2024
- CNA #61 will be terminated today.
Facility Investigation findings for Resident #42 Incident Occurring on 03/02/24
Resident investigation noted that resident had a shower on 02/28/24 and was scheduled for a shower on 03/02/24 but had not actually had one on this day due to time of incident. Also noted that cameras were observed that shows resident door had been left open for the night and into the morning of incident. Cameras also show no outside entry of anyone other than staff for care provision into residents room and also adjoining room. Room mate is bed bound as are the 2 neighboring residents in adjoining room. When asked all residents in room and neighboring room deny hearing any type of noises that night. One neighboring resident did say that she ha heard the bathroom door shut before but on this night. Resident was shown on camera in wheelchair awaiting for ambulance transfer eating and tapping right foot on the floor with no obvious signs of pain when sitting. Was not able to bear weight when being placed on the gurney for transport which also was observed on the camera. Staff are being interviewed for recount of the shifts working on 03/01/24 and 03/02/24 and oncoming staff for shift change. Resident alarms were reordered upon re-entry due to psychotropic meds ordered. Resident alarms were discontinued on 03/28/24 due to residents behavior had been disagreeable with use and carrying on her lap instead of leaving in place causing her to become upset with use and with staff attempting to place. Resident was also noted to be receiving PT and restorative services. Wheelchair was her primary mode of locomotion daily. Dycem to wheelchair and hipsters remained ordered for safety. Hipsters were noted to be half way down on thigh area above knees when oncoming staff went in to do their bed check and to get resident up for breakfast and this is when injuries were found and unwitnessed accounts of how they were sustained. This was immediately reported to OHFLAC, APS, Ombudsman and physician was notified for immediate transport orders for evaluation due to injuries following observation by LPN on duty. Resident did remain alert and verbal without loss of consciousness or changes to mental or communicative status. (Name of local hospital) reported that resident did have a right hip fracture but did not perform a head CT due to resident having aggressive behavior per nurse report. Was transported to (name of medical center) and found to have an active subdural hemorrhage. Were making arrangements for surgery to right hip for repair per nursing report when calling to find out status of resident. Noted to have surgical repair to right hip while at name of medical center when they were called to check the status of resident. Also was noted that the subdural hemorrhage had ceased prior to surgery on hip without intervention. Resident had reportedly done well for the surgical process, however, had passed away while aftercare was being done. Compiled by the facility Social Worker.
Plan of Correction
The facility submitted the following plan of correction on 03/3/24:
Element 1:
On March 2, 2024 Nurse was notified by incoming day shift CNA's on resident's condition. The residents (family member), the facility Administrator, DON, Director of Social Services were notified of the incident, and the required reporting documents were completed and reported to APS, OHFLAC, Ombudsman immediately. The facility Risk Manager and Social Services Director began investigating the incident on this date.
Element 2:
Because this has the potential to impact all residents, on March 6, 2024 two (2) employee statements indicated the potential for neglect on there behalf. The two (2) employees received disciplinary action and education on abuse and neglect and the importance of hipsters and protective devices on this date. All other facility employees were in-serviced on the proper reporting procedures of allegations of Abuse and Neglect on this date as well. The Social Services Director reported the potential for neglect for both employees to the CNA Registry on this date as well. On 03/06/24 the facility began an audit on residents with hipsters. Spot checks are performed on all shifts by the CNA shift supervisor.
Element 3:
The CNA Supervisor developed a monitoring log on 03/06/24 to ensure all residents with an order for hipsters have them in place as ordered. The on-shift CNA Supervisor will complete the log on each shift daily for 90 days, every other day for two weeks, then randomly thereafter. The DON will review the logs on a monthly basis for accuracy and completeness. Audits will be re-evaluated at the quarterly Quality Assurance Meeting to ensure continued compliance. To ensure all residents are free from abuse and neglect the Social Services Director will continue to complete a Abuse and Neglect Log to monitor the potential abuse and neglect that a resident may receive. To continue compliance the Social Services Director will complete a Quarterly Abuse and Neglect Log to turn in at our quarterly Quality Assurance Meeting to ensure continued compliance. All accusations of abuse and neglect will be investigated and reported and the accusative will be properly disciplined.
Interviews were conducted on 03/12/24 with the following staff members regarding the education of reporting abuse and neglect and the use of hipsters:
LPN #19 at 1:20 PM Answered questions correctly regarding reporting of abuse and neglect and the use of hipsters.
Housekeeping Aide #52. Answered question correctly regarding reporting of abuse and neglect. HA #52 stated that she knows nothing regarding hipsters that that is not her job.
NA #60 at 1:30 PM. Answered questions correctly regarding reporting of abuse and neglect and the use of hipsters.
NA #32 at 1:33 PM. Answered questions correctly regarding reporting of abuse and neglect and the use of hipsters.
NA/Restorative #5 at 1:40 PM. Answered questions correctly regarding reporting of abuse and neglect and the use of hipsters.
NA #71 at 1:43 PM. Answered questions correctly regarding reporting of abuse and neglect and the use of hipsters.
RN #109 and LPN #70 at 2:55 PM. Answered questions correctly regarding reporting of abuse and neglect and the use of hipsters. RN #109 stated that we are monitoring all residents who are ordered hipsters every shift to see that they are appropriately applied.
Interviewed the DON and LPN #59 at 2:58 PM Answered questions correctly regarding reporting of abuse and neglect and the use of hipsters.
NA # 129 at 3:00 PM. Answered questions correctly regarding reporting of abuse and neglect and the use of hipsters.
The Hipster Monitoring log was reviewed and found the monitoring started on 03/06/24 and was ongoing during the complaint investigation. The following residents were being monitored for ordered hipsters:
Resident # 300, #307, #62, #46 and #303. Random observations during the complaint investigation (03/12-13/24) of each resident found the hipsters were applied correctly.
On 03/13/24 at 10:39 AM a survey team member reported the following interviews:
NA #123 an interview on 03/13/24 at 9:56 AM with NA #123 stated that everything must be reported. If she sees anything suspicious she is to remove/protect the resident and immediately report it to her nurse. NA #123 also states administration goes over this stuff with us and so does the nurses.
At 10:02AM NA #98 stated that he would report any abuse or neglect to his nurse but would also make sure the resident was removed or safe first then report NA # 98 also states he is inserviced on abuse and neglect reporting regularly/yearly.
At 10:10 AM Activity Assistant (AA) #117 stated that she would make sure the resident is safe and free from abuse and immediately call for the nurse/ person in charge . AA #117 stated I would report anything and everything I may think is abuse or neglect, because even if it aint it still needs to be looked into.
LPN #58 at 10:21 AM stated that there is a book behind the nurses stations on how to report. After the resident is safe, you must report within two (2) hours to all agencies and investigate.
Jan 2024
7 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected 1 resident
Based on observation, resident interview, and staff interview, the facility failed to provide a safe, clean, comfortable and homelike environment. This was a random opportunity for discovery. Resident...
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Based on observation, resident interview, and staff interview, the facility failed to provide a safe, clean, comfortable and homelike environment. This was a random opportunity for discovery. Resident Identifier: 4. Facility Census: 77.
Findings included:
a) Resident #4
On 01/02/24 at approximately 12:47 PM, Resident #4 ' s room was observed to have a strong urine odor. There were multiple wet spots in the floor in Resident # 4's room along with dirty wheelchair tracks streaked through the liquid in the floor. Resident #4 stated he/she had soiled their clothes and changed themselves. Soiled clothes were observed laying on the bathroom floor with wet spots leading out into Resident #4's bedroom.
Resident #4 stated in the interview he/she had soiled their clothes, and got a pack of underwear from the aides so I could change myself. Resident #4 indicated he/she had changed their clothes and left them on the bathroom floor.
On 01/02/24 at 12:50 PM, Housekeeper #100 entered the room and acknowledged the smell, wet spots, dirt spots, and soiled clothes on the floor.
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 ensure a facility initiated thirty day notice of discharge contained the date the discharge notice was issued and the effective disch...
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Based on record review and staff interview, the facility failed to ensure a facility initiated thirty day notice of discharge contained the date the discharge notice was issued and the effective discharge date . This was true for one (1) out of two (2) Residents reviewed for discharges. Resident identifier: #29. Facility census: 77.
Findings included:
a) Resident #29
Record review found resident #29 had multiple physical and verbal altercations with staff and residents. The facility implemented numerous interventions when behaviors occurred with no success. The facility issued a 30 day discharge notice, stating the Resident was a danger to self and other Residents. With no placement being found for Resident #29, he currently remains at the facility.
On 01/03/24 at 1:00 PM, record review found the 30 day discharge notice for Resident # 29 did not contain the date the discharge was initiated or the effective discharge date on the letter issued to the responsible party and the required State authorities.
On 01/03/24 at 1:54 PM, the administrator confirmed the notice was not dated as to when it was provided and the effective date of the discharge was not included on the 30 day discharge notice.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Assessment Accuracy
(Tag F0641)
Could have caused harm · This affected 1 resident
Based on recorded review, resident interview, and staff interview the facility failed to have an assessment that accurately reflected the resident's status. This was true for one (1) out of four (4) R...
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Based on recorded review, resident interview, and staff interview the facility failed to have an assessment that accurately reflected the resident's status. This was true for one (1) out of four (4) Residents reviewed for the care area of falls. Resident identifier: Resident # 32. Facility census 77.
Findings included:
a) Resident # 32
During a review of the Minimum Data Set (MDS), it was documented that Resident #32 had a fall with a major injury.
On 01/02/24 at 2:23 PM, Resident # 32 was asked about the fall and the major injury. Resident #32 stated he fell out of his chair last summer, but he did not get hurt.
On 01/03/24 at 10:28 AM medical records Clerk #103 stated Resident #32 only had one fall on 07/31/23 with no injuries.
On 01/03/24 at 1:46 PM, the Director of Nursing (DON) confirmed Resident #32's fall with injury was coded incorrectly by the MDS nurse. The DON said the major injury was from a resident-to-resident altercation on 09/14/23, not from a fall.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
PASARR Coordination
(Tag F0644)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to complete a new pre-admission screening and resident review (PA...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to complete a new pre-admission screening and resident review (PASARR) when four (4) of five (5) reviewed for the care area of PASARR received a new diagnosis of a serious mental disorder. Resident identifiers: 66, 10, 62, 24. Facility Census: 77.
Findings included:
a) Resident #66
On 01/02/24 at approximately 01:45 PM, record review indicates that Resident #66 was admitted to the facility with a PASARR indicating no diagnosis of Major Depressive Disorder. Resident #66 was diagnosed with Major Depressive Disorder, Single Episode, on 04/14/23 and the PASARR was not updated to reflect the diagnosis.
On 01/03/24 at approximately 09:56 AM, the Director of Nursing (DON) #23 presented copies of Resident #66's diagnoses, care plan, and PASARR. The DON #23 acknowledged the diagnosis of Major Depressive Disorder, the missing on the most recent PASARR, and acknowledged there was no updated PASARR to reflect the diagnosis.
b) Resident #10
On 01/02/24 at approximately 02:00 PM, record review indicates that Resident #10 was admitted to the facility on [DATE] with a PASARR that indicated no diagnosis of Major Depressive Disorder. Upon admission, Resident #10 was diagnosed with Major Depressive Disorder. The PASARR was not updated to reflect the diagnosis of Major Depressive Disorder.
01/03/24 09:56 AM Director of Nursing (DON) #23 presented copies of Resident #10's diagnoses, care plan, and PASARR. The DON #23 acknowledged the diagnosis of Major Depressive Disorder, was missing on the PASARR, and acknowledged there was no updated PASARR to reflect the diagnosis.
c) Resident #62
During a medical record review on 01/02/24, revealed Resident #62 had a new psychiatric diagnosis of major depressive disorder on 10/01/23. There was no new PASARR completed with the new psychiatric diagnosis.
In an interview with the Director of Nursing (DON) on 01/02/24 at 4:30 PM, she verified the new diagnosis of major depressive disorder for Resident #62 on 10/01/22 had no new PASARR completed to update the new diagnosis of major depressive disorder.
d) Resident #24
During a medical record review on 01/02/24, revealed Resident #24 had a diagnosis of schizoaffective disorder on 04/06/23. The PASARR completed on 08/16/23 did not include the psychiatric diagnosis of schizoaffective disorder.
In an interview with the Director of Nursing (DON) on 01/02/24 at 4:30 PM, she verified the diagnosis of schizoaffective disorder for Resident #24 had not been included on the PASARR completed on 08/16/23.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to ensure one (1) of one (1) Resident reviewed for the care area ...
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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 one (1) of one (1) Resident reviewed for the care area of death received medications as ordered by the physician. Resident identifier: 80. Facility census: 77.
Findings included:
a) Resident #80
Record review found the resident was admitted to the facility on [DATE]. The Resident expired at the facility on [DATE].
Review of the Medication Administration Record (MAR) found an order for Lisinopril, oral tablet, 5 milligrams (mg's) give 1 tablet by mouth, one time a day, The start date of the Lisinopril was [DATE]. HOLD if systolic Blood pressure is less than 120 or if heart rate is less than 60 beats per minute (BPM) and Notify MD (doctor.) The medication was ordered to be given at 9:00 AM. The diagnosis for use of this medication was, Essential Hypertension.
Review of the MAR found the following days when the medication was administered, but should have been held according to the physician's order because the systolic blood pressure was lower than 120 and/or the heart rate was lower than 60 BPM:
[DATE] Blood Pressure (BP) 102/58,
[DATE] BP 108/62
[DATE] BP 102/44
[DATE] BP 116/68
[DATE] BP 102/64
[DATE] BP 112/68
[DATE] BP 96/62, heart rate: 56
[DATE] BP 116/56
[DATE] BP 110/69
[DATE] BP 118/68, Heart rate: 57
[DATE] BP 118/64, Heart rate: 57
[DATE] BP 118/78
[DATE] BP 102/60
[DATE] BP 118/56
[DATE] BP 118/62
[DATE] BP 112/64
[DATE] BP 112/64
[DATE] BP 112/64
[DATE] BP 118/64
[DATE] BP 118/64
[DATE] BP 116/72
In addition the Resident had an order to receive Coreg Oral Tablet 6.25 mg., give 1 tablet by mouth two (2) times a day at 9:00 AM and 9:00 PM for a diagnosis of Unspecified Diastolic Congestive Heart Failure. HOLD if systolic Blood pressure is less than 120 or if heart rate is less than 60 beats per minute (BPM) and Notify MD (doctor.) The start date of the medication was [DATE]. The start date was [DATE].
On the following days at 9:00 AM the medication was given outside the ordered physician's parameters:
[DATE] Blood Pressure (BP) 102/58,
[DATE] BP 108/62
[DATE] BP 102/44
[DATE] BP 116/68
[DATE] BP 102/64
[DATE] BP 112/68
[DATE] BP 96/62, heart rate: 56
[DATE] BP 116/56
[DATE] BP 110/69
[DATE] BP 118/68, Heart rate: 57
[DATE] BP 118/64, Heart rate: 57
[DATE] BP 118/78
[DATE] BP 102/60
[DATE] BP 118/56
[DATE] BP 118/62
[DATE] BP 112/64
[DATE] BP 112/64
[DATE] BP 112/64
[DATE] BP 118/64
[DATE] BP 118/64
[DATE] BP 116/72
On the following days the 9:00 PM dosage was administered outside the physician's parameters:
[DATE] BP 102/58
[DATE] BP 108/62
[DATE] BP 108/66
[DATE] BP 102/44
[DATE] BP 100/42
[DATE] BP 104/60
[DATE] BP 118/58
[DATE] BP 110/68
[DATE] BP 69/62
[DATE] BP 116/56
[DATE] BP 110/78
[DATE] BP 118/66
[DATE] BP 118/62
[DATE] BP 116/58
[DATE] BP 118/78
[DATE] BP 102/60
[DATE] BP 118/56
[DATE] BP 118/62
[DATE] BP 112/64
[DATE] BP 112/64
[DATE] BP 66/60
[DATE] BP 118/64
[DATE] BP 116/72
On [DATE] at 11:53 AM, the Director of Nursing (DON) said the order says to contact the physician so most likely the physician was contacted and the physician ordered the medications to be given. The DON said she would look for evidence the physician was contacted.
On [DATE] at 1:14 PM, the DON said she could not find any evidence the physician was contacted. The DON confirmed the medication should not have been given on 61 occasions during 30 days in November and 8 days in December, 2023.
At 11:10 AM on [DATE], the DON was asked if she could explain why the Resident's blood pressure was 69/62 on [DATE] and 66/60 on [DATE] as recorded on the MAR? Both readings would have been considered critically low.
The DON provided information indicating these recordings were made in error. Nurses document on paper and then enter the numbers on the MAR. On [DATE] the hand written information indicated the BP was 114/72 and on [DATE] the BP was 96/62. The DON said on both occasions the medication should have been held.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected multiple residents
Based on observation and staff interview the facility failed to ensure food was stored in accordance with professional standards for food service safety. This deficient practice had the potential to a...
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Based on observation and staff interview the facility failed to ensure food was stored in accordance with professional standards for food service safety. This deficient practice had the potential to affect any resident receiving nourishment from the kitchen. Facility census: 77.
Findings included:
a) Kitchen tour
During the kitchen tour on 01/02/24 at 11:15 AM, it was discovered the drip pan had a large accumulation of grease build up. In the walk-in cooler a bin holding four (4) ounce orange juice cups had two (2) cups that had been crushed and the orange juice had poured out over the other juice cups and accumulated in the bottom of the bin. There was a used paper towel and a strip of cardboard lying on top of the orange juice cups.
An interview with the Dietary Manager (DM) on 01/02/24 at 11:15 AM, verified the grease drip pan needed to be cleaned and the two (2) damaged orange juice cups had contaminated the other orange juice cups.
MINOR
(C)
Minor Issue - procedural, no safety impact
Garbage Disposal
(Tag F0814)
Minor procedural issue · This affected most or all residents
Based on observation and staff interview the facility failed to ensure garbage storage area was maintained in a sanitary condition to prevent the harborage and feeding of pests. It was discovered the ...
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Based on observation and staff interview the facility failed to ensure garbage storage area was maintained in a sanitary condition to prevent the harborage and feeding of pests. It was discovered the dumpster's were full and overflowing with several garbage bags lying on each of the dumpster's.
Facility census: 77.
Findings included:
a) Garbage storage area
During an observation of the garbage storage area on 01/03/24 at 10:45 AM, it was discovered the three (3) dumpster's were full and had several garbage bags lying on top of the lids of the dumpster's.
An interview with the Nursing Home Administrator (NHA) the on 01/02/24 at 12:30 PM, verified the area trash disposal company was to deliver an extra dumpster for the holidays. He reported they had not provided an extra dumpster for Christmas or New Years Day. He also reported he had not contacted the company regarding the non delivery of the extra dumpster's.
Aug 2023
1 deficiency
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on observation and staff interview, the facility failed to maintain a safe, clean, comfortable and homelike environment....
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on observation and staff interview, the facility failed to maintain a safe, clean, comfortable and homelike environment. This failed practice has the potential to affect more than a limited number of residents and was discovered during a complaint investigation. Facility census 85.
Findings included:
a) Observation on 08/29/23 at approximately 9:44 a.m., revealed the shared restroom for Resident Rooms 313/315 had a strong sewer smell and the floor was stained with a brown/watery substance.
b) Observation on 08/29/23 at approximately 9:56 a.m., revealed the shared restroom for Resident Rooms 208/210 had strong sewer smell and the toilet appeared shifted / unsecured to the floor and would not flush and appeared to be stopped up.
c) Observation on 08/29/23 at approximately 10:03 a.m., revealed the toilet appeared shifted / unsecured to the floor and the sealant at the base of the toilet appeared to be stained with a mold/mildew substance in the shared restroom for Resident Rooms 204/206.
d) Observation on 08/29/23 at approximately 10:09 a.m., revealed damaged door trim and scuffed paint/exposed drywall in the shared restroom of Resident Rooms 404/406.
e) Observation on 08/29/23 at approximately 10:13 a.m., revealed cobwebs in the upper right hand corner of the room near the resident bed and a missing floor transition at the entrance door to the room in Resident room [ROOM NUMBER].
f) Observation on 08/29/23 at approximately 10:16 a.m., revealed the base of the toilet appeared to be stained with a mold/mildew substance in the shared restroom for Resident Rooms 401/403.
g) Observation on 08/29/23 at approximately 10:27 a.m., revealed base trim that was missing paint and appeared worn throughout the room and scuffed/peeling paint on the wall near the window in Resident room [ROOM NUMBER].
h) Observation on 08/29/23 at approximately 11:56 a.m., revealed vegetation growing in the gutters and wooden garden planters that were broken/disrepair in the Non-Smoking Courtyard.
i) Observation on 08/29/23 at approximately 1:48 p.m., revealed the ceiling vents throughout the Kitchen appeared stained and loaded with dust/debris.
j) Observation on 08/29/23 at approximately 1:53 p.m., revealed the floor to the Walk-In Cooler in the Kitchen appeared rusty and unsealed.
k) Interview on 08/29/23 at approximately 1:54 p.m. with the Maintenance/Housekeeping/Laundry Supervisor verified these findings. These findings were also acknowledged by the Administrator at the exit interview on 08/29/23 at approximately 4:15 p.m.
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Nov 2022
14 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Free from Abuse/Neglect
(Tag F0600)
Could have caused harm · This affected 1 resident
.
Based on resident interview, record review and staff interview the facility failed to ensure a Resident was free from neglect. The failed practice was true for one (1) of three (3) Residents reviewe...
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Based on resident interview, record review and staff interview the facility failed to ensure a Resident was free from neglect. The failed practice was true for one (1) of three (3) Residents reviewed for abuse. Resident identifier: #20. Facility census: 77.
Findings included:
a) Resident #20
During an interview on 10/31/22 at 10:20 AM, Resident #20 stated that she wished the facility would get her a wheelchair so she could get out of bed.
An observation on 10/31/22 at 10:20 AM, showed Resident #20 lying in bed with no available wheelchair located in Resident # 20's room.
During an interview on 11/01/22 at 3:25 PM, Resident # 20 stated she was not able to get out of bed yesterday and had not been out of bed today. Resident # 20 stated she asked her Nurse Aides (NA) to get up out of bed earlier today and was told they did not have time to get her up and out of bed today. Resident # 20 stated she would love a wheelchair so she could wheel around the facility.
An observation on 11/01/22 at 3:25 PM, showed Resident #20 lying in bed and there was no available wheelchair located in Resident # 20's room.
During an interview on 11/01/22 at 3:50 PM, Licensed Practical Nurse (LPN) #7 stated if Resident # 20 wanted to get out of bed she may do so.
An observation on 11/01/22 at 3:51 PM, found LPN #7 went to Resident # 20's room to discuss the desire to get out of bed. Resident # 20 stated to LPN #7 and the Surveyor that she would like to get up and enjoy the company of others. Resident # 20 stated it had been a long time since she was able to get out of bed. LPN #7 asked Resident # 20, did you ask someone to get up today? Resident #20 replied, I did, I asked the NA earlier but was told they didn't have time to get me up. LPN #7 replied anytime a NA says they don't have time to get you up and you want to up; press the call light and talk to your nurse about getting up. LPN #7 went to look for the assigned NAs to assist Resident #20 out of bed. Resident #20's assigned NAs were not seen in the hallway and LPN #7 could not find them. LPN # 7 stated the next step would be to report the incident to her supervisor, talk with the NAs and assist Resident # 20 in getting up to attend activities.
An observation on 11/01/22 at 4:10 PM, showed Resident # 20 sat in a geriatric chair and was attending activities. Resident #20 was assisted out of bed after surveyor intervention.
During an interview on 11/01/22 at 4:20 PM, Resident # 20 stated that she was very happy she was able to get up out of bed and attend activities. Resident # 20 stated it was lonely in her room alone all the time and she enjoyed being out with others. Resident # 20 stated it felt good to get out of bed and be around others as she had not been out of bed for a long time.
Review of Resident #20's medical record showed the last activity assessment completed on Resident #20 was dated 07/20/22. The activity assessment stated Resident #20's mobility should be with a wheelchair and required assistance. The activity assessment stated Resident preferred own room activities which contradicted interview findings with Resident #20. The care plan stated that resident #20 mainly was a loner and preferred to do her own room activities that also contradicted Resident 20 interview findings.
Further review of Resident # 20's medical record showed, multiple progress notes:
A progress note dated 10/27/22 at 1:29 PM, stated, Resident noted in geri chair watching television in east side lounge.
A progress note dated 10/27/22 at 7:00 PM, stated, Resident in bed at this time finishing dinner tray.
A progress note dated 10/30/2022 at 11:59 AM, stated, Resident in bed at this time with HOB raised using her tablet. Resident took all medications per MAR with ease including lokelma pkt. Resident requested PRN pain medication during AM med pass stating her bottom was hurting and rated pain 7/10. PRN pain medication administered.
A progress note dated 11/01/22 at 4:41 PM, stated, Resident up in geri chair sitting in dining room at this time.
During an interview on 11/02/22 at 11:25 AM, LPN #7 stated that that incident with Resident #20 was reported to the Assistant Director of Nursing (ADON) on 11/01/22.
During an interview on 11/02/22 at 11:47 AM, the ADON stated that LPN #7 did report an incident about Resident #20 and ADON followed up with NAs. The ADON stated that the NAs were already in the process of getting Resident #20 out of bed. The ADON stated that Resident # 20 was perfectly capable of letting her needs be known. ADON stated that she was unaware and was not informed by LPN #7 that the NAs were not available on the floor when Resident #20 made the allegation of neglect. ADON stated that all she could do was say I'm sorry and would provide an in-service to all staff regarding providing care and when Residents ask for care, staff need to listen and complete resident care.
During an interview on 11/02/22 at 1:55 PM, the ADON stated that an allegation of NAs not providing care to residents would be considered an allegation of neglect. The ADON stated, I am going to be honest; I did not report the incident with Resident #20 yesterday. The ADON stated that an allegation of neglect should have already been reported by now and was not reported in a timely manner.
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CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0604
(Tag F0604)
Could have caused harm · This affected 1 resident
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Based on record review, observation and staff interview, the facility failed to ensure one (1) of (1) residents having a physical restraint, received care according to standards of practices during ...
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Based on record review, observation and staff interview, the facility failed to ensure one (1) of (1) residents having a physical restraint, received care according to standards of practices during the time in which a restraint was used. Resident #48 did not receive restraint checks and releases from the restraint in a timely manner. The facility failed to ensure Resident #48 had the correct device applied as ordered by the physician, and did not receive periodic evaluations by all members of the interdisciplinary team to identify less restrictive means to the restraint usage. The facility also failed to identify a continued need for treatment on a periodic basis. Resident identifier: Resident #48. Census: 77.
Findings included:
a. Resident #48
A review of the Policy: Restraints (physical) policy, dated 07/2008: showed the physician order must include instructions for release and positioning/ toileting every two (2) hours, release during activities, meals or periods of 1:1 (meals, personal care, etc.)
If physical restraints are used, each resident must be reviewed at least quarterly by the care plan committee to determine if restraint reduction is possible.
A review of Policy: Restraint Reduction, dated 07/2008, noted the need for restraint reduction is assessed every three (3) months and as needed by the interdisciplinary team and the therapy department. A physician's order is required before reducing restraints.
Under procedure , section 1. , all residents using restraints are identified and evaluated for restraint reduction using the physical restraint elimination review done quarterly.
Under item 2. A licensed therapy assistant screens and /or evaluates each resident being considered for restraint reduction and documents his/her recommendation in the medical record.
An observation on 10/31/22 at 10:45 AM, revealed Resident #48 in a wheelchair, with a pelvic apparatus, sitting in the day room. The resident was not able to release the apparatus when requested.
A record review, showed an order for a positioning belt, when up in wheel chair to aid in maintaining posture while in wheelchair. Staff were to check every 30 minutes and release every two (2) hours for skin integrity and re-evaluate every three (3) months.
An observation of Resident #48, on 11/01/22 at 01:11 PM, revealed the resident to be seated in the dayroom, with the pelvic apparatus in place and not a positioning belt as noted in the current physician's order. The order was not specific to include a pelvic type of device that could not be self- released as observed applied to the resident.
On 11/02/22 at 01:35 PM, Resident #48 was observed in the same position as observed at 01:11 PM.
An interview with Nursing Assistant (NA) #42, on 11/01/22 at 01:45 PM, revealed this nursing assistant was assigned to provide care to Resident #48 and stated further, the resident is assisted out of bed to the wheelchair at 10:00 AM and the pelvic apparatus had been applied. It was learned, at this time, the resident had not received checks every 30 minutes and had not been released every 2 hours in order to provide care to the resident. During the interview on 11/01/22 at 01:45 PM, NA #42 confirmed Resident #48 was unable to release the belt from the pelvic apparatus.
Further record review noted a Quarterly Review for the Use of the Physical restraint, dated 09/12/22 with a recommendation for the use of the restraint, but the type of restraint was not documented and there was no rationale or reason for the decision documented. The quarterly review for Use of the Physical Restraint, dated 09/12/22, noted how the restraint use affected the by documentation the restraint was used per resident preference.
Further reviews of the Use of the Physical Restraint, dated 03/14/22 and 06/10/22, also, showed no reason for the continuation of the restraint usage, the type of restraint in use, and continued to document the restraint was being used in accordance with resident preference.
The resident was assessed by facility staff to have a brief mental status of five (5) which indicated moderate cognitive impairment on the Minimal Data Sets (MDS) since 12/27/21 and had been deemed incapacitated by the physician on 08/11/22.
An interview with the Director of Therapy Services, on 11/02/22 at 12:38 PM, revealed there had been no change in Resident #48 and therefore, no need for re-evaluation. The director of Therapy Services confirmed Resident #48 had not been evaluated for restraint usage every three (3) months as addressed in facility policy.
An interview, on 11/02/22 at 12:43 PM, with the Physical Therapy Assistant (PTA) #77, revealed therapy may be consulted through a quarterly review for further assessment of a restraint if it was problematic for the resident and confirmed therapy services had not been involved in the quarterly review for restraint usage for Resident #48. PTA #77, revealed during this interview, that she was unaware Resident #48's device was considered a restraint and thought the resident had a positioning device being used.
An interview with the Assistant Director of Nursing (ADON) on 11/02/22 at 01:18 PM , verified the resident had not been provided care in accordance to the physician's order and verified the resident
had a pelvic belt because of positioning. The ADON, stated further, during the interview, that she had taken the belt off back in June 2022 and Resident #48 would not sit still and the evaluation failed.
There was lack of evidence the Therapy services had been involved in this decision as outlined in the facility's policy.
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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
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Based on resident interview, record review and staff interview the facility failed to ensure a Resident was free from neglect. The failed practice was true for one (1) of three (3) Residents reviewe...
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Based on resident interview, record review and staff interview the facility failed to ensure a Resident was free from neglect. The failed practice was true for one (1) of three (3) Residents reviewed for abuse. Resident identifier: #20. Facility census: 77.
Findings included:
a) Resident #20
During an interview on 10/31/22 at 10:20 AM, Resident #20 stated that she wished the facility would get her a wheelchair so she could get out of bed.
An observation on 10/31/22 at 10:20 AM, showed Resident #20 lying in bed with no available wheelchair located in Resident # 20's room.
During an interview on 11/01/22 at 3:25 PM, Resident # 20 stated she was not able to get out of bed yesterday and had not been out of bed today. Resident # 20 stated she asked her Nurse Aides (NA) to get up out of bed earlier today and was told they did not have time to get her up and out of bed today. Resident # 20 stated she would love a wheelchair so she could wheel around the facility.
An observation on 11/01/22 at 3:25 PM, showed Resident #20 lying in bed and there was no available wheelchair located in Resident # 20's room.
During an interview on 11/01/22 at 3:50 PM, Licensed Practical Nurse (LPN) #7 stated if Resident # 20 wanted to get out of bed she may do so.
An observation on 11/01/22 at 3:51 PM, found LPN #7 went to Resident # 20's room to discuss the desire to get out of bed. Resident # 20 stated to LPN #7 and the Surveyor that she would like to get up and enjoy the company of others. Resident # 20 stated it had been a long time since she was able to get out of bed. LPN #7 asked Resident # 20, did you ask someone to get up today? Resident #20 replied, I did, I asked the NA earlier but was told they didn't have time to get me up. LPN #7 replied anytime a NA says they don't have time to get you up and you want to up; press the call light and talk to your nurse about getting up. LPN #7 went to look for the assigned NAs to assist Resident #20 out of bed. Resident #20's assigned NAs were not seen in the hallway and LPN #7 could not find them. LPN # 7 stated the next step would be to report the incident to her supervisor, talk with the NAs and assist Resident # 20 in getting up to attend activities.
An observation on 11/01/22 at 4:10 PM, showed Resident # 20 sat in a geriatric chair and was attending activities. Resident #20 was assisted out of bed after surveyor intervention.
During an interview on 11/01/22 at 4:20 PM, Resident # 20 stated that she was very happy she was able to get up out of bed and attend activities. Resident # 20 stated it was lonely in her room alone all the time and she enjoyed being out with others. Resident # 20 stated it felt good to get out of bed and be around others as she had not been out of bed for a long time.
Review of Resident #20's medical record showed the last activity assessment completed on Resident #20 was dated 07/20/22. The activity assessment stated Resident #20's mobility should be with a wheelchair and required assistance. The activity assessment stated Resident preferred own room activities which contradicted interview findings with Resident #20. The care plan stated that resident #20 mainly was a loner and preferred to do her own room activities that also contradicted Resident 20 interview findings.
Further review of Resident # 20's medical record showed, multiple progress notes:
A progress note dated 10/27/22 at 1:29 PM, stated, Resident noted in geri chair watching television in east side lounge.
A progress note dated 10/27/22 at 7:00 PM, stated, Resident in bed at this time finishing dinner tray.
A progress note dated 10/30/2022 at 11:59 AM, stated, Resident in bed at this time with HOB raised using her tablet. Resident took all medications per MAR with ease including lokelma pkt. Resident requested PRN pain medication during AM med pass stating her bottom was hurting and rated pain 7/10. PRN pain medication administered.
A progress note dated 11/01/22 at 4:41 PM, stated, Resident up in geri chair sitting in dining room at this time.
During an interview on 11/02/22 at 11:25 AM, LPN #7 stated that that incident with Resident #20 was reported to the Assistant Director of Nursing (ADON) on 11/01/22.
During an interview on 11/02/22 at 11:47 AM, the ADON stated that LPN #7 did report an incident about Resident #20 and ADON followed up with NAs. The ADON stated that the NAs were already in the process of getting Resident #20 out of bed. The ADON stated that Resident # 20 was perfectly capable of letting her needs be known. ADON stated that she was unaware and was not informed by LPN #7 that the NAs were not available on the floor when Resident #20 made the allegation of neglect. ADON stated that all she could do was say I'm sorry and would provide an in-service to all staff regarding providing care and when Residents ask for care, staff need to listen and complete resident care.
During an interview on 11/02/22 at 1:55 PM, the ADON stated that an allegation of NAs not providing care to residents would be considered an allegation of neglect. The ADON stated, I am going to be honest; I did not report the incident with Resident #20 yesterday. The ADON stated that an allegation of neglect should have already been reported by now and was not reported in a timely manner.
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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 comprehensive care plan.
This was true for two (2)...
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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 comprehensive care plan.
This was true for two (2) out of twenty-three (23) Residents reviewed during the long term care survey process. Resident Identifiers: #330 and #77 Facility Census: 77
a) Resident # 77
Resident #77 is currently a smoker. Her name is on the smokers list provided by the facility. She has a smoking evaluation dated 10/13/22. According to this evaluation she is to be supervised while smoking. The resident was observed smoking with supervision on 11/01/22 at 1:10 PM.
According to the Smoking Policy with a revision date of 4/2021 .The resident's smoking status will be documented in the care plan . Resident #77 does not have a focus of smoking on her care plan. This was confirmed with Licensed Practical Nurse (LPN) # 32 at 11/02/22 at 9:45 AM.
b) Resident #330
Resident #330 has an current order dated 10/26/22 for a life vest to be worn at all times, change the battery every 24 hours. Upon the initial long term survey process on 10/31/22 at 10:10 AM, the Resident did not have the life vest on. This was confirmed with LPN #32 on 10/31/22 at 10:12 AM.
On 11/01/22 at 9:08 AM, the Resident did not have the life vest on. This was confirmed with LPN #61 at 9:10 AM. At this time, LPN #61 stated she could not fine the life vest.
On 11/01/22 at 12:01 PM, there was documentation that Registered Nurse (RN) #62 spoke with the Residents wife and she has taken the life vest to her house. The order for the life vest was then discontinued.
The Resident was admitted on [DATE] at which time there was an initial admission care plan started. The life vest was not on the initial admission care plan.
According to the Medication Administration Record (MAR) for October and November, 2022, the resident did wear the life vest on October 31 and November 1, 2022. However, the life vest was not on the Resident when the surveyor observed the resident on those dates.
The above information was confirmed with LPN #32 on 11/2/22 at 10:01 AM.
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CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on record review and staff interview the facility failed to follow a physicians order for a life vest to be on the 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 follow a physicians order for a life vest to be on the Resident at all times. This was a random opportunity for discovery. Resident identifier: #330 Facility Census: 77.
a) Resident #330
Resident #330 has an current order dated 10/26/22 for a life vest to be worn at all times, change the battery every 24 hours. Upon the initial long term survey process on 10/31/22 at 10:10 AM, the Resident was not wearing the life vest. This was confirmed with Licensed Practical Nurse (LPN) #32 on 10/31/22 at 10:12 AM. On 11/01/22 at 9:08 AM, the Resident did not have the life vest on. This was confirmed with LPN #61 at 9:10 AM. At this time, LPN #61 stated she could not find the life vest.
On 11/01/22 at 12:01 PM, there was documentation that Registered Nurse (RN) #62 spoke with the Residents wife and she has taken the life vest to her house. The order for the life vest was then discontinued.
The Resident was admitted on [DATE] at which time there was an initial admission care plan started. The life vest was not on the care plan.
According to the Medication Administration Record (MAR) for October and November, 2022, the resident did wear the life vest on October 31 and November 1, 2022. However, the life vest was not on the Resident when the surveyor observed the resident.
The above information was confirmed with LPN #32 on 11/2/22 at 10:01 AM.
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CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
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Based on observation, record review and staff interview, the facility failed to ensure supervision and devices to prevent accidents that could lead to injury. Resident #130 had orders for devices to...
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Based on observation, record review and staff interview, the facility failed to ensure supervision and devices to prevent accidents that could lead to injury. Resident #130 had orders for devices to prevent injury due to poor safety awareness that were not provided in accordance to the physician's orders This was true to one (1) of one (1) reviewed for accident/injury concerns. Resident identifier: Resident #130. Census: 77.
Findings included:
Resident #130
A record review for Resident #130 showed the resident being at risk for falls/injuries because of poor safety awareness. Physician's orders were noted for Resident #130 to include the following:
- Geri sleeves bilateral upper extremities due to fragile skin integrity
- Hipsters to be worn at all times which would aid in the prevention of a hip fracture in case of falls
- Abdominal binder to be worn to prevent tugging and pulling out peg tube
An observation made, on 10/31/22 at 12:40 PM, revealed Resident #130 laying in bed with no geri sleeves, abdominal binder or hipsters noted being applied to the resident for safety measures to prevent accidents or injury.
An interview, with Licensed Practical Nurse (LPN) #34, on 10/31/22 at 12:40 PM , verified the abdominal binder, and the geri sleeves were not in place. Additionally, LPN #34 checked the resident and stated the hipsters were not in place. During the interview with LPN #34, it was verified the devices ordered were not found in the bed or on the floor where the resident may have removed them.
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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
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on record review and staff interview the facility failed to provide care and services to maintain acceptable parameters ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on record review and staff interview the facility failed to provide care and services to maintain acceptable parameters of nutritional status to prevent weight loss. This failed practice was true for one (1) out of six (6) residents reviewed for nutrition. Resident identifier: #15. Facility census 77.
Findings included:
a) Resident #15
A review of medical records revealed Resident #15 was a admitted to the facility on [DATE], with an admission weight of 168.2 pounds.
Diagnoses included: Hypertension, acute and chronic respiratory failure, Vitamin D deficiency, Chronic kidney disease, and diabetes.
On 04/08/2022, the resident weighed 168.2 pounds. On 10/22/22, the resident weighed 127 pounds which is a -24.49 % Loss.
A review of the medical chart found a form titled, Physicians Progress Notes, dated 07/20/22 revealed the following information:
It was mentioned by the physician about a weight loss from admission to July and a weight of 135 pounds. However, there was no new orders for any supplements or any interventions addressing the weight loss.
On 07/28/2022, the resident weighed 137.0 lbs. On 10/20/2022, the resident weighed 126.0 pounds which is a -8.03 % Loss.
Facility Dietitian notes. Dated 05/08/22:
Diet order: No Added Salt (NAS), Low Concentrated Sweets (LCS).
UBM: admission [DATE] 168 pounds, 05/11/22 157 pounds, a 6.2 percent weight loss in one month.
Note: At this time will monitor weight with lab history showing low sodium a concern for edema. Resident will eat several meals good and then slow poor intake. At this time will monitor and no recommendations.
Labs: 04/06/22
Sodium low
H/H 9.6/31.4 low
A1C 8.0 high
TSH 5.098 high
Albumin 2.2 low
total protein 6.1 low.
A review of the facility form, Physician Progress, dated 09/18/22, revealed the physician wrote Weights are stable at time, 127.2. She continues Glucerna three times daily.
Next Dietitian note dated 09/20/22.
Diet order: NAS, LCS, Glucerna 8 ounces three times a day started on 08-2022.
UBW: weight at time of admission [DATE] 168 pounds, 08/11/22 134 pounds loss of 24.24 percent weight loss.
Note: Resident has shown weight loss since admission. Resident is fed by staff or assisted. PO (by mouth) intake poor to fair for most meals. Supplement started and will monitor that supplement for goal of stable weight.
Labs: 08/08/22
HCB A1C 6.6
Albumin 3.1 low,
Sodium 139
Potassium 4
BUN 22 high
Creatinine 1.99 high
H/H 15.3/47.7
Dietitian note dated 10/15/22.
Diet order: NCS, LCS, no spicy food, nuts, corn or popcorn, Glucerna 237 ml three times a day.
UBW: admission weight 168 pounds, loss of 27.4 percent 09/01/22.
Note: PO intake continue to be poor with meals refused. Resident is fed by staff. Staff works to encourage but resident usually states too tired to eat and not hungry.
Labs: 09/14/22
H/H 13.8/42.6
Sodium 141
Potassium 4.3
BUN 26 high
Creatinine 2/14 high
During an interview on 11/01/22 at 2:20 PM, with License Practical Nurse (LPN) #16 (also acting as scribe for facility physician,) LPN #16 was asked about the excessive weight loss for Resident #15. LPN #16 stated it was due to the resident moving around so much. LPN #16 was asked if the weight loss was brought to the attention of the physician, because she as the [NAME] wrote the Resident's weight was stable?
LPN stated she did not, but that the physician did order a pill for Resident #15 around 10/15/22 to stimulant the resident's appetite.
A review of the care plan found that on 10/14/22, an appetite stimulant (Mirtazapine) was started.
A review of the Medical Administration Record (MAR) found that Mirtazapine was not on the MAR for the month of October. There was no indication the medication was started on 10/14/22.
On 11/02/22 at 1:30 PM, LPN #16 was searching to find the MAR with the medication for the appetite stimulant, Mirtazapine.
On 11/02/22 at 2:00 PM, Assistant Director of Nursing (ADON) was asked for the documentation to show that the Glucerna supplement was given and how much was consumed, in addition to finding documentation that the appetite stimulant was given. The ADON said the Nurse Aides would document the intake of Glucerna.
The document provided by the ADON did not include the supplement drink, Glucerna.
At the close of this survey no additional information was provided from LPN #16 or the ADON.
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CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Tube Feeding
(Tag F0693)
Could have caused harm · This affected 1 resident
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Based on observation, record review, and staff interview, the facility failed to ensure enteral feedings were administered in accordance to professional standards. The facility failed to ensure ente...
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Based on observation, record review, and staff interview, the facility failed to ensure enteral feedings were administered in accordance to professional standards. The facility failed to ensure enteral feedings were identified with a label as to the type of feeding being administered, by a pump and time of administration to ensure safety of contents and accuracy of administration, to a resident. This was found to be true for one (1) of one (1) resident reviewed during the Long-Term Care Survey Process (LTCSP). Resident identifier: Resident #130. Census: 77
Findings included:
a.) Resident #130
A record review, for Resident #130, showed physician's orders for Isosource 1.5 via pump per feeding tube. The feeding was to be off at 10:00 AM daily and started at 14:00 (2:00 PM) daily.
An observation, on 10/31/22 at 09:55 AM, revealed Resident #130 was receiving an enteral feeding though a pump. The bag was half full with feeding contents. The feeding being administered was not labeled to show the type of feeding being administered or the time the feeding was placed on the pump. Additionally the tubing was not dated to verify when the tubing/administration set had been changed.
An interview with Licensed Practical Nurse (LPN) #34, on 10/31/22 at 09:55 AM, confirmed there was feeding remaining in the bag but no label showing what type of feeding was being administered to Resident #130 or the time the feeding was started. LPN #34 verified there was no date on the administration set noting when how long it had been in use.
An interview with the Assistant Director of Nursing (ADON), on 11/02/22 at 01:20 PM , verified she was aware of the tube feeding issues identified by the surveyor. The ADON confirmed, during the interview, the facility's policy was to label and date the feeding bag with the type of feeding, time administered, the date, and the date the administration set the tubing. The ADON confirmed staff had not done so.
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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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b) Resident #61
An observation on 10/31/22 at 10:08 AM, showed Resident # 61 in bed with oxygen being administered via nasal cannula at a flow rate of three (3) liters per minute.
Review of Reside...
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b) Resident #61
An observation on 10/31/22 at 10:08 AM, showed Resident # 61 in bed with oxygen being administered via nasal cannula at a flow rate of three (3) liters per minute.
Review of Resident #61's medical record showed a physician order dated 10/29/22: O2 @ 4L Via NC.
During an interview on 10/31/22 at 1:30 PM, Licensed Practical Nurse (LPN) #3 confirmed Resident # 61 was being administered oxygen at a flow rate of three (3) liters per minute and should have been receiving oxygen administered at four (4) liters per minute.
Based on observation, record review and interview, the facility failed to provide oxygen therapy in accordance with professional standards and practices. The facility failed to ensure the flow rate of oxygen was administered in accordance with physician's orders. This failed practice was true for two (2) of two (2) residents receiving oxygen therapy, reviewed during the Long -Term Care Survey Process (LTCSP). Resident identifiers: Resident #68 and #61. Census: 77.
The findings included:
a) Resident #68
An observation, on 10/31/22 at 10:00 AM, revealed Resident #68 was receiving oxygen therapy with a flow rate of four (4) liters (L) per minute.
An additional observation made on 10/31/22 at 01:30 PM, revealed Resident #68 continued to receive the oxygen at a flow rate of 4L/minute.
On 10/31/22 at 01:30 PM, LPN #3 verified the oxygen flow rate to be set on 4 L/min. On 10/31/22 at 01:35 PM, LPN #3 stated, during an interview, the order had been verified and Resident #68 should have been receiving the oxygen therapy at a flow rate of 2L/minute. Additionally, LPN #3 confirmed , at this time, the resident was receiving the oxygen at an incorrect rate of administration and needed to be corrected.
An interview, with the Assistant Director of Nursing (ADON), on 11/02/22 at 01:20 PM, confirmed the oxygen for Resident #68 had not been administered according to physician's orders and provided a policy for review. The policy, titled: Oxygen Concentrator, dated 07/2008, item 6. noted staff were to set the concentrator per Physician's order. It was further stated by the ADON, at this time, the facility had not followed the policy directive when providing oxygen to Resident #68.
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CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Medication Errors
(Tag F0758)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on observation, record review and staff interview the facility failed to ensure one (1) of five (5) residents reviewed w...
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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 one (1) of five (5) residents reviewed was free from unnecessary medications. Resident Identifier: #12. Facility census 77.
Findings included:
a) Resident #12
A review of medical records revealed Resident #12 had a physician's order for Seroquel for Alzheimers disease and behaviors.
A review of the nursing behavior notes revealed the last behavior noted was made on 10/26/20.
On 11/01/22 at 1:16 PM, the Assistant Director of Nursing (ADON) was interviewed regarding Resident # 12 receiving Seroquel for behaviors and no documented behaviors in two years.
On 11/01/22 01:25 PM, ADON confirmed there were no recent behaviors noted.
The ADON provided a form from a mental health service that sees the resident. The form was dated 10/11/22, which read,
GDR (Gradual Dose Reduction) Determination: GDR clinically inadvisable currently. No other rational was provided.
The ADON was asked if the physicians that manages her mental health care were made aware there has not been a behavior in two years? The ADON stated she did not know, but they have access to the resident's medical chart.
The Attending Physician's current order reads:
Seroquel tablet 25 MG give 12.5 mg by mouth two times a day related to Alzheimer's disease with late onset Dementia in other disease classified elsewhere with behavioral disturbance.
On 11/01/22 at 1:53 PM, the ADON agreed the way the order is written, indicates Seroquel was to be given for behaviors.
On 11/01/22 at 2:03 PM, License Practical Nurse and Facility nurse [NAME] (LPN) #16 was asked about the GDR requested by the facility Pharmacist on 11/17/21.
LPN #16 confirmed she completed the form for the GDR, and the response written by her. LPN #16 said she wrote what she was told to because the physician was out of the country at the time.
Physician Recommendation Form date 11/17/21.
A box on the form was checked:
Discontinuation likely to be harmful to resident and/or others or it will disrupt their provision of care.
Target symptoms continue to persist in the resident. Reduction is clinically contraindicated as a result.
Physician/Prescriber response:
She (Resident #12) continues aggression with direct care staff. She also is easily annoyed with others, continued wandering, risk for elopement. She follows with (named the mental health services) who report a GDR would increase and exacerbate her dementia with negative behaviors causing interference in her quality of daily living. This was dated 12/07/21.
LPN #16 was asked why the response stated Resident #12 was having behaviors daily when it had been 14 months since Resident #12 had a documented behavior. LPN #16 she thinks that maybe the staff told her that. LPN #15 was asked if she had reviewed the medical chart belonging to Resident #12. LPN #16 stated she did not and the facility physician was not informed either.
LPN #16 agreed Resident #12's physician should have had a tired a GDR per the above Pharmacist recommendation. LPN #16 was asked if she had witnessed any behaviors. She said no. The surveyor told LPN #16, Resident #12 was not seen anywhere but in her bed since the beginning of the survey. LPN #16 stated she was sure Resident #12 was up in a wheelchair yesterday after 5 PM.
Resident #12 was observed lying quietly in her bed on the below date and times:
*10/31/22 at 9:15 AM
*10/31/22 at 12:45 PM
*10/31/22 at 4:30 PM
*11/01/22 at 8:30 AM
*11/01/22 at 1:13 PM
*11/01/22 at 4:15 PM
*11/02/22 at 8:45 AM
*11/02/22 at 2:09 PM
*11/02/22 at 4:48 PM
A GDR was not tried until March of 2022, and again in June of 2022. The GDR was successful.
On 11/02/22 at 1:27 PM, ADON was made aware of the above findings and agreed two years without having behaviors, but still receiving Seroquel is an unnecessary psychotropic medication.
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CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Garbage Disposal
(Tag F0814)
Could have caused harm · This affected 1 resident
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Based on observation and staff interview the facility failed to ensure the garbage dumpster was in good and sanitary condition to prevent the harborage and feeding of pests. This was a random opport...
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Based on observation and staff interview the facility failed to ensure the garbage dumpster was in good and sanitary condition to prevent the harborage and feeding of pests. This was a random opportunity for discovery. The failed practice had the potential to affect a limited number of Residents. Facility census: 77.
Findings included:
a) Garbage dumpster
An observation on 11/02/22 at 11:30 AM, showed a garbage area with three (3) dumpsters. One (1) dumpster located in the middle of the three (3) garbage dumpsters had a big hole in the front of it with garbage hanging out of the hole. Three (3) rats were observed exiting the hole of the dumpster.
During an immediate interview on 11/02/22 at 11:30 AM, Dietary Staff (DS) #95 stated those are rats. DS # 95 stated the other day there was also a bear around the garbage dumpster with the rats.
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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, facility documentation and staff interview the facility failed to have completed temperature logs for the refrigerators, freezer and dishwasher. The facility failed to complete...
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Based on observation, facility documentation and staff interview the facility failed to have completed temperature logs for the refrigerators, freezer and dishwasher. The facility failed to complete and document food temperatures of food before serving on 11/01/22 for breakfast and lunch. This was a random opportunity for discover. The failed practice had the potential to affect more than a limited number of residents. Facility census: 77.
Findings included:
a) Refrigerators/Freezer Temps
An observation during the initial kitchen tour on 10/31/22 8:45 AM, showed incomplete temperature logs for the refrigerators and freezer as followed:
1. Refrigerator (Walk-In)Temperature Log:
10/02/22- Morning (AM) and Evening (PM) temperatures missing
10/20/22- PM temperature missing
10/31/22- AM temperature missing
2. Refrigerator (Kitchen) Temperature Log
10/02/22- PM temperature missing
10/18/22- PM temperature missing
10/20/22- PM temperature missing
10/22/22- PM temperature missing
10/23/22- PM temperature missing
10/26/22- PM temperature missing
10/31/22- AM temperature missing
3. Freezer Temperature Log
10/02/22- AM temperature missing
10/08/22- PM temperature missing
10/20/22- PM temperature missing
20/21/22- PM temperature missing
10/31/22- AM temperature missing
During an interview on 10/31/22 at 8:50 AM, [NAME] #4 stated usually the temperatures are taking in the morning however staff did not get the temperature logs completed this morning due to being busy.
b) Dish Washer Log
An observation on 10/31/22 at 8:55 AM, showed no dish washer temperature log available.
During an interview on 10/31/22 at 8:55 AM, Dietary Staff (DS) #95 stated that the kitchen was short staffed today and dish washing was not a normal work assignment. DS #95 stated she did not know where the dish temperature log was located. There was no dietary staff that could locate where the dish washer temperature log was kept.
c) Food Temperature Checks
An observation on 11/01/22 at 11:52 AM , showed there was no completed food temperature log dated for 11/01/22. The food temperature log binder ended with the date of 10/31/22.
During an interview on 11/01/22 at 11:30 AM, [NAME] #4 stated, I guess we don't have the food temperatures documented for 11/01/22 yet. [NAME] #4 stated that dietary staff were busy with the food tray line, making the lunch trays to go out to be served to residents.
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CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0838
(Tag F0838)
Could have caused harm · This affected multiple residents
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Based on facility documentation and staff interview the facility failed to include direct staffing levels / direct overall number of staff for the resident acuity in the facility assessment. This ha...
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Based on facility documentation and staff interview the facility failed to include direct staffing levels / direct overall number of staff for the resident acuity in the facility assessment. This has the potential to affect all resident in the facility. The Facility census 77.
Findings included:
a) Facility Assessment
Review of the facility assessment on 11/02/22 at 4:21 PM, found a lack of information provided for nursing staff and nurse aides providing resident care.
Position:
--Registered Nursing.
Job Description & Qualifications:
--Individuals who have successfully completed a state approved training and competency evaluation program and required testing.
Standard Deployment Plan:
--Licensed Practical Nurse (LPN) see PBJ reports.
Average Hours a Day.
--Eight (8) to 12 per Registered Nursing Aide (RNA)
During an Interview with the Administrator and the Assistant Director of Nursing (ADON) on 11/02/22 at 5:13 PM the ADON verified that the Direct Care Staff needed by the facility was incomplete and the Facility Assessment was not correct without the information.
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CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0919
(Tag F0919)
Could have caused harm · This affected multiple residents
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Based on observation, resident interview, and staff interview the facility failed to Resident #23 had a call system within reach. The bathrooms in rooms 405, 407, 404, and 406 did not a cord to acti...
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Based on observation, resident interview, and staff interview the facility failed to Resident #23 had a call system within reach. The bathrooms in rooms 405, 407, 404, and 406 did not a cord to activate the call system to contact staff. These observations were a random opportunity for discovery. Facility census 77.
Findings included:
a) Resident #23
During an interview on 10/31/22 at 9:30 AM, Resident #23 was in a wheelchair, located between the two beds in the Resident's room. Resident #23 was asked if she could reach her call light.
Resident #23 stated she did not know where it was, but if she needed something she would wheel down to the nurse's station.
On 10/31/22 at 9:45 AM, Nurse Aide #45 was asked if she could find the call light for Resident #23. NA #45 located the call light which was on the floor behind the nightstand and was tied to the bed not occupied by Resident #23.
On 10/31/22 at 9:50 AM, Resident #23 confirmed she slept in the bed next to the door of the room. The call light was tied to the bed next to the window.
b) Bathroom call lights
On 10/31/22 at 9:52 AM, NA #45 was asked about the call light in Resident #23's bathroom. NA #45 pointed out a white switch, located behind the grab bar on the wall. The switch looked like a regular light switch, that can be flipped up and down. There was not a pull-cord of any type attached to the switch to enable the resident to activate the call system if the resident fell and was lying in the floor.
Observation with Licensed Practical Nurse (LPN) #58 on 11/02/22 at 9:15 AM, confirmed there was no pull-cord on the call lights in the bathrooms for rooms: 405, 407, 404, and 406. LPN #58 stated she would let someone know about the missing cords.
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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
- • 33% turnover. Below West Virginia's 48% average. Good staff retention means consistent care.
Concerns
- • 30 deficiencies on record, including 1 serious (caused harm) violation. Ask about corrective actions taken.
- • $25,237 in fines. Higher than 94% of West Virginia facilities, suggesting repeated compliance issues.
- • Grade C (50/100). Below average facility with significant concerns.
Bottom line: Mixed indicators with Trust Score of 50/100. Visit in person and ask pointed questions.
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About This Facility
What is Trinity Health Care Of Mingo's CMS Rating?
CMS assigns TRINITY HEALTH CARE OF MINGO an overall rating of 3 out of 5 stars, which is considered average nationally. Within West Virginia, this rating places the facility higher than 99% of the state's 100 nursing homes. This mid-range rating indicates the facility meets federal standards but may have areas for improvement.
How is Trinity Health Care Of Mingo Staffed?
CMS rates TRINITY HEALTH CARE OF MINGO's staffing level at 4 out of 5 stars, which is above average compared to other nursing homes. Staff turnover is 33%, compared to the West Virginia average of 46%. This relatively stable workforce can support continuity of care.
What Have Inspectors Found at Trinity Health Care Of Mingo?
State health inspectors documented 30 deficiencies at TRINITY HEALTH CARE OF MINGO during 2022 to 2025. These included: 1 that caused actual resident harm, 28 with potential for harm, and 1 minor or isolated issues. Deficiencies causing actual harm indicate documented cases where residents experienced negative health consequences.
Who Owns and Operates Trinity Health Care Of Mingo?
TRINITY HEALTH CARE OF MINGO is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility operates independently rather than as part of a larger chain. With 90 certified beds and approximately 72 residents (about 80% occupancy), it is a smaller facility located in WILLIAMSON, West Virginia.
How Does Trinity Health Care Of Mingo Compare to Other West Virginia Nursing Homes?
Compared to the 100 nursing homes in West Virginia, TRINITY HEALTH CARE OF MINGO's overall rating (3 stars) is above the state average of 2.7, staff turnover (33%) 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 Trinity Health Care Of Mingo?
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 Trinity Health Care Of Mingo Safe?
Based on CMS inspection data, TRINITY HEALTH CARE OF MINGO has a clean safety record: no substantiated abuse findings (meaning no confirmed cases of resident harm), no Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death), and is not on the Special Focus Facility watch list (a federal program monitoring the lowest-performing 1% of nursing homes). The facility has a 3-star overall rating and ranks #1 of 100 nursing homes in West Virginia. While no facility is perfect, families should still ask about staff-to-resident ratios and recent inspection results during their visit.
Do Nurses at Trinity Health Care Of Mingo Stick Around?
TRINITY HEALTH CARE OF MINGO has a staff turnover rate of 33%, 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 Trinity Health Care Of Mingo Ever Fined?
TRINITY HEALTH CARE OF MINGO has been fined $25,237 across 2 penalty actions. This is below the West Virginia average of $33,331. While any fine indicates a compliance issue, fines under $50,000 are relatively common and typically reflect isolated problems that were subsequently corrected. Families should ask what specific issues led to these fines and confirm they've been resolved.
Is Trinity Health Care Of Mingo on Any Federal Watch List?
TRINITY HEALTH CARE OF MINGO 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.