Berkeley Springs Healthcare Center

Based on resident interview, record review, and staff interview, the facility failed to accommodate resident food preferences. This was true for one (1) of 28 residents reviewed in the Long-Term Care Survey Process. Resident identifier: 19. Facility census: 99. Findings included: a) Resident #19 During an interview on 03/25/25 at 11:03 AM, Resident #19 reported he disliked fish, and it was listed as a dislike in his dietary record. The resident reported he was served fried fish on 03/10/25 and 03/24/25. The resident then showed Surveyor pictures of the fried fish on his tray beside his tray tickets for 03/10/25 and 03/24/25. During a medical record review, completed on 03/25/25 at 7:30 PM, the Diet History / Food Preferences assessment reflected resident disliked fish. On 03/26/25 at 8:40 AM, the Culinary Director confirmed that Resident #19 was erroneously served fried fish on 03/10/25 and 03/24/25. The Culinary Director stated it had been an oversight and immediately revised resident's dislike information to prevent the error from occurring again.

Based on observation and staff interview the facility failed to store garbage and kitchen refuse in a proper manner. Facility Census 99. Findings included: a) On 03/25/25 at 2:30 PM a tour of the outside of the facility revealed medical supplies and kitchen refuse in the parking lot and along grass area beside parking lot. (disposable plates, face masks, hair nets, gloves etc.). On 03/25/25 at 2:50 PM during an interview with the Facility Administrator (FA), the FA acknowledged that there were medical supplies and kitchen trash outside of the facility in the parking lot and on the property. He reported that he would take care of it and hold an in-service with staff.

Based on observation and staff interview, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections with regards to the resident's personal products and unsanitary practices. This failed practice was a random opportunity of discovery. Resident identifier: #82.Facility census: 99. Findings included: a) Resident #82 During an interview with resident #82, on 03/24/25 at 3:34 PM, it was observed a geri-chair in her room had rips and holes in the plastic cover on both of the arm rests. Resident #82 stated she used that geri chair when going out to activities, dining room, and to the shower room. In an interview with the Infection Prevention manager, on 03/25/25 at 3:50 PM, she acknowledged the geri-chair had holes and rips in the plastic arm pads and agreed the chair could not be cleaned to prevent infection. The chair was immediately removed from the room.

Based on observation and staff interview, the facility failed to ensure each resident had the right to personal privacy during treatments and confidentiality of personal health information for three (3) of three (3) residents whose treatments were observed. This was found true for Residents #41, #20 and #1 who was not provided privacy during a treatment and Residents #41, and #1 had personal medical care instructions displayed above the beds in the room. Resident identifiers: #41, #20 and #1. Facility census: 101. Findings included: a) Policy Review A review of the policy titled: Resident's Rights, Policy #NS1021-00, not dated, showed under the Procedure, Section 1. d., residents would have their privacy respected when treatment, medication or care was being administered including, door closed or privacy curtain drawn. b) Resident #20 An observation of a treatment for Resident #20, on 05/30/23 at 1:36 PM, revealed Licensed Practical Nurse (LPN) #73 providing the treatment without pulling the privacy curtain or closing the door. An interview, with the Director of Nursing (DON) on…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and staff interview, the facility failed to ensure a complete and accurate Minimum Data Set (MDS) assessments for three (3) of 26 residents reviewed during the long-term care survey process. Resident identifiers: #49, #76, #93. Facility census: 102. Findings included: a) Resident #49 Review of Resident #49's medical records showed the resident experienced a fall on 1/2/2023 during which he fractured his left clavicle. Resident #49's Minimum Data Set (MDS) assessment with Assessment Reference Date (ARD) 03/13/23 showed the resident had not experienced a fall since the last assessment. During an interview on 03/29/23 at 10:21 AM, the Director of Nursing (DON) confirmed Resident #49's MDS assessment with ARD 03/13/23 was incorrect. The DON stated the MDS had been corrected to reflect the resident had experienced one (1) fall with major injury. No further information was provided through the completion of the survey process. b) Resident #76 Review of Resident #76's medical records showed the resident developed an unstageable pressure ulcer on her right lateral…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

b) Resident #93 A record review on 03/28/23 at 8:30 AM, revealed a physician order dated 02/28/23 - Ipratroplum-Albuterol Aerosol Solution 20-100MCG/ACT 1 inhalation inhale orally every 8 hours for cough congestion wheezing URI. A record review on 03/28/23 at 8:32 AM, found Resident #93's comprehensive care plan did not include the Nebulizer treatment. During an interview on 3/28/23 at 10:45 AM, the MDS Coordinator #89 acknowledged the care plan did not reflect the Nebulizer treatment. During an interview on 03/28/23 at 2:50 PM the DON acknowledged the care plan was incomplete. c) Resident #99 During a confidential interview on 03/27/23 at 12:12 PM, a resident reported Resident #99 sometimes enters the resident's room. The resident reported he was concerned Resident #99 might remove or destroy his personal property. At the time of the interview, Resident #99 was observed walking in the hallway. During an interview on 03/28/23 at 10:40 AM, Registered Nurse (RN) #9 stated Resident #99 does go into other residents' rooms and the resident requires extra monitoring to prevent this. RN #9…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on facility record review and staff interview the facility failed to ensure the Director of Nursing was not working dual roles and a Registered Nurse was in the facility at least eight (8) hours every day. This failed practice had the potential to affect more than a limited number of residents. Facility census 102. Findings included: a) Role of DON During an interview on 03/29/23 at 12:45 PM, the Administrator said the Director of Nursing (DON) was also the Infection Preventionist (IP) from 01/01/22 to 06/01/22. The Administrator confirmed the facility census was above 60 residents during the entire time frame. The above information was discovered while reviewing the sign-in sheets for the Quality Assessment and Assurance committee. b) No Registered Nurse Coverage for 8 Hours Per Day Record review on 03/28/2023, of the facility's Staff Postings for the last two weeks revealed three (3) days that did not have the required eight (8) hours of Registered Nurse (RN) coverage: On 03/16/2023 there were zero (0) RN hours worked On 03/18/2023 there were zero (0) RN hours worked On…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation and staff interview, the facility failed to ensure medications, used in the facility, were stored, in accordance with current accepted professional practices. This was true for medications stored in two (2) of two (2) medication storage rooms. The facility failed to ensure the temperature of the refrigerator was monitored in both medication storage rooms to ensure medications stored in the medication room refrigerator were maintained at the manufacturer's acceptable temperature range for storage. This practice had the potential to effect more than a minimum number of residents. Facility census: 102 Findings included: a.) 100 Hall Medication Storage Room An observation, with Licensed Practical Nurse (LPN #1), on 03/29/23 at 08:20 AM, revealed the refrigerator contained Insulin pens, the medications Orencia and Embrel with manufacture's instructions to store the medications at 36 to 46 degrees Fahrenheit. A review of the temperature log for the refrigerator instructions, showed staff were to record temperatures twice each work day. After each month has ended, each…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, resident interviews, resident council meetings, and staff interview, the facility failed to provide notification of changes of the menu by not updating the menu and/or residents were not notified of the change, when substituting foods. This had a potential to affect more than a limited number of residents receiving nourishment from the facility kitchen. Facility Census: 102 Findings Included: a) Confidential Interviews During an initial interview on 03/27/23 Confidential Resident stated the food is awful, we never get what the menu says or the meal tray ticket. The meal is always different from what they say. When you look forward to getting something and they don't have it on your tray its disappointing. During an initial interview on 03/27/23 Confidential Resident stated the menus are not being followed, the new company is trying to save money. The menu in our rooms and the menus on our trays are not the same as what we receive. Last week the menu said meatloaf and we all received chicken. b) Observation During the tour of the kitchen on 03/27/23 at 8:06 AM…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, facility policy review and staff interview, the facility failed to store food in accordance with professional standards for food safety. The facility failed to label and date food items that were open and failed to dispose of expired food items. The facility also failed to complete the daily refrigerator and freezer temperature log. In addition, the facility also documented food and drink temperatures prior to the meal being prepared. This has a potential to affect more than a limited number of residents receiving nourishment from the facility kitchen. Facility Census: 102 Findings Included: A review of a facility policy titled Food Preparation with a revision date 09/2017 revealed the following. Procedures .14. Temperature for TCS foods will be recorded at time of service, and monitored periodically during meal service periods. Another review of a facility titled Food Storage: Cold Foods with a revision date 04/2018 revealed the following. Procedures .4. An accurate thermometer will be kept in each refrigerator and freezer. Q written record of daily…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation and staff interview the facility failed to ensure garbage and refuse containers were in good condition. This deficient practice has the potential to affect more than a limited number of residents that reside in the facility. Facility Census: 102. Findings Included: a) Outside garbage receptacle An observation on 03/28/23 at 10:26 AM, found two (2) of the facility's outside garbage receptacle were full of bagged trash reaching the top, one of them was missing a closure lid. Another garbage receptacle was full of bagged trash with a bent lid which was unable to close properly. During an interview on 03/28/23 at 10:27 AM, Maintenance Assistance (MA) #1 acknowledge the missing closure lid and bend lid. The MA #1 stated I have called the (local Sanitary office name)several times to bring new lids, they have never brought them. I will call them again today. During an interview on 03/28/23 at 3:23 PM, the Administrator stated we have called them several times for new lids, which we have never received. I should have just spray painted a cardboard box and changed it…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and staff interview, the facility failed to ensure complete and accurate medical records. Physician Orders for Scope of Treatment (POST) forms were incomplete and/or inaccurate for five (5) of 26 records reviewed in the long-term care survey sample. Resident identifiers: #59, #60, #5, #27, and #96. Facility census: 102. Findings included: a) Resident #59 Review of Resident #59's Physician Orders for Scope of Treatment (POST) form showed that verbal consent was obtained from the resident's representative on 12/28/21. The consent was witnessed by two (2) staff members. However, the resident representative's actual signature was never obtained. The 2021 POST form guidance titled, Using the POST Form: Guidance for Health Care Professionals, 2021 edition, available on-line, stated, If the incapacitated patient ' s MPOA [medical power of attorney] representative or health care surrogate is unavailable at the time of form completion, this section can be signed by two witnesses for verbal confirmation of agreement from the patient ' s MPOA representative or health…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on facility document review and staff interview the facility failed have all required members of the Quality Assessment and Assurance (QAA) attended at least one meeting every quarter. This failed practice had the potential to affect more than a limited number of residents that currently reside at the facility. Facility census 102. Findings included: While reviewing the attendance sign-in sheets for the QAA meetings it was noted that there was not an Infection Preventionist (IP) on record from January 2022 until June of 2022. In addition, there was not a Medical Director in attendance during the third quarter of the year 2022. During an interview on 03/29/23 at 12:45 PM, the Administrator verified the Medical Director was not in attendance during the third quarter. The Administrator said the Director of Nursing (DON) was also the IP from 01/22 to 06/22. The administrator said it was hard to find staff. He confirmed the facility census was over 60 residents during this time frame. .

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . d) Hand Hygiene A dining observation on 03/28/23 beginning at 11:55 AM found the lunch meal trays arrived in the 200 Hall at 12:03 PM. Nurse Aide (NA) # 107 was observed passing three (3) lunch trays. During the observations hand hygiene was not offered to the residents prior to receiving their lunch trays. This surveyor intervened and inquired about hand hygiene. Hand sanitizer wipes were not placed on the meal trays . There were no hand sanitizer bottles observed near the serving areas. During an interview on 03/28/23 at 12:07 PM, NA #107 stated I just got here, I did not give any hand hygiene. No, I did not offer the Residents hand hygiene. During an interview on 03/28/23 at 12:07 PM, Registered Nurse (RN) #104 acknowledged no hand hygiene was provided. RN #104 stated this hand hygiene is being cited at every facility I have been working at. RN #104, stated I just washed this resident's hands with wet paper towels before I served her tray, is that good enough? RN #104 stated How are we supposed to wash…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review, staff interview, and policy review, the facility failed to follow the current recommendation from the Center for Disease Prevention and Control (CDC) guidance for the Pneumococcal vaccine. One (1) resident received the vaccine to soon, two (2) residents were not offered a pneumococcal immunization. This was true for three (3) out of five (5) residents reviewed for immunizations. Resident Identifiers: #44, #5, and #77. Facility census 102. Findings included: Facility Policy titled, Resident Pneumococcal Vaccines. . Offer PCV20 if resident has received only PPSV23 greater than or equal to one (1) year ago. a) Resident #44 Medical record found Resident #44 received the Pneumovax 23 (PPSV23) on 02/25/22 and Prevnar 20 (PVC 20) 11/18/22. The recommendation from the CDC is to wait at least one (1) year after receiving the PPSSV23 before giving the PVC20. During an interview with facility Infection Preventionist (IP) on 03/29/23 at 8:00 AM, the IP stated he will report a medication error for giving Resident #44 the PCV 20 nine months after receiving the PPVS23,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation and staff interview, the facility failed to equip corridors with firmly secured handrails on each side. This was a random opportunity for discovery and the potential to affect a limited number of residents who reside in the facility. Facility census 102. Findings included: Observation on 03/28/23 at 4:23 PM, found multiple loose handrails on the 100 hall. This was verified at the time with Licensed Practical Nurse #110 and the Director of Nursing (DON). The DON stated she would have maintenance fix it right away. On 03/29/23 at 3:10 PM, the Administrator was informed of the above findings. .

Based on observation and staff interview, the facility failed to ensure meal trays were delivered in a manner to protect and promote the rights of resident dignity by failing to serve roommates a meal tray at the same time. This was based on a random opportunity for discovery and had the potential to affect a limited number of residents. Census: 102. Findings included: a) Resident #67 An observation of the tray delivery, on 03/27/23 at 12:38 PM, revealed Resident #67's roommate was served the noon meal and began eating. Resident #67 continued to wait on the meal tray for 27 minutes after the resident's roommate had been served and was eating. On 03/27/23 at 01:04 PM, Resident #67's roommate had finished the tray when Nursing Assistant #61 served Resident #67 the meal tray. An interview with the Director of Nursing (DON), on 03/28/23 at 01:14 PM , revealed it was facility policy to serve residents at the same time regardless of whether residents ate in the room or in the dining room and stated further it was a breach in a dignity standard that Resident #67 did not receive the meal…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and staff interview, the facility failed to ensure the resident's representative was notified when the resident had a change in condition. The resident representative was not notified when the resident experienced weight loss for one (1) of three (3) residents reviewed for the care area of nutrition. Resident identifier: #85. Facility census: 102. Findings included: a) Resident #85 Review of Resident #85's medical records showed the resident weighed 175 pounds on 02/10/23. On 2/24/2023, Resident #85 weighed 144 pounds. The resident did not have capacity to make medical decisions. The medical records contained no documentation the resident's representative was notified regarding Resident #85's weight loss. On 03/28/23 at 12:34 PM, the Director of Nursing (DON) presented a nursing note written on 3/6/2023 at 2:50 PM. The nursing note stated, Spoke with niece who was her care giver. Talked about resident having issues recently with vomiting after eating. Resident did not have a history of issues with vomiting. She said the vomiting started while in the hospital.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on record review and staff interviews, the facility failed to provide a notice of discharge to resident/representative and/or ombudsman for two (2) of two (2) residents reviewed for the category of hospitalization, during the long term care survey. Resident identifiers: #30 and #41. Facility census 102. Findings Included: a) Resident #30 On 03/28/2023 at 9:51 AM, discharge /transfer documentation was requested from the Administrator for resident #30 regarding recent hospitalization. On 03/28/2023 at 12:22 PM, the administrator stated, I do not think anything was sent with the resident, in regards to discharge paperwork. He stated that they are still looking. On 03/28/2023 at 12:50 PM, the Director of Nursing (DON) reviewed the medical record with the surveyor. The DON confirmed Resident #30 lacks capacity per capacity form dated 02/13/2023. An e-interact transfer form was located under the assessment tab, dated 03/26/2023, stating that the patient was notified of the transfer, not the Medical Power of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on record review and staff interviews, the facility failed to the resident/represenative of their bed hold policy for two (2) of two (2) residents reviewed for the category of hospitalization, during the long term care survey. Resident identifiers: #30 and #41. Census 102. Findings Included: a) Resident #30 On 03/28/2023 at 9:51 AM discharge /transfer documentation was requested from the Administrator for resident #30 regarding recent hospitalization. On 03/28/2023 at 12:22 PM, the administrator stated, I do not think anything was sent with the resident. He stated that they are still looking. Record review also indicates that the residents most recent Brief Interview for Mental Status (BIMS) score was a five (5), indicating severe impairment. On 03/28/2023 at 2:15 PM, the Director of Nursing (DON) confirmed that the incapacity determination on 02/13/2023 was the most recent capacity form completed for resident #30. The DON stated she was unable to locate an information to indicate the Resident's…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and staff interview, the facility failed to ensure the resident's comprehensive care plan was revised when the resident experienced weight loss. This deficient practice had the potential to affect one (1) of three (3) residents reviewed for the care area of nutrition. Resident identifier: #85. Facility census: 102. Findings included: a) Resident #85 The facility's Policy and Standard Procedure titled Resident Height and Weight was reviewed. No implementation date was given on the policy. The policy stated the Interdisciplinary Care Plan would be updated as needed. Review of Resident #85's medical records showed the resident weighed 175 pounds on 02/10/23. On 2/24/2023, Resident #85 weighed 144 pounds. This was a 17% weight loss in two (2) weeks. Resident #85's comprehensive care plan contained the following focus, initiated on 02/13/23, Resident with potential for altered nutrition status/nutrition related problems d/t: Elevated BMI [body mass index], disease dx [diagnosis] HTN [hypertension], morbid obesity. Resident #85's comprehensive care plan did not…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, medical record review and staff interview the facility failed to provide care required to maintain proper hygiene to a female resident who was dependent for Activities Of Daily Living (ADL) care. This is true for one (1) of four (4) residents reviewed for ADL's care area during the Long-Term Care Survey Process. Resident Identifier: Resident #27. Facility Census: 102 Findings Included: a) Resident #27 During the initial interview on 03/27/23 at 1:17 PM, Resident #27 was unable to answer questions appropriately. Observation of Resident # 27 found she had facial hair under her chin and on her upper lip. Resident #27 was rubbing her chin and pulling her untrimmed hair during the interview. During an interview on 03/28/23 at 10:18 AM Hospitality aide (HA) #10 stated, I shave the men and women, everyone gets checked daily and most men get shaved daily. I trim the women when I see a little bit of fuzz on them. Resident #27 refused to let me trim her, it takes two aides. She hits and bites me. I have told the aides and the nurses that Resident # 27 needs to be trimmed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and staff interview the facility failed to follow a physician's order to notify the physician when blood sugar is above 400. This was true for one (1) of five (5) residents reviewed for the care area of unnecessary medications. Resident identifier: Resident #5. Facility census 102. Findings included: a) Resident #5 A review of the medical records revealed an order to notify the physician if Resident #5 had a blood sugar above 400. A review of the Medication Administration Record (MAR) on 03/06/23, found the Resident's blood sugar was greater than 400. There was no documentation to support the physician was notified per the physician order. On 03/28/23 at 11:23 AM, the Director of Nursing (DON) confirmed there was no nursing notes or assessment notes showing physician notification of the elevated blood sugar on 03/06/23. .

Based on medical record review and staff interview, the facility failed to ensure the environment is free from accident hazards over which it has control. This was a random opportunity for discovery. Resident Identifier: Resident # 56. Facility Census: 102 Findings Included: a) Resident #56 During the initial interview on 03/27/23 at 10:22 AM, Resident # 56 stated they were supposed to fix my lift chair. Resident # 56 showed this surveyor the wired remote to her recliner. The wires were exposed and bare with an attempt of a repair with electrical tape peeling away. Resident # 56 stated they were supposed to order me a new cord but never did they just taped this one. During an interview on 03/27/23 at 11:56 AM, the administrator acknowledged the recliner was an accident hazard and needed to be replaced. .

Based on record review and staff interview, the facility failed to monitor residents who experienced weight loss in accordance with accepted standards of care. This deficient practice had the potential to affect two (2) of three (3) residents reviewed for the care area of nutrition. Resident identifiers: #85 and #91. Facility census: 102. Findings included: a) Resident #85 The facility's Policy and Standard Procedure titled Resident Height and Weight was reviewed. No implementation date was given on the policy. The following procedures were given: - On admission, obtain weekly weights times four (4) weeks for baseline. - Compare weight to previous weight obtained. If a variance of five (5) pounds or more is noted, reweigh resident to verify weight. Review of Resident #85's medical records showed the resident weighed 175 pounds during her admission weight on 02/10/23. The resident's initial physician's order was for monthly weights. On 02/17/23, the physician wrote an order for weekly weights for four (4) weeks until stable. Resident #85 was not weighed on 02/17/23 despite the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation and staff interview, the facility failed to provide necessary respiratory care consistent with professional standard practice. Resident #93 and Resident #90's nebulizer masks were on their bedside tables with no protective covering. This was a random opportunity for discovery. Resident identifier: Resident #93 and Resident #90. Facility census: 102. Findings Included: a) Resident #93 During the initial tour on 03/27/23 at 11:36 AM, Resident # 93's nebulizer mask was on the bedside table without a protective covering. During an interview on 03/27/23 at 11:38 AM, RN #9 acknowledged the mask was not stored appropriately. b) Resident #90 During the initial tour on 03/27/23 at 11:36 AM, Resident # 90's nebulizer mask was on the bedside table without a protective covering. During an interview on 03/27/23 at 11:38 AM, RN #9 acknowledged the mask was not stored appropriately. .

Based on observation, record review, and staff interview, the facility failed to ensure staff had the appropriate competencies and skill sets to care for a resident receiving enteral (tube) feeding. This deficient practice had the potential to affect one (1) of one (1) resident reviewed for the care area of tube feeding. Resident identifier: #41. Facility census: 102. Findings included: a) Resident #41 The facility's policy titled Enteral General Nutritional Guidelines with no implementation date on the policy defined bolus enteral feeding as delivered using a syringe or gravity that provides for a single dose or preparation delivered all at one time. A review of physician's orders for Resident #41 showed an order for enteral feedings, Jevity 1.5 bolus, 247 ml, every four (4) hours, related to dysphagia following a cerebral Infarction, beginning 02/20/23. The resident had a gastrostomy tube (G-tube). The resident also had an order to flush the G-tube with at least 30 cc of water before and after feeding. Further review of previous physician's orders revealed on 02/20/23, an order…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and staff interview the facility failed to ensure the attending physician provided a rationale as to why a Gradual Drug Reduction (GDR) suggested by the facility Pharmacist was not acted upon. This was true for one (1) out of five (5) residents reviewed for unnecessary medication. Facility census 102. Findings included: a) Resident #16 Record review found two occasions when the facility pharmacist suggested a GDR. On 04/29/22 and 09/28/22 the pharmacist recommended a reduction in the dose of Seroquel 50 mg (given for behaviors of pacing) and Sertraline 100 mg (given for depression). No rationale was provided by the attending physician for not complying with the recommendation. At 2:46 PM on 03/29/23, the Director of Nursing (DON) confirmed there was no documentation from the physician as to why the identified irregularities were not acted upon. .

Based on staff interview, document review of the facility's concern log and review of two (2) of four (4) residents reviewed for falls, the facility failed to report injuries in a timely manner. The failed practice was true for four (4) of nine (9) residents reviewed for falls and selected from the concern log. Resident identifiers: #7, #13, #71 and #76. Facility census: 78. Findings included: a) Resident #7 Record review of a nursing progress note and fall note both dated 12/09/20 showed Resident #7 had a fall on 12/06/20 at 10:34 AM. An x-ray was completed on 12/09/20 and showed Resident #7 had an acute distal femoral shaft impaction fracture, moderate size suprapatellar hemarthrosis. Record review of the facility's December 2020 Reportables revealed, Resident #7's serious bodily injury of an acute distal femoral shaft impaction fracture was not reported. During an interview on 10/06/21 at 11:45 AM, the Social Worker (SW), stated, any fall with major injury should be reported. SW stated, job requirements in the facility do not allow the social worker to report falls with major…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation and staff interview the facility failed to ensure staffing information was for the correct date and was readily accessible to all residents in the facility. This was a random opportunity for discovery. The failed practice had the potential to affect more than a limited number of residents currently residing in the facility. Facility census 78. Findings included: a) Daily Staff Posting An observation, on 10/05/21 at 12:35 PM, revealed a daily staff posting dated 10/04/21 hung on the bulletin board near the nurses station on the 100 hall. There was no daily staff posting was available for the 200 hall or 300 hall. During an interview on 10/05/21 at 12:40 PM, the Director of Nursing (DON), stated, we had only been posting the staffing information at the front entrance of the facility. DON stated, the facility had a mock survey last week and it was recommended that daily staff postings be posted at all nurses stations so everyone could see the information. The DON stated, the facility had just failed to follow the recommendations of the mock survey by not posting or…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and observation, the facility failed to serve food at a safe palatable temperature. The facility was using a thermometer to test food temperatures which was inaccurate by 24 degrees. This practice had the potential to affect more than an isolated number of residents. Facility Census 78 Findings included: A review of the facilities policy titled Calibrating Thermometers with revision date 05/03/21 states, Thermometers should be calibrated routinely and as needed (i.e.,after extreme temperature change, or after dropping) to ensure accurate measurement of temperatures. a) Test Tray Temperatures During this survey some residents voiced cold food concerns. Test trays were done on 100 Hall for both tray carts. On 10/04/21 at 12:44 PM Test Tray for 100 Hall second Cart to 100 hall came on the hall at 12:06 PM. At 12:36 PM the Dietary Manager obtained the temperatures of the last tray on the cart at the time of service the following temperatures were obtained: -- Nectar Coffee 137 degrees -- Pureed Fruit 80.2 degrees -- Chicken 140.2 degrees -- Mashed Potatoes 132 degrees…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation and interview the facility failed to store, prepare and serve foods in accordance with professional standards for food service safety. This practice had the potential to affect a more than a limited number of residents who receive nutrients from the kitchen. Facility Census 78 Findings include: a) Food Service On 10/04/21 at 8:53 AM during the initial tour of the kitchen with the dietary manager(DM) #16 the following issues were found: -- A measuring cup on a shelf containing a white substance. The measuring cup was not covered or labeled to identify the contents or how long it had been there. The DM indicated the white substance was food thickener and it needed to be discarded because it was not covered or labeled. -- Inside the walk in freezer was opened polish sausage with no date to indicate when the item was opened or when it should be discarded. The DM agreed the polish sausage needed to be discarded. An observation of the 100 hall pantry refrigerator at 9:10 am on 10/04/21 found an opened box containing egg rolls which was not dated to indicate when it…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on observation, record review, and staff interview, the facility failed to ensure resident dignity was protected. Resident #68 required staff assistance in dressing. Staff failed to promote dignity by dressing Resident #68 in mismatched socks resulting in embarrassment. This was a random opportunity for discovery. Resident Identifier: #68. Facility census: 78. Findings included: a) Resident #68 On 10/04/21 at 9:41 AM, Resident #68 reported being dressed in mismatched socks which is somewhat embarrassing. Resident #68 pulled the blanket to the side to show the Surveyor her mismatched socks. The quarterly Minimum Data Set (MDS) assessment, with an assessment reference date of 08/28/21, revealed Resident #68 required substantial/maximal assistance of staff to put on and take off socks. During an interview with Resident #68, on 10/05/21 at 12:10 PM, an inventory of socks in the room resulted in the following findings: -1 no show gray, pink, green, and white [NAME] sock that was missing a mate -1 no show…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review, observation and interview, the facility failed to provide reasonable accommodations of residents needs and preferences for a resident who was visually impaired. This practice affected one (1) of 19 sampled residents. Resident Identifier: Resident # 18. Census: 78 Findings included: a) Resident #18 During an interview, on 10/04/21 at 10:00 AM, Resident #18 expressed he had a problem with vision and sometimes this caused problems when staff did not tell him where the food items were on his tray. A record review, on 10/04/21 showed a comprehensive assessment dated , 07/10/21, noting Resident #18 required glasses for adequate vision under Section B1000 and B1200 of the Minimum Data Set (MDS), An observation of Resident #18, during the noon meal, on 10/04/21 at 12:15 PM , revealed Resident #18 eating the lunch meal in bed, without glasses. Resident #18 was observed lifting the spoon with no food and bringing it to his mouth as if he was getting a bite of food. This was observed while Resident #18 was trying to eat chicken and pears. On 10/04/21 at 12:15 PM,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on review of resident council minutes, interview, and observation, the facility failed to honor the resident's right to a homelike environment. The facility failed to exercise reasonable care for the protection of Resident #18's property. This was true for one (1) of 19 sampled residents in the long-term care survey process. Resident identifier #18. Facility census: 78. Findings included: a) Resident #18 On 10/04/21 at 8:20 PM, a review of April 2021 thru September 2021 resident council minutes was completed. The July 2021 resident council minutes reported Resident #18 expressed, Roommate gets into things in middle of the night. The facility response to this concern was to install safety latches on Resident #18's dresser drawers. During an interview, on 10/06/21 at 8:25 AM, Resident #18 reported the issue had not been resolved and the roommate was still getting into things. Resident #18 reported there may have been a week or two where the safety latches were effective, but that they no longer were. With resident's permission, the Surveyor inspected the dresser which had 4…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interview, the facility failed to assure each resident received an accurate assessment, reflective of the resident's status at the time of the assessment. The facility did not accurately code the Nursing Home Discharge Minimum Data Set (MDS) assessment for Resident #85. The facility assessed a resident as being discharged to an acute care hospital, when the resident was actually discharged to home. This was true for one (1) of three (3) closed records reviewed during the long-term care survey process. Resident Identifier: #85. Facility census: 78. Findings included: a) Resident #85 A record review, on 10/05/21 at 9:00 AM, revealed a nursing home discharge MDS, with an assessment reference date of 07/09/21. The MDS coded Resident #85's discharge status as an acute care hospital. Further record review revealed a nursing note, dated 07/09/21 at 10:30 AM, documenting Resident #85 was discharged to home. During an interview, on 10/05/21 at 11:40 AM, the Minimum Data Set (MDS) Coordinator stated Resident #85 was coded as being discharged to an acute care…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on observation of medication administration, interview and record review of one (1) of three (3) closed records, the facility failed to ensure care was provided within professional standards of practice relating to medication administration and disposition of medications of a discharged resident. This was a random opportunity for discovery and had the potential to affect a limited number of residents residing in the facility. Resident Identifier: Resident # 85. Census: 78 Findings included: a.) Medication Administration An observation of Medication Administration Pass, on 10/05/21 at 7:33 AM, revealed Licensed Practical Nurse (LPN) #112 at the medication cart preparing medications for a resident in room [ROOM NUMBER]. LPN #112 took the medications from the packaging and placed the medications in a medication cup. The medications included the following: Biotin 5 mg Centrum Silver Folic acid 1000 mcg Senna S Methopredinisone 4mg (5 tablets) Movantik 25 mg Doxyclycline 100 mg Dyazide 37-25 mg Tylenol 300-30…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review, and interview, the facilty failed to provide care and services , consistent with professional standards of practice to promote healing and prevent further infection and prevent new sores from developing for one (1) of three (3) residents reviewed who, based on the comprehensive assessment, had pressure ulcers. Resident Identifier: #64. Census: 78 Findings included: a) Resident #64 A review of the facility's policy, on 10/06/21, titled , Skin Assessment, revision date of 05/03/21, noted under section 7. (c), if wounds were observed, the staff were to initiate and complete a weekly wound assessment. Record review for Resident #64, found on 07/20/21 Resident #64 was assessed to have developed an unstageable pressure ulcer on the right heel with measurements of 2x2.5 centimeters (cm) The documentation failed to address if exudate was present and failed to describe presence or absence of odor and failed to include the assessment of the condition of the tissue which as required of the weekly wound assessment according to policy. Further review of the record for…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on policy review, record review, observation, and interview, the facility failed to ensure supervision and assistive devices for one (1) of three (3) closed resident records reviewed and one (1) of 19 current sampled residents. When a senior center wheelchair van arrived to take Resident #85 home, a manilla envelope with medications was sent with Resident #85 despite the fact the facility had assessed Resident #85's cognitive ability as severely impaired. The facility failed to ensure #14 was wearing a soft helmet, geri sleeves, and hipsters per physician orders. Resident identifiers: #85 and #14. Facility census: 78. Findings included: a) Policy Review The facility policy entitled, Discharge to Home Medication, dated 06/21/17, outlines the following: Discharge medication information is entered on the Discharge Medication / Leave of Absence Release / Receipt Form to include: a. Resident name b. Date completed c. Facility name d. Check if leave of absence or discharge e. Date and time leaving f. List all medication giving to resident or responsible party Include: -Name of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation 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 had the potential to affect one (1) of two (2) residents receiving oxygen therapy. Resident identifier: Resident #35. Census: 78 Findings included: An observation on 10/04/21 at 3:09 PM , revealed Resident #35 receiving oxygen (O2) at 4 liters per minute. An interview on 10/04/21 at 3:26 PM, with Licensed Practical Nurse (LPN) #111 verified the O2 flow rate was set at 4 liters per minute. A record review for Resident #35 showed the resident had current physician orders for the oxygen flow rate to be 2 liters per minute and not the 4 liters that had been observed and verified with staff. An interview with the Assistant Director of Nursing on 10/05/21 at 2:38 PM verified it was the facility policy to provide the correct flow rate and verified O2 should be administered in accordance with physicians orders. .