Shenandoah Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on record review, staff interview and resident interview the facility failed to honor residents' preference for bed bath/showers. This failed practice was found true for five (5) of (7) seven residents reviewed for the care area of choices during the Long-Term Care Survey Process. Resident identifiers: #60, #63, #40, #3 and #48. Facility Census: 71. Findings included: a) Resident #60 During the initial interview, on 07/22/24 at 1:22PM, Resident #60 stated, I don't get showers often. Heck, I would be happy with at least a bed bath once a week. I was in an actual shower probably over a month ago. I have asked for showers, and they say they will get to me as soon as they can and then end up doing a bed bath or not a bath at all. A record review on 07/24/24 at 12:10 PM, revealed the following care plan: Focus: I need assistance with my ADL's due to my physical limitations and history of electrolyte imbalance and weakness. Intervention: - Shower/bed bath scheduled per my preference. Monitor and document…

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 and staff interviews the facility failed to keep residents' medical information confidential. Facility staff left a laptop open with resident information which was visible to the public. This was a random opportunity for discovery and had the potential to affect more than a minimal number of residents residing in the Long-Term Care facility. Facility census :71 Findings include: On 07/23/24 at 11:04 PM Licensed Practical Nurse (LPN) #48 was observed setting at the nurses' station on the computer. On 07/23/24 at 11:08 PM a computer was observed sitting on top of the medication cart unattended by staff. On the screen was resident identifiable information. During an interview on 07/23/24 at 11:12 PM, LPN #48 returned to the medication cart and locked the computer screen. He stated he was aware it was unlocked. During an interview with the Director of Nursing(DON) on 07/24/24 at 10:00 AM, The DON stated the computer and med (Medication) cart should have been locked.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on observation, resident interview and staff interview, the facility failed to provide a comfortable, homelike environment for residents residing in room [ROOM NUMBER], #202, #203, #303, #306, #309, #310, #312, #402, #404, #407, #408, #409, #410 and the slats of the packaged terminal air conditioner (PTAC) in Resident #60's room. These were random opportunities for discovery and had the potential to affect more than a limited number of residents. Facility Census: 71. Findings included: a) Resident Doors On 07/23/24 at 11:25 PM, a tour of the facility was complete. The tour found the following resident doors had putty applied to the visible cracks and door frames with rough edges of wood: --201 --202 --203 --303 --306 --309 --310 --312 --402 --404 --407 --408 --409 --410 On 07/24/24 at 9:55 AM, the Administrator was notified of issues found with the resident doors. The Administrator stated, I'll have maintenance check those. b) Resident #60 During the initial observation on 07/22/24 at 1:40 PM, it was…

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 interview the facility failed to develop and/or implement care plans related to Dementia, Anxiety, Dialysis and showers. This failed practice was found true for seven (7) of 34 residents reviewed for care plan accuracy and implementation during the Long-Term Care Survey Process. Resident identifiers: #54, #22, #65, #51, #61, #9 and #71. Facility Census 71. Findings included: a) Resident #54 A record review on 07/23/24 at 12:30PM, of Resident #54's medial record revealed a diagnosis of Dementia with an onset date of 10/04/23. Further record review showed no diagnosis of Dementia within the care plan. During an interview on 07/24/23 at 1:30PM, The Director of Nursing (DON), confirmed the diagnosis of Dementia was not in Resident #54's care plan. b) Resident #61 On 07/24/24 at 9:00 AM, a record review was completed of Resident #61's medical record. The review found the care plan had not been developed regarding the diagnosis of anxiety disorder. The resident was seen on two (2)…

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, policy review, and staff interview the facility failed to ensure the resident environment over which it had control was as free from accident hazards as possible. This was a random opportunity for discovery and had the potential to affect more than a limited number of residents currently residing at the facility. Facility Census: 71. Findings Include: a) Treatment Cart On 07/22/24 at 12:50 PM, an observation found an unlocked, unattended treatment cart in the resident tv room. The cart was in a place which was easily accessible allowing access to these medication/treatment supplies by residents, unauthorized persons, or visitors. On 07/22/24 at 1:42 PM, during an interview with Registered Nurse (RN) #21, it was confirmand the Treatment cart was unlocked. RN #21 verified the treatment cart should not be unlocked when unattended. She closed and locked the cart at this time. b) Resident #57 An observation on 07/22/24 at 1:23 PM found nystatin powder generic myconustatin 60 gm, at Resident #57's bed side, unsecured and unattended and allowing access to this…

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 conduct yearly performance evaluations for each Nurse Aide. This was true for three (3) out of five (5) Nurse Aides reviewed during the survey process. Staff identifiers: NA #34, NA #63, NA# 61. Facility census: 71. Findings included: A) Record review At approximately 2:45 PM on 07/23/24 a review of yearly performance evaluations and educations were conducted for randomly selected Nurse Aides (NA). During review, it was discovered the facility was missing yearly performance evaluations for NA #34, NA #63, and NA #61. B) Staff interviews At approximately 3:30 PM on 07/23/24 an interview was conducted with the Administrator. During the interview, the administrator confirmed the absence of performance evaluations for the three (3) NAs. The administrator stated We knew there were some missing and we are aware of it. We are trying to get caught up on them.

Based on record review and staff interview the facility failed to do behavior and side effect monitoring for psychotropic medications. This failed practice was found true for (1) one of (5) five residents reviewed for unnecessary medications during the Long-Term Care Survey Process. Resident identifier: #54. Facility Census 71. Findings include: a) Resident #54 Record review, on 07/24/24 at 4:00 PM, of Resident #54's orders revealed Resident #54 was ordered Lorazepam Oral Tablet 0.5 Milligrams (MG) on 12/22/23. It further read, (1) one tablet by mouth at bedtime for Anxiety. Monitor for Sedation, morning hangover, ataxia, nausea and report side effects to physician. Further record review of Resident #54's Medication Administration Record (MAR) for behavior and side effect monitoring showed no monitoring for 12/2023, 01/2024, 02/2024, 03/2024, 04/2024, and 05/2024. During an interview on 07/25/24 at 10:00 AM, The Director of Nursing (DON) stated, We did identify a problem and are now working on it. She later confirmed the behavior and side effect monitoring was not being done.

Based on observation, record review and staff interview, the facility failed to record temperatures for the medication refrigerator. This was a random opportunity for discovery and had the potential to affect more than a limited number of residents. Facility Census: 71. Findings Include: On 07/25/24 at 9:25 AM, the medication room was observed. The observation found the medication refrigerator temperatures were not completed for March 2024 through July 2024. The following dates were not completed: --03/16/24 PM --03/17/24 PM --03/18/24 PM --03/19/24 PM --03/20/24 PM --03/21/24 PM --03/22/24 PM --03/23/24 AM --03/25/24 PM --03/26/24 PM --03/28/24 PM --03/29/24 AM --03/29/24 PM --03/30/24 PM --03/31/24 AM --04/01/24 PM --04/02/24 PM --04/04/24 PM --04/05/24 PM --04/06/24 PM --04/08/24 PM --04/09/24 PM --04/10/24 PM --04/11/24 PM --04/12/24 AM --04/13/24 PM --04/14/24 PM --04/15/24 AM --04/15/24 PM --04/16/24 PM --04/17/24 PM --04/18/24 PM --04/19/24 PM --04/21/24 PM --04/22/24 PM --04/23/24 AM --04/23/24 PM --04/24/24 PM --04/25/24 AM --04/25/24 PM --04/26/24 PM --04/27/24 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 observation and staff interview the facility failed to ensure food was discarded after the expiration date. This failed practice had the potential to affect more than a limited number of residents currently residing in the facility. Facility Census 71. Findings included: a) Kitchen During the initial observation on 07/22/24 at 1:30 PM, the following items were found to be out of date and/or covered in an mold like substance in the kitchen: 1. Scalloped potatoes were wrapped in plastic wrap in the walk-in refrigerator with a discard date of 07/11/24. 2. There was a box of onions in the walk-in refrigerator with 8 onions in it, 4 of the onions were covered in what appeared to be mold. During an interview on 07/22/24 at 1:40 PM, The Dietary manager in training (DMT) stated, Yes, those potatoes are out of date. I will get the potatoes and onions thrown out.

Based on observation, and staff interview, the facility failed to ensure the resident call system was functioning as designed. This failed practice had the potential to affect more than a limited number of residents currently residing in the facility. Facility Census: 71. Findings included: a) Observation tour, on 07/22/24 at 2:30 PM, of the 200 and 300 halls, found the call light system turned off at the end of the halls. The volume was too low to be heard throughout the unit. During an interview, on 07/23/24 at 12:26 PM, the Maintenance Assistant verified it was turned off at the end of the hall. At this time, he turned the audible switch back on. He stated the staff turned it off. During an interview, on 07/23/24 at 12:33 PM, the Maintenance Director confirmed the call system was visual and audible. He stated all the call systems in the building were turned down and it had been that way since he started.

Based on record review and staff interview, the facility failed to notify the State ombudsman of a discharge for Resident #71. This was true for one (1) of two (2) residents reviewed under the care area of discharges. Resident identifier: 71. Facility Census: 71. Findings Include: a) Resident #71 On 07/23/24 at 9:45 AM, a record review was completed for Resident #71. The review found the resident had been discharged to another facility on 05/09/24. However, the facility could not provide evidence of the notification of discharge was sent to the State ombudsman. On 07/23/24 at 1:00 PM, the Administrator was notified and stated, We do not have the notification to the Ombudsman regarding the discharge.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on record review and staff interview, the facility failed to complete an accurate Minimum Data Set (MDS) regarding the discharge destination for Resident #71 and #72. This was true for two (2) of two (2) residents reviewed under the care area of discharges. Resident identifiers: #71 and #72. Facility Census: 71. Findings included: a) Resident #71 On 07/23/24 at 12:29 PM, a record review was completed for Resident #71. The review found the resident was discharged on 05/09/24 to another long-term facility. The MDS dated [DATE] listed the discharge destination of home. On 07/23/24 at 1:00 PM, the Administrator was notified and confirmed the MDS was incorrect. The Administrator stated, The resident did go to another facility .not home. b) Resident #72 On 07/23/24 at 1:10 PM, a record review was completed for Resident #72. The review found the resident was discharged on 05/02/24 to home. The MDS dated [DATE] listed the discharge destination as short-term general hospital. On 07/23/24 at 2:47 PM, 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 record review and staff interview the facility failed to ensure Resident #9's care plan was revised when the status of her pressure ulcer changed. This was true for one (1) of 34 sampled residents reviewed during the long term care survey process. Resident Identifier: #42. Facility Census: 71. Findings Include: a) Resident #42 A record review on 07/23/23 at 9:48 AM revealed an order for Resident #42 which read as follows: Cleanse Stage IV to right heel with wound cleanser and pat dry. Apply Calc alginate and cover with opti-foam heel protection every day. Every day shift. Further record review showed a care plan for a Pressure Ulcer to the right heel staged as a stage 2 (two) pressure ulcer. The skin and wound evaluation effective 07/22/24 has the Pressure Ulcer to the right heal as an unstageable pressure ulcer. During an interview on 07/26/24 at 10:00 AM, The Director of Nursing (DON) stated, Yes we have been having problems with this, Now, we have someone is looking at them and working on getting them all revised.

Based on observation, record review, and staff interview the facility failed to provide an activity program to meet the needs and interest of the residents and failed to provide scheduled one-to-one visits for residents. This failed practice was found true for (1) one of (6) six residents reviewed for activities during the Long-Term Care Survey Process. Resident identifiers #27. Facility Census 71. Findings include: a) Resident #27 During the initial observation on 07/22/24 at 1:30 PM, Resident #27 was sitting in the Television Lounge in front of the TV. Further observation at 3:45PM, showed Resident #27 sitting in the Television Lounge in front of the TV. Further observation at 5:40PM , showed Resident #27 sitting in the Television Lounge in front of the TV. A record review on 07/24/24 at 1:00 PM of Resident #27's Activity care plan read as follows: Focus: While in the facility, I state that it is important that I have the opportunity to engage in daily routines that are meaningful relative to my preferences. GOAL: I receive one-to-one visits three times/week as tolerated through…

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 resident and staff interviews, the facility failed to provide services and/or treatment to Resident #64 to prevent reduction in range of motion. This was true for one (1) of four (4) residents reviewed for limited range of motion during the survey process. Resident identifier: 64. Facility census: 71. Findings include: A) Resident #64 At approximately 9:16 AM on 07/23/24, an interview was conducted with Resident #64. During the interview, it was noted the resident seemed to have contractures in both knees, with his left knee being worse than the right. During the interview, Resident #64 states I don't remember much about when I came in, so I don't really remember when my knees got this way, I know they weren't like this when I came in, but I just don't remember when they got this way. Resident #64 stated no staff member helped him work on range of motion during times when care is being provided. At approximately 10:30 AM on 07/23/24, during a review of Resident #64'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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on observation, record review, and resident and staff interview, the facility failed to have sufficient staff to provide care for residents at the facility. This has the potential to affect all residents currently residing at the facility. Resident identifier: #64. Facility census: 71. Findings include: A) Resident #64 At approximately 9:16 AM on 07/23/24, an interview was conducted with Resident #64. During the interview, it was noted the resident seemed to have contractures in both knees, with his left knee being worse than the right. During the interview, Resident #64 states, I don't remember much about when I came in, so I don't really remember when my knees got this way, I know they weren't like this when I came in, but I just don't remember when they got this way. Resident #64 stated no staff member helped him work on range of motion during times when care is being provided. At approximately 10:30 AM on 07/23/24 during a review of Resident #64's medical record, it was noted that the Minimum Data…

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 resident and staff interviews, the facility failed to accurately document the dental condition of Resident #227 on the admission assessment. This was a random opportunity for discovery. Resident identifier: #227. Facility census: 71. Findings included: a) Resident #227 At approximately 9:00 AM on 07/24/24 an interview was conducted with Resident #227. During the interview, the resident stated, I only have four (4) teeth and can't chew the food very well. At approximately 9:30 AM on 07/24/24 a review of Resident #227's record was conducted. On the resident's clinical admission evaluation dated 07/19/24 at 4:24 PM, the box has own teeth was marked. However, the rest of the dental portion of the evaluation was incomplete. At approximately 2:00 PM on 07/24/24 an interview was conducted with the Administrator regarding the incomplete assessment. The administrator reviewed the dental section of the assessment and confirmed it was incomplete.

Based on deficiencies cited, resident interviews, resident representative interview, review of resident council minutes, resident council member interviews, review of the facility assessment, and facility staffing details, the facility failed to ensure sufficient qualified nursing staff were available at all times to provide nursing and related services to meet the residents' needs safely and in a manner that promoted resident rights, physical, mental and psychosocial well-being. This failed practice had the potential to affect all residents currently residing in the facility. Facility census: 74. Findings Included: a) Citations During the facility's long-term care survey relevant citations included: --See F561 --See F609 --See F657 --See F684 --See F689 --See F695 --See F697 --See F698 --See F727 --See F732 --See F755 --See F880 --See F885 b) Anonymous Resident Interviews The first anonymous resident interview was conducted on 09/26/22 at 10:06 AM. Resident reported she feels there isn't enough staff to care for her. The second anonymous resident interview was conducted on 09/26/22…

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 Registered Nurse (RN) was present at the facility for at least eight (8) consecutive hours a day, seven (7) days a week. This was true for one (1) of six (6) randomly sampled dates from July 2022 - October 2022. This had the potential to affect all residents who currently reside at the facility. Facility census: 74. Findings included: a) RN Coverage On 09/26/22 at 2:56 PM, a review of the staffing timesheets/schedules for RN coverage found one (1) occasion when RN coverage was not present in the facility. On Saturday, 07/02/22, RN coverage was 0.00 hours. There was no RN coverage in the facility. On 10/03/22 at 10:45 AM, the Director of Nursing (DON) confirmed the facility timesheets did not reflect any RN coverage on Saturday, 07/02/22. The DON went on to report the nurse that would have normally been scheduled to work that particular day had been on vacation. The DON noted there must have been an oversight when making the schedule because normally the DON would have filled in for any opening in 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 facility documentation and staff interview the facility failed to Inform residents, their representatives, and families of those residing in facilities by 5 PM the next calendar day following the occurrence of a confirmed infection of COVID-19. This failed practice had the potential to affect all residents in the facility. Facility Census: 74. Findings included: a) Covid-19 Notification On 09/27/22 a facility documentation review revealed a confirmed case of Covid-19 for a resident in the facility on 09/17/22. Continued review found no residents, representatives or families were notified until 09/21/22. During an interview on 09/27/22 at 2:38 PM The Director of Nursing (DON) confirmed no family, resident or representative was notified before 5 PM 09/18/22. She stated that she notified residents, their representatives, and families on 09/21/22.

Based on observation, record review, resident interview, staff interview and facility documentation review facility failed to provide a resident transportation to a scheduled outside medical appointment. The facility failed to provide one (1) of two (2) residents reviewed for dialysis with transportation services to dialysis. The facility failed to obtain a physician order for a fall mat in place for one (1) of six (6) residents reviewed for falls. Resident identifiers: # 30, #33 and # 34. Facility census: 74. Findings included: A record review of the facility's policy titled, Dialysis: Hemodialysis- Communication and Documentation Policy, revised on 06/01/21, showed that the facility staff must assist Residents in making arrangements with safe transportation to and from the dialysis facility. a) Resident #30 A review of Resident #30 ' s medical record showed a progress note dated 08/06/22 that stated, Resident up and ready for dialysis but their is no driver to take her. Called dialysis facility and let them know she will be unable to make it due to no available transportation.…

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 the facility was free from accident hazards in which it had control. Two (2) medication carts and one (1) treatment cart were left unlocked and unattended, allowing access to medications by residents and unauthorized persons. Additionally, the facility failed to lock and secure chemicals / disinfectant supplies. These were random opportunities for discovery and had the potential to effect more than a limited number of residents. Facility Census: 74. Findings included: a) 400 Hall Med Cart An observation, on 10/02/22 at 5:10 PM, found the 400 Hall Med Cart unlocked and unattended. Surveyor remained with the unlocked cart until a staff member noticed the cart had been opened by Surveyor. During an interview, on 10/02/22 at 5:12 PM, Licensed Practical Nurse (LPN) #30 questioned, Did it just pop open? It's been acting up. LPN #30 then locked the cart. b) Treatment Cart An observation, on 10/02/22 at 5:15 PM, found the facility's Treatment Cart by the Director of Nursing's (DON's) office unlocked and unattended. LPN…

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 medical record review and staff interview the facility failed to assess resident's conditions and monitor for complications before and after dialysis treatments. This was true for two (2) of two (2) residents reviewed for dialysis treatment during the Long-Term Care Survey Process (LTCSP). Resident Identifiers #47 and #30. Facility census 74. Findings Included: a) Resident #47 Medical record review of resident #47s chart revealed there were no pre and post dialysis assessments completed in resident's active chart. Continued review found a physician's order: Dialysis center every Monday, Wednesday, and Friday with chair time at 11:30 am. On 09/27/22 at 12:58 PM the facility staff were unable to locate Resident #47s dialysis communication book. During an interview on 09/27/22 at 1:05 PM, the Assistant Director of Nursing (ADON) stated that Resident #47s dialysis communication book could have been left on the transportation bus yesterday when he went to the dialysis center. The ADON verified, staff would not be able to review residents' condition during the dialysis treatment…

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 post the daily nurse staffing. This was a random opportunity for discovery. Facility census 74. Findings included: a) No Daily Nurse Staffing Posted Observation on 10/02/22 at 5:05 PM, found the daily nurse staffing posted was dated 09/29/22. An immediate interview with Licensed Practical Nurse (LPN) #41 confirmed that the daily nurse staffing had not been posted for the following dates: --Friday, 09/30/22 --Saturday, 10/01/22 --Sunday, 10/02/22

Based on observation, medical record review, and staff interview, the facility failed to provide routine and emergency drugs and biologicals to its residents as prescribed. This is true for 2 of 3 residents reviewed during medication administration. Resident identifiers: #120 and #62. Facility census: 74. Findings include: a) Resident (R) #120 The over the counter medication Zinc 220 milligrams (mg) was not available in the medication cart or the med storage room, during an observation of medication administration on 09/28/22 at 7:30 AM. Licensed practical Nurse (LPN) #60 acknowledged the Zinc was not available during the morning medication pass. LPN #60 stated it needed to be discontinued anyway, since the resident no longer has Covid. A review of the medical record on 09/28/22 at 10:30 AM revealed an order was written to discontinue the Zinc at 09:17 AM on 09/28/22. b) R #62 During an observation of medication administration on 09/28/22 at 08:00 AM, LPN #5 noted the prescribed supplemental medication Vitamin D3 400 units was not available in the facility to administer during 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, food temperature checks, record review and staff interview the facility failed to ensure sufficient staff were employed to carry out the functions of the food and nutrition services in accordance with the facility assessment. These were random opportunities for discovery. The failed practice had the potential to affect more than a limited number of residents. Facility census: 74. Findings included: a) Kitchen staffing An observation on 09/26/22 at 8:45 AM, during the initial tour showed only two (2) dietary staff working in the kitchen area. During an interview on 09/26/22 at 9:15 AM, Resident # 40 stated most of the time Resident #40 does not eat because the food tastes bad and the food was cold. During an interview on 09/26/22 at 10:04 AM, Resident #46 stated that food was always cold. During an interview on 09/26/22 at 12:05 PM, Resident # 30 stated, the food is sucky. Resident # 30 stated the food tastes sucky and was always cold. During an interview on 09/26/22 at 12:05 PM, Resident #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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident interview, staff interview, facility documentation, and resident council minutes the facility failed to provide food in the amount for resident needs and preference. This affected [NAME] than a limited number of residents during the Long-Term Care Survey Process (LTCSP). Resident identifier #46. Facility census: 74. Findings included: a) Resident #46 During an interview on 09/26/22 at 10:04 AM Resident #46 stated the food is cold when they get it, and you don't get enough food when it's served. Review of Grievance and Concerns found a concern dated 05/08/22 about the lunch meal: Residents received two (2) small pieces of hotdog in a crescent roll and pasta salad in a four (4) ounce condiment cup with lid. A review from the Resident food committee on 05/10/22 at 10:30 AM revealed, Residents concerns about serving sizes. A review of Resident Council Minutes revealed: Resident Council 07/14/22: New Business -Meals and Dining, --Portion sizes are small. Resident Council 09/15/22: New Business…

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 resident interviews, observation and staff interviews the facility failed to serve food at an appetizing and preferable temperature. This was a random opportunity for discovery. The failed practice had the potential to affect more than a limited number of Residents. Facility census: 74. Findings included: a) Food Tray Temperatures During an interview on 09/26/22 at 9:15 AM, Resident # 40 stated most of the time Resident #40 does not eat because the food tastes bad and the food was cold. During an interview on 09/26/22 at 10:04 AM, Resident #46 stated that food was always cold. During an interview on 09/26/22 at 12:05 PM, Resident # 30 stated, the food is sucky. Resident # 30 stated the food tastes sucky and was always cold. During an interview on 09/26/22 at 12:05 PM, Resident #4 stated that the food sucks, I'm going to have to buy my own food. The food is always cold. A food tray temperature check of the last tray served on hallway 400, on 09/26/22 at 1:15 PM, revealed the following temperatures:…

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 staff interview the facility failed to ensure meals were served at times in accordance with resident's needs, preferences, and requests. This was a random opportunity for discovery. The failed practice had the potential to affect more than a limited number of Residents. Facility census: 74. Findings included: a) Meal Serving Time Record review of the facility's mealtimes were as followed: Breakfast- 7:00 AM Lunch- 11:30 AM Dinner- 5:00 PM During an interview on 09/26/22 at 12:05 PM, Resident # 30 asked, where was lunch? Resident #30 stated lunch should be here before noon and it is already 12:05 PM. An observation on 09/26/22 at 1:10 PM, Resident # 30 was served lunch. During an interview on 09/26/22 at 1:10 PM, Resident # 30 stated, I hate squash that's on the tray and did not want the chicken sandwich. Resident # 30 asked for an alternative. An observation on 09/26/22 at 1:55 PM, Resident # 30 received chef salad as an alternative meal. During an interview on 09/26/22 at 1:55 PM, Resident #30 stated the chef salad was pleasurable but had to…

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 the temperature logs were complete and up to date for the walk- in refrigerator, walk-in freezer, free standing refrigerator, and dish machine. This was a random opportunity for discovery. The failed practice had the potential to affect more than a limited number of residents. Facility census: 74. Findings included: a) Temperature Logs An observation on 10/02/22 at 5:20 PM, showed the October 2022 Walk-in Refrigerator Temperature Log, Walk-in Freezer Log, Dish Machine Log and Free-standing Refrigerator Temperature Logs were not completed for 10/01/22 and the morning of 10/02/22. During an interview on 10/02/22 at 5:30 PM, Dietary Staff #84 verified the temperature logs for the walk-in refrigerator, walk-in freezer, free standing refrigerator, and dish machine were not completed for 10/01/22 or the morning of 10/02/22.

Based on observation, record review and staff interview the facility failed to ensure the required thoroughness of the facility assessment to include the Dietary Manager as it related to food and nutritional services. This was a random opportunity for discovery. The failed practice had the potential to affect more than a limited number of Residents. Facility census: 74. Findings included: a) Dietary Staffing An observation on 09/27/22 at 11:30 AM, showed only two (2) Dietary staff working in the kitchen with a facility census of 74. During an interview on 09/27/22 at 11:30 AM, Dietary Manager (DM) stated food trays are started at 11:30 AM serving the dining room first and the expectation was food to be out to the halls and served within an hour after the dining room is served. DM confirmed that that daily kitchen duties were staffed with just one (1) cook and one (1) aide on every shift. An observation on 09/28/22 at 9:45 AM, showed only two (2) Dietary staff working in the kitchen with a facility census of 74. Record review of the Facility Assessment updated on 07/13/22, showed,…

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 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. The nurse failed to use a barrier during medication pass and touched the residents pills with her bare hands during medication prep. This was a random opportunity for discovery and was true for Resident #121. Resident identifier: #121. Facility census: 74. Findings include: a) Resident (R) #121 During an observation of medication preparation on 09/28/22 at 7:40 AM, Licensed Practical Nurse (LPN) #60 broke a B12 500 microgram tablet in half with her bare hands and thumb nail to administer the prescribed dose of 250 micrograms. LPN #60 dropped the lisinopril tablet on the medication cart, picked it up with her bare hand and placed it in the medicine cup with R #121's other meds. LPN #60 dropped the spirolactone tablet in the medication cart drawer, picked it up with her bare hand and placed it in…

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 resident interview, record review, and staff interview, the facility failed to ensure each resident had the opportunity to exercise autonomy regarding preferences that were important to their life. The facility failed to honor a resident's preference to receive a shower in the morning. This was true for one (1) of 18 residents reviewed during the annual long-term care survey process. Resident identifier #64. Facility census: 74. Findings included: a) Resident #64 During an Interview on 09/27/22 at 9:00 AM, Resident #64 stated she would prefer to have a shower in the morning, but the facility frequently does not have enough staff to honor that request and she is told, We don't have anybody here to do it. Resident states she frequently refuses to shower later in the afternoon / evening hours simply because it is not her preference to shower later in the day. Resident reports she mostly gets bed baths as a result. A record review, completed on 09/27/22 at 3:33 PM, revealed Resident #64 had not received a shower at any time from 09/06/22 - 09/27/22. Instead, Resident #64…

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 interview, the facility failed implement written abuse and neglect policies and procedures for reporting in order to prevent all types of abuse. The facility failed to report an incident of neglect/mistreatment with Resident #221. This practice affected one (1) of two (2) residents reviewed using the abuse pathway in the survey process. Resident identifier: #221. Facility census: 74. Findings included: a) Facility Policy Review Review of the facility's policy titled Abuse Prohibition, with a revision date of 05/01/22, revealed the center prohibits abuse, mistreatment, neglect for all patients. According to the policy employees are designated as mandated reporters and are obligated to immediately report any suspicions. The facility further defines mistreatment and neglect as: --Mistreatment is defined as inappropriate treatment or exploitation of a patient. --Neglect is defined as the failure of the Center, its employees, or service providers to provide goods and services to a…

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 interview, the facility failed to ensure a resident fall resulting in serious bodily injury and an allegation of neglect/mistreatment by staff, were reported in a timely manner to the appropriate state agencies. The failure to make a timely report was true for one (1) of five (5) sampled residents for falls and was true for one (1) of two (2) residents reviewed for abuse. Resident identifiers: #66 and #221. Facility census: 74. Findings included: a) Requirements for reporting seriously bodily injury. The Federal regulation 483.12(c)(1) directs incidents involving serious bodily injury must be reported to the state survey agency within two (2) hours after the injury is noted. The Office of Health Facility Licensure and Certification (OHFLAC) Long-Term Care Reporting Requirements guidance, dated December 4, 2019, instructs that OHFLAC and Adult Protective Services (APS) should receive the serious bodily injury report within two (2) hours. The guidance also instructs that OHFLAC and…

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 medical record review and staff interview, the facility failed to complete accurate Minimum Data Set (MDS) assessments for one (1) of 18 assessments reviewed during the Long-Term Care Survey Process (LTCSP). The MDS assessment for Resident #72 did not accurately reflect the resident's discharge status. Resident identifier: #72. Facility census: 74. Findings included: a) Resident #72 On 09/27/22 at 3:48 PM, a review of the electronic medical record was completed. Review of the Discharge MDS, with an Assessment Reference Date (ARD) of 07/21/22, revealed Section A was marked as Resident #72 being discharged to an acute hospital. However, the discharge plan documentation, dated 07/20/22, noted resident was scheduled for a discharge to home with family on 07/21/22 at 9:00 AM. During an interview on 10/03/22 at 11:15 AM, the MDS Coordinator confirmed Resident #72 was discharged to home. The MDS Coordinator noted the MDS coding reflecting a discharge to an acute hospital was in error and stated, I will go in and correct that now.

Based on medical record review and interview, the facility failed to revise person-centered comprehensive care plans for Resident #68's nutritional services and Resident #4's area of smoking. This practice affected two (2) of 18 Resident care plans reviewed during the Long-Term Care Survey Process (LTCSP). The failure to ensure the comprehensive care plan was reviewed and revised for the resident's highest practicable well-being placed the residents at risk of not receiving services that would meet their desires or wants and a decreased quality of life. Resident Identifiers #68 and #4. Facility census: 74. Findings included: a) Resident #68 On 09/27/22 a review of Resident (R#68's) medical records revealed, a physician's order: --Patient to have pleasure foods, with the order date 09/02/22. A review of the Resident #68's current care plan with the review date 09/02/22 with completion date 09/08/22 showed there was an active care plan addressing enteral feeding tube. The active goal, Resident is non-compliant with nothing by mouth (NPO) status and will take food from roommates and…

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, record review and staff interview the facility failed to ensure there was a current physician order to administer oxygen to a resident. This was a random opportunity for discovery. Resident identifier: #38. Facility census: 74. Findings included: a) Policy Review Record review of the facility's policy titled Oxygen: Nasal Cannula, revised on 01/01/04, showed directions and steps in administering oxygen to Residents. The first step to oxygen administration was to Verify order. b) Resident #38 An observation on 09/26/22 at 9:44 AM, showed Resident # 38 laid in bed with oxygen being administered via nasal cannula at three (3) liters per minute. Record review of Resident #38's medical record showed no current oxygen order. An additional observation on 09/27/22 at 9:36 AM. Showed Resident #38 laid in bed with oxygen being administered via nasal cannula at three (3) liters per minute. During an interview on 09/27/22 at 9:40 AM, the Director of Nursing (DON) stated Resident # 38 should be on oxygen and verified there was no current order for oxygen. The DON stated…

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 resident interview, record review and staff interview the facility failed to ensure pain medications were administered in accordance with professional standards of practice. The failed practice was true for one (1) of four (4) Residents reviewed for pain. Resident identifier: #38. Facility census: 74. Findings included: a) Resident #38 During an interview on 09/26/22 at 9:45 AM, Resident # 38 stated that she was in pain a lot of the time. Resident #38 stated the facility only had pain medication scheduled as needed and some staff will give pain medication every 6 hours and others do not. Resident felt pain medication was administered inconsistently. Record review of Resident #38's physician orders showed the following orders for pain medications: OxyCODONE HCl Tablet 10 MG *Controlled Drug*- Give 1 tablet by mouth every 6 hours as needed for moderate to severe pain. Acetaminophen Tablet 325 MG (Acetaminophen)-Give 2 tablet by mouth every 4 hours as needed for Mild Pain More than 3 doses in 48 hours, notify physician/advanced practice provider (APP) Do not exceed 3g/day.…

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.