Tygart Center At Fairmont Campus

Based on record review and staff interview the facility failed to include all appropriate diagnosis on the most recent Pre-admission Screening and Resident Review (PASARR). This failed practice was found true for (2) two of (5) five residents reviewed for PASARR accuracy during the Long-Term Care Survey Process. Resident identifiers: #5, and #10. Facility Census: 106. a) Resident #10 A record review on 02/10/26 revealed that Resident #10 has a current diagnosis of Schizophrenia with a start date of 10/30/25. Further record review of Resident #10's most recent PASSAR completed on 05/02/22, revealed that Schizophrenia is not indicated on section 30, or listed in any other section of the PASSAR. During an interview on 02/10/26 at 2:12 PM, The Licensed Social Worker (LSW) #59, confirmed that Resident #10 had a diagnosis of Schizophrenia and that it is not indicated on the most recent PASSAR. LSW #59 stated, We just missed it. We are starting an audit now. Findings Include: a) Resident #5 A record review on 02/10/26 at 1:25 PM, revealed that Resident #5 has a current diagnosis 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, record review, and staff interview the facility failed to develop and/or implement care plans related to physician dietary orders and Auditory needs. This failed practice was a random opportunity for discovery during the Long-Term Care Survey Process. Resident identifiers: #30, and #104. Facility census: 106. Findings Included:a) Resident # 30 On 02/10/2026, at12:06 PM, During Dining Room tray pass, It was observed that Resident #30's meal ticket stated, 1:1 Feed Assist and Supervision for all meals. Employee #17 retrieved Resident #30's tray, assisted in set up, then went back to get another resident's tray leaving Resident # 30 unsupervised for 8 minutes. Record Reviews:On 02/10/2026 at 1:15PM, a completed record review of Resident #30's Physician Orders coincided with the meal ticket stating resident was a 1:1 feed assist and ordered supervision for all meals.On 02/10/2026 at 1:28PM, a record review of Resident # 30's Care Plan stated as written:Resident is receiving a regular dysphagia pureed diet and thin liquids with 1:1 supervision at meals. Date…

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 interviews, the facility failed to ensure a resident's care plan was revised in the areas of discontinued physician orders and for resident advance directive status. Resident identifiers: #4 and #11. Facility Census:106 a)Resident #4 A record review on 02/11/26 at 10:00 AM, of Resident #4's Care Plan stated : Focus: Name is receiving antibiotic treatment for a Urinary Tract Infection. Interventions: Administer medication(s) as ordered. date initiated 01/21/26 A Further record review of Resident #4's Physician Orders, an order for the antibiotic could not be found. During an interview on 02/11/26 at 2:55 PM, The Director of Nursing (DON) She provided the discontinued Physician Order written below: Physician Orders were as follows: Fosfomycin Tromethamine Oral Packet 3GM Give 1 packet by mouth one time only for UTI for 1 day. start date 01/21/26 and confirmed that the care plan was not revised to reflect Resident #4's antibiotic treatment for the Urinary tract infection had been discontinued. b) Resident #11 A record review on 02/11/26 at 9:00 AM, 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 record review, staff interview and observation, the facility failed to ensure the residents' environment remained as free of accident hazards as possible. Resident Identifier: #80. Facility Census: 106. Findings included:a) Resident #80 The facility failed to ensure suction equipment was in place with the suction machine at the resident's bedside. On 02/09/26 at 2:00 PM, during the initial interview process, Resident #80 had a suction machine on his bedside table. No canister was in the suction machine or around the machine. On 02/09/26 observation of Suction machine at bedside revealed no canister was attached. At 2:05 PM, Nurse Aide #3 verified there was no canister in the suction machine. On additional observations during the Long Term Care Survey Process, a package containing the sterile catheter, container and gloves was hanging on the resident's bedside table. On 02/11/2026 Nurse Educator #81 reported they were looking at getting the order discontinued for the suction machine. The Director of Nursing and Nurse Educator reported they don't set the suction machines up…

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 electronic medical record review, and staff interview, the facility failed to ensure two (2) of four (4) resident's Pre admission Screening and Resident Review (PASARR) was current and accurate. This failed practice had the potential to affect a limited number of residents. Resident identifiers: #16, #67. Facility census: 106. a) Resident # 67 On 02/10/26 at approximately 2:55PM, a record review found that Resident # 67 was diagnosed with vascular dementia, moderate, with anxiety was not updated in the PASARR. In an interview with the DON on 02/10/26 at 3:25 PM, she acknowledged Resident # 67's PASARR was not updated r/t (related to) the diagnosis of vascular dementia, moderate, with anxiety. She stated she was aware that PASARRs facility wide were in need of updating and an audit was started to rectify the issue. b) Resident #16 On 02/12/26 at 12:15 AM a review of Resident #16's medical record found a PASARR dated 12/23/24. Under physician recommendations was marked as the resident eventually returned home or be discharged in less than three (3) months. The physician…

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 observation, the facility failed to ensure call lights were within the resident's reach for two (2) residents. Resident Identifiers: #40 and #50. Facility Census: 106.Findings included: a) Resident #40 The policy and procedure for Call Lights stated, 4. Staff will ensure the call light is within reach of the patient and secured as needed. On 02/09/2026 at 12:45 PM, Resident #40's call light was observed not to be within the resident's reach. Nurse Practitioner #24 confirmed the call light was not in reach, unwrapped the call light from the bedrail and placed the call light within the resident's reach. b) Resident #50 On 02/02/26 at 12:30 PM, Resident #50's call light, tv remote and bed remote were observed on the floor. The resident's lunch tray was passed. At 1:05 PM, the resident's call light, tv remote and bed remote remained on the floor beside the resident's bed. Licensed Practical Nurse # 32 confirmed the resident's call light was in the floor and not within reach and stated, I'm sorry. The policy and procedure for Call Lights…

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 upon record review and staff interview, the facility failed to provide accurate daily staffing posting for actual hours worked. This was found to be true for 14 (fourteen) of 15 (fifteen) days of staffing data reviewed during the annual survey process. Facility census: 106 Findings included: Nursing staffing data and time and attendance reports were reviewed for the following dates: 04/25/25, 04/26/25, 03/21/25, 03/22/25, 03/23/25,02/20/25, 02/21/25, 02/22/25, 02/23/25 01/01/25, 01/02/25, 01/03/25, 12/31/24, 11/25/24, 11/27/24 Examples of staffing data not aligning with time and attendance reports: On 11/27/24, posted nurse staffing data showed 258 total hours worked for RNs, LPNS, and Certified Nurse Aides. A review of the time and attendance report for the same date, showed 227.78 hours worked. On 12/31/24, posted nurse staffing data showed 264 total hours worked for RNs, LPNs, and Certified Nurse Aides. A review of time and attendance reports for the same date shows 231.40 total hours worked. On 04/26/25, posted nurse staffing data showed 243 total hours worked for RNs,…

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 maintain an effective pest control program so the facility is free of pests and rodents. This was a random opportunity for discovery with the possibility of affecting multiple residents. Facility census: 106. Findings include: a) During a walk-through of the dish room side of the kitchen, on 04/30/25, at 12:00 PM, many mature gnats were observed swarming around the drain area under the dishwasher table. In an interview with the district manager on 04/30/25 at 12:15 PM, he acknowledged the gnats and stated the facility had contacted the extermination for advice a week ago, but the facility had not yet been treated for the gnats.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and staff interview, the facility failed to ensure resident's rooms were a clean and homelike environment (residents' privacy curtains were stained). This is true for Resident #94 and Resident #133. Findings included: a) On 04/29/25 at 9:45 AM an observation of Resident #94's room revealed that her privacy curtain was dirty with stains. On 04/29/25 at 9:50 AM an interview was conducted with Licensed Practical Nurse #133 who acknowledged that the curtain in Resident #94's room needed cleaned. She stated that generally when they see them dirty they will contact house keeping to be cleaned, b)On 04/29/25 at 12:53 PM during an interview with Resident #103, stains on his privacy curtain were observed and he stated it was vomit. Based on observations and staff interviews, the facility failed to ensure a safe, clean, comfortable and homelike environment for three (3) residents. Resident identifiers: #82, #65, and #3. Room identifiers: #404, #400, #412. Facility census: 106. Findings include: 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.

c) Resident #85 A review of Resident #85's medical record found the following transfers to the hospital 08/09/24, 08/31/24, 09/06/24,and 10/22/24. Resident #85 went on therapeutic leave of absence on 11/27/24. On the afternoon of 05/06/25 the facility was asked to provide the notice of the transfer, the bed hold agreement, and the ombudsman notification for each of the aforementioned discharges. Later in the afternoon on 05/06/25 the Person In Charge provided two incomplete Bed Hold Notices dated 08/31/24 and 09/06/24. The only information completed on the form was the residents name and medical record number along with the nursing signature. On the form date 08/31/24 the nurse signed both the resident and the center representative space. On the form dated 09/06/24 the nurse signed the center representative space and documented a verbal notification of the resident representative. Neither form contained the number of bed hold days remaining. No other information was provided for the discharges. The PIC stated, This is all we have. He confirmed he could not find any of 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.

b) Resident #20 A review of the Resident #20's medical record on the after noon of 04/30/25 found Resident #20 sustained a fall on 03/12/25 at 5:30 PM. The incident report indicated neurological assessments were done per policy. The facility was asked to provide the completed neurological assessments related to this fall. On 05/01/25 at 9:08 AM the Director of Nursing (DON) stated they could not locate the neurological assessments for this fall. Based on record review and staff interview, the facility failed to discontinue wound treatment for Resident #21, when the wound was healed and failed to complete neurological (neuro) checks for Resident #20. This was true for two (2) of 42 residents reviewed during the survey process. Resident Identifiers: #21 and #20. Facility Census: 106. Findings Include: a) Resident #21 On 05/06/25 at 2:55 PM, a record review was completed for Resident #21. The review found an active physician's order for wound care to the resident's left gluteus. The wound treatment was cleanse left gluteus with IHWC (in-house wound cleanser), pat dry. Apply hydrogel…

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 staff interview and resident interview the facility failed to ensure Resident #21, and Resident #22 received the treatment and care in accordance with professional standards of practice, the comprehensive care plan, and the resident's choices, related to pain management. This was true for two (2) of 10 residents reviewed for the care area of pain during the long-term care survey process. Resident identifiers: #21, and #22. Facility Census: 106. Findings Include: a) Resident #21 On 04/29/25 at 1:36 PM Resident #21 stated, she had been asking them for pain medication, and they had not given her any yet. The resident was asked to rate her pain on a scale from zero (0) to ten (10) with zero (0) being no pain and ten (10) being the worst pain ever. Resident #21 stated that her pain was an eight (8). The surveyor immediately reported Resident #21's pain level to Registered Nurse (RN) #10. RN #10 stated, I told her she could not have any just yet because it had not been 12 hours since…

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, resident interview and staff interview the facility failed to ensure Resident Meals were served, which were palatable and at an appetizing temperature. This failed practice has the potential to affect more than an isolated number of Residents. Facility Census: 106 a) Resident #6 During an interview with Resident #6 on 04/29/25 at 10:27 AM, Resident stated food was terrible here. When I asked her if it was not the proper temperature, did not taste b) Resident #11 On 04/29/25 at 1:43 PM during an interview, Resident #11 reported the food has no taste, sometimes it is too cool, and she was concerned about the nutritional status. She went on to report on the facility does not serve fresh fruits or veggies and the food has no seasoning and is not appealing. c) Resident #35 On 04/29/25 at 1:38 PM during an interview, Resident #35 reported the food does not taste good. She also reported that she has never been told about an always available menu. d) Resident #21 During an interview with Resident #21 on 04/29/25 at 1:30 PM the resident indicated the food here is…

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 e) Reheated food during the noon time meal service o 05/05/25. An observation of the noon time meal on 05/05/25 at 12:35 PM, found [NAME] #124 reheated broccoli which was previously held for service but fell below the acceptable temperature of 135 degrees Fahrenheit (F). She reheated the broccoli to a degree of 160 degrees f. Dietary Account Manager #96 told her 160 degrees F was an acceptable temperature and it was okay to serve the broccoli. [NAME] #124 then served the reheated broccoli. An interview with the corporate account manager at 2:04 PM on 05/05/25 confirmed the broccoli should have been reheated to 165 degrees F. He stated, They told me that but there was not much to do about it after the fact. Based on observation, resident interview, and staff interviews, the facility failed to distribute and serve food in accordance with professional standards for food service safety, to ensure meals were served at a palatable, appetizing and temperature, safe and sanitary manner, preventing the spread 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.

b) Resident #102 An observation on the afternoon of 05/05/25 found Resident #102's10:00 AM mighty shake still sitting at the nurses' station unopened. A review of the Medication Administration Record (MAR) found Registered Nurse (RN) #10 had documented Resident #102 had consumed 100 percent of his 10:00 am mighty shake. An interview with RN #10 immediately following the record review found she should have documented refused on the mighty shake. c) Resident #78 An observation on the afternoon of 05/05/25 found Resident #78's 10:00 am mighty shake still sitting at the nurses' station unopened. A review of the Medication Administration Record (MAR) found Registered Nurse (RN) #10 had documented Resident #78 had consumed 100 percent of his 10:00 am mighty shake. An interview with RN #10 immediately following the record review found she should have documented refused on the mighty shake. Based on record review and staff interview, the facility failed to ensure an accurate and complete record for Resident #37's skilled nursing evaluation, documentation of supplements for Resident #102 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 maintain infection control standards during wound care for Resident #61, storage of a nebulizer and mask for Resident #60 and maintaining a wheelchair for Resident #19. These were random opportunities for discovery. Resident identifiers: #61, #60 and #19. Facility Census: 106. Findings include: a) Resident #61 On 05/01/25 at 10:08 AM, an observation of the wound care provided by Registered Nurse (RN) #32 was completed. As RN #32 provided the wound care to the right gluteal fold, RN #32 touched her glasses multiple times. On 05/01/25 at 10:30 AM, Nurse Aide (NA) #25 set a bath basin of water and wash cloths on the over-the-bed table which was the sterile field for the wound care. On 05/01/25 at 10:42 AM, an interview was held with RN #32. RN #32 was asked, Did you realize you touched your glasses multiple times during the wound care? RN #32 stated, No, I didn't realize. RN #32 was asked, Do you think the bath basin of water placed on the over-the-bed table disturbed your sterile field? RN #32 stated, I…

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, resident interview and staff interviews, the facility failed to ensure food choices were obtained and honored. This was true for one (1) of six (6) residents reviewed during the annual survey process. Resident identifier: #309. Facility census: 106 Findings included: a) Resident #309 On 04/29/25 at 10:32 AM, during an interview with Resident #309, the resident stated they had not been asked about food choices. The Resident said, They just bring me whatever they want, if I like it, I eat it. If I don't like it, I just go without. When asked if anyone had told them about the Always Available menu, they were not aware of it. When asked if anyone had asked what they liked and disliked food-wise, they stated, no. On 05/06/25 at 10:53 AM, a phone interview was completed with the dietician. When asked to describe the process of obtaining newly admitted resident's food choices, the dietician stated that within 24 hours of admission [NAME] #124, was supposed to obtain the food preferences from the resident. The dietician further stated she did the nutritional…

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 implement their abuse prohibition policy by ensuring allegations of mental/emotional abuse were reported to the required state agencies within the required time frames. This was a random opportunity for discovery for Resident #93. Resident identifier: #93. Facility Census: 106. Findings Include: a) Resident #93 On 05/01/25 at approximately 1:20 PM while passing through the dining room this surveyor overheard a nurse (later Identified at LPN #133) say to Resident #93, You can't have your pain medicine until you eat at least half of your food. The nurse then left the dining room. This was reported to facility staff immediately after the observation. Facility staff intervened and had the nurse give Resident #93 her Tylenol. An interview with the resident in the dining room prior to the nurse returning found she did not feel like eating because her arm was hurting. She then stated, They told me I had to eat to get my medicine. A review of the medical record found Resident #93's order for the as needed Tylenol…

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 all allegations of mental abuse were reported to the required state agencies with in the required time frames. This was a random opportunity for discovery and as true for Resident #93. Resident Identifier: #93. Facility Census: 106. Findings Include: a) Resident #93 On 05/01/25 at approximately 1:20 PM while passing through the dining room this surveyor overheard a nurse (later Identified at LPN #133) say to Resident #93, You can't have your pain medicine until you eat at least half of your food. The nurse then left the dining room. This was reported to facility staff immediately after the observation. Facility staff intervened and had the nurse give Resident #93 her Tylenol. An interview with the resident in the dining room prior to the nurse returning found she did not feel like eating because her arm was hurting. She then stated,They told me I had to eat to get my medicine. A review of the medical record found Resident #93's order for the as needed Tylenol did not contain any special directions…

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, resident interview and staff interview, the facility failed to develop and/or implement the care plans for three (3) of 42 sample residents. Resident identifiers: #48, #9, and #309. Facility Census: 106. Findings Include: a) Resident #48 An interview with Resident #48 on 04/2925 at 12:46 PM found she was a hemodialysis patient. She stated, They use the port in my groin for now, but I have one in my upper arm that needs to mature. A review of Resident #48's medical record found she returned from the hospital on [DATE] after the placement of an Arteriovenous Fistula (AVF) in her left upper arm. A review of Resident #48's care plan found it was void or any mention of the residents AVF in her left upper arm. An interview with the Director of Nursing (DON) on the afternoon 05/06/25 confirmed a care plan was not developed for Resident #48's AVF. The facility failed to develop and or implement the care plan. PS RL a) #48 AVF b #9 contractures ASC c) #309 incomplete blanks KW Resident #48…

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 revise a care plan for a change in code status for Resident #99. This is true for one (1) of four (4) residents reviewed under the care area of advanced directives. Resident Identifier: #99. Facility Census: 106. Findings Include: a) Resident #99 On 05/05/25 at 2:15 PM, a record review was completed for Resident #99. The review noted the [NAME] Virginia Physician's Order for Scope of Treatment (POST) form was Do Not Resuscitate, Comfort Measures and no artificial means of nutrition, which was dated 03/03/25. However, the care plan indicated the resident was a full code. On 05/05/25 at 3:10 PM, the Director of Nursing (DON) confirmed the care plan had not been revised to indicate the change in code status.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, the facility failed to provide activities of daily living for dependent Resident #259 and #35. This was true for two (2) of four (4) residents reviewed under the care area of activities of daily living. Resident identifiers: #259 and #35. Facility Census: 106. Findings Include: a) Resident #259 On 05/06/25 at 8:15 AM, a record review was completed for Resident #259. The review found the resident did not receive showers or bed baths for the timeframe of 03/21/25 through 03/28/25; which is seven (7) days. The resident was listed as dependent for showers and bed baths on the discharge Minimum Data Set (MDS) dated [DATE]. On 05/06/25 at 9:00 AM, the Director of Nursing (DON) confirmed there was no documentation to indicate the resident received showers and/or bed baths for the seven (7) days between 03/21/25 and 03/28/25. b) Resident #35 During an interview with resident on 04/29/25 at 01:38 PM she reported that she would like a shower at least once per week and that she…

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, resident interview and staff interview the facility failed to ensure Resident #48 who required dialysis received such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences. This was true for one (1) of one (1) residents reviewed for the care area of dialysis during the long-term care survey process. Resident identifier: #48. Facility Census: 106. Findings Include: a) Resident #48 A review of Resident #48's medical record on 05/05/25 found the resident received dialysis on Monday, Wednesday and Friday at a local dialysis center. Each day the facility completed and sent with the resident a Hemodialysis communication sheet. The sheet consisted of three (3) Sections. The first and third were to be completed pre and post dialysis by the facility's nurse. The middle section is to be completed by the dialysis center. A review of the electronic medical record found the following missing dialysis…

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 upon record review and staff interview, the facility failed to ensure they maintained the requirements of their policy for the time allotted for the physician to respond to gradual dose reduction recommendations from the pharmacist. The facility also failed to ensure the pharmacist identified the need for possible gradual dose reduction for a resident receiving an antidepressant. This was found to be true for 1 (one) of 42 (forty-two) residents reviewed during the annual survey process. Resident identifier: #50. Facility census: 106. Findings included: a) Resident #50 Record review revealed the resident had a physician's order for: Mirtazapine Tablet 7.5 MG (Remeron) Give 2 tablets by mouth at bedtime for depression The Medication Regimen Review reports for 02/27/25 and 12/28/24, had a notation which revealed there was a more detailed report. On the detailed report for 12/28/24, the pharmacist recommended a Gradual Dose Reduction (GDR) review for Mirtazapine. The attending physician failed to provide the response within the facility's 30 calendar day time-frame per their…

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 upon record review and staff interview, the facility failed to ensure nurse aides completed 12 hours of required education annually. This was found to be true for one (1) of five (5) nurse aide personnel files reviewed during the annual survey process. Staff identifier: #46. Facility census: 106. Findings included: a) Nurse Aide (NA) #46 Nurse Aide #46 completed 9 hours and 34 minutes of education during the calendar year 2024. She completed 24 minutes of education on dementia. This was reviewed with the DON on the morning of 05/06/25, and asked if she had any additional education for this Nurse Aide to support the 12 hours required training, to please provide it No additional education was supplied prior to the survey exit.

Based on record review, interview, and investigation, the facility failed to conduct the required training and education for staff on issues which impacted resident care. Resident Identifier: #74. Facility Census: 110. Findings include: a) Resident #74 A Facility Reported Incident (FRI) report submitted on 05/01/24, indicated Resident #74 had complained of abuse by staff. The complaint stated, staff were rough when providing care. During an interview, with Resident #74 on 01/29/25 at approximately 11:55 AM, she stated, she had pain in her left leg, was be bound, and incontinent. She stated, she wears briefs, but her bed linen frequently becomes soiled. Upon being questioned about the staff being rough, she stated some staff members pulled on her leg a little too hard when changing her diaper and removing bed linen. She further stated, the staff members who were 'rough' were no longer employed at the facility. Record review of resident's care plan revealed the following notes: FOCUS: [Resident] requires assistance/is dependent for ADL care in bathing, grooming, personal hygiene,…

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, investigation, and interview, the facility failed to provide sufficient preparation and orientation and take steps under its control to ensure one of one resident discharge was safe and orderly. Resident #111 was taken to a local homeless shelter who was not equpieed to meet her needs to her physical limitations. Resident identifier: #111. Facility Census: 110. Findings included: a) Resident #111 A record review revealed, the facility notified the resident of a pending discharge on [DATE] at 9:12 AM. The resident was discharged from the facility on 03/13/24 at 9:39 AM. In addition the facility made the referral to a homeless shelter without adequate planning to ensure the shelter could meet the needs of the resident. When the homeless shelter declined to accept the resident, the facility kept the resident in the transport vehicle, while searching for other shelters that would be able to accept the resident. A record review revealed the following notes in resident's medical record: 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 develop and implement a comprehensive person-centered care plan for a venous access device. This was true for one (1) of one (1) residents reviewed. Resident identifier: #113. Facility Census: 110. Findings Include: a) Resident #113 On 01/29/25 at 11:30 AM a record review found Resident #113 had a central line while a resident at the facility from 10/20/23 through 01/10/24. He was transferred to the facility from a local hospital with a central ([NAME]) Intravenous line in his right chest. On 01/29/25 at 3:30 PM a record review of the comprehensive care plan for Resident #133 found there was no care plan implemented for care of the central line. According to documentation and an interview provided by the Director of Nursing (DON) on 01/29/25 at 1:10 PM, they follow their pharmacy (PharMerica) recommendations for venous access devices which is also stated in their policy. The document provided from the pharmacy, Catheter Care and Flush Protocols…

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 provide proper care for a venous access device according to their Infection Prevention Measures Policy and standard practice of care. This was true for one (1) of one (1) resident reviewed. Resident identifier: #113 Facility Census: 110. Findings Include: a) Resident #113 On 01/29/25 at 11:30 AM a record review found Resident #113 had a central line while a resident at the facility from 10/20/23 through 01/10/24. He was transferred to the facility from a local hospital with a central ([NAME]) Intravenous line in his right chest. According to documentation and an interview provided by the Director of Nursing (DON) on 01/29/25 at 1:10 PM, they follow their pharmacy (PharMerica) recommendations for venous access devices which is also stated in their policy. The document provided, Catheter Care and Flush Protocols stated that tunneled venous access device will have a transparent dressing changed every seven (7) days and as needed (PRN). The facility…

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 meetings with the Quality Assessment and Assurance (QAA)/QAPI (Quality Assurance and Performance Improvement) committee quarterly. An effective QAPI programs are critical to improving the quality of life, and quality of care and services delivered in nursing homes. This failed practice had the potential to affect more than a limited number of residents that currently reside at the facility. Facility census 107. Findings included: a) QAA/QAPI On 03/15/23 at 1:06 PM, the Administrator (NHA) stated that has only had one (1) QAPI meeting with all of the members present. The NHA provided the sign in sheet for the one (1) and only meeting conducted for the last 12 months, dated 02/06/23. The NHA stated that she came to this facility in August going forward was going to have the meetings. .

Based on observation and staff interview, the facility failed to ensure a comfortable and homelike environment, in regards of the temperature in the dining room and library used by residents. This failed practice had the potential to affect more than a limited number of residents that currently reside in the facility. Facility census: 107. Findings included: An observation in the dining room and Library,on 03/14/23 at 1:33 PM, found residents were wheeling around wearing coats, sweaters and blankets. In addition, the housekeeping staff were cleaning and wearing sweatshirts over their scrub tops. The thermostat in the Library (doors are open to the dining room) read 70 degrees Fahrenheit (F) . The thermostats are about 50 inches high on the wall. The thermostat in the dining room read 72 degrees F and was set on cooling. The room is a large room and felt much cooler from thigh level down. The Administrator (NHA), facility cooperate nurse were witness to the finding and of the concerns. The NHA was asked for the Maintenance Supervisor (MS) to bring an infrared thermometer to check 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 record review, observations and staff interview, the facility failed to implement or develop a care plan. This is true for five (5) of 28 residents reviewed in the care plan care area. Facility identifiers: #55, #68, #22, #29 and #85. Facility census: #107. Findings included: a) Resident #55 On 0/15/23 at 10:44 AM upon record review of Resident #55's smoking evaluations, found missing smoking evaluations that were to be completed, according to the Smoking Policy and Procedure (revision date 10/24/22), upon admission, quarterly and with a change in condition. Resident #55 was due for a smoking evaluation in the following months: February 2022, May 2022, August 2022, November 2022 and February 2023. There were no smoking evaluations completed in August 2022 or February 2023. The resident is an independent smoker. According to the care plan, she may smoke independently per her smoking assessment. She will be allowed to smoke safely through the next review and remain in compliance with the smoking policy.…

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, observation, and staff interview, the facility failed to ensure Resident's received treatment and care in accordance with professional standards of practice. Specifically, physician's orders were not followed. This was true for four (4) of 28 residents reviewed during the Long-Term Survey Process (LTCSP). Residents identifiers: R#95, R#3, R#29, and R#28. Facility census: 107. Findings included: a) Resident #95 1) During an observation on 03/14/23 at 9:22 AM Resident #95 was laying in bed with an adductor wedge in place between his legs. A record review for Resident #95 on 03/15/23 at 10:40 AM found no physician order for placement, no care plan, or Nurse Aide (NA) task for the adductor pillow placement. During an interview 03/15/23 at 11:37 AM, the Director of Nursing (DON) verified Resident #95 did not have a physician order for an adductor wedge. The DON stated that she would correct it now. 2) A record review revealed Resident #95's had an unwitnessed fall on 02/24/23 in his room. Continued review for Resident #95's Neurological Evaluation from 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, staff interview and a collection of deficient practices throughout the survey process, the facility failed to be administered in a manner that enables it to use its resources effectively and efficiently to attain and/or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. This failed practice had the potential to affect more than a limited number of residents that currently reside at the facility. Facility census 107. Findings included: a) Quality Assessment and Assurance (QAA)/Quality Assurance and Performance Improvement(QAPI) On 03/15/23 at 1:06 PM, the Administrator (NHA) stated that she only had one (1) QAPI meeting with all of the members present. The NHA provided a sign in sheet with the one (1) and only meeting conducted for the last 12 months, dated 02/06/23. The NHA stated that she came to this facility in August. The NHA said going forward she was going to have the meetings. The NHA was asked after seeing the education sign-in sheets for staff done in the fall of last year on documenting on activities,…

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 four (4) of 19 residents reviewed during the long-term care survey process had a Physician Orders for Scope of Treatment (POST) form completed per directions specified by the [NAME] Virginia Center for End-of-Life Care in conjunction with the [NAME] Virginia Health Care Decisions Act (16-30-1). The POST forms were unsigned by the Resident or Medical Power of Attorney (MPOA). Resident identifiers: Resident #56, R#77, R#66, and R#29. Facility census: 107. Findings included: A review of the [NAME] Virginia End-of-Life Center instructions for completing a POST form was reviewed. The review found the following: If the incapacitated patient's MPOA representative or health care surrogate is unavailable at the time of form completion, this section can be signed by two witnesses for verbal confirmation of agreement from the patient's MPOA representative or health care surrogate. The form should be signed at the earliest available opportunity. (Typed as written.) a) Resident #56 Record review on 03/13/23 at 2:16 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 record review and staff interview, the facility failed to provide the required Skilled Nursing Facility Advanced Beneficiary Notice of Non-Coverage (SNF ABN) form to two (2) of three (3) residents reviewed for the facility's beneficiary protection notification practice. This failed practice placed residents at risk of not being informed of their rights prior to the end of Medicare Part A covered services. Resident identifiers: #102, and #80. Facility census: 107. Findings included: a) Resident (R) #102 A facility record review of the SNF ABN for the Long-Term Survey Process revealed, no notice was given to R #102 prior to the end of skilled service(s). During an interview on 03/14/23 at 12:42 PM, the Coordinator-Clinical Reimbursement (CRC) #2 verified the SNF ABN was not given to R#102 or the representative. The CRC #2 stated that she was just starting to be trained on the SNF ABN. b) Resident #80 A facility record review of SNF ABN for the Long-Term Survey Process revealed, no notice was given to R# 80 prior to the end of skilled service(s). During an interview 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 policy review titled Abuse Prohibition, resident interview, record review, and staff interview, the facility failed to ensure implemention of the facility written abuse prohibition policy in regard to investigating and reporting to proper agencies an alleged allegations of abuse. This has to potential to affect a limited number of residents that reside at the facility. Resident identifiers: R #83 and R #92. Facility census: 107. Findings included: a) Policy review Record review of the facility's policy titled, Abuse Prohibition, showed: --The Administrator, or designee, is responsible for operationalizing policies and procedures that prohibit abuse, neglect, involuntary seclusion, injury of unknown source, exploitation, and misappropriation of property. The center must ensure that all staff are aware of reporting requirements and must support an environment in which covered individuals report a reasonable suspicion of a crime. --Immediately upon receiving information concerning a report of suspected or alleged abuse, mistreatment, or neglect the administrator of designee…

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 Abuse Policy review, Resident interview, record review, and staff interview, the facility failed to identify and report all allegations of abuse and neglect to appropriate state agencies within regulation time frames. This had the potential to affect a limited number of residents that reside in the facility. Resident identifiers: R#83 and R#92. Facility census: 107. Findings included: a) Policy review Record review of the facility's policy titled, Abuse Prohibition, showed: --The Administrator, or designee, is responsible for operationalizing policies and procedures that prohibit abuse, neglect, involuntary seclusion, injury of unknown source, exploitation, and misappropriation of property. The center must ensure that all staff are aware of reporting requirements and must support an environment in which covered individuals report a reasonable suspicion of a crime. --Immediately upon receiving information concerning a report of suspected or alleged abuse, mistreatment, or neglect the administrator of designee will perform the following. --Report allegations involving abuse…

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, resident interview and staff interview, the facility failed to complete an accurate Minimum Data Set (MDS) with a new diagnosis of cataracts. This was true for one (1) of 28 residents reviewed under the vision/hearing care area. Resident Identifier: #85. Facility census: 107. Findings Included: a) Resident #85 On 03/13/23 at 11:25 AM, an interview was held with Resident #28. The resident stated, I'm not doing to good .I have cataracts. On 03/14/23 at 10:18 AM, a record review was completed. The record review found the resident had an eye examination on 10/20/22 stating #3 (number three) as cataracts with a follow up examination with pictures in four (4) months. (Typed as written.) The resident was noted with a vision consult on 12/15/22 for decreased vision in both eyes. The impression/plan stated, #1 (number one) Assessment Age-related nuclear cataract, bilateral; and, plan cataracts are mild; we will monitor for progression. (Typed as written.) A review of the quarterly MDS dated…

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 policy, record review, and staff interview, the facility failed to ensure a Level II of the [NAME] Virginia Department of Health and Human Resources Pre-admission Screening and Resident Review (PASARR) was complete as directed on the initial PASARR. This was true for one (1) of one (1) PASARR's reviewed during the long term survey process. Resident identifier: #69 Facility census: #107. Findings included: a) Policy review According to the facility Pre-admission Screening for Mental Disorder and/or Intellectual Disability Patients Policy with revision date of 01/15/21, the facility purpose was .to ensure that individuals identified with Mental Disorders (MD) or intellectual Disability (ID) are evaluated and received care and services in the most integrated setting appropriate to their needs. Practice Standards on the policy states Social Services will coordinate and/or inform the appropriate agency to conduct the evaluation and obtain results if: 1.1 It is learned after admission that the Pre-admission Screening and Resident Review (PASARR) was not completed or is…

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 policy review, record review, and staff interview, the facility failed to ensure a Level II of the [NAME] Virginia Department of Health and Human Resources Pre-admission Screening and Resident Review (PASARR) was completed as directed on the initial PASARR. This was true for one (1) of one (1) PASSR's reviewed during the long term survey process. Resident identifier: #69 Facility census: #107 Findings included: a) Policy review According to the facility Pre-admission Screening for Mental Disorder and/or Intellectual Disability Patients Policy with revision date of 01/15/21, the facility purpose was .to ensure that individuals identified with Mental Disorders (MD) or intellectual Disability (ID) are evaluated and received care and services in the most integrated setting appropriate to their needs. Practice Standards on the policy states Social Services will coordinate and/or inform the appropriate agency to conduct the evaluation and obtain results if: 1.1 It is learned after admission that the Pre-admission Screening and Resident Review (PASARR) was not completed…

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, resident interview and staff interview, the facility failed to ensure residents unable to carry out activities of daily living (ADLs) received necessary services in the areas of personal hygiene. This was true for two (2) of five (5) residents reviewed under the care area of activities of daily living during the long-term care survey process. Resident identifiers: #29 and #69. Facility census: 107. Findings included: a) Resident #29 On 03/13/23 at 8:45 AM, an interview was held with Resident #29. The resident stated, I haven't had a bath in 3 (three) weeks A record review of bathing for the dates of 02/13/23 through 03/13/23 was completed on 03/14/23 at 2:00 PM. The review found no evidence for the following dates regarding showers and/or bed baths: --02/18/23 --02/19/23 --02/25/23 --02/26/23 --03/01/23 --03/04/23 --03/05/23 --03/07/23 --03/10/23 --03/11/23 --03/12/23 An interview with Nurse Aide (NA) #15 was held on 03/15/23 at 8:25 AM. NA#15 stated, the resident refuses showers and refuses to get up. The resident gets bed baths on Monday 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on record review, observation, resident interview, and staff interview, the facility failed to implement an ongoing activity program designed to meet the interests of and support the well-being of each resident. This has to potential to affect more than a limited number of residents residing in the facility. Resident identifiers: #83. Facility census 107. Findings included: a) Resident #83 During an Interview with Resident #83 on 03/13/23 at 10:38 AM, he stated that he has trouble getting books to read. He stated that there is a media room at the facility, but they don't have any books available, and staff don't offer any books or reading materials. Resident #83's was admitted [DATE] with a quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/01/23 noted the resident had a score for Brief Interview for Mental Status (BIMS) of 15. A BIMS score of 15 indicates that the resident is cognitively intact and has capacity. A review of the care plan revealed the following: Focus:…

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 follow physicians order to provide humidity on the oxygen concentrator. This was true for one (1) of one (1) Residents reviewed in the Respiratory care area. Resident identifier: #22 Facility census: #107. Findings included: a) Resident #22 On 03/13/23 at 11:34 AM during record review found the following order for Resident #22: Continuous oxygen at 2 L/min via Nasal Cannula w/humidity. The oxygen concentrator was observed to have no humidification device. This was confirmed with Licensed Practical Nurse (LPN) #75 on 03/13/23 at 11:34 AM. Review of Resident #22's care plan read as follows: Encourage resident to wear oxygen at 2L/min with humidity per nasal cannula continuously and may titrate to keep 02 sats >90%. The care plan was not implemented due to the facility failing to provide the humidity to the oxygen concentrator. This was confirmed with LPN #75 on 03/13/23 at 11:34 AM. .

Based on record review and staff interview, the facility failed to complete hemodialysis communication records between the facility and the dialysis center. This is true for one (1) of one (1) residents reviewed under the care area of dialysis. Resident identifier: #64. Facility census: 107. Findings included: a) Resident #64 A record review was completed on 03/13/23 at 10:03 AM. The resident is scheduled for hemodialysis at (Name of dialysis center) on Monday, Wednesday, and Fridays at 11:00 AM. The dialysis communication sheets were reviewed from 06/24/22 through 03/13/23. The dialysis communication sheets communicate from the facility to the dialysis center pre-dialysis information. The pre-dialysis information includes vital signs, assessment of the arteriovenous fistula (AV) shunt, and the general condition of the resident. This information also includes the facility licensed nurse's signature and date. The dialysis communication sheets also communicate from the dialysis center to the facility post dialysis information. The post-dialysis information includes pre- and post…

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 staff interviews and record reviews, the facility did not ensure timely notification of the physician of a Resident's significant weight loss. This was true for one (1) of two (2) Resident's reviewed for weight loss. Resident identifiers: R #77. Facility census: 107. Findings included: a) Resident #77 A medical record review of Resident #77 on 03/13/23 revealed, significant weight loss of 10.38 % in one (1) month. Resident #77's Weight log showed the following: 03/05/2023 143.4 Lbs. 02/16/2023 149.0 Lbs. 02/09/2023 160.0 Lbs. Subsequent review of the resident's medical record showed no evidence of Resident #77's physician being notified of a significant weight loss. Continued Medical record review of Resident #77's Care Plan found: Focus: --Resident #77 is on a Regular/liberalized diet. Dx include: hypothyroidism, dementia, recent fractures, Chronic Kidney Disease stage three (3). Severe weight loss over past 1 week; question accuracy of admit weight. Range of 140-15 lb. BMI is >19. Goal: -- (Resident name) will consume on average 55% or greater of meals every day 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.

Based on record review and staff interview, the facility failed to ensure a resident's drug regimen was free from unnecessary drugs. An unnecessary drug is any drug when used without adequate indications for its use. Resident identifier: # 63. Facility census 107. Findings included: a) Resident # 63 A review of medical records found Resident # 63 is receiving Trimethoprim ( an antibiotic) for prophylactic without a diagnosis or a reason for the use of the drug. The order read as the follows: Start date: 08/10/22 Trimethoprim tablet 100 mg Give 0.5 tablet by mouth at bedtime for prophylactic. During an interview with the Director of Nursing (DON) on 03/15/23 at 11:31 AM, she was asked what the indications was for giving this antibiotic Trimethoprim. The DON stated that she would have to find out. On 03/15/23 at 1:40 PM, the DON provided a report from an outside facility. This report was dated 08/10/22 and stated the medication was for reoccurring Urinary Tract infections. The DON stated she was going the correct the order. .

Based on record review and staff interview, the facility failed to ensure each resident was offered a pneumococcal immunization in accordance with the current Centers for Disease Control (CDC). This was true for two (2) of five (5) residents reviewed for immunizations. Resident identifiers: R# 56 and #35. Facility census 107. Findings included: a) Resident #56 During a review of medical records, noted that Resident #56 not eligible for pneumonia vaccine. On 03/15/23 at 8:30 AM, the Infection Preventionist (IP) was asked about Resident #56 not being eligible for a pneumococcal vaccine. The IP said she would have to look into it. On 03/15/23 at 9:31 AM, The IP stated that she was not aware of the new guide lines from the CDC for Prevnar 20. The IP agreed Resident #35 is eligible for the Prevnar 20 because Resident #56 turned 65 on 01/23/23 and was eligible. b) Resident #35 A review of the medical records Resident # 35 received pneumococcal 23 on 9/16 and Prevnar 13 on 8/15 (7 years since the last one). On 03/15/23 at 8:30 AM, the IP was asked if Resident #35 was offered the Prevnar 20…

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 the facility Smoking Policy for smoking evaluations. This was true for one (1) of one (1) residents reviewed in the accident care area for smoking. Resident identifier: #55 Facility census: #107. Findings included: a) Resident #55 On 03/15/23 at 10:44 AM a record review of Resident #55's smoking evaluations, found missing smoking evaluations that were to be completed, according to the Smoking Policy and Procedure (revision date 10/24/22), upon admission, quarterly and with a change in condition. Resident #55 was due for a smoking evaluation in the following months: February 2022, May 2022, August 2022, November 2022 and February 2023. There were no smoking evaluations completed in August 2022 or February 2023. The resident is an independent smoker. According to the care plan she may smoke independently per her smoking assessment. Resident #55 will be allowed to smoke safely through the next review and remain in compliance with the smoking policy. The facility failed to implement the care plan as they failed 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.