Rosewood Center

Based on observation, record review, and staff interviews, the facility failed to ensure Medicaid residents receive routine dental services. This deficient practice was found for (1) one of (1) one residents reviewed for dental services during the Long-Term Care Survey Process. Resident identifier: #70. Facility census: 67. Findings Include: The facility policy titled, Dental Services, directs: Center will provide or obtain from an outside resource routine and emergency dental services, including 24-hour emergency dental care, to meet the needs of each patient. The policy defined routine dental services as follows: An annual inspection of the oral cavity for signs of disease, diagnosis of dental disease, dental radiographs as needed, dental cleaning, fillings (new and repairs), minor partial or full denture adjustments, smoothing of broken teeth, and limited prosthodontic procedures, e.g., taking impressions for dentures and fitting dentures. a) Resident #70 The initial observation on 03/22/26 at 12:15 PM, revealed Resident #70 in the dining room, waiting for her lunch tray.…

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 maintain a complete and accurate medical record related to intellectual disability. This failed practice was found true for one (1)of five (5) residents reviewed for unnecessary medications during the Long-Term Care Survey Process. Resident identifier: #8. Facility census: 67.Findings Include: a) Resident #8 A record review, on 03/23/26 at 2:25 PM, revealed Resident #8's most recent Pre-admission Screening and Resident Review (PASARR) dated 03/06/26, indicated Resident #8 has a diagnosis of Mental Retardation (intellectual disability). Further record review revealed a History and Physical (H&P), dated 01/28/26, under the History of Present illness section, the last sentence read, Patient has underlying mental retardation unable to communicate much. There was no diagnosis of Mental Retardation (intellectual disability) listed in Resident #8's medical record. During an interview on 03/23/25 at 3:35 PM, the Administrator confirmed that Mental Retardation (intellectual disability) was not listed on Resident #8's medical…

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 staff was educated/ informed on the Covid Vaccine. The facility failed to provide education on the benefits, risks, and potential side effects of the COVID-19 vaccine to staff. This was true for one (1) of one (1) staff members selected. Census: 67. Findings include: a) Record Review Certified Nursing Assistant (CNA) #18 was randomly selected to verify if Covid-19 vaccine education/information was given as well as if the vaccine was offered. No record existed. b) Staff Interview Interview with Nursing Home Administrator (NHA), on 03/24/2026 2:25 PM, confirmed CNA #18 was not educated on the Covid-19 vaccine. No documentation existed showing any employee was offered or educated on Covid-19 vaccinations.

Based on observation, resident and staff interviews, the facility failed to ensure resident call lights were within reach. This was a random opportunity for discovery resident identifier: #27. Facility Census: 67. Findings Included: a) Resident #27 During an interview with Resident #27, on 03/23/2026 at 11:50 AM, he stated he couldn't find his call button. The staff forgot to put it back after my bed bath today. They usually clip it to my shirt. Surveyor pushed the roommate's call button. Employee #84 came into the room to answer the call light. She found the call bell behind the back of the bed and reclipped it to his shirt. b) Staff Interviews In an interview with Employee #84, on 03/23/26 at 12:02 PM, she acknowledged the call bell was not within resident's reach and clipped it to his shirt. During an interview on 03/23/26 at approximately 2:25 PM, the Director of Nursing stated she had been made aware of the call button not being within resident's reach.

Based on review of the resident council minutes, resident council meeting, and staff interview, the facility failed to inform residents both orally and in writing in a language that the residents understood of their rights and all rules and regulations governing resident conduct and responsibilities on a yearly basis. Resident identifiers: #9, #18, #22, #26, #31, #38, #40, #48, and #51. Census: 64. Findings included: a) On 02/19/25 at 10:38 AM, a review of the past 12 months of Resident Council meeting minutes was completed. Resident rights were not listed in the discussions during the Resident Council meeting minutes. During a Resident Council meeting, on 02/20/25 at 11:00 AM, the residents stated resident rights were not talked about during previous meetings. They could not remember staff discussing them in any fashion since the day of admission. During an interview on 02/20/25 at 11:55 AM, the Director of Social Services (DoSS) the DoSS stated, other than upon admission, she had not discussed resident rights with the residents since she started this facility as a social worker…

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 the resident council meeting, observation, and staff interviews, the facility failed to post notice of the availability of the most recent survey results in areas of the facility that were prominent and accessible to the public. This was a random opportunity for discovery. Facility census: 64. Findings included: a) During the resident council meeting on 02/19/2024 at 11:00 AM, the residents stated they were unaware they had the right to see the most recent state survey results and did not know where the results were in the building. During a facility walk-through on 02/20/25 at 12:30 PM, it was observed that the facility did not post signage regarding the availability of the most recent survey results. During an interview on 02/20/25 at approximately 12:38 PM, the former Interim Administrator (FIA) acknowledged the absence of a posted notice regarding the availability of the most recent survey results for residents and/or visitors to review.

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 two (2) residents reviewed during the annual survey process. Additionally, the facility failed to provide the required Notice of Medicare Non-Coverage (NOMNC) letter to one (1) of two (2) residents reviewed during the annual survey process. This failure placed residents at risk of not being informed of their rights prior to the end of Medicare Part A covered services. Resident identifiers: #218, #317, and #318. Facility census: 64. Findings Included: a) SNF ABN On 02/19/25 at 2:15 PM, a review was completed regarding the beneficiary protection notification liability notices given for two (2) residents who remained at the facility. - Resident #218 began Medicare Part A skilled services on 09/05/24. The last covered day of Part A service was 10/16/24. There was no evidence that a SNF ABN form was provided. - Resident #317 began Medicare Part A skilled services on 10/17/24. The last covered day of Part…

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, observation, and staff interview, the facility failed to notify residents individually or through postings in prominent locations throughout the facility of the right to file grievances orally (meaning spoken) or in writing; the right to file grievances anonymously; the contact information of the grievance official with whom a grievance can be filed, that is, his or her name, business address (mailing and email) and business. This was a random opportunity for discovery. Resident identifiers: #9, #18, #22, #26, #31, #32, #38, #40, #48, and #51. Facility census: 64. Findings included: a) During a resident council meeting, on 02/19/25 at 11:00 AM, the residents stated they knew they were able to file a grievance with the social worker, but did not know how or where to file an anonymous grievance or complaint. During a facility walk-through with the Administrator, on 02/20/25 at approximately 12:30 PM, the Administrator acknowledged there were no grievance forms available nor were there any posted signs stating residents were able to file a grievance…

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 residents were free from resident-to-resident abuse. This was true for six (6) of six (6) facility reported incidents reviewed. Resident identifiers: #54, #30, #216, #48, #218, #32, and #12. Facility census: 64. Findings included: a) A record review, completed 02/19/25 at 6:30 PM, revealed there was a resident-to-resident altercation on 11/27/24 at 12:00 PM. The facility reportable and investigation revealed that staff observed Resident #54 pushing Resident #30 in his wheelchair down the hallway. Resident #54 aggressively shoved the wheelchair forward causing Resident #30 to fall to the floor. Resident #30 had an abrasion on his head and some skin tears on his right hand. A record review, completed on 02/19/25 at 7:15 PM, revealed there was a resident-to-resident altercation on 12/01/24 at 4:15 PM. The facility reportable and investigation revealed that staff were notified by the family of Resident #216 that Resident #54 was yelling at them and becoming hostile while they were trying to visit. Resident #54…

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 complete their self-identified corrective action which was intended to protect residents following an investigation into a resident-to-resident physical altercation that was verified as abuse. The facility failed to oversee the complete implementation of staff being retrained on the facility's 1:1 Supervision policy. This failed practice had the potential to affect more than a limited number of residents in the building. Facility Census: 64 Findings included: a) Resident #54 A record review, completed on 02/20/25 at 5:07 PM, revealed there was a physical resident-to-resident altercation on 12/28/24 at 1:19 PM. The facility reportable and investigation revealed staff reported Resident #54 was in the dining room for the communal lunch program. There were approximately 6-7 resident remaining in the dining room at the time of the incident. The Activities Assistant was about 20 feet away from Resident #54 when Resident #218 returned to the dining room. Resident #54 got up and walked over to Resident #218 and kicked him 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.

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 a comprehensive care plan regarding Resident #219's activities preferences, weights, and dental issues, Resident #220 anticoagulation therapy, Resident #42's behavior and side effect monitoring of medications as well as activities, Resident #8's leave of absence and Resident #54's physical behavior. This is true for (5) five of 32 residents reviewed during the survey process. Resident identifiers: #219, #220, #42, #8 and #54. and Facility census: 64. Findings include: a) Resident #219 On 02/19/25 at 10:00 AM, a record review was completed for Resident #219. The review found the care plan was not developed under the risk for limited engagement related to diagnosis of major depression, prostate cancer, anemia, morbid obesity. (Typed as written.) The following interventions under this focus area were: --I like to participate in (blank) with groups of people. --I am of (blank) faith and would like to participate in religious…

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 they provided care to facility residents based on their comprehensive assessment and that residents received treatment and care in accordance with professional standards, a comprehensive care plan and the resident's choices for three (3) of 32 residents. The facility failed to follow physician's orders regarding medication administration, weight orders, and medical appointments for Resident #129, correct diagnosis for an antipsychotic medication for Resident #42 and Resident #7's choice to be placed in bed. Resident identifiers: #219, #42 and #7. Facility Census: 64. Findings Include: a) Resident #219 On 02/25/25 at 10:48 AM, a record review was completed regarding medication administration and treatments. The review of the 07/24 through 10/24 documentation found multiple wholes on the medication and treatment administration records for 08/24. The following medications/treatments were not administered as ordered: --Fingerstick blood glucose twice daily for diabetes mellitus--08/07/24 6:00 AM --Normal saline…

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 and resident interview, the facility failed to ensure they followed the recipe for the meal served. This had the potential to affect more than isolated number of residents. Facility census: 64. Findings included: a) Observation of food served on 02/20/25 at 12:35 revealed tuna melt served was an open faced piece of bread with toasted tuna and a slice of cheese. A review of recipe for Tuna Melt Sandwich Corporate Recipe # 4560 on 02/20/25 at approximately 12:43 PM included the following: Ingredients- Fish, tuna, chunk light, in water, can or pouch Mayonnaise, Heavy, Bulk Bread, White, Sliced Tomato, Red, Ripe, Fresh Cheese, American, Sliced Procedure- 1. Combine tuna and mayonnaise. 2. Slice tomato into 6-8 slice. 3. Preheat oven to 350 degrees Fahrenheit. Arrange bread in a single layer on a sheet pan sprayed with food release. 4. Spread a #12 (twelve) scoop of tuna mixture on each slice of bread. Top with (2) two tomato slice and (1) one cheese slice. 5. Place assembled melts in oven until cheese is fully melted. - During an interview…

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 interviews the facility failed to provide food that was appetizing and appealing to residents. This issue had the potential to affect more than an isolated number of residents. Resident identifiers: #55 and #20. Facility census: 64. Findings included: a) Resident #20 On 02/18/25 at 1:05 PM Resident #20 was eating lunch and reported that the sandwich was mushy and microwaved. Observation by the surveyor revealed the food was unappealing. The bread was observed as mushy upon being served. b) Resident #55 On 02/18/25 at 02:29 PM Resident #55's daughter reported the food had been served and reported the food had been horrible. The daughter said, We wasn't even sure what some of it was. On 2/20/25 at 12:20 PM the kitchen supplied a test food tray of the following: Tuna Melt French Fries Mandarin oranges or Chicken Tenders French Fries Mandarin Oranges The survey team observed the Tuna Melt to be unappealing, appearing dry missing the tomato as stated in the faility's recipe.

Based on staff and resident interview and resident council meeting interview, the facility failed to offer bedtime snacks to all residents. Resident identifiers: #51 and #35. Facility census: 64. Findings included: a) Resident #51 On 02/18/25 03:20 PM during an interview with Resident #51, she reported residents are not offered evening snacks but staff will get them one if they ask for it. On 02/18/25 3:30 PM during an interview with resident #35, she reported that residents are not offered evening snacks unless they have them ordered. Observation of nutrition room at nurses station on 02/18/25 at approximately 1:30 PM revealed the following food items available to all residents: -One loaf of bread -four single serving bags of potato chips -an unopened box of fudge round lunch cakes. -Coffee -A pitcher of Kool-Aid - Individually wrapped condiments. During Resident Council meeting held on 02/20/25 at 11:00 AM the council expressed concern that bedtime snack is not offered - residents stated snacks have to be asked for not offered. An interview with Nurse Aide (NA) #21 was held on…

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

Based on observation and staff interviews, the facility failed to wear hair covers in accordance with professional standards for food service safety. This has the ability to affect all residents that get their nutrition from the kitchen. Facility census: 63. Findings Included: a) Kitchen An observation on 02/19/25 at about 3:35 PM found the Cook/Aide #53 preparing resident drinks without a beard covering. During an interview 02/19/25 at about 3:35 PM, Cook/Aide #53 verified a beard net should be in place. At this time, he put a beard net on. b)The facility failed to wear hair nets during meal preparation. During observation of food preparation on 02/18/25 at 11:12 AM Kitchen aide #200 was observed with her hair not fully contained in her hair net. This was brought to the attention of the District Manager #68 who acknowledged and directed KA #200 to readjust her hair net. c) The kitchen failed to properly store and dispose of food in the walk-in refrigerator. During initial kitchen visit on 02/18/25 at 11:42 AM observed a large vat of prepared tea sitting in the floor of the walk 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 observation and staff interview, the facility failed to properly contain kitchen waste in kitchen waste receptacles. This practice had the potential to affect more than an isolated number of residents. Facility census: 64. Findings included: a) Initial tour and observation of the kitchen area on 02/18/25 at 11:50 AM, revealed a large kitchen trash can overflowing with lid unable to fit and trash spilling into the kitchen floor. The surveyor observed the trash can at the hand washing sink. This can had trash spilling out of the top of container and on the floor. b) An interview was held on 02/18/25 at 11:55 AM with District Manager (DM) #68 who acknowledged the trash should have been contained and emptied from the receptacle.

Based on observation, resident and staff interviews, the facility failed to incorporate an effective pest control program. This has the potential to affect all residents residing in the facility. Facility census: 63. Findings included: a) A review of an exterminator report dated 11/19/24 revealed findings of cockroaches in the kitchen area. During an interview with the Maintenance Director (MD) on 02/19/25 at about 3:20 PM the MD revealed no exterminator had serviced the facility since 11/19/24. The MD stated the maintenance department has been trying to exterminate the roaches with boric acid in the remodeled walls. During an interview the Account Manager (AM) #39 on 02/19/25 at about 3:40 PM AM #39 stated he observed roaches in the kitchen area two (2) days prior. A pest control company serviced the facility on 02/20/25 and returned on 02/26/25 for weekly treatments.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and staff interview, the facility failed to ensure a safe and homelike environment regarding packaged terminal air conditioner (PTAC). This has the potential to affect all residents living in the facility. Room Numbers: #104, #210, #118, #123, #124. Facility census: 63. Findings include: a) An observation in room [ROOM NUMBER], on 02/24/25 at 12:35 PM, revealed lent, dirt and debris in the packaged terminal air conditioner (PTAC) units. When the filter was removed from the unit, it was observed to be old, torn and covered with thick lint. A continued sample review of rooms #210, #200, #118, #123 and #124 found the PTAC unit filters were old, torn and covered with thick lint. During an interview, on 02/25/25 at 1:12 PM, the Maintenance Director confirmed the PTAC units had not been cleaned or had the filter changed. He also stated they had not been following a cleaning schedule for cleaning PTAC units.

Based on observation, resident and staff interviews, the facility failed to incorporate an effective pest control program. This had the potential to affect all residents residing in the facility. Facility census: 63. Findings included: a) A review of the exterminator report dated 11/19/24 revealed findings of cockroaches in the kitchen area. An interview with the Maintenance Director (MD) on 02/19/25 at about 3:20 PM revealed no exterminator had serviced the facility since 11/19/24. MD stated the maintenance department had been trying to exterminate the roaches with boric acid in the remodeled walls. During an interview with Account Manager (AM) #39 on 02/19/25 at about 3:40 PM AM #39 stated that he observed roaches in the kitchen area two (2) days prior. A pest control company serviced the facility on 02/20/25 and returned on 02/26/25 for weekly treatments. During the 02/26/25 treatment period an interview was conducted with the exterminator. He confirmed there were issues with roaches in the kitchen and service hall areas.

Based on resident interview and observation, the facility failed to promote dignity by not serving residents who reside in the same room their meals at the same time. Resident identifier: #20. Facility census: 64. Findings included: a) Resident #20 On 02/18/25 at 12:35 PM, Resident #20 and roommate were observed in their rooms during the lunch meal. Resident #20's roommate had been served a meal and was eating. Resident #20 was being visited by her husband. On 2/18/2025 at 1:05 PM Resident #20's husband was opening resident's food tray in her room. He reported that she was never served a tray, and he had to ask staff to get her one. He stated that the meatball sandwich served had mushy bread and was too hot as if it had been microwaved. Resident # 20 reported that she was just going to eat the meatballs out of the inside of the sandwich. Resident #20's husband reported that he asked why his wife was not served her meal at the same time as her roommate and replied they did not know.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews, the facility failed to inform the resident of the reason they were receiving hospice care. This was true for one (1) of eight (8) residents interviewed. Resident identifier: 40. Facility census: 64. Findings include: a) Resident #40 During an interview, on 02/25/25, at approximately 1:10 PM, Resident #40 stated that hospice nurses visited him regularly. When asked why he was receiving hospice care, he expressed that he did not know what hospice was. He mentioned that he believed the hospice nurses visited everyone at the facility. The resident further stated that he was unaware of the specific hospice services being provided to him, saying, The staff bring me my medications and meals; otherwise, I take care of everything by myself. A record review conducted on 02/25/25, at 1:55 PM revealed that the resident had been admitted to the facility on [DATE]. He had been discharged from the hospital after an acute hospitalization for sepsis due to a urinary tract infection. 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 interview, the facility did not notify or include the resident in the planning of their care. This included the right to be involved in the planning process, the right to request meetings, and the right to ask for revisions to their care plan. Resident identifier: #40. Facility census: 64. Findings include: a) Resident #40 During an interview, on 02/18/25 at approximately 11:18 AM, the resident stated he wanted to have his status re-evaluated. He stated his physician had documented that he did not have the capacity to make medical decisions. The resident stated he had requested a meeting with the facility staff. During an interview with the Director of Social Services (DSS) #7 on 02/18/25, at approximately 11:55 AM, she was notified that Resident #40 wanted his capacity evaluated. DSS #7 stated it was a difficult situation because Resident #40's Brief Interview for Mental Status conducted on 02/10/25 had revealed Resident #40's cognition was intact. However, the resident's physician still had some reservations about the resident's ability to care for…

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

Based on the interview and record review, the facility failed to assess the resident's potential for independent ambulation, and failed to provide him with the assistance necessary to accomplish his choices. The resident has a right to make choices about aspects of his or her life in the facility that are significant to the resident. Resident identifier: #22. Facility Census: 64. Findings include: a) Resident #22 During an interview on 02/19/25 at approximately 11:11 AM, the resident stated he wanted to ambulate. He further stated that he had attempted to ambulate by walking behind his wheelchair, but staff stop him and ask him to sit in his wheelchair. Resident further stated if there was any reason why he was not allowed to ambulate by himself, he would like to be evaluated by occupational therapy. Record review on 02/19/25 at approximately 12:15 PM, revealed the resident had been on hospice since 11/11/24. Hospice was renewed on 02/01/24 with a diagnosis of Atherosclerotic Cardiovascular Disease (ASCVD) Further record review on 02/19/25 at approximately 12:15 PM revealed the…

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

Based on observation and staff interview, the facility failed to provide a safe, clean, comfortable, and homelike environment. Resident #1's room was not in good repair. This was true for one (1) of 32 residents reviewed during the long term care survey process. Room identifier: 210-A. Resident identifier: #1. Facility census: 64. Findings included: a) Resident #1 During an observation, on 02/18/25 at 3:43 PM, Resident #1's wall was observed on the right side with multiple drywall patches. One (1) large patch was approximately the size of a basketball. Three (3) smaller patches were also on the wall beside residents bed. When glancing at the right corner of the wall, it was observed that there was a crack measuring approximately 6 to 8 in length. Additionally, the right wall, when entering residents room, had nine (9) square drywall patches which were approximately 3 x 3 inches in size. This particular wall had a collection of resident's artwork, pictures, and personal items on display. Resident #1 enjoyed showing Surveyor her possessions and discussing each one with great pride. b)…

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 allegations of resident-to-resident abuse were reported within two (2) hours to the appropriate state agencies. The failure to make a timely report was true for one (1) of nine (9) sampled resident-to-resident altercations involving abuse that were reviewed during the Long-Term Care Survey Process as well as complaint investigations. Resident identifiers: #54, #216. Facility census: 64. Findings included: a) A record review, completed on 02/19/25 at 7:15 PM, revealed there was a resident-to-resident altercation on 12/01/24 at 4:15 PM involving Resident #54 and Resident #216. The record reflected the facility notified the Office of Health Facility Licensure and Certification (OHFLAC) on 12/01/24 at 4:46 PM. However, the facility did not notify Adult Protective Services (APS) until two (2) days later, on 12/03/24 at 10:36 AM. During an interview on 02/24/25 at 3:45 PM, the former Interim Administrator acknowledged there was no evidence APS had been notified within the mandated two (2) hour window and that it…

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

Based on record review and staff interview, the facility failed to revise the care plan regarding the amount of assistance needed for activities of daily living (ADLs) for Resident #45. This was true for one (1) of five (5) residents reviewed under the care area of activities. Resident identifier: #45. Facility Census: 64. Findings include: a) Resident #45 On 02/20/25 at 11:03 AM, a record review was completed for Resident #45. The record review found under the care plan focus area of risk for decreased ability to perform ADLs (activities of daily living) in bathing, dressing .related to limited mobility. The intervention listed was, provide with partial/moderate assist for bathing as needed. However, the Minimum Data Set (MDS) quarterly dated 01/02/25 listed the resident needed substantial/maximal assistance for bathing. An interview was held with the Director of Nursing (DON) on 02/20/25 at 2:10 PM. The DON stated, the care plan is incorrect .the MDS is correct. regarding assistance needed for bathing.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to assess the resident's potential for independent ambulation, and to ensure that appropriate treatments and services could be provided to maximize the resident's functional abilities. Resident Identifier: #22. Facility Census: 64. Findings Include: a) Resident #22 During an interview on 02/19/25 at approximately 11:11 AM, the resident stated that he wanted to ambulate. He further stated that he has attempted to ambulate by walking behind his wheelchair, but staff stop him and ask him to sit in his wheelchair. Resident further stated that if there was any reason why he was not allowed to ambulate by himself, He would like to be evaluated by occupational therapy. Record review on 02/19/25 at approximately 12:15 PM, revealed resident has been on hospice since 11/11/24. Renewed on 02/01/24 with a diagnosis of Atherosclerotic Cardiovascular Disease (ASCVD) Further record review on 02/19/25 at approximately 12:15 PM revealed the following notes: A nursing note…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and staff interview, the facility failed to provide activities of daily living for a dependent resident (Resident #45). This was true for one (1) of five (5) residents reviewed under the care area of activities of daily living. Resident identifier: #45. Facility Census: 64. Findings include: a) Resident #45 On 02/18/25 at 12:00 PM, an initial interview was held with Resident #45. Upon entering the resident's room, a foul smell of body odor was noted. A review of the quarterly Minimum Data Set, dated [DATE] indicated the resident required substantial/maximal assistance needed for bathing. On 02/20/25 at 11:03 AM, a review of bathing under the tasks tab from 01/01/25 through 02/20/25 was completed. The review found the resident went multiple days without any form of bathing. The following list indicates the timeframe: --01/02/25 shower --01/06/25 bed bath (four days) --01/09/25 shower (three days) --01/13/25 bed bath (four days) --01/23/25 shower (ten days) --01/27/25 shower…

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 interviews, the facility failed to provide hearing, and vision care for two (2) residents. Resident Identifiers: #40, #219. Facility Census: 64. Findings include: a) Resident #40 During an interview, on 02/18/25 at approximately 11:05 PM, Resident #40 stated that he was having difficulty hearing. Resident #40 was observed wearing hearing aids. The resident stated that his hearing aids were not working well, and that he had mentioned it to staff. He stated that the staff was aware that his hearing aids were faulty, and they spoke loudly to ensure they were heard. RN # 74 on 02/18/25 at approximately 12:02 PM confirmed the resident wore hearing aids but was unable to hear well. She stated that at times, his hearing was better. A review of the resident's Care Plan revealed he would benefit from hearing aids due to hearing loss. This plan was created on 11/10/24. On 02/18/25 at approximately 2:16 PM, the Director of Nursing (DON) was made aware that the resident was having difficulty hearing. DON stated that she would schedule the resident for an…

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 an environment that was free from accident hazards over which the facility had control. This was true for one (1) of 32 residents reviewed in the annual Long-Term Care Survey Process. Resident identifier: #1. Facility census: 64. Findings included: a) Resident #1 Observation in Resident #1's room, on 02/18/2025 at 11:30 AM, found an opened box containing a 2.5 fluid oz. bottle of maximum strength Aspercreme with Lidocaine in Resident #1's bathroom. Resident #1 stated, The Nurse told me it would help my back pain. A subsequent record review revealed there was no physician order stating that Resident #1 could administer her own medication. Nor was there a physician order for the Aspercreme with Lidocaine which had been in the resident's possession. Review of the MSDS revealed the following information: -This product is not meant for oral consumption or for ophthalmic use. -Inhalation: May cause irritation of nose and throat -Ingestion: May be harmful if swallowed -Skin Contact: May cause slight…

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 that pain management was provided in a manner consistent with professional standards of practice. This was true for one (1) of two (2) residents reviewed under the pain pathway during the Long-Term Care Survey Process. Resident identifier: #19. Facility census: 64. Findings included: a) Resident #19 A record review, completed on 02/19/25 at 1:49 PM, revealed the following order for Resident #19: -Norco Oral Tablet 10-325 MG (Hydrocodone-Acetaminophen) *Controlled Drug* Give 1 tablet by mouth every 6 hours as needed for Pain scale 5-10. Review of the Medication Administration Record for December 2024 revealed the following details: -On December 4, 2024, on the afternoon shift Resident #19's pain level was rated as 0. Norco was administered. -On December 6, 2024, on the day shift Resident #19's pain level was rated as 0. Norco was administered. -On December 16, 2024, on the day shift Resident #19's pain level was rated as 2. Norco was administered. -On December 19, 2024, on the day shift Resident #19's pain…

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 care and services, in addition to professional standards to address the needs of a trauma/post-traumatic stress disorder (PTSD)survivor for Resident #27. This is true for one (1) of four (4) residents reviewed under the care area of mood and behavior. Resident identifier: #27. Facility Census: 64. Findings include: a) Resident #27 On 02/18/25 at 12:30 PM, an initial interview was attempted with Resident #27. The resident appeared to be sleeping. An observation was made of the mirror at the shared sink in the resident's room being covered with paper. At this time, the roommate, Resident #43 stated, They did that for him .he thinks people are coming through the mirror and the window after him. Multiple attempts were made to interview the resident. The final attempt was made on 02/19/25 at approximately 9:30 AM. The resident was non-interviewable with garbled speech. On 02/19/25 at 12:14 PM, an interview was held with the Director of Rehabilitation Services (DORS) #52. DORS #52 was present in the room to offer…

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.

The facility failed to ensure the daily nursing posting was completed accurately for three (3) days throughout the long-term care survey process. This was a random opportunity for discovery. Facility census: 63. Findings included: a) An observation on 02/18/25 and 02/19/25 of the facility posted staffing data, found the required resident census was not documented. Also, the posting was printed on 02/12/25 with no changes to the scheduled staff levels. A review of posted staffing data found on 07/07/24, 8/18/24, 9/22/24, 12/21/24, 12/22/24, 01/24/25 and 01/25/25, the posting was printed prior to the date of posting with no changes to the scheduled staff levels. During an interview on 02/22/25 at 10:08 AM the Interim Administrator verified the census was not documented and the staffing levels were not updated to reflect accurate levels.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, the facility failed to ensure routine dental care was provided for Resident #219. This was true for one (1) of one (1) residents reviewed under the care area of dental services. Resident Identifier: #219. Facility Census: 64. Findings include: a) Resident #219 On 02/24/25 at 7:20 PM, a record review was completed for Resident #219. The review found the resident was admitted to the facility on [DATE]. The clinical admission was completed on 07/11/24 under section EENT (Eye, Ear, Nose, Throat) group which documented the resident was edentulous. A progress note dated 09/18/24 during a regulatory visit with the facility physician stated, He says that he met with a VA (Veteran's Administration) representative earlier today about getting dentures . On 02/25/25 at 11:48 AM, the Director of Nursing (DON) acknowledged there were no appointments scheduled regarding the resident's dental issues.

Based on record review, the facility failed to provide an accurate and complete record regarding anticoagulation therapy for Resident #220. This was true for one (1) of one (1) residents reviewed under the care area of anticoagulation. Resident Identifier: #220. Facility Census: 64. Findings Include: a) Resident #220 On 02/19/25 at 2:20 PM, a record review was completed for Resident #220. The review found a physician's order dated 02/18/25 for Warfarin (Coumadin) 3mg (milligrams) by mouth in the evening. The physician's order did not list a diagnosis for the use of Warfarin. On 02/19/25 at 3:15 PM, the Administrator confirmed the physician's order did not include a diagnosis for the use of the medication.

Based on observations and staff interviews, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment. This practice affected one (1) of three (3) residents reviewed for urinary catheters. Resident identifier #59. Facility census: 63. Findings included: a) Resident #59 An observation on 02/18/25 at 12:03 PM found, Resident #59 In a low bed with the catheter bag laying directly on the floor. A second observation on 02/18/25 at 2:12 PM found, Resident #59 in a low bed with the catheter bag laying directly on the floor. A third observation on 02/18/25 at 3:23 PM found, Resident #59 In a low bed with the catheter bag laying directly on the floor. No receptacle/barrier was in the room. During an interview with Licensed Practical Nurse (LPN) #74, on 02/18/25 at 3:28 PM, verified the catheter bag was on the floor. LPN #74 stated that a catheter bag should never touch the floor. At this time, LPN #74 sent a nurse aide to retrieve a receptacle to place the catheter bag in.

Based on record review and staff interview the facility failed to ensure the staff abuse and neglect training contained training related dementia management and resident abuse prevention. This was true for five (5) of five (5) nurse aides reviewed. This failed practice had the potential to affect more than an isolated number of residents. Nurse Aide (NA) Identifiers: #10, #11, #12, #13, and #14. Facility Census: 62. Findings Include: a) Abuse Training Review A review of the following nurse aides personnel record found the following: -- NA #10 had a hire date of 03/23/22. Her training record was reviewed from 01/01/23 until 12/31/24. This review found she had the following abuse training: Protecting residents from assault and abuse for a total of 40 minutes. A review of the learning objectives for this training found it was void of any specific training related to dementia management and resident abuse prevention. -- NA # 11 had a hire date of 06/04/00. Her training record was reviewed from 01/01/23 until 12/31/24. This review found she had the following abuse training: Protecting…

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 Nurse Aide (NA) # 14 had a performance evaluation completed every 12 months as required. This was true for one (1) of five (5) nurse aide files reviewed. This failed practice had the potential to effect more than isolated number of residents. Staff identifier: NA # 14 Facility Census: 62. Findings include: a) NA # 14 On 09/11/24 in the early afternoon the employee file for NA #14 was requested. N #14's hire date was 02/08/22. As part of the request her 12-month performance evaluation was requested. When the facility provided the employee file there was no performance evaluation found. The performance evaluation was again requested from Clinical Advisor #22. Later in the afternoon Clinical Advisor #22 returned and stated they did not have an up-to-date performance evaluation for NA #14. She stated, The DON was on leave, and this was missed.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, facility reported incident review, and staff interview the facility failed to ensure the resident record was complete and accurate. Resident #63 expired at the facility on [DATE] and cardiopulmonary resuscitation was initiated but failed. The medical record contained no information regarding the events of [DATE]. Resident identifier: #63. Facility Census: 62. Findings include: a) Resident #63 On [DATE] the state agency received a five (5) day follow-up report regarding and incident that took place on [DATE] involving Resident #63. The five (5) day follow-up report read as follows: [DATE] FIVE DAY FOLLOW UP REPORT Alleged Perpetrator: (First and Last Name of RN #2), RN Alleged Victim: (First and Last Name of Resident #63) , resident On [DATE], (First name of Resident #63) was found unresponsive with no pulse or respirations by staff around 6:45 AM. (First and last name of Resident #63) was admitted to (Name of Facility on [DATE] for a skilled stay. His pertinent diagnoses include:…

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 maintain appropriate infection control standards for the storage of clean linen in the shower room. This was a random opportunity for discovery and had the potential to affect more than a limited number of residents. Facility Census: 83. Findings included: a) Shower Room On 01/03/24 at 1:50 PM, a tour of the C wing shower room was completed. The tour found a cart of clean linens uncovered. On 01/03/24 at 1:52 PM, Nurse Aide (NA) #19 confirmed the cart of clean linen was left uncovered. I just finished giving a shower .I was coming to cover it back up. On 01/03/24 at 2:00 PM, the Administrator and the Director of Nursing (DON) were notified and confirmed the clean linen should be covered. No further information was obtained during the survey process.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and staff interviews the facility failed to provide a clean, comfortable, and homelike environment for rooms 114, 130 and 131. Facility also failed to ensure a resident was free of urine odor in her wheelchair and in her bed. This was a random opportunity for discovery. Resident identifiers #32. Facility census 65 Findings included: a) Resident #32 During an observation on 01/03/24 at 1:20 PM there was a strong urine odor on hall B. The urine odor was found to be coming from a soiled wheelchair. The wheelchair belonged to Resident #32 who at this time was lying in bed. During an observation on 01/03/24 at 1:22 PM there was a strong urine odor coming from Resident #32's room. It was found to be coming from the resident's mattress. During an interview on 01/03/24 at 1:30 PM with Nursing Assistant (NA) employee # 45, she stated, All the residents on this hall had UTI'S that's why it smells like this. During an interview on 01/03/24 at 1:45 PM with the Director of Nursing (DON) she stated, They…

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 to reflect a change from eternal tube feeding to a by mouth diet. This failed practice was a random opportunity for discovery. Resident identifier #55. Facility census 65 Findings included: a) Resident #55 During an observation on 01/03/24 at 2:00 PM this surveyor heard Resident #55 hollering for something to drink, he was chewing on his blanket. During a record review, on 01/03/24 at 2:15 PM, of Resident #55's care plan it showed he had an eternal feeding tube and inability to take nutrition PO (by mouth). During a record review, on 01/03/24 at 2:25 PM, of Resident #55's nutritional assessment dated for 12/27/23 it reflected the following change, discontinue order of Glucerna 1.5 bolus via gravity 356ml if meal intake is <50%. Keep HS bolus and flush orders the same. During an interview, on 01/03/24 at 2:30 PM, with the Therapy Manager, she stated, He just recently transitioned from tube feeding to PO intake. During an interview, on 01/03/24 at 2:32, with the DON, she stated, It should of been 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 record review and staff interview, the facility failed to maintain a complete and accurate medical record for Resident #67. This is true for one (1) of two (2) residents reviewed during the survey process. Resident Identifier: #67. Facility Census: 65. Findings included: a) Resident #67 On 01/04/24 at 10:45 AM, a record review was completed for Resident #67. The review found the resident was determined to have capacity. The capacity form was completed on 02/15/23. Upon reviewing the [NAME] Virginia Physician's Orders for Scope of Treatment (POST) form, verbal consent was taken by the resident's Medical Power of Attorney (MPOA), which was completed on 02/17/23. Resident #67 did have the capacity to make medical decisions. The consent should have been obtained from the resident. On 01/04/24 at 11:00 AM, the Administrator and the Director of Nursing (DON) were notified and confirmed the consent should have been obtained from the resident not the MPOA. No further information was obtained during the survey process.

d) Resident #24 Record review found the resident is receiving Hospice services for chronic medical conditions. Diagnoses included: PVD, History (HX) of Cardiac Ischemia, HX of alcohol dependance, HX of tobacco dependance, hypertension, atrial fibrillation, and Cerebral infarction. A review of the medical records for Resident #24 revealed the following information: The facility uses a system called Swift, this a program using a camera to measure and document all wounds. On 01/31/23, Registered Nurse 54 stated the facility began using the SWIFT on 09/29/22. In addition, the facility staff do weekly skin checks. Record review found the facility documented the resident had an Arterial wound on his right foot, 2nd digit. Date: 12/01/22 Location: Right foot, 2nd digit (second toe) New- Age unknown Acquired: In-House Acquired Length: 9.66 cm Width: 7.64 cm The picture of the foot observed by the surveyor on the morning of 01/31/23 revealed all five (5) toes on the right foot including the front portion of the foot, were black in color. The facility failed to mention any of the other toes…

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, staff interview, record review and resident interview, the facility failed to ensure residents with pressure ulcers received the routine necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for four (4) of four (4) residents reviewed for the care area of pressure ulcers. Resident identifiers: #210 #27, #111 and #24. Facility census: 64. Findings included: a) Resident #210 During initial screening 01/30/23 12:16 PM Resident stated he had pain level of 8 on a 1 -10 pain sale. Resident stated his left heel was throbbing and hurting. Residents heel protector boot was noted to be lying on the floor at the foot of his bed. Certified Nurse Aide #38 verified heel protector boot was laying on floor and the Resident's left heel was resting directly on the mattress. Record review showed Resident #210 had a Brief Interview for Mental Status (BIMS) score of 14 as indicated on the admission…

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 provide appropriate before and after hemodialysis care and services. This was true for one (1) of one (1) reviewed for end-stage renal disease requiring hemodialysis. This had the potential to affect all residents receiving hemodialysis services. Resident identifier: #111. Facility census: 64. Findings included: a) Resident #111 a.1. Hemodialysis access: A review of the Hemodialysis Communication Book for Resident #111 revealed four (4) of nine (9) incomplete Hemodialysis Communication Records. The records provided no evaluations of the dialysis access site (permcath in right chest) before and after the hemodialysis treatment on 01/04/23, 01/09/23, 01/11/23 and 01/30/23. a.2 Smooth edged clamps: The facility failed to maintain two (2) smooth edged clamps with patient at all times. Observation on 12/30/23 at 1:30 PM found no smooth edge clamps at bedside noted. Confirmed by Employee #2, a Licensed Practical Nurse (LPN). Observation on 12/31/23 at 10:00 am, found resident in bed with no smooth edge clamps noted…

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 and staff interview, the facility failed to ensure nursing staff had the competencies and skill sets necessary to provide nursing and related services to meet the residents needs safely and in a manner that promotes each resident's rights, physical, mental and psychosocial well-being. The facility failed to ensure staff administered medication as directed (before meals) and timely (within one hour before or one hour after scheduled times). Staff failed to identify and follow physician orders for skin conditions (non-pressure). Additionally, the staff failed to assess, identify and treat pressure ulcers per professional standards. Resident identifiers: #13, #37, #21, #24, #27, #210, and #111. Facility census: 64. Findings include: I) Quality of care issues a) Resident #13 On 01/30/23 at 11:57 AM, the resident said she had stomach pain every day. Record review found the resident's physician documented the resident had capacity to make medical decisions on 10/08/22. Observation 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on observation, record review, and staff interview, the facility failed to ensure systems were in place to ensure the care and services it delivers meet acceptable standards of quality in accordance with recognized standards of practice. The facility's Quality Assessment and Assurance committee failed to identify pressure ulcers that were not identified/assessed, measured and treated. This had the potential to affect more than a minimal number of residents at the facility. Facility census: 64. Findings included: I) Pressure ulcers a) Resident #210 During initial screening 01/30/23 12:16 PM Resident stated he had pain level of 8 on a 1 -10 pain sale. Resident stated his left heel was throbbing and hurting. Residents heel protector boot was noted to be lying on the floor at the foot of his bed. Certified Nurse Aide #38 verified heel protector boot was laying on floor and the Resident's left heel was resting directly on the mattress. Record review showed Resident #210 had a Brief Interview for Mental Status…

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

Based on record review and staff interview, the facility failed to ensure the Quality Assessment and Assurance (QA&A) committee consisted of the required members. The infection preventionist was not present for the QA&A meetings during the first and second quarter of 2022. Facility census: 64. Findings included: a) Attendance at QA&A meetings Review of the signed attendance records of facility staff members who attended the quarterly QA&A meetings for 2022 found the infection preventionist did not attend any meetings held during the first and second quarter (January, February, March, April, May, and June) of 2022. On 02/01/23 at 1:57 PM, the Administrator and the Director of Nursing confirmed the infection preventionist did not attend any QA&A meetings for the first and second quarters in 2022. .

Based on resident interview, staff interview and record review the facility failed to ensure one (1) of two (2) residents reviewed for the care area of choices was afforded the opportunity to exercise her autonomy regarding those things that are important in her life, specifically health care options/decisions. Resident identifier: #4. Facility census: 64 Findings included: a) Resident #4 An interview with the resident on 01/30/23 at 12:20 PM, found the facility does not tell her when her medications are ordered, changed, or discontinued. The resident stated she has blood pressure issues and needs her medication. Record review found documentation from the physician on 07/31/21, determining the resident has capacity to make her own medical decisions and has remained so throughout her stay at the facility. The resident was admitted to the facility with a Guardian/Conservator in place, appointing WV DHHR as the resident's Guardian and the Sheriff as the resident's Conservator. A Discontinuance of Conservator was filed on March 14, 2022, removing the Sheriff from the Conservatorship,…

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, record review and staff interview, the facility failed to notify the ombudsman when the facility discharged Resident #40 and Resident #25 to the hospital. This was true for two (2) of four (4) residents reviewed for the care area of hospitalization. Resident identifiers: #40 and #25. Facility census: 64. Findings included: a) Resident #40 On 01/30/23 at 12:51 PM, the resident said he was recently admitted to the hospital for pneumonia. Record review found the resident was transferred to the hospital on [DATE]. 10/30/2022 11:41 General Note: MD (medical director) ordered to send resident to (name of hospital) ER (emergency room) for eval (evaluation.) Message left for (name of family), emergency contact. Report called into (name of hospital) ER (name of hospital employee), and to EMS. Appropriate transfer documentation completed. The resident returned to the facility on [DATE]. On 01/31/23 at 1:07 PM, the Director of Nursing (DON) confirmed she had no verification the ombudsman 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 . b) Resident #24 Record review found the resident was transferred to the hospital on [DATE]. 01/26/2023 3:40 am- General Note: Found resident unresponsive in room. (Name of on call physician) contacted and ordered to send resident to (name of hospital) ER (emergency room) for eval (evaluation.) Message left for (name of family), emergency contact. Report called into (name of hospital). The resident returned to the facility on [DATE]. The facility failed to notify the resident and the resident's representative(s) of the bed hold agreement. On 02/01/23 at 12:07 PM, the Director of Nursing (DON) confirmed the resident and the representative was not notified of the bed hold agreement when discharged to the hospital on [DATE]. She verified the notification was blank. Based on record review and staff interview, the facility failed to ensure Resident's #40 and #25 received notice of the bed hold agreement when sent to the hospital. This was true for two (2) of four (4) residents discharged to the hospital. Resident…

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 an accurate minimum data set (MDS) assessment of one (1) of twenty MDS assessments reviewed during the investigation process of the survey. The medication section of the MDS assessment for Resident #14, was not coded to include the date of last gradual drug reduction (GDR) for Zyprexa noted on 06/24/22. Resident identifier: #14. Facility census: 64. Findings include: a) Resident #14 During a medical record review found an annual comprehensive MDS assessment for Resident #14 with an assessment reference date (ARD) of 06/28/22 revealed the section for Medications for date of last GDR was blank. Further medical record review found a GDR for Zyprexa was approved by the attending physician on 06/24/22. In an interview with the Director of Nursing (DON), on 02/01/23 at 11:15 am, she verified the MDS section for Medications did not have the date of last GDR of 06/24/22. .

Based on record review, staff interview, and resident interview, the facility failed to ensure two (2) of two (2) residents reviewed for area of care plan during the long-term care survey process had the opportunity to participate in the development, review, and revision of his/her care plan. Resident Identifiers #40 and #13. Facility census 64. Findings included: a) Resident #40 Resident interview on 01/30/23 at 11:55 AM, found the resident said he had not heard of a care plan meeting and had never attended any care plan meeting. When the surveyor explained what a care plan meeting was, he again said he had never attended one and no one had ever invited him to one. Record review found the resident's physician determined the resident has capacity to make his own medical decisions on 10/08/21. On 01/31/23 at 12:48 PM, the Social Worker (SW) and Minimal Data Set (MDS) Coordinator were asked where to find documentation noting residents were invited and participated in their care planning process. The SW did not have a response, only looked over to the MDS Coordinator who said the…

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

Based on observation, record review and staff and family interview, the facility failed to ensure the head of the bed was at an appropriate level during continuous tube feeding administration for Resident #210. This was a random opportunity for discovery. Resident identifier: #210. Facility census: 64. Findings included: a) Observation Observation on 02/01/23 at 10:40 AM showed Resident #210 to be lying flat in bed while continuous tube feeding was being administered at 65 ml hour. Registered Nurse (RN) #54 grabbed the bed control from between the head on the wall raised the head of the bed to a 45-degree angle. RN#54 verified the head of the bed was not in an appropriate position for the tube feeding to be administered. b) Record Review Record review showed an order for Enteral Feed every shift for supplemental feed. Jevity 1.5 CAL to be administered continuous via Pump 65ML per hour. Start Date 01/27/2023. Record review of the facility's policy and procedure titled, Enteral Feeding: Administration by Pump, revised date 02/01/23, showed in step #6 to elevate head of bed to 30 - 45…

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

Based on record review and staff interview the facility failed to ensure the consulting pharmacist's recommendations were answered in a timely manner for Resident #14 and additionally, the Director of Nursing (DON) failed to ensure a gradual dose reduction (GDR) for Resident #14 in a timely manner after the attending physician had approved the GDR. This was true for one (1) of five (5) residents reviewed for the care area of unnecessary medications during the Long Term Care Survey Process (LTCSP). Resident Identifier: #14. Facility Census: 64. Findings included: a) Resident #14 A review of Resident #14's medical record found a consultant pharmacist recommendation issued on 06/20/22. This recommended Zyprexa be reduced and/or discontinued. The attending physician agreed on 06/24/22 for the Zyprexa to be reduced. The medication was not reduced until 07/20/22. Further medical record review found a pharmacist consultant report issued on 10/25/22. This recommendation was not addressed until 12/06/22; this was after the consultant pharmacist next medication regimen review (MRR) on…

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

Based on record review and staff interview, the facility failed to ensure Resident #14's drug regimen was free from unnecessary antipsychotic medications. The attending Physician agreed to do a gradual dose reduction (GDR) for Resident #14's Zyprexa on/or about 06/24/22, this medication was not reduced until 07/20/22. This was true for one (1) of five (5) residents reviewed for the care area of unnecessary medications. Resident Identifier: #14. Facility Census: 64. Findings include: a) Resident #14 A review of Resident #14's medical record found a pharmacy consultation report date issued was 06/20/2022. This recommended a possible GDR for Zyprexa of five (5) milligrams (mg) daily for treatment of schizophrenia. The physician responded to this recommendation on 06/24/22 and replied to reduce Zyprexa to 2.5 mg daily. Further review of the medical record found the Zyprexa was not reduced until until 07/20/22. Review of the Medication Administration Record (MAR) found the resident had received Zyprexa 5 mg daily from 06/24/22 through 07/20/22 daily. An interview with the Director of…

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

Based on observation and staff interview the facility failed to ensure foods were stored in accordance with professional standards for food service safety. This had the potential to affect a limited number of residents. Facility census 64. Findings included: a) tour of the kitchen On 01/30/23 at 11:25 AM, the first tour of the kitchen found a half empty bucket of sherbet in the walk in freezer. There was no date to indicate when the sherbet was opened. This finding was verified with the Cooperate Kitchen Manager. .

Based on record review and staff interview, the facility failed to ensure one (1) of 20 residents reviewed, for the care area of advance directives, had a Physician Orders for Scope of Treatment (POST) that was accurate and complete. Resident identifier: #9. Facility census: 64. Findings included: a) Resident #9 Record review found a POST form completed on 03/07/17. Section E requiring Advance Directive (Living Will or Medical Power of Attorney), Organ and Tissue Documentation of Gift, Court-appointed Guardian, Health Care Surrogate Selection, and the name, address, and phone number of the MPOA/Surrogate/Court-appointed Guardian/Parent of Minor Contact Information was not completed. Policy review of Using the POST form 2016 Edition regarding Section E states: .This section includes a list of documents including advance directives to which the person completing the form may have referred for guidance. They include a living will, medical power of attorney form, organ and tissue document of gift, court-appointed guardian, and healthcare surrogate selection form. For situations when the…

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

Based on observation and staff interview, the facility failed to ensure the call system was accessible to one (1) of 20 residents reviewed during the long term care survey process. This was a random opportunity for discovery. Resident identifier: #35. Facility census: 64. Findings included: a) Resident #35 Observation at 11:35 AM on 01/30/23 with nurse aide (NA) #39 found the resident was in bed sleeping. The call light was not within reach of the resident. NA #39 was asked to locate the Resident's call system. NA #39 found the call light on the floor, under the resident's bed and placed the call light within the resident's reach. Review of the resident's care plan found the resident is able to use her call light when needed: Focus: Resident is at further risk for falls: s/p (status post) fall with lumbar fracture The goal associated with the problem: Resident will have no fall related injury through next review. Interventions included: Provide resident/caregiver education for safe techniques (including when to use call light) of transferring from wheelchair to bed Place call light…

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.