Keyser Healthcare Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure that residents were provided with assistance for toileting and appropriate care to prevent potential urinary tract infections. This was true for two (2) of three (3) residents sampled. Resident Identifiers: #45 and #73. Facility Census: 109.Findings Include a) Resident #45During an interview on 11/18/25 at approximately 11:22 AM, the resident stated that she was incontinent and must wait for assistance when she needs to go to the bathroom, frequently ending up sitting in wet briefs for long periods of time. Resident #45 added that she had submitted a complaint to the facility on [DATE].A review of the complaint revealed the following note: [Typed as Written] Resident reported that she is tired of using the bathroom in her brief. She puts light on to go to the bathroom and they don't in time to take her!The facility stated that they had updated orders and care plan stating Resident is to be toileted Q 2 hrs.During the interview on 11/18/25 at…

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 monthly pharmacy reviews were signed, dated or provided with a response to the pharmacisit recommendationby the facility physician. This was true for two (2) of five (5) residents reviewed under the care area of unnnecessary medications. Resident Identifiers: #5 and #12. Facility Census: 109.b) Resident #12 On 11/24/25 at 9:30 AM, a record review was completed for Resident #12. The review revealed the monthly pharmacy review for 05/25/25 was not signed by the physician and no response was recorded. The issue and recommendation read as follows: Resident was prescribed Divalproex and was due for a Valproic Acid level (ordered for every 6 (six) months). Please consider obtaining this level on the next convenient lab day. This note was completed by the consultant pharmacist. On 11/24/25 at 3:13 PM, interview with Regional Director revealed the facility did not have a signed copy of the lab recommendation. Findings Include: a) Resident #5 On 11/24/2025 at 8:54 PM, a record review was completed for Resident #5. 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 interview, the facility failed to designate a licensed nurse to serve as a charge nurse on each tour of duty. Additionally, the facility failed to ensure sufficient staffing to allow residents to dine in the communal areas for breakfast and dinner. This deficient practice had the potential to affect all residents residing in the building. Census: 110. Findings included: a) Charge Nurse Review of staff postings from 12/01/23, to 12/31/23, and further confirmed on 01/02/24, revealed no licensed nurse designated as a charge nurse on any shift in the building. Interview with the Director of Nursing (DON) on 01/03/24, at 12:01 PM confirmed the facility does not formally designate charge nurses. Instead, staff rely on the on-duty RNs for supervision. However, this system lacked a clearly identified individual with leadership and accountability for each tour of duty. b) Sufficient Staffing Observations on 01/03/24, 01/04/24, and 01/09/24, confirmed all residents ate breakfast in their rooms, with no residents using the communal dining areas.…

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 have an RN at least 8 hours a day, 7 days a week. This deficient practice had the potential to affect all residents in the building. Census: 110. Findings included: a) Registered Nurse Review of staff postings from 12/1/23, to 12/31/23, confirmed no Registered Nurse (RN) designated in the building on 12/23/23. Subsequent review of staff time punches verified RN#35 was on-call but not physically present in the building on 12/23/23. Interview with the Director of Nursing (DON) on 01/09/24 at 12:01PM, confirmed no RN was available on-premises during any shift on December 23, 2023. At 5:00PM on 1/9/24 the DON clarified that RN#35 was scheduled for that shift but ultimately did not cover due to LPN#80 picking up the shift, resulting in an oversight on an alternate staffing matrix.

Based on observation, resident council meeting and staff interviews the facility failed to make grievances forms accessible to all residents and/or residents family/representatives residing in the facility. This had the potential to affect more than a limited number of residents living in the facility. Facility Census: 110 Findings Included: A review of the facility policy titled Grievance/Concern with an effective date of 01/12/17 read as follows. .Policy: .The facility will make available to all residents posting in a prominent location in the facility information of the right to file grievances orally or in writing; the right to file grievances anonymously. a) Grievance Forms During the Long-Term Care Survey Process from 01/02/24 to 01/10/24 many observations throughout the facility revealed no evidence of grievance forms being made accessible to the residents and/or resident representatives. During the Resident Council Meeting held on 01/09/24 at 10:05 AM, the residents as a group were asked the question, Do you know how to file a grievance? Do you know where to access your…

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) Based on medical record review, resident interview and staff interview the facility failed to provide care required to maintain hygiene to a resident who was dependent for Activities of Daily Living (ADL) care. This is true for three (3) of four (4) reviewed for the ADL care area. Resident Identifiers: Resident #70, Resident #52, and Resident #90. Facility Census: 110. Findings Included: a) Resident #70 During an interview on 01/03/24 at 8:29 AM, Resident # 70 stated they never follow the shower schedule. Resident #70 said, I get mine on Monday and Thursday. I had visitors on Christmas day, so I refused to take a shower at that time and the staff never came back and asked me to get a shower and did not get one on Thursday. I should have been showered on Monday New Year's Day but not enough staff for showers. During a record review reviewed 01/03/23 at 2:00 PM, Resident # 70's medical records revealed the showers were scheduled on Mondays and Thursdays. The records revealed documentation for the following showers: -01/01/24 not applicable -12/28/23 not applicable -12/25/23…

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 #49 During an Interview with Resident #49 on 01/02/24 at 11:26 AM, he stated that there are no activities offered in the evening. He continued to say that the only thing to do in the evenings is watch television. Resident #49 stated that there are only two activities a day and he would like to have more or even be offered evening activities. An observation on 01/03/24 at 10:09 AM, Resident #49 sitting outside the activities room asking staff passing by to help him find something to do. A record review of Resident #49's participation sheets revealed he participated in scheduled group activities. A continued record review of Resident #49's Annual 12/06/24 Minimum Data Set (MDS), found the resident's brief interview for mental status was fifteen (15) the highest score obtainable. A review of the current care plan showed: Focus: o prefers independent activities on occasion he does join the group for higher level activities d/t his age and ability. Goal: o will attend group activities of his choice through next review date o will pursue independent activities of his choice…

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 ensure dialysis services were provided in accordance with professional standards of care. This deficient practice had the potential to affect one (1) of (1) residents reviewed for the care area of dialysis. Resident identifier: #24. Facility census: 110. Findings included: a) Resident #24 During an interview, on 01/02/24 at 4:20 PM, Resident #24 stated he received dialysis treatments on Mondays, Wednesdays, and Fridays. The resident stated he had two (2) dialysis access sites, a central venous catheter in his left chest and a graft in his right upper arm. Review of Resident #24's comprehensive care plan showed the resident was on fluid restrictions. On 01/09/24 at 10:07 AM, Resident #24 stated he didn't know if he was on fluid restrictions. The resident stated he received a renal diet. On 01/09/24 at 10:39 AM, Nurse Aide (NA) #105 stated the resident was on fluid restrictions. A nutritional assessment completed on 01/02/24…

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

Based on resident interview, record review, and staff interview the facility failed to monitor efficacy of psychotrophic medication via monitoring behavior and symptoms. This deficient practice had the potential to effect 1 of 5 residents reviewed for the care area of Behavioral-Emotional wellbeing. Resident identifier: #48. Census: 110. Findings included: a) Monitoring Resident interview (#48) conducted on 01/02/24, at 12:57PM revealed feelings of frustration with the facility, decreased activity participation, and food avoidance. Progress notes documented on 12/04/23 at 11:32AM, indicated R#48 has a history of depression and suicide attempts/ideation. Review of the medication administration record (MAR) confirmed R#48 is on multiple psychotropic medications (Celexa, Trazodone, Risperidone, Buspar). Review of the care plan dated 12/20/22, with revision on 11/08/23, identified goals of decreased depressed mood and behavior through psychotropic medication management. Interview with the Director of Nursing (DON) on 01/09/24 at 9:43AM, confirmed the MAR does not currently monitor…

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

Based on observation, policy review and staff interview the facility failed to store food in accordance with professional standards for food safety. The facility failed to label and date food items that were open and failed to dispose of expired food items. The facility also failed to record accurate food temperatures and failed to ensure hot foods were held at 135.0 degrees Fahrenheit or higher on the steam table. The facility also failed to keep utensils stored appropriately and equipment clean and sanitized. This failed practice had the potential to affect all residents currently receiving nourishment from the facility's kitchen. Facility Census: 110. Findings Included: a) Labeling and Dating During the initial tour of the kitchen on 01/02/23 at 12:58 PM, with the Culinary Director (CD) #95 revealed the following issues: -Ice Cream Freezer two (2) 1-gallon cartons of ice cream no received date -Pantry a container with an opened 50-pound bag of sugar not dated or labeled. -Dessert Refrigerator two (2) uncovered cakes with icing not labeled and/or dated. - Walk in refrigerator 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.

Based on facility record review and interview the facility failed to explain Binding Arbitration Agreement accurately and, in a form, and manner residents or Resident Representatives can understand. This has the potential to affect all residents or Residents Representatives that sign a Binding Arbitration Agreement. Facility Censes: 110. Findings included: a) Binding Arbitration Agreement A facility record review of the found 47 Residents or Residents Representatives signed a Binding Arbitration Agreement. During an interview 01/03/24 at 1:22 PM the admission Coordinator was unable to explain a Binding Arbitration Agreement accurately. He stated the resident or representatives could rescind their decision at any time. When the admission Coordinator was asked questions about the Binding Arbitration Agreement, he was unable to explain. The admission Coordinator currently stated residents do not usually ask questions about the form. He continued to say the form was not worth the paper it was written on and that he would need to better familiarize himself with the Agreement.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident interview, and staff interview, the facility failed to ensure a safe, clean, comfortable, home-like environment. Window curtains were dirty in room [ROOM NUMBER] and privacy curtains were dirty in room [ROOM NUMBER]. These were random opportunities for discovery. Resident identifiers: #90, #58. Facility census: 110. Findings included: a) room [ROOM NUMBER] During observation on 01/03/24 at 9:49 AM, the window curtains in room [ROOM NUMBER] were noted to have brown stains on them. Resident #90, who occupied the bed beside the window, stated the curtains had been dirty for a long time. On 01/08/24 at 3:08 PM, the Housekeeping Director confirmed the curtains were dirty and stated they would be changed immediately. b) room [ROOM NUMBER] During an observation on 01/08/24 at 3:00 PM, both privacy curtains in room [ROOM NUMBER] were noted to have brown stains on them. Resident #58 stated that the curtains were filthy. On 01/08/24 at 3:10 PM, the Housekeeping Director confirmed the…

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

Based on record review and staff interview, the facility failed to complete an accurate Minimum Data Set (MDS) assessment for two (2) of 24 residents reviewed in the long-term care survey sample. Resident identifiers: #69, #115. Facility census: 110. Findings included: a) Resident #69 Review of Resident #69's medical records showed the resident had a tracheostomy since being admitted to the facility in 2021. Resident #69's quarterly Minimum Data Set (MDS) assessment with Assessment Reference Date (ARD) 10/13/23 indicated the resident did not have a tracheostomy. During an interview on 01/08/24 at 2:13 PM, the Director of Nursing (DON) confirmed Resident #69's MDS assessment with ARD 10/13/23 was incorrect and should have coded the resident had a tracheostomy. b) Resident #115 During a record review on 01/08/24 at 12:41 PM, Resident # 115's medical record revealed the following social service note dated 11/8/23 at 11:19 AM, typed as written (Resident #115's name) who requested to speak to SS via therapy. Resident #115's name) is requesting to go home tomorrow because that is when 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 and staff interviews, the facility failed to ensure that the resident's Pre-admission Screening (PAS) reflected pre-admission diagnoses for two (2) of three (3) residents reviewed for the category of PASARR, during the long-term care survey. Resident identifier #43 and #40. Census 110. Findings Included: a) Resident #43 On 01/08/24, a record review of the resident's electronic medical record (EMR), the resident's admission PASARR, dated 04/18/23, indicated no level II was needed. Section lll #30 MI/MR Assessment indicated None. A continued record also revealed the resident received a psych diagnosis of Major Depression and Schizophrenic Disorder on the diagnosis listed on admission [DATE] but did not receive a new PAS to address whether or not specialized services were needed. On 01/09/24 at 10:50 AM, an interview with Director of Nursing confirmed the PAS presented to the surveyor did not indicate Major Depression and Schizophrenic Disorder was missed on admission. b) Resident #40 During…

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 two (2) of four (4) residents had a person-centered comprehensive care plan developed and implemented to meet his activities preferences and goals and address the resident's quality of life needs. The failure to ensure the comprehensive care plan was developed for the resident's highest practicable well-being placed the residents at risk of not receiving services that would meet their desires or wants and a decreased quality of life. Resident identifier: #49. Facility census: 110. Findings included: a) Resident #49 During an Interview with Resident #49 on 01/02/24 at 11:26 AM, he stated there were no activities offered in the evening. He continued to say the only thing to do in the evenings was watch television. Resident #49 stated there were only two (2) activities a day and he would like to have more or even be offered evening activities. An observation, on 01/03/24 at 10:09 AM, revealed Resident #49 sitting outside the activities room asking staff passing by to help him find something to do. A record…

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 the physician's orders to label a tube feeding formula container and administration set with the resident's name, date, time, and nurse's initials. This deficient practice had the potential to affect one (1) of one (1) residents reviewed for the care area of tube feeding. Resident identifier: #97. Facility census: 110. Findings included: a) Resident #97 Review of Resident #97's physician's orders showed the resident had an order for enteral (tube) feedings to infuse at 70 milliliters (ml) an hour, for 21 hours a day. The resident also had an order written on 11/15/23 to label the tube feeding formula container and administration set with resident's name, date, time, and nurse's initials. On 01/08/24 at 1:02 PM, Resident #97 was noted to be resting in bed with tube feeding infusing. The tube feeding formula container and administration set had no labels on them. Registered Nurse (RN) #47 confirmed the tube feeding formula container and administration set had not been labeled with the resident's…

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

Based on record review, observation and staff interview the facility failed to provide appropriate treatment for urinary catheter care, specifically to ensure the resident's catheter had an anchor strap to prevent trauma. This is true for one of one reviewed for catheter care. Facility Census: 110. Findings Included: a) Resident #97 Medical record review found Physician Orders for Resident #97: - Foley Cath #18fr /10ML to Continuous drain. - Indwelling urinary Foley catheter is in privacy bag and leg strap on at all times. - Secure indwelling catheter tubing using anchoring device to prevent movement and urethral traction. A review of the current care plan with the initiated date of 11/ 06/2023 showed the care plan: -Focus: Resident has indwelling 18fr/10ml Foley Catheter, renal failure / hematuria/ nephrology referred. Goal: - Resident will be/remain free from catheter-related trauma through review dat. Interventions: -Position catheter bag and tubing below the level of the bladder and provide privacy bag. Secure catheter to leg with security device. Observation of catheter care 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 a medical record review, resident interview and staff interview the facility failed to ensure the attending physician supervises the resident medical care. The facility failed to notify the physician of weight loss for one (1) of two (2) residents reviewed for the care area of nutrition. Resident identifier: #40. Facility Census: 110. Findings included: a) Resident #40 During a record review on 01/03/24 at 9:28 AM Resident#40's medical records revealed the following. On 11/09/2023, the resident weighed 140 pounds (lbs.). On 12/11/2023, the resident weighed 124 pounds which is a -11.43 % Loss. Further record review was void of any notification to the physician of the 16-pound weight loss in a month. During an interview on 01/09/24 09:34 AM the Director of Nursing acknowledged there was no documentation of notification to the physician.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and staff interview, the facility failed to ensure storage of point-of-care testing devices within acceptable standards of practice. Two vials of urine reactant strips stored in the medication room had expired. Facility census: 110. Findings included: a) North medication room On [DATE] at 10:00 AM, the north medication room was inspected with Licensed Practical Nurse (LPN) #82 in attendance. Two (2) vials of urine reactant strips stored in the medication room had expired according to the expiration dates on the bottles. A vial of Immunostics urine reactant strips had a labeled expiration date of [DATE]. A vial of Medline urine reactant strips had a labeled expiration date of [DATE]. Urine reactant strips are used to test for abnormalities in the urine. Expired strips could give inaccurate results. LPN #82 stated she would dispose of the expired urine reactant strips.

Based on record review and staff interview, the facility failed to obtain laboratory services to meet the needs of its residents. This deficient practice had the potential to affect one (1) of six (6) residents reviewed for the care area of behavioral/emotional. Resident identifier: #47. Facility census: 110. Findings included: a) Resident #47 Review of Resident #47's physician's orders showed the resident was ordered the medication Depakote (divalproex sodium), 250 mg, twice a day, on 10/25/22 as recommended by the psychiatrist for agitation. The psychiatrist recommended a Depakote level be checked in one (1) week. High Depakote levels can lead to altered mental status, central nervous system depression, and death. On 10/30/22, an order was written to increase Resident #47's Depakote to three (3) times a day. Further review of Resident #47's physician's orders showed orders for Depakote levels to be checked on 11/01/22, 04/03/23, and 09/29/23. A nurse's note written on 04/03/23 at 2:03 PM stated, Labs received and faxed to MD [physician] for review. A nurse's note written on…

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

Based on observation and staff interview, the facility failed to ensure trash was disposed of properly and dumpster lids were closed. This was a random observation. Facility census: 110. Findings included: On 01/03/24 at 11:34 AM an observation of the three (3) dumpster's found a pair of gloves, two (2) cold cup lids and a white substance leaking from beneath two (2) of the three (3) dumpster's. Two (2) of the dumpster's had open lids and one (1) had garbage bags exposed. On 01/03/24 at 1:45 PM during an interview with the Dietary Manager (DM) the findings at the dumpsters were discussed. The DM stated that she would take care of this.

Based on record review and staff interview, the facility failed to ensure a complete and accurate medical record. The indication for Resident #47's psychotropic medication, Depakote, was incorrect. This deficient practice had the potential to affect one (1) of six (6) residents reviewed for the care area of behavioral/emotional. Resident identifier: #47. Facility census: 110. Findings included: a) Resident #47 Review of Resident #47's medical records showed a psychiatrist note written on 10/25/22 recommending Depakote for agitation. The psychiatrist's note stated the resident had been having the following behaviors: crying, yelling, kicking, hitting, pushing, and grabbing. The psychiatrist stated the resident had a diagnosis of anxiety. The psychiatrist also stated the resident's medical record also showed a diagnosis of post-traumatic stress disorder. The resident's current order for Depakote was written on 12/08/22 and gave the indication for the medication as post-traumatic stress disorder. During an interview, on 01/09/24 at 1:07 PM, the Director of Nursing (DON) stated 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 each resident had the right to a clean, comfortable homelike environment that was in good repair. Walls were observed to be scarred and/or with missing or torn wallpaper for Resident # 107 and #53. Cove base trim was missing from Resident #59's room. Wallpaper and cove base trim , in the hallway adjacent to the North Nursing Station, was gaped and/or torn not allowing for effective cleaning. This deficient practice was true through a random opportunity for discovery and had the potential to affect more than a limited number of residents. Resident identifiers: Resident #107, #53 and #59, Census: 109. Findings included: a) Resident #107 An observation, during the initial tour, on 12/05/22 at 1:08 PM, revealed a large piece of wallpaper to be missing directly behind Resident #107's bed. An interview with the facility's Maintenance Director, on 12/06/22 at 12:05 PM, revealed there was an area behind Resident #107's bed that measured three (3) feet by four (4) feet where the wallpaper was torn off exposing the bare…

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 label medications when opened and administered to residents to ensure the safety and effective use of medications. This failed practice was identified through a random opportunity for discovery and was found to be true for two (2) of two (2) medication carts observed. Insulin pens, currently being administered to residents, were not dated when opened to provide staff administering the insulin, a reference date, based on manufacture's guidelines, for safe usage date. Over the Counter medications were not dated when opened. This failed practice had the potential to affect more than a limited number of residents. Resident identifiers: Resident # 168, #57, # 59 and #9. Facility census: 109 Findings included: a) Insulin Quick Pens (North Hall) An observation, of the North Hall Medication Cart, on 12/06/22 at 08:02 AM, revealed three (3) Insulin Quick pens were noted to be open and being administered to residents. The Insulin Quick pens had no date on the pen of when it was initially opened, inorder for staff to know 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 and interview the facility failed to honor residents' personal dietary choices and preferences. This affected five (5) of (31) resident reviewed, during the Long-Term Care Survey Process (LTCSP). Resident identifier #2, #30, #85, #68 and #95. Facility census: 109. Findings included: a) Resident #85 During an Interview on 12/05/22 at 12:43 PM, Resident #85 stated that the kitchen always sends her items that's on her dislikes list. She stated that for breakfast they sent her scrambled eggs, that is on her dislike list. She stated that the staff will get her other items, but it takes awhile and everything else gets colder. A review of Resident #85's tray card on 12/05/22 found, no dislikes listed on her tray card. A second Interview on 12/06/22 at 9:45 AM with resident #85 revealed she received scrambled eggs again this morning for breakfast and received Turkey for her 12/05/22 evening meal. This is also, an item on her dislike list. A medical record review of Resident # 85's current 11/01/22…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on record review and staff interview, the facility failed to maintain an accurate medical record for one three (3) of 32 sampled residents reviewed during the Long-Term Care Survey process. Resident identifiers: #43, #54, and #81. Facility census: 109. Findings included: a) Resident #43 A brief record review, completed on [DATE] at 2:31 PM, identified resident had a Physician Orders for Treatment (POST) form on file. The facility had obtained verbal consent from resident's Health Care Surrogate (HCS) on [DATE]. The 2021 POST Form Guidance instructs, 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. During an interview on [DATE] at 8:38 AM, Social Worker #152 acknowledged verbal consent had been accepted over a year ago 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 and staff interview, the facility failed to ensure a resident representative was informed of medical treatment and allowed to make treatment decisions for a resident who lacked decision making capacity. There was a delay in appointing a Health Care Surrogate (HCS) decision maker for Resident #115. This was a random opportunity for discovery. Resident identifier: #115. Facility census: 109. Findings included: a) Resident #115 A medical record review, completed on 12/07/22 at 11:53 AM, identified the following details: -Prior to admission to the facility, a neurologist completed a Physician's Determination of Capacity and stated Resident #115 demonstrated a lack of capacity to make medical decisions. The neurologist did not appoint a Health Care Surrogate (HCS) at that time. A [NAME] Virginia Department Health and Human Resources (WVDHHR) Adult Protective Services (APS) Worker was trying to resolve this issue when resident was hospitalized for an acute illness. -Following a brief…

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, family interview, resident interview, facility documentation of reportable occurrences review, and staff interview, the facility failed to ensure that all alleged violations of abuse and neglect, were reported immediately, and failed to ensure the results of the investigation were reported within five (5) working days of the occurrence, to other officials (including to the State Survey Agency and Adult Protective Services (APS) where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures. This deficient practice was identified through a random opportunity for discovery and had the potential to affect more than a limited number of residents. Two (2) residents were found to have reported allegations of abuse to facility staff; however, the allegations were not reported in accordance with State law and results of a five-day follow-up were not reported accordingly. Resident identifiers: Resident #53 and #68. Census: 109. Findings included: a) Policy Review A review of the policy titled: 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 family interview, resident and staff interview, record review and review of facility documentation of reportable incidents, the facility failed to ensure, in the response to allegations of abuse, neglect, exploitation or mistreatment, evidence that all alleged violations were thoroughly investigated for two (2) residents reviewed during the Long Term Care Survey Process. This deficient practice was based on a random opportunity of discovery and had the potential to affect more than a limited number of residents residing in the facility. Resident #53 and Resident #68 were found to have allegations of abuse reported to facility staff and had not been investigated and evidence of the investigation maintained by the facility. Resident identifiers: Resident #53 and #68. Census: 109. Findings included: a) Policy Review A review of the policy titled: Policy and Procedure: Compliance with Reporting Allegations of Abuse/Neglect/Exploitation, revision date, 05/03/21, showed the definition of an Alleged violation as being a situation or occurrence that is observed or reported by…

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 medical record review and staff interview, the facility failed to provide evidence a resident/resident's representative was provided a written Notice of Transfer for an acute hospital transfer. This was true for one (1) of two (2) residents reviewed for hospitalizations/discharges during the long-term care survey process. Resident identifier: #101. Facility census: 109. Findings included: a) Resident #101 An electronic medical record review was completed on 12/06/22 at 1:00 PM. Resident #101 was discharged to the hospital on [DATE]. There was no evidence a written Notice of Transfer/Discharge was provided to Resident #101 or legal representative. A subsequent review of the resident's paper chart at the nurses station found there was no written Notice of Transfer/discharge on the paper chart. During an interview on 12/06/22 at 1:25 PM, Medical Records Director #53 stated she was unable to find a scanned Notice of Transfer/Discharge in the electronic medical record. She went on to state that typically…

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 medical record review and staff interview, the facility failed to provide evidence a resident/resident's representative was provided a written Bed Hold Notice for an acute hospital transfer. This was true for one (1) of two (2) residents reviewed for hospitalizations/discharges during the long-term care survey process. Resident identifier: #101. Facility census: 109. Findings included: a) Resident #101 An electronic medical record review was completed on 12/06/22 at 1:00 PM. Resident #101 was discharged to the hospital on [DATE]. There was no evidence a written Bed Hold Notice was provided to Resident #101 or legal representative. A subsequent review of the resident's paper chart at the nurses station found there was no written Bed Hold Notice on the paper chart. During an interview on 12/06/22 at 1:25 PM, Medical Records Director #53 stated she was unable to find a scanned Bed Hold Notice in the electronic medical record. She went on to state that typically their office would receive such a form and…

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

Based on medical record review and staff interview, the facility failed to develop a care plan for a resident with long term antibiotic use. This is true for one (1) of one (1) reviewed for antibiotics. Resident identifier: #113. Facility census: 109. Findings included: a) Resident (R) #113 Review of the medical record on 12/06/22 revealed R #113 was admitted to the facility from an acute care center on 11/13/22. Diagnoses included stroke, high risk for endocarditis, high risk for prosthetic valve infection and infection of the implanted cardiac defibrillator, persistent staphylococcus epidermis bacterium with a possible central nervous system septic emboli. admission medications included the following antibiotics: Vancomycin 1 gram intravenous (IV) every 12 hours x 6 weeks, Gentamycin 100 milligrams every 12 hours x 14 days, and Rifampin 300 milligrams every 8 hours by mouth x 6 weeks. The admission Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 11/20/22 identifies the long term use of antibiotics in section 18000F. The care plan with a completion 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, resident interview and staff interview, the facility failed to notify the physician of abnormal blood glucose readings for two (2) of two (2) Residents reviewed for insulin. The facility also failed to complete neurological checks for one (1) of four (4) Residents reviewed for accidents. These failed practices had the potential only affect a limited number of residents. Resident identifiers: #36, #54, #53. Facility census: 109. Findings included: a) Resident #36 On 12/05/22 at 12:20 PM Resident #36 stated that his blood sugars had been running high, and he could not eat the cake sent on lunch tray, he was a diabetic. Review of Resident #36's orders showed an order Finger stick blood sugar four times a day for DMII. Notify physician if blood glucose less than 60mg/dl or over 400 milligrams per deciliter (mg/dl) Review of Resident #36's Medication Administration Record (MAR) for October and November 2022 indicated the Residents blood glucose readings were above 400 mg/dl without any physician notification on the following dates: 10/11/22 6:00 AM - 594 mg/dl…

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 anchor Resident #50's indwelling catheter with a leg band. This failed practice was random opportunity for discovery and had the potential to affect only a limited number of Residents. Resident identifier: #50. Facility census: 109. Findings included: Observation on 12/06/22 at 11:06 AM found Resident #50 to be laying on her left side in bed with her bent. The indwelling catheter drainage tube was noted to be coming out of her intergluteal cleft leading to the bed side collection bag that was hanging on the right side of the bed . The Resident did not have a leg band secure device in place for the indwelling catheter. Registered Nurse (RN) #101 verified no catheter secure leg strap was in place, and stated the resident usually had one. During an interview on 12/07/22 at 11:30 AM the Assistant Director stated that the facility's policy for appropriate use of indwelling catheters did not mention the leg strap secure device, however Resident #50 should have one. The ADON further stated, She [resident #50] has had…

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 council minutes, resident interviews, resident representative interviews, grievances, resident council, and review of the Payroll Based Journal staffing report, and the CMS Nursing Home Compare's Report, the facility failed to ensure sufficient qualified nursing staff were available at all times to provide nursing and related services to meet the residents' needs safely and in a manner that promoted resident rights, physical, mental and psychosocial well-being. Facility census: 109. Findings included: a) Resident Council Minutes On 12/06/22 at 8:40 AM, a review of resident council minutes from January 2022 - November 2022 identified the following resident concerns: --03/23/22 Resident Council Minutes revealed residents were concerned their beds were not being made. --04/27/22 Resident Council Minutes revealed residents were concerned their beds were not being made. b) Anonymous Resident Interviews Anonymous Resident Interview #1 Resident stated the facility was a little short in evening after…

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 develop an individualized, person-centered approaches to address the care and treatment for a resident with dementia. This practice affected one (1) of one (1) residents reviewed for dementia during the Long-Term Care Survey Process (LTCSP). The failure to ensure the comprehensive care plan was developed for the resident's highest practicable well-being placed the residents at risk resulting in the Residents inability to achieve the highest level of functioning. Resident Identifier: #6. Facility census: 109. Findings included: a) Resident #6 On 12/06/22 a review of Resident (R#6's) medical records revealed, the diagnoses of Alzheimer's and Dementia. A review of the current care plan with the initiated date of 12/06/22 showed there was no care plan addressing dementia care, with interventions and goals. This showed it was not updated to reflect the resident's current status. During an interview on 12/07/22 at 11:10 AM the Assistant Director of Nursing (ADON) confirmed Resident #6 has a diagnosis of Alzheimer's…

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

Based on record review, staff interview, and policy the facility failed to have drug regimen reviews available on the resident medical record. This was true for two (2) of five (5) reviewed for unnecessary medications. Resident identifier #2 and #6. Facility census: 109. Findings included: Record review of the facility's policy titled, Medication Monitoring, with an effective date 06/21/17 showed: -- The consultant Pharmacist shall document the Medication Regimen Review on the individual Resident's Chronological Record of Medication Regimen review form or the designated are of the Resident 's Electronic Health Record (EHR). -- A Record of off-site Medication Regimen Reviews, such as those that may be necessary for residents with acute changes of condition or expected stays of less than 30 days, will be documented and forwarded to the facility in accordance with that policy and procedure, and placed into the Resident's medical record in a location consistent with the documentation of other medication regimen reviews. --If no irregularities are identified, the consultant Pharmacist…

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, Resident interview, and medical record review the facility failed to provide a nourishing diet to Resident #30. This is true for one (1) of five (5) reviewed for diet preferences. Facility census: 109. Findings included: a) Resident #30 An observation and interview with Resident #30 on 12/05/22 at 12:30 PM found the lunch meal of only a peanut butter and jelly sandwich, a piece of cake and a ginger ale. When ask about her noon meal, Resident #30 stated that she asked for a peanut butter and jelly sandwich, one time and that's all she gets for lunch every day. Resident #30 stated that she would like to have something else for lunch. A medical record review for Resident #30 found a physician order for a regular diet, regular texture with ground meats, an order date 8/27/20. A second observation and interview on 12/06/22 at 12:44 PM with resident #30 revealed she had received a peanut butter and jelly sandwich, a cup of fruit cocktail and a ginger ale. During the interview she stated that…

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.