Seneca Trail Healthcare Center

Based on observation, record review, and staff interview, the facility failed to implement the care plan regarding an indwelling urinary catheter. This was true for one (1) of three (3) residents reviewed for the care area of urinary catheters. Resident Identifier: #29. Facility Census: 78. Findings included: a) Resident #29Resident #29's comprehensive care plan had a focus relating to an indwelling suprapubic catheter related to obstructive uropathy and overactive bladder. An intervention/task was Position catheter bag and tubing below the level of the bladder and provide privacy bag. Upon observation on 03/16/2026 at 3:00 PM, Resident #49's urine collection bag for his suprapubic catheter did not have a privacy cover. The urine collection bag was hanging from the bed frame away from the door and could only be visualized by people entering the room and walking around to the other side of the resident's bed.On 03/18/2026 at 9:27 AM, Resident #49's urine collection bag continued to not have a privacy cover. Although the urine collection bag continued to hang from the bed frame away…

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, staff interviews, and record review, the facility failed to ensure the retained documentation to reflect Resident #57 was given the choice on a daily basis to wear splints on both hands to prevent further decrease in range of motion. This was true for one (1) of three (3) residents sampled for limited range of motion (ROM) throughout the Long-Term Care Survey Process. Resident identifier: #57. Census: 79.Findings included:a) Resident #57 During an initial interview on 03/16/2026 at 2:43 PM. Resident #57 was observed to have limited ROM in both hands with no orthotics (externally applied medical device used to support, align, prevent, or correct deformities, or to improve the function of movable parts of the body) in place. Resident #57 was observed again on 03/17/26 and 03/18/26 with no orthotics in place. An interview with Occupational Therapist (OT) #66, at 2:15 PM on 03/18/26, confirmed Dynaflex splints were in Resident #57's closet. OT #66 stated education had been provided to aides for donning splints, but she has rarely seen them on the resident and his…

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 interviews, the facility failed to ensure Resident #57 was offered sufficient fluid intake to maintain proper hydration. This was true for one (1) of two (2) residents sampled for hydration throughout the Long-Term Care Survey Process. Resident identifier: #57. Census: 79.Findings included:a) Resident #57 Review of the facility policy titled General Hydration Services revealed the following expectations:-Provide fresh water at bedside in the proper consistency and drinking device, if appropriate. Review of physician orders revealed Resident #57 had an order for honey thickened liquids in a Kennedy cup with meals and at bedside. Review of Resident #57's care plan revealed the resident was at risk for dehydration and directed staff to provide assistance with fluid intake as needed. On 03/16/2026 from approximately 1:00PM until approximately 4:00PM it was observed that Resident #57 had no fluids available in resident's room. On 03/17/26 at Resident #57 was observed to have no drinks in the room at 10:02 AM. At 10:18 AM, Resident #57 had 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 observation, record review, and staff interviews, the facility failed to ensure Resident #1 received oxygen therapy as ordered by physician. This was true for one (1) of one (1) residents sampled for respiratory care throughout the Long-Term Care Survey Process. Resident identifier: #1. Census: 79.Findings included:During an initial interview, on 03/16/26 at 1:15PM, it was observed by two (2) surveyors that Resident #1's oxygen concentrator was set on 5L/min (5 liters per minute). A review of Resident #1's physician orders reveal the following order: O2 [Oxygen] at 2L via NC [Nasal Cannula] continuous as needed. During a second observation, on 03/17/26 at 10:14 AM, Resident #1's oxygen was set at 5L/min. During a third observation, on 03/17/26 at 12:20 PM, Nurse Aide #68 confirmed the oxygen was set at 5L/min. Registered Nurse (RN) #22 was alerted that Resident #1's oxygen was set at 5L/min. RN #22 confirmed the physician order was for oxygen at 2L/min and that Resident #1 was set at 5L/min at 12:30 PM on 03/17/26.

Based on observation, record review and staff interview, the facility failed to update the daily staff postings at the beginning of the shifts regarding changes in staffing numbers. This was true for nine (9) of nine (9) daily staff postings reviewed under the care area of staffing throughout the Long-Term Care Survey Process. Facility Census: 79.Findings Included: a) Daily Staff Postings On 03/17/2026 at 11:00 AM, a review of nine (9) daily staff postings was completed. The review found all nine (9) daily staff postings had not been updated at the beginning of the shift to indicate changes in staffing. The dates were as follows: --02/15/25-a decrease in nurse aides from seven (7) to six (6) on the 6:00 PM-6:00 AM shift.--11/29/25-a decrease in licensed practical nurses from four (4) to three (3) on the 6:00 PM-6:00 AM shift.--11/29/25-a decrease in licensed practical nurses from three (3) to two (2) on the 7:00 PM-7:30 AM shift.--12/26/25-a decrease in licensed practical nurses from four (4) to three (3) on the 7:00 PM-7:30 AM shift.--12/26/25-a decrease in registered nurses from…

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 residents were provided adaptive eating equipment as ordered by the physician. This deficient practice had the potential to affect one (1) of eight (8) residents reviewed for the care area of nutrition. Resident Identifier: #13. Facility Census: 78.Findings included: a) Resident #13Review of Resident #13's physician's orders revealed an order written on 01/23/26 for the resident to have a Kennedy cup with meals and at bedside. A Kennedy cup is a lightweight plastic cup with a handle and a lid to prevent spills. On 03/18/26 at 9:00 AM, Resident #13 was noted to have a plastic one-handled coffee cup on her overbed table. The cup did not have a lid. The cup appeared to have soda in it, as there was also a can of soda on her overbed table. On 03/18/2026 at 12:19 PM, Registered Nurse (RN) #69 was observed delivering Resident #13's lunch tray to the resident's room. The lunch tray did not have a Kennedy cup on it. The resident continued to have the coffee cup on her overbed table. The resident's meal…

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

Based on observation, record review and staff interview the facility failed to ensure food was stored and served under sanitary conditons and that food temperatures were logged for three (3) meals. There were items not labeled, opened and expired. Census 78. Findings included: a) Initial Tour of Kitchen-Freezer -On 09/03/24 at 11:15 AM a bag of breakfast sandwiches were observed in the walk-in freezer having no label and no date. -On 09/03/24 at 11:15 AM interview with Culinary Director #3 (three), revealed that this was food served at that mornings breakfast and someone failed to label it. b) Initial Tour of Kitchen-Walk in Cooler -On 09/03/24 at 11:30 AM observed a large container of unknown beverage not labeled or dated. -On 09/03/24 at 11:30 AM an interview with [NAME] #17 who stated the liquid in the large container was tea, and acknowledged it was not labeled or dated and disposed of it. c) Initial Tour of Kitchen- Dry Storage -On 09/03/24 at 11:35 AM it was observed that 4 bags of grits with best by date of 12/10/23 and marked 05/16/23 were in the dry storage. -On 09/03/24 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 observation and staff interview, the facility failed to ensure trash and debris were stored in a safe and sanitary manner to prevent harborage of pests. The facility failed to keep the dumpster closed when not in use. This failed practice had the potential to affect more than a limited number of residents. Facility census: 78. Findings included: a) On 09/09/24 at 12:43PM observation revealed the facility dumpster lid was open while not in use and no staff present. b) On 09/09/24 at 12:46PM during an interview, the Administrator acknowledged the dumpster lid was open on facility dumpster and that it should be closed. She had dumpster door closed after interview. c) 09/09/24 at 3:55 PM, during an interview the Culinary Director reported there was no policy or procedure on waste disposal regarding the dumpster or otherwise.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview the facility failed to ensure the Minimum Data Set (MDS) record was completed correctly for a resident's discharge. This was true for one (1) of 24 residents whose MDS records were reviewed during the long-term care survey process. Resident Identifier: #78. Facility Census: 78. a) Resident # 78 During a medical record review on 09/05/24 at approximately 9:00 AM the MDS dated [DATE] was reviewed and identified the following; * Section (A) A 0310- (f) that the discharge assessment anticipated the resident to return. * Section (A) A 2105 the resident is discharged to home/community. * Section (A) A 2123 was not completed to identify if the provision of the current reconciled medication list for the resident at discharge was provided at time of discharge. A review of the notes by Social Services Designee (SSD) #90 dated 09/17/24 at 9:03 AM revealed the resident admission paperwork was unable to be completed by the Social Services Designee (SSD) #90 because the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview the facility failed to implement Resident #77's care plan. For Resident #77, the facility failed to implement the care plan to educate on end-of-life decisions. This was true for one (1) of two (2) residents reviewed for the Long-Term Care Survey Process. Resident identifier: #77. Facility census: 78. Findings include: a) Resident #77 On [DATE] at 11:37 AM, a review of Resident #77's medical record was conducted revealing that on [DATE], Resident #77 had been seen by the facility Nurse Practitioner (NP) after an acute hospitalization for urinary tract infection, pneumonia and chronic obstructive pulmonary disease. At that time, the facility Nurse Practitioner documented, Unable to perform complete chart review due to no hospital documentation available at this time. Code status was discussed with facility leadership and resident made decision to change Physician's Order for Scope of Treatment (POST) form to DNR-CC (Do Not Resuscitate-Comfort Care), no labs, no weights…

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 revise the comprehensive care plan for anxiety. This was true for 1 of 5 residents reviewed for unnecessary medications, psychotropic medications, and medication regimen review during the long term care survey process. Resident Identifier: #60. Facility Census: 78. a) Resident #60 During a medical record review on 09/05/24 it is identified that Resident #60 has a diagnosis of anxiety order date 03/09/23. It is further identified that the resident has a past medical history of anxiety, depression, insomnia, mood disorder and inappropriate sexual behaviors. It is identified that the resident has been seen for psychiatric services since 01/26/24 due to behaviors including but not limited to sexual behaviors. The physician visit encounter note documented in Gehrimed on 04/16/24 under the clinical education section referenced to the anxiety disorder for non-pharmacological interventions recommendations is noted: (Typed as written) Offer a calm…

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 care and services provided to one (1) of three (3) resident's were in accordance with professtional standards of practice to meet the resident's highest possible level of functioning and well being of the resident. Resident #67 received enteral feeding. The resident experienced a weight loss. The facility had not ensured the resident's enteral feeding volume was being documented and the nurse practitioner did not follow up for concerns regarding the resident's weight loss. Resident identifier: #67. Facility census: 78. Findings include: a) Resident #67 On 09/03/24 at 02:03 PM, a record review was conducted for Resident #67. On 03/03/2024, Resident #67 weighed 199 pounds (lbs.). On 09/02/2024, Resident #67 weighed 178 lbs., which was a -10.55 % Loss. A review of Resident #67's physician's orders was then performed, Resident #67 was noted to be receiving the following orders for nutrition: 1. Regular diet, Dys Puree texture, Honey Thickened…

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 review of the facility records and staff interviews, the facility failed to ensure the staff posting forms were accurate with direct care nursing staff totals and direct care nursing staff hour totals. The facility also failed to retain the staff posting form for 18 months. This was identified during the long term survey process and had the ability to affect a limited number of residents. Facility Census: 78. Findings included: a) Inaccurate total count of direct care nursing staff and the direct care nursing staff total hours; During a review of the staff posting forms on 09/09/24 at approximately 11:00 AM it is identified that the total count of direct care nursing staff and the direct care nursing staff total hours includes nursing staff with administrative duties and their nursing staff administrative hours. -09/04/23 Registered Nurse (RN) count of staff total 3 RN hours 24 During a review with Medical Records (MR) #44 on 09/09/24 at approximately 11:45 AM the total count of direct care staff included 8 hours of the RN Unit Manager hours. MR #44 agreed that the RN…

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 ensure the residents medical record was completed accurately when completing the skilled documentation. This was true for one (1) of 24 residents' medical records reviewed during the long-term care survey process. Resident Identifier: #56. Facility Census: 78. a) Resident #56 During a medical record review on 09/10/24 at 12:31 PM it is identified that the Skilled Documentations (User Defined Assessment) UDA's from 08/15/24 through 09/02/14 was completed with the functional status under section (A), number four (4), that Resident #56 was receiving occupational and physical therapy services per each day from 08/15/24 through 09/02/14. Further review of the resident's orders, the occupational and physical therapy services had been discontinued as of 08/14/24. The occupational and physical therapy services were not identified in the resident's care plan. During an interview, with the Director of Nursing and the Administrator, on 09/10/24 at approximately 10:00 AM it was agreed that the Skilled Documentations (User…

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

Based on observation, resident interview and staff interview, the facility failed to maintain an effective pest control program for flies. This was a random opportunity for discovery during the long term care survey process. This had the opportunity to affect a limited number of residents. Resident #55. Facility Census. 78. Findings included: a) Resident #55 On 09/05/24 at 01:56 PM during an interview with Resident #55, the resident was observed to be lying in her bed with her lower legs uncovered. A fly was identified to be sitting on the inside of her left ankle. The resident stated, The flies are terrible here. During an interview, on 09/05/24 at approximately 2:00 PM, with Licensed Practice Nurse (LPN) LPN #87 acknowledged the fly as it was still sitting on the residents leg and would fly around and land again on the residents leg/ankle on different areas. LPN # 87 stated the flies stay in there and that she would notify maintenance. During an interview with the Administrator on 09/05/24 at approximately 3:20 PM the Administrator stated that with the facility being so close to…

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

Based on resident interview, and staff interview the facility failed to implement written policies and procedures that: promptly report, investigate and protect the resident from an alleged abuser in a timely manner. This had the potential to affect all Residents at the facility. Resident identifier: #9. Facility census 77. Findings included: Facility Policy titled, West Virginia Abuse, Neglect and Misappropriation. Immediately: Means as soon as possible, in the absence of a shorter State time frame requirements, but not later than 2 hours after the allegations are made. Corporal Punishment: which is physical punishment used as a means to correct or control behavior. Involuntary Seclusion: the separation of a resident from other residents or confinement to his/her room Metal Abuse: is the use of verbal or nonverbal conduct which causes or has the potential to cause the resident to experience humiliation, intimidation, fear, shame, agitation, or degradation. a) Resident #9 On 09/27/23 at 1:10 PM, Resident #9 asked if the people here at the facility were allowed to threaten to close…

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, and staff interview the facility failed to promptly report an allegation of alleged verbal abuse and mistreatment to the proper State authorities. This had the potential to affect all residents at the facility. Resident identifier: #9. Facility census 76. Findings included: a) Resident #9 On 09/27/23 at 1:10 PM Resident #9 asked if the people here at the facility were allowed to threaten to closed her door if she does not do as she is told. She went on to say she is very claustrophobic and does not like her door closed and the staff know that. Resident #9 said she reported this two (2) days ago to the Social Worker (SW) #95. That NA #80 was the person that did that. During an interview on 09/27/23 at 2:15 PM, the Social Worker #95 was asked if Resident #9 had talked to her about Nurse Aide (NA) #80 closing her door? SW #95 said yes, she did, however, I have not had time to get NA #80's side of the story yet. SW #95 was asked what if anything has, she done about this allegation? SW #95 said nothing yet. On 09/27/23 at 2:25 PM, the Administrator 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.

Based on Resident interview, Resident council meeting members, observation and review the facility Grievance/ Concerns forms found the facility failed to ensure all meals served were palatable, attractive, and served at a safe and appetizing temperature. This failed practice had the potential to affect more than a limited number of residents who reside at the facility. Resident identifiers: #42, #6, #52, #15, #77, #68, #48, #76, #39, #9, #13, #2, #8, #14, #56, #55, and #7. Facility census 77. Findings include: a) Resident Council members On 09/28/23 at 10:00 AM, the following Residents attended the Resident Council meeting, #42, #6, #52, #15, #77, #68, #48, #76, #39, #9, #13, #2, #8, and #14. All 14 of the residents complained about the food being cold when they receive it in addition to the potatoes being under cooked and hard, not receiving condiments like butter, crackers, ketchup, mayo, and mustard. In addition, other food on their plates are getting soggy from the watery vegetables. The crust on the bread is hard. There are not enough veggies in the vegetable soup. Not enough…

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 received treatment and care in accordance with professional standards of practice. The physician's orders were not followed regarding the amount of nutritional supplement to be given. This deficient practice had the potential to affect one (1) of three (3) residents reviewed for the care area of nutrition. Resident identifier: #19. Facility census: 71. Findings included: a) Resident #19 Review of Resident #19's physician's orders showed an order written on 06/24/22 for the nutritional supplement Resource 2.0, 60 milliliters (ml), twice a day for abnormal weight loss. Review of Resident #19's medication administration record (MAR) for October 2022 showed 17 times the resident was administered more than the amount of resource ordered. These dates and times were as follows: - On10/02/22 at 9:00 AM, 240 ml was administered. - On10/04/22 at 9:00 PM, 100 ml was administered. - On10/05/22 at 9:00 AM, 120 ml was administered. - On10/05/22 at 9:00 PM, 240 ml was administered. - On10/06/22 at 9:00 PM, 240 ml…

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 that a copy of the Notice of Transfer was sent to the Office of the State Long-Term Care Ombudsman. This was true for one (1) of three (3) reviewed for the care area of hospitalization during the Long-Term Care Survey Process. Resident Identifiers: Resident #62. Facility Census: 71. Findings Included: a) Resident #62 A review of a facility policy titled Transfer of a Resident with an effective date of 10/01/22 found the following. .8. The facility will send a copy of the notice to the State Long-Term Care Ombudsman as directed by state law. A medical record review on 10/31/22 at 3:24 PM revealed Resident # 62 had the following hospital stays: -On 07/10/22 Resident #62 was sent to the local emergency room for behaviors, admitted to another hospital then returned to facility on 07/25/22. -On 08/30/22 Resident #62 was sent to the local emergency room for behaviors, admitted to another hospital then returned to the facility…

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

Based on medical record review and staff interview the facility failed to accurately code the minimum data set (MDS) in the area of a ventilator for Resident #47. This was true one (1) of 23 resident MDS assessments reviewed during the Long Term Care Services Process. Resident identifier: #47. Facility census: 71. Findings included: a) Resident #47 A medical record review on 10/31/22, revealed the MDS indicator was incorrect for Resident #47 for the Special Treatment Section O: Resident #47 was coded as being on a ventilator. During an interview on 11/02/22 at 2:15 PM, with the MDS Coordinator reported the MDS for Resident #47 was coded incorrectly for a ventilator. .

Based on observation, resident interview, record review and staff interview the facility failed to ensure a resident received treatment and care in accordance with professional standards of practice and the comprehensive care plan. This was true for two (2) of 23 sampled residents during the Long-Term Care Survey Process. Resident Identifiers: Resident #61 and Resident #28. Facility census: 71. Findings Included: a) Resident #61 During an interview on 10/31/22 at 11:52 AM Resident # 61 stated I can't hear you. I don't have my hearing aides in. During an interview on 10/31/22 at 11:53 AM Activity Assistant #28 stated No Resident #61 does not have her hearing aides in, I will let someone know. During an interview on 10/31/22 at 11:54 AM Licensed Practical Nurse (LPN) #30 stated she only wears them at times. She refuses to wear them a lot. During an observation on 11/01/22 12:19 PM Resident # 61 was sitting the 2nd floor Dining Room, This surveyor asked Resident # 61 Did the staff help you put your hearing aids in today? Resident # 61 stated no I don't have them in. 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, resident interview, medical record review and staff interview the facility failed to provide care to a resident that required assistance for hearing aid placement, for a resident who is dependent for Activities Of Daily Living (ADL) care. This was true for one (1) of two (2) review in the care area of ADL's. Resident Identifiers: Resident #61. Facility Census: 71 Findings Included: a) Resident #61 During an interview on 10/31/22 at 11:52 AM Resident # 61 stated I can't hear you. I don't have my hearing aides in. During an interview on 10/31/22 at 11:53 AM Activity Assistant #28 stated No Resident #61 does not have her hearing aides in, I will let someone know. During an interview on 10/31/22 at 11:54 AM Licensed Practical Nurse (LPN) #30 stated she only wears them at times. She refuses to wear them a lot. During an observation on 11/01/22 12:19 PM Resident # 61 was sitting in the 2nd floor Dining Room, This surveyor asked Resident # 61 Did the staff help you put your hearing aids in today? Resident # 61 stated no I don't have them in. During an interview on…

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

Based on observation, record review, and staff interview, the facility failed to ensure residents received necessary treatment and services to promote the healing of a pressure ulcer, prevent complications, and prevent new ulcers from developing. This deficient practice had the potential to affect one (1) of four (4) residents reviewed for the care area of pressure ulcers. Resident identifier: #28. Facility census: 71. Findings included: a) Resident #28 Review of Resident #28's medical records showed the resident developed a wound under the top of the hard cast to her right ankle fracture on 10/12/22. On 10/14/22, Resident #28's wound was assessed by the orthopedic surgeon. The handwritten consultation report stated the surgeon recommended daily dressing changes with Xeroform gauze and well-padded sterile dressing. The consultation report also stated the surgeon wanted to check the resident again the next Tuesday. The appointment/outing return progress note written by the nurse on 10/14/22 at 10:57 AM stated, Wound dressing with Xeroform and sterile dressing. Order to keep dressing…

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 and record review the facility failed to ensure the resident's environment was as free from accident hazards as possible. The facility failed to complete a post fall investigation for one (1) of (3) three residents reviewed for falls. During a random opportunity for discovery, a Medication cart was found to be left unlocked while unattended by staff. These failed practices had the potential to affect a limited number of residents. Resident identifier: #28. Facility census: 71. Findings incuded: a) Medication Cart Observation on 11/03/22 at 12:12 PM found the Long Hall Medication cart on the first floor sitting outside of the dining room in the hallway, the medication cart was unlocked and unattended by staff. Registered Nurse (RN) #4 returned to the medication cart at 12:13 PM. RN #4 was asked, Is your med cart locked? RN #4 replied, No and locked the cart. During an interview on 11/03/22 at 12:40 PM, Corporate Register Nurse (RN) #106 was informed that the medication cart…

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 enteral (tube) feeding was administered in accordance with professional standards of practice. The bags containing enteral tube feeding and enteral water flush were not labeled to indicate when the bags and tubing had been hung. This failed practice had the potential to affect one (1) of two (2) residents reviewed for care area of tube feeding. Resident identifier: #27. Facility census: 71. Findings included: a) Resident #27 The facility's procedure titled Enteral Tube Feeding via Continuous Pump with effective date 11/18/19 and revision date 02/17/20 recommended the bag or container containing the feeding be labeled with the date. Observation of Resident #27 on 11/01/22 at 10:32 AM showed the resident was receiving enteral feeding and water flush through a continuous pump. Neither the bag of enteral feeding nor the bag of water flush were labeled with the date to indicate when the bags and tubing had been hung. Licensed Practical Nurse #51 verified the bags had not been labeled with the 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 observation, staff interview, and record review the facility failed to use proper infection control measures during the storage of Bilevel Positive Airway Pressure (BiPap) mask for Resident #29. This failed practice was random opportunity for discovery and was true for Resident #29. Resident identifier: #29. Facility census: 71. Findings included: Observation on 10/31/22 at 11:45 AM showed Resident #29's Bilevel Positive Airway Pressure (BiPap) mask to be laying on top of a tissue box face down on the Resident's bedside table. The BiPap mask was not stored in a bag. Resident #29 stated, I used last night, I use it every night. Sometimes it's [Bipap mask] in a bag and sometimes not, they [facility staff] got bags but I guess we both forget. At 11:46 Registered Nurse (RN) #8 verified the mask was not stored properly and stated they should have changed it [storage bag] last night because they do it on Sundays. Record review showed an order to apply BiPAP at IPAP of 15, EPAP of 5, 3L of oxygen at bedtime every night. Date order intiated 09/12/22. During an interview on 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.