Lindside Healthcare Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, the facility failed to offer Pneumococcal vaccinations to aid in the prevention of Pneumonia. This failed practice was found true for (2) two of (5) five residents reviewed for vaccinations during the Long-Term Care Survey Process. Resident identifiers: Resident #15 and Resident #4. Facility Census 53.Findings included: a) Resident #15A record review, completed on 03/11/26 at 9:43 AM, revealed that Resident #15 lacked documentation showing the pneumococcal vaccination was offered.During an interview on 03/11/26 at 10:05 AM, the Infection Preventionist (IP) stated, He had the vaccinations before he came here. She presented a document from a local pharmacy indicating he had all vaccinations except the pneumococcal vaccination. The State Agency (SA) pointed out to the IP that the document did not indicate the pneumococcal vaccination had been given. The IP stated, I guess he refused it.Further record review revealed no declination in the medical record for 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 document review and staff interview, the facility failed to provide written documentation upon discharge on the right to appeal and provide contact information to the Ombudsman and local State Agency. This was true for 3 of 3 residents reviewed (Residents #61, #62, and #63). Facility census 58. Review of the discharge documentation on 02/10/26 during the hours of 10:15 a.m. through 11:15 a.m. for Residents #61, #62, and #63 revealed no readily available documentation that included any written information on the resident's right to appeal discharge with contact information to the local Ombudsman or State Agency. An interview on 02/10/26 at 11:40 a.m. with the facility's Director of Nursing (DON) verified these findings. These findings were also acknowledged by the facility's Administrator at the exit conference on 02/10/26 at approximately 12:30 p.m.

Based on record review and staff interview the facility failed to implement the facility Policy and Procedure entitled, West Virginia Abuse, Neglect and Misappropriation by failing to thoroughly investigate incidents of abuse between residents. The facility failed to obtain statements from staff who were working at the time of the incident. Furthermore, the facility failed to assess and interview like residents of the facility. This failed practice was true for three (three) of 5 (five) residents reviewed for abuse. Resident identifiers: #30, #54, and #1. Facility census: 54. Findings included: a) Resident #30 On 08/21/24 at approximately 10:00 AM, a review of the Facility Reported Incident (FRI) dated 07/26/24 was conducted revealing that on the morning of 07/26/24 at 10:30 AM. Licensed Practical Nurse (LPN) #82 witnessed Resident #207 pat Resident #30's mid section through his clothing. Further review of this investigation revealed 3 (three) statements which are typed as written and read as follows: Statement from LPN #82: I witnessed Resident #207 touching Resident #30 on 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 and staff interview the facility failed to thoroughly investigate thoroughly investigate 2 (two) instances of resident-to-resident sexual abuse and one instance of resident-to-resident physical abuse by failing to obtain statements from staff who were working at the time of the incidents, furthermore the facility failed to assess and interview like residents of the facility. This failed practice was true for 3 (three) of 5 (five) residents reviewed for abuse. Resident identifiers: #30, #54, #1 and #39. Facility Census: 54. Findings included: a) Resident #30 On 08/21/24 at approximately 10:00 AM, a review of the Facility Reported Incident (FRI) dated 07/26/24 was conducted revealing that on the morning of 07/26/24 at 10:30 AM, Licensed Practical Nurse (LPN) #82 witnessed Resident #207 pat Resident #30's mid section through his clothing. Further review of this investigation revealed 3 (three) statements which are typed as written and read as follows: Statement from LPN #82: I witnessed Resident #207 touching Resident #30 on his genital area outside his pants. I…

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

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. The facility also failed to provide evidence that a copy of the Notice of Transfer was sent to the Ombudsman. This was true for three (3) out of four (4) hospital transfers reviewed during the long-term care process. This had the potential to affect all residents being transferred or discharged . Resident identifiers: #20, #38, and #29. Facility census: 54. Findings included: a) Resident #29 Medical Record review on 08/21/24 revealed resident #29 was discharged to the hospital on [DATE]. Subsequent review of Resident #29's medical record showed it did not contain documentation that the Notice of Transfer or Discharge was provided to the Resident Representative, or the Ombudsman was notified of the discharges on 08/13/24. On 08/21/24 at 5:58 PM during an interview the Administrator verified, there was no evidence…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, resident, and staff interview. The facility failed to ensure that a resident received the treatment and care in accordance with professional standards of practice in regard to monitoring pain levels. This was true for three (3) of five (5) residents reviewed for pain during the Long-Term Survey Process. Resident Identifier: #26, #29, and #157. Facility census: 54. Findings included: a) Resident #29 Medical record review revealed Resident #29 had a broken hip. The resident had a physician orders for pain management. The oder was for Acetaminophen Oral Tablet (Acetaminophen). Give 500 mg by mouth every six (6) hours as needed for pain. The order stated, Do not exceed 3000mg total dose in a 24-hour period from any medication with a state date 08/02/24. A continued review of Medication Administration Record (MAR) revealed: --08/13/24 at 8:06 AM pain level 8 - Acetaminophen 500 mg tablet given. --08/14/24 at 7:09 AM pain level 8 - Acetaminophen 500 mg tablet given. An interview on 08/21/24 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 resident interview, staff interview and record review, the facility failed to ensure the right to make choices about aspects of life that is important to one (1) of three (3) residents reviewed for choices. Specifically, Resident #35 was not given showers when requested or the choice. Resident identifiers: #19, and #35. Facility census: 54. Findings included: a) Resident #35 During an interview with Resident #35 on 08/19/24 at 2:44 PM, she stated she never received her shower when she prefered. Resident #35 continued to say that she would like to have showers at least every other day. Medical record review revealed, Resident #35's shower schedule was on Saturday, Sunday, Monday, Wednesday, and Thursday on day shift. A review of the 06/07/24 Quarterly Minimum Data Set (MDS), found the resident's brief interview for mental status was fifteen (15). A continued review of Resident #35s ADL documentation found; she was not receiving showers as scheduled. On 08/21/24 at 3:37 PM during an Interview with Assistant Director of Nursing (ADON) stated that they have been working with…

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 notify the representative/family of an acute hospitalization. This was true for two (2) out of three (3) residents reviewed for the care area of hospitalization during the Long-Term Care Survey process. Resident identifier: Resident #20. Facility census 54. Findings included: a) Resident #20 A record review, completed, on 08/20/24 at 7:09 PM, revealed Resident #20 had capacity to make his own medical decisions. Record review also revealed Resident #20 was transferred to the hospital on [DATE]. A Nurses Note, dated 02/16/2023 at 10:41 PM, noted that Resident #20 had informed the nurse he was not feeling well and that he just wanted to go to the hospital. The physician was notified and new orders were received to send resident to the emergency room for evaluation. There was no evidence resident's daughter was notified. Section E. Key Contacts of the eInteract Transfer form, dated 02/16/24, listed resident as his own Resident Representative. There…

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 timely report allegations of suspected abuse between residents timely within the 2 (two) hour window to the appropriate State Agency. This failed practice was true for 2 (two) of 5 (five) residents reviewed for abuse. Resident Identifiers: Resident #39, Resident #01 and Resident #207. Facility Census: 54. Findings include: a) Resident #39 On 08/21/24 at approximately 10:00 AM, a review of the Facility Reported Incident (FRI) dated 06/18/24 was conducted revealing that on the morning of 06/13/24 during the afternoon Licensed Practical Nurse (LPN) #71 reported that Resident #207 appeared to be touching the private are of Resident #39. LPN #71 stated she immediately separated the residents and re-directed each of them. During the review of this FRI, it was noted the allegation type selected was sexual abuse, which according to the reporting requirements of the Office of Health Facility Licensure and Certification Long Term Care Nursing Home Program must be reported to the appropriate state agency within 2 hours of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical review and staff interview, the facility failed to provide the resident/resident representative notice of the bed hold policy when Resident #29 was transferred to a local hospital. This was true for one (1) of three (3) residents reviewed for transfers. Resident identifier: #29. Facility census: 54. Findings included: a) Resident #29 Medical Record review on 08/21/24 revealed Resident #29 was discharged to the hospital on [DATE]. Continued review of Resident #29's medical record showed it did not contain documentation that the resident or the resident's representative received a copy of the bed hold policy at the time of transfer. In addition, there was no documentation in the medical record of contacting the resident / resident representative regarding the bed hold policy. In an interview with the Administrator on 08/21/24 at 5:58 PM, the Administrator confirmed there was no documentation regarding staff notifying the resident/resident representative of the bed hold policy for the hospital…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, resident, and staff interview. The facility failed to assist dependent Residents with activities of daily living (ADL's) in accordance with the Residents assessed needs for care. This is true for one (1) of three (3) residents reviewed for ADL care. Resident identifiers: #108. Facility census: 54. Findings included: a) Resident #108 During an interview, on 08/19/24 at 1:02 PM, Resident #108 stated she had never had a bath / shower or had her hair washed since she was admitted . A record review revealed Resident #108 was admitted to the facility on [DATE]. Continued review found no documentation of bathing from 08/14/24 through 08/21/24. On 08/21/24 at 3:37 PM during an Interview with Assistant Director of Nursing (ADON) stated that they have been working with staff and trying to get resident showers when they prefer. She verified Resident #108 was not getting her showers as scheduled.

Based on record review and staff interview the facility failed to follow a physician's order to be notified of blood sugar greater than 400 for Resident #23. This was true for 1 (one) of 1 (one) residents reviewed for the Long Term Care Survey Process. Facility census: 54. Resident identifier: #23. Findings included: a) Resident #23 On 08/19/24 at 03:48 PM, a record review was conducted for Resident #23 revealing orders for the following: Lantus Subcutaneous Solution 100 UNIT/ML (Insulin Glargine) Inject 48 unit subcutaneously one time a day for DM 2 Obtain blood sugar at 6 AM and PM. Notify physician if blood glucose less than 60 or over 400 two (2) times a day for diabetes On 08/20/24 at 03:06 PM, a review was conducted of Resident #23's progress notes and Medication Administration Record (MAR) revealing the following documentation: 1. 08/03/2024 5:46 PM - Medication Administration Note Note Text: Obtain blood sugar at 6 AM and PM. Notify physician if blood glucose less than 60 or over 400. 2. 08/01/2024 16:38 Nurses Note Note Text: BS 455. Left message with NP. Awaiting…

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, interviews with facility staff, and a review of facility policy and procedures, it was determined that the facility failed to follow acceptable infection control practices that controlled, or prevented, the spread of infection. This practice had the potential to affect all residents that reside in the facility. Facility Census: 54. Findings included: a) Water Management On 08/23/24 at 3:34 PM, during a review of water management, it was discovered that the facility lacked a Water Management Plan. Additionally, there was no text and flow documentation available that detailed the facility's water system, including control points where Legionella control measures, like dead leg water flushes, were required. During a face-to-face interview with Executive Director (ED) #29 on 08/23/24 at 3:52 PM, she stated that she was not aware of the requirement for a text and flow description of the water system. The Regional Director of Clinical Operations (RDCO) #110 overheard the conversation and mentioned that the facility's Emergency Management Plan should contain this…

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

Based on staff interview, observation, and facility documents the facility failed to ensure the facility cleaning solution used to disinfect was used in accordance with manufacture directions. This failed practice had the potential to affect more than a limited number of residents. Facility census 60. Findings included: a) Using the facility disinfectant On 10/04/23 at 10:34 AM, Housekeeping Director (HD) #77 was asked about the cleaning agents used to clean resident rooms. On 10/04/23 at 11:08 AM, HD #77 provided a facility document titled Product Specification Document. The Direction for use of this product is as follows: Apply solution with a cloth, sponge, mop, or spray. Allow to air dry. Rinse food contact surfaces with potable water prior to reuse. For Spray applications, spray 6 to 8 inches from the surface. Allow the surface to remain wet for 3 minutes. Allow to air dry or after 3 minutes wipe with mop, cloth, or sponge. During an interview on 10/04/23 at 1:42 PM, Housekeeper (HK) #62 was asked about using the facility cleaning agent, Multi-Purpose Plus Disinfectant Cleaner.…

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, staff interview, and Resident council meeting. The facility failed to meet the needs and Preferences of each resident, through an ongoing program to support residents in their choice of activities, both facility-sponsored group and individual activities and independent activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the community. This failed practice had the potential to affect more than a limited number of residents that currently reside in the facility. Resident identifiers: #41, #32, #17, #3, #40, #31, #8, #26, #11, #37, and #39. Facility census 60. Findings included: a) Resident #26 b) Resident council On 10/04/23 at 2:30 PM a Resident Council meeting was held and the following members were present: Resident: #41, #32, #17, #3, #40, #31, #8, #11, #37, and #39. The residents said they do not feel like they have enough activities and even less on the weekends. All of the residents were in agreement that one hour…

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 employee record review, and staff interview the facility failed to ensure all dietary staff had a food handlers' card, to ensure the safe handling of the food for the Residents. This failed practice had to potential to affect more than a limited number of Residents that currently reside at the facility. Facility census 60. Findings included: a) Food handlers' cards On 10/04/23 at 10:00 AM a review of the facility's food handler cards for all dietary staff found, [NAME] #25 did not have a food handlers card. Cook #25 was hired on 09/08/23 and does not have a food handler card. An interview with Culinary Director on 10/04/23 at 10:20 AM said [NAME] #25 is signed up to have a class on 10/16/23. However, she can take the course online today.

Based on record review, policy review, and staff interview, the facility failed to honor the Resident's rights by not providing a written notice prior for a Residents room change. This is true for two (2) of two (2) Residents reviewed for room change. Resident Identifiers: Resident # 29 and Resident #7. Facility Census: 56. Findings Included: A review of the facility policy titled Resident Room Change Policy read as follows. .Procedure: .2. Notification of Change/Updates a. Social Services will complete Notification of Room Change and New Roommate Notification forms in the Electronic Medical Record (EMR) b. Social Service will document discussions with both residents and residents representatives. a) Resident #29 During a record review on 08/14/23 at 6:30 PM, Resident #29's medical record revealed Resident #29 had room changes on the following dates: -05/23/23 -06/02/23 -06/19/23 -07/05/23 Further record review revealed a Social Services Note for room change dated 6/19/2023 at 12:59 PM(typed as written) Spoke with resident regarding room change. Patient is agreeable to room change…

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, facility policy, and staff interview the facility failed to provide evidence that a Transfer Notice was sent to the Office of the State Long-Term Care Ombudsman when three (3) residents were transferred to the hospital. This was true for three (3) of three (3) Residents reviewed for hospital transfers. Resident identifiers: #37, #43, and #29. Facility census: 56. Findings Included: A review of the facility policy titled Bed Hold Policy with no initiated or revision date read as follows. .Procedure: 1. In the event a resident returns to the hospital or goes on a leave, the following process will be followed by the facility: a. The nurse or designee will present the Acute Transfer letter at time of transfer with a copy going with the resident and a copy going to the Business Office Manager. Designee will scan to the Ombudsman. a) Resident #37 During a record review on 08/14/23 at 12:45 PM, Resident #37's medical record revealed Resident #37 was transferred to a local hospital on [DATE] with…

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, staff, and resident interview the facility failed to ensure medication used in the treatment of diabetes was available for administration. This failed practice was true for one (1) of three (3) residents reviewed for insulin administration. Resident identifier: #8. Facility census: 56. Findings included: a) Resident #8 Record review showed an order for Trulicity Subcutaneous Solution Pen-injector 0.75 MG/0.5ML (Dulaglutide). Inject 0.75 mg subcutaneously one time a day every Thursday for Type 2 diabetes. Review of the Medication Administration Record (MAR) showed Resident #8 missed 2 doses of Trulicity in July. On 07/13/23 the drug was documented as refused with no other explanation. On 07/20/23, the dose was documented as not given and the MAR stated see nurses note. The nurse's note for that occurrence stated, awaiting delivery from pharmacy. During an interview on 08/14/23 at 3:58 PM, Resident #8 stated that she does not remember refusing any insulin shots. The Resident stated that is one thing she wants to keep up on because she doesn't want…

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 and follow the specified pain parameters described within the physicians' order when administering pain medication. This was true for one (1) of three (3) Residents reviewed in the care area of pain. Resident identifier: #12. Facility census: 56. Findings included: a) Resident #12 Record review showed an order for Percocet Oral Tablet 5-325 MG (Oxycodone w/ Acetaminophen) Give 1 tablet by mouth every 6 hours as needed (PRN) for moderate to severe pain. Start date of order 07/14/23. Review of Resident #12's Medication Administration Record (MAR) showed Resident #12 was administered the as needed Percocet Oral Tablet 5-325 MG for 26 occurrences for a pain level of zero (0) in the month of July and August: 07/17/23 at 5:45 PM 07/17/23 at 11:00 PM 07/18/23 at 4:50 AM 07/19/23 at 12:15 PM 07/20/23 at 7:38 AM 07/20/23 at 8:34 PM 07/21/23 at 3:05 AM 07/22/23 at 3:49 AM 07/22/23 at 7:15 PM 07/24/23 at 4:47 PM 07/24/23 at 10:53 PM 07/26/23 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, staff interview, and Resident interviews, the facility failed to provide Residents with evening snacks. This is true for 11 of 23 Residents requiring evening snacks. Resident identifiers: Resident #30, Resident #1, Resident #7, Resident #43, Resident #51, Resident #4, Resident #8, Resident #15, Resident #14, Resident #53 and Resident #37. Facility Census 56. Findings Included: a) Snacks During a tour of the nourishment room on 08/14/23 at 8:55 AM, the refrigerator revealed a tray of snacks dated 08/12 Sat (Saturday) PM for the following residents: -Pudding: Resident #37 Resident #43 -Nectar Thickened Water: Resident #30 -½ Sandwiches: Resident #1 Resident #7 Resident #51 Resident #4 Resident #8 Resident #15 Resident #14 Resident #53 During an interview on 08/14/23 at 9:44 AM, the Director of Nursing (DON) stated the Residents might have eaten something else, I will have to look at the snack documentation record to see what was documented. During an interview on 08/14/23 at 11:43 PM, the Culinary Director (CD) stated we send out the snacks, but the nurses…

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 council meeting, resident interview and staff interviews, the facility failed to implement an ongoing resident centered activities program designed to meet the interest of and support the physical, mental and psychosocial well-being of each resident. The facility failed to implement evening activities of interest for the residents. This was a random opportunity for discovery. Facility census: 57. Findings Included: a) Resident Council During the Resident Council Meeting held on 10/18/22 at 2:43 PM the Residents as a group were asked the question, How are the activities? The following concerns were voiced. -Could be more activities, -We need evening activities, we do nothing but sit in our rooms after dinner. -It's so boring in the evenings, We need more to do in the evening. -We need someone to help us set out the games and stuff but some of the others need help participating in the games that are available. -The last activity is at 2:00 PM and then nothing. A review of previous Resident Council minutes revealed a Resident Council Meeting held on…

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

Based on medical record review and staff interview, the facility failed to have two (2) licensed nurses to sign off at the beginning and ending of the shift to verify the control substances were accurate and accounted for as directed. This failed practice had the potential to affect more than a limited number of residents. This was discovered during the medication pass on 10/18/22. Facility census: 57. Findings included: Review of Unit 1/2 medication cart found the following days the narcotic book was only signed by one (1) licensed nurse: 10/02/22-not signed by oncoming nurse on the 6a-6p shift and the off going nurse on the 6p-6 am 10/06/22- not signed by oncoming nurse on the 6a-6p shift and the off going nurse on the 6p-6 am 10/10/22- not signed by oncoming nurse on the 6a-6p shift and the off going nurse on the 6p-6 am 10/15/22- not signed by oncoming nurse on the 6a-6p shift and the off going nurse on the 6p-6 am 10/16/22-not signed by oncoming nurse on the 6a-6p shift and the off going nurse on the 6p-10/18/22- not signed by oncoming nurse on the 6a-6p shift and the off going…

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 consultant pharmacist failed to complete a medication regimen review every thirty (30) days. This was true for Residents #13, #29, #16 and #36. Additionally, the facility failed to timely complete a gradual dose reduction (GDR) as approved by the physician. Resident identifiers: #13, #29, #16 and #36. Facility census: 57. Findings included: a) Policy A review of the policy titled Medication Regimen Review (MRR) Time Frame with an implemented date of 11/27/17 and a review date of 05/03/21 was as follows: The medication regimen of each patient is reviewed at least once a month by a licensed Consultant Pharmacist. b) Resident #13 A review of Resident #13's MRR completed by the consultant pharmacist monthly for the last year revealed on 03/28/22, the consultant pharmacist stated this date was done on 03/28/22 for the period of 02/01/22 through 02/28/22. There was not an MRR completed for February 2022. c) Resident #29 A review of Resident #29's MRR completed by the consultant pharmacist monthly for the last year revealed 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, 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. This failed practice had the potential to affect more than a limited number of residents currently receiving nourishment from the facility's kitchen. Facility Census: 57 Findings Included: A facility policy titled labeling and dating with a date of 2017 stated the following. .Guidelines for Labeling and Dating .Food labels must include: -The food name -The date of preparation/receipt/removal from freezer -The use by date . Use By Dating Guidelines -The manufacturer's expiration date, when, available is the use by for unopened items a) Walk-in Refrigerator A facility policy titled food storage and retention guide with a date of 2017 stated the following. .Shelf Stable Foods . Condiments after opening in refrigerator less than 41 degrees Fahrenheit -Pickles: one (1) to two (2) weeks -Salad dressing: three (3) months -Vinegar: two…

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 and staff interview, and record review, the facility failed to provide an extra over-the-bed table for meals to prevent further injury due to spilled tray which cause a second (2nd) degree burn on right foot. Resident identifier: #2. Facility census: 57. Findings included: a) Resident #2 An interview and observation with Resident #2, on 10/17/22 at 1:53 PM, found the resident in bed with the right foot wrapped in a cling dressing. Resident #2 stated that she had suffered a burn from coffee on 10/10/22. She stated her tray fell off because she keeps her personal items close to be able to reach them throughout the day and her tray doesn't fit on the table very well. Review of Resident #2's incident report dated 10/10/22 at 3:30 PM, which reads: Resident requested her Unna Boot ( is a compressive dressing used in the treatment of venous stasis ulcers) to be removed due to her tray had spilled and coffee had went into her Unna boot on the right foot and it was burning. When the boot was removed, it was noted to have a blister measuring 2 centimeters (cm)…

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 record review and staff interview, the facility failed to ensure a Physicians Orders for Scope of Treatment (POST) form was completed by the appropriate designee for one (1) of two (2) residents reviewed for advance directives. This failed practice had the potential to affect only a limited number of residents. Resident identifier: #35. Facility census: 57. Findings included: a) Resident #35 Record review showed Resident #35's POST form was completed and signed by the Resident's Health Care Surrogate (HCS) on 02/26/20. Further record review showed a physician's determination of capacity that was completed on 11/01/21 indicating at that time the Resident demonstrated incapacity to make medical decisions. During an interview on 10/19/22 at 12:46 PM, the Director of Nursing (DON) verified the POST form was completed by the Resident's HCS prior to the Resident being incapacitated. The DON confirmed the Resident should have been the one to complete and sign the form at that time. .

Based on observation, medical record review and staff interview, the facility failed to follow the physician orders for Resident #109 with a order for Lidocaine patches without a dosage and Resident #2's orders for treatment of a second degree burn on the right foot. These failed practices had the potential to affect a limited number of residents. Resident identifiers: #109 and #2. Facility census: 57. Findings included: a) Resident #109 During medication pass on 10/18/22 at 8:15 AM Resident #109 had an order for a Lidocaine patch to be applied to the left hip topically daily for eleven (11) days for pain. The order on the electronic Medication Administration Record (MAR) did not have a dosage. Further review found the physician had ordered a Lidocaine patch 4%. In an interview with the Director of Nursing (DON) on 10/18/22 at 1:15 PM confirmed the order failed to have the dosage and the order was updated immediately. b) Resident #2 Review of Resident #2's incident report dated 10/10/22 at 3:30 PM, which reads: Resident requested her Unna Boot (is a compressive dressing used in the…

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

Based on observation and staff interview, the facility failed to ensure the resident's environment was as free of accident hazards as possible. Unit 3/4 medication cart was left unlocked and unattended. This was a random opportunity for discovery. Facility census: 57. Findings included: On 10/18/22 at 3:11 PM, the Unit 3/4 medication cart was observed to be unlocked and unattended. The Director of Nursing was notified immediately. A list of residents who wanders was requested. The list of wandering residents contained the following residents: #47, #28, #15, #49, #52, #41, #55 and #53. No further information was provided. .

Based on medical record review, staff interview and resident interview, the facility failed to ensure a complete and accurate medical record. The facility failed to document Resident #6's bathing task and Resident #51's weights in the electronic medical record. This was a random opportunity of discovery. Resident identifiers: Resident #6 and Resident #51. Facility Census: 57 Findings Included: a) Resident #6 During an interview on 10/17/22 at 2:03 PM, Resident # 6 stated that I get a shower most of the time, they skip a few, don't get as many as I should, I think I am scheduled two (2) times a week. During a medical record review on 10/18/22 revealed Resident #6's bathing documentation as follows: Bed bath: -09/20/22 at 2:29 PM -09/22/22 at 11:58 AM -09/25/22 at 11:41 AM Showers: 09/24/22 at 12:48 AM No evidence of the bathing task was in the electronic medical record since 09/25/22. During an interview on 10/18/22 at 10:55 AM, the Director of Nursing (DON) stated that Resident #6 had showers scheduled on Wednesday and Saturday. She received her showers. The showers were documented…

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.