Marmet Center

Based on record review and staff interview, the facility failed to ensure complete and accurate Minimum Data Set (MDS) assessments. This deficient practice had the potential to affect one (1) of three (3) residents reviewed for the care area of resident assessment and one (1) of five (5) residents reviewed for the care area of unnecessary medications. Resident Identifiers: #7 and #69. Facility census: 88. Findings included:a) Resident #7 Resident #7's Minimum Data Set (MDS) assessment with Assessment Reference Date (ARD) 03/18/26 coded the resident had a wound infection. However, the resident's medical records did not show the resident had a wound infection in the seven (7) day look-back period. On 04/20/26 at 11:00 AM Licensed Practical Nurse (LPN) Clinical Reimbursement #15 confirmed the MDS was incorrect and Resident #7 did not have a wound infection during the look-back period. She stated the diagnosis pulled from an old MDS that correctly coded a wound infection. LPN #15 stated she would modify and correct the MDS. b) Resident #69 Resident #69's quarterly MDS with ARD 03/02/26…

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 that the administration of enteral nutrition is consistent with and follows physician orders. This failed practice was found true for (1) one of (2) residents reviewed for the care area of tube feeding during the Long-Term Care Survey Process. Resident identifier #59. Facility Census: 88. a) Resident #59A record review on 04/19/26 at 11:30 PM, revealed an order for Resident #59 that read as follows:One time a day Isosource 1.5 @60ml/hr X18 hrs. Volume 1080ml.Instructions for the 18-hour tube feeding were to start at 12:00 PM, and end at 6:00 AM.An observation on 04/19/26 at 12:10 PM, found Resident #59 asleep in bed. No tube feeding was being administered.Further observations at 12:30 PM, 1:00 PM, and 1:45 PM found no tube feeding being administeredDuring an interview on 04/19/26 at 1:55 PM, The Director of Nursing confirmed that the tube feeding for Resident #56 was not hanging and should have started at 12:00 PM.During an interview on 04/19/26 at 1:55 PM, Licensed Practical Nurse (LPN) #68…

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 a resident received double entree portions as ordered by the facility. This was a random opportunity for discovery. Resident Identifier: #69. Facility Census: 88. Findings included:a) Resident #69 Review of Resident #69's physician's orders showed an order written on 12/15/24 for double entrees with meals. On 04/20/2026 at 1:02 PM, Resident #69 was observed eating in the dining room. Nurse Aide (NA) #5 was sitting with the resident and assisting him. The resident's tray ticket stated he was to receive double entree. However, the resident only received one (1) BBQ sandwich. NA #5 left the table to get a clean spoon for Resident #69's tablemate. Resident #69 picked up his BBQ sandwich and had eaten almost all of it by the time NA #5 returned to the table. There was some bun left. Resident #69 picked off some of the BBQ meat that had fallen onto his shirt and put that in his mouth. When NA #5 returned to the table, she began feeding Resident #59 some chopped marinated vegetable salad with a spoon.…

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 administer COVID-19 vaccinations in accordance with professional standards of care. This deficient practice had the potential to affect one (1) of five (5) residents reviewed for the care area of COVID-19 vaccination. Resident Identifier: #1. Facility Census: 88. Findings included:a) Resident #1 The facility's policy titled, COVID-19 Vaccination, with an effective date of 12/14/20 and a revision date of 12/16/24, stated COVID-19 vaccination would be administered with patient or patient representative consent. Review of Resident #1's medical records showed the resident lacked capacity to make medical decisions. On 02/24/26, Resident #1's representative verbally declined the 2025-2026 COVID-19 vaccination for the resident. The form stated, I do not give consent for the person named at the top of this form to be vaccinated with the COVID-19 vaccine. Resident #1's medication administration record (MAR) documented that the resident received the 2025-2026 COVID-19 vaccination on 03/02/26. On 04/20/26 at 12:07 PM, 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 interviews conducted and observation, the facility failed to maintain a safe, functional, sanitary, and comfortable environment. This practice had the potential to affect more than an isolated number of residents. Facility census 89.Findings included:a) An anonymous interview was conducted during the complaint investigation process and during the interview, the interviewee identified areas in the facility where there would be evidence of mice droppings. A second anonymous interview was conducted and the interviewee verified that they had seen mouse droppings behind resident's furniture in 2 resident rooms which were identified during the first anonymous interview.During an observation on 01/30/26 at approximately 1:00 p.m., this surveyor observed mice droppings located on the floor near the outer wall to the left in the Activities Director's office located in B Hall. Interview with the Regional Administrator (RA) verified this finding on 01/30/26 at approximately 1:10 p.m. On 01/30/26 at approximately 5:00 p.m., an exit interview was conducted with the facility'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 observation, document review, and staff interviews, the facility failed to ensure they stored food in accordance with professional standards for food quality. The facility failed to maintain proper refrigerator temperatures of the refrigerator located in the Rehab pantry room. This deficiency has the potential to affect more than an isolated number of residents, staff and visitors within the Facility census: 84. Findings include: a) On 06/25/25 at approximately 10:30 a.m., the Rehab Pantry room refrigerator had temperatures documented greater than 41 degrees Fahrenheit on the PM temperature check on the following dates with no documentation of the corrective issue (06/09/25, 06/14/25, 06/17/25, 06/21/25, 06/22/25, and 06/24/25). On 06/25/25 at approximately 10:30 a.m., there was no documented temperature for the AM temperature check on 06/24/25. Interview with the facility's Director of Nursing verified these findings at the time of discovery. The finding was also acknowledged by the facility Administrator at the time of discovery and upon exit on 06/25/25 at approximately…

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

Based on observation and staff interviews, the facility failed to maintain a sanitary environment related to gnats and a damaged countertop located in the Rehab pantry room. This deficiency has the potential to affect more than an isolated number of residents. Facility census: 84. Findings include: On 06/25/25 at approximately 11:05 a.m., this surveyor observed several gnats on the left hand side of the Rehab pantry room sink countertop . On 06/25/25 at approximately 11:05 a.m., this surveyor observed exposed damp wood on the left hand side of the countertop sink located in the Rehab Pantry room. Interview with the facility's Maintenance Director verified the findings at the time of discovery. The finding was also acknowledged by the facility Administrator at the time of discovery and upon exit on 06/25/25 at approximately 12:45 p.m.

Based on observation, policy review and staff interview the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. This had the potential to affect more than an isolated number of residents. Facility census: 88. Findings Include: a) Upon entry of the facility on 02/03/25 there was a sign in place on the main entrance door that indicated the facility was in a COVID outbreak. This was confirmed with the Administrator. On 02/03/25 at 12:20 PM Nurse Aides #40 and #51 were seen on C Hall with their N-95 mask off their face and down under their chin. According to the facility policy for Infection Control (IC405 COVID-19) revision date of 07/01/24 under General Standard Precautions: .follow Center for Disease Control and Prevention (CDC) published guidance related to the use of facemask, respirators, gowns, gloves and eye protection . The CDC recommends general standard precautions to prevent 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 observation, record review, resident interview and staff interview the facility failed to provide a dignified and respectful existence for Resident #84. This was true for one (1) resident of one (1) residents reviewed during the survey process. Resident identifier: #84. Facility census: 88. Findings include: a) Resident #84 On 02/03/25 at 10:00 AM, a record review was completed for Resident #84. The review found the resident had been placed on one-on-one (1:1) monitoring on 01/17/25 at 6:00 PM. The reason for the 1:1 monitoring was noted in the change in condition dated 01/17/25. The reason noted was resident trashed his room, kicking heater, letting the water run in his sink trying to flood room, cursing, throwing razors all over his room. The 1:1 monitoring was for 24 hours daily since 01/17/25. The resident's door was always left open; including during toileting, bathing and changing clothes. On 02/03/25 at approximately 12:30 PM, the resident was interviewed regarding the 1:1 monitoring. 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 report two (2) changes in conditions for reasonable suspicion of a crime to the appropriate State agencies for Resident #84. This was true for one (1) of one (1) residents reviewed during the survey process. Resident identifier: #84. Facility Census: 88. Findings include: a) Resident #84 On 02/03/25 at 10:00 AM, a record review was completed for Resident #84. The review found two (2) changes in conditions for the resident regarding behaviors; and the staff calling the local police to report a suspicion of a crime on 01/17/25 and 01/24/25. The incident on 01/17/25 was related to resident trashed his room, kicking heater, letting water run in his sink trying to flood room, cursing, throwing razors all over his room. (Typed as written.) The facility physician recommended sending the resident to an acute care facility for a psychiatric evaluation. The resident had the capacity to make medical decisions and refused to go out of the facility. The staff called the local police department due to the resident's behaviors. 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 obtain a Physicians order to place a resident on one-on-one observation status. There was also no indication the facility updated the physician when the resident refused to go out for evaluation. These issues were found for one (1) of one (1) residents reviewed. Resident identifier: #84 Facility census: 88 Findings Include a) Resident #84 On 01/17/25 at 6:00 PM the facility placed Resident #84 on a one-on-one observation status due to behavior. This continued to be in place as of 02/03/25 at the time of the complaint investigation. The incident on 01/17/25 was related to resident trashed his room, kicking heater, letting water run in his sink trying to flood room, cursing, throwing razors all over his room. (Typed as written.) The facility physician recommended sending the resident to an acute care facility for a psychiatric evaluation. The resident had the capacity to make medical decisions and refused to go out of the facility. The staff called the local police department due to the resident's behaviors. 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 record review and staff interview, the facility failed to maintain accurate and complete medical records for Resident #84. This was true for one (1) of one (1) residents reviewed during the survey. Resident identifier: #84. Facility Census: 88. Findings Include: a) Resident #84 On 02/03/25 at 10:00 AM, a record review was completed for Resident #84. The review found the [NAME] Virginia (WV) Physician Order for Scope of Treatment (POST) form did not have documentation of the preparer's signature or date. On 02/03/25 at 10:10 AM, the Administrator stated, We will get this corrected.

Based on observation and staff interview, the facility failed to ensure the resident environment over which it had control was as free from accident hazards as possible when a medication cart was left unlocked and unattended and razors were found at the bedside. This was a random opportunity for discovery. This deficient practice had the potential to affect more than a limited number of residents. Resident identifiers: #69 and Facility. Facility Census: #89 Findings include: a) Medication carts On 12/16/24 at 7:55 AM upon arriving on the C-hall it was observed that the medication cart parked between Rooms #C-24 and #C-26 was unlocked and unattended. Licensed Practical Nurse (LPN) #26 came out of Room #C-22 which she had been in with the door closed.This was confirmed with LPN #26 at this time. At 8:01 AM LPN #26 retrieved medications for the resident in #C-26 and went into the room, leaving the medication cart unattended and did not lock the medication cart. On 12/16/24 8:30 AM it was confirmed with the Director of Nursing who confirmed the medication carts should remain locked when…

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

Based on record review and staff interview, the facility failed to ensure the pharmacist completed monthly medication regimen reviews and that the physician addressed recommendations made by the pharmacist. This deficient practice had the potential to affect three (3) of five (5) residents reviewed for the care area of unnecessary medications. Resident identifiers: #34, #16, #54. Facility census: 89. Findings included: a) Policy review The facility's policy titled Medication Regimen Review and Reporting dated January 2024 stated the consultant pharmacist would review the medication regimen and medical chart of each resident at least monthly. The policy also stated the facility would follow up on pharmacy recommendations to verify appropriate action had been taken within thirty calendar days for issues that did not require urgent action. For issues requiring physician intervention, the attending physician would accept or reject recommendations, documenting rationale for rejections. b) Resident #34 Review of Resident #34's pharmacist medication regimen reviews showed a review…

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 store medications in accordance with professional standards of practice. Multi-use vials of medications stored in the D hallway med cart were past the manufacturer's expiration dates. Additionally, insulin pens for three (3) residents were not dated when first accessed. These were random opportunities for discovery during the medication storage and labeling facility task investigation. Resident identifiers: #390, #34, #7. Facility census: 89. Findings included: a) Expired medications On 12/16/24 at 8:40 AM, Licensed Practical Nurse #24 was observed preparing medications for Resident #80. The resident poured a vitamin C tablet from a multi-use bottle. The manufacturer's expiration date on the bottle was September 2024. The bottle had been dated as opened by the facility on 10/24/24. LPN #24 confirmed the vitamin C tablets were past the manufacturer's expiration date. Examination of the D hallway medication cart also found the following multi-dose medication bottles were past the manufacturer's expiration dates: - Senna…

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 follow the menus by not providing the appropriate serving size to residents.This failed practice was a random opportunity for discovery and had the potential to affect more than a limited number of residents during the Long-Term Care Survey Process. Facility Census 89. Findings Include: a) Food service in the Alzheimer's unit A dining observation on 12/15/24 at 12:30 PM, in the Alzheimer's unit, revealed that the Activity Directory (AD) was in a kitchen area fixing the plates for the lunch meal for the residents on that unit. Further observation revealed that the AD was serving the turkey with a mouth sized fork, serving the stuffing with a spatula, and serving the peas with a ladle. During an interview on 12/15/24 at 12:32 PM, the AD stated, I don't have the right size utensils over here. The kitchen did not send them. During an interview on 12/15/24 at 12:40 PM, the administrator confirmed that the appropriate utensils for portion size were not being used. A review on 12/16/24 at 2:30 PM, of the…

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

Based on observation, staff interview, and policy review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. This was a random opportunity for discovery and had the potential to affect more than a limited number of residents during the Long-Term Care Survey Process. Facility Census 89. Findings Include: a) Alzheimer's unit refrigerator The initial tour of the Alzheimer's unit on 12/15/24 at 11:44 AM, revealed a kitchen area with a refrigerator that had 14 apple crisp in it on a tray with no date. During an interview on 12/15/24 at 11:45 AM, Licensed Practical Nurse (LPN) #33 stated, I am not sure when the Apple crisp was put in here. Maybe this morning. I really don't know. LPN #33 confirmed that the apple crisp did not have a date on them. A review on 12/16/24 at 3:00 PM, of the policy titled {5.7 Refrigerated/Frozen Storage}, under Process, refrigeration, 1.5 reads as follows: Prepared foods are labeled and dated with name of product, date opened, and use by date. b) Kitchen walk-in freezer 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, staff interview, and observation the facility failed to operate and provide services in compliance with all applicable Federal, State, and local laws, regulations and codes by not ensuring staff serving food had a food handlers card. This failed practice was a random opportunity for discovery and had the potential to affect more than a limited number of residents. Facility Census 89. Findings Include: a) Food Handlers Card A dining observation on 12/15/24 at 12:30 PM, in the Alzheimer's unit, revealed that the Activity Directory (AD) was in a kitchen area fixing the plates for the lunch meal for the residents on that unit. During an interview on 12/15/24 at 12:32 PM, the surveyor asked the AD if she had a food handlers card. The AD replied, No, I do not. A review on 12/16/24 at 2:30 PM, of the Kanawha-[NAME] Health Department web site revealed the following requirement for Food Handlers in Kanawha county: If you handle, prepare, serve. sell or give away food for human consumption, even if…

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 medical records were complete and accurate. This deficient practice had the potential to affect two (2) of 26 residents in the long-term care survey sample. Resident #34's skilled nursing evaluations were inaccurate in the area of genitourinary status. Resident #10's Physician Orders for Scope of Treatment form was not signed by the resident's representative. Resident identifiers: #34, #10. Facility census: 89. Findings included: a) Resident #34 Review of Resident #34's medical records showed the resident was admitted on [DATE] with an indwelling urinary catheter that had been inserted in the hospital. A physician's order was written on 06/22/24 to remove the catheter and monitor the resident's urine output. However, Resident #34's skilled nursing evaluations on 06/23/24, 06/24/24, 06/25/24, 06/26/24, 06/27/24, and 07/02/24 continued to document the resident had an indwelling urinary catheter. On 12/18/24 at 10:08 AM, the Clinical Resource…

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

Based on observation, record review and staff interview, the facility failed to implement Enhanced Barrier precautions in accordance with professional standards of care and the facility's policies and procedures. These were random opportunities for discovery that had the potential to affect more than a limited number of residents. Resident identifiers: #22, #37. Facility census: 89. Findings included: a) Policy and Procedures The facility's policy and procedure titled Enhanced Barrier Precautions with effective date 01/06/24 and revision date 12/16/24 stated Enhanced Barrier Precautions (EBP) would be used for residents with an indwelling medical device without secretions or excretions that are unable to be covered or contained and not known to be infected or colonized with any multi-drug resistant organisms. The procedure also stated the appropriate EBP sign would be posted on the patient's room door. b) Resident #22 On 12/15/24 at 12:23 PM, Resident #22 was observed to have a tube feeding pump in her room. The resident was non-interviewable. There was not an EBP sign on the door…

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 policy review the facility failed to maintain all electrical equipment in safe operating condition. This failed practice was a random opportunity for discovery and had the potential to affect more than a limited number of residents. Facility census 89. Findings include: a) Stove in the Alzheimer's unit The initial tour of the Alzheimer's unit on 12/15/24 at 12:30 PM, revealed an electric cooking stove in a kitchen area. The stove had (4) four places for stove eyes. (1) one stove eye was in place. The other (3) three stove eyes were missing and replaced with a glass serving plate. During an interview on 12/15/24 at 12:38 AM, Licensed Practical Nurse (LPN) #33 stated, It's been like this for a while. We don't use the stove. Activities use it sometimes. During an interview on 12/15/24 at 12:40 PM, The administrator confirmed that the stove eyes were not in place and the holes were covered with glass plates. A review on 12/16/24 at 2:30 PM, of the policy titled {FNS411 Department Mainenance}, revealed: To ensure the environment and equipment…

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 a physical environment with an effective pest control program. Observations were made of gnats in two (2) different resident rooms. Room identifiers: #A01, #B11. Facility census: 89. Findings included: a) Observations during the initial tour on 12/15/24 revealed gnats were observed flying in the bathrooms of Rooms #A01, #B11; and the administrative conference room. The observation in Room #A01 was at 11:30 AM and #B11 was12:30 AM. In an interview with facility administrator on 12/16/24 at 1:20 PM administrator stated she would request housekeeping to take care of this.

Based on record review and staff interview the facility failed to ensure a resident's Preadmission Screening and Resident Review (PASARR) reflected the pre admission diagnoses sheet for schizophrenia and anxiety disorder, This was true for one (1) of three (3) PASRR's reviewed. Resident identifier: #37. Facility Census: #89. Findings include: a) Resident #37 On 12/16/24 at 9:10 AM record review of the PASARR for Resident #37 showed a preadmission diagnosis of schizophrenia and anxiety disorder. Review of the PASRR provided by the facility which was submitted on 04/02/19, when the resident was transferred from another facility, did not have a preadmission diagoses of schizophrenia or anxiety disorder. Resident #37 had the following active orders: Ativan Oral Tablet 0.5 milligram (MG) (Lorazepam) Give 1 tablet by mouth at bedtime for Anxiety/agitation As evidenced by (AEB): pulling out PEG tube RisperiDONE Oral Solution (Risperidone) Give 0.125 mg via G-Tube at bedtime for schizophrenia AEB: poor impulse control On 12/16/24 at 2:10 PM, during an interview with Social Worker #98, 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.

Based on record review and staff interview, the facility failed to develop a comprehensive care plan in the area of anticoagulant medication for one (1) of five (5) residents reviewed for the care area of unnecessary medications. Resident identifier: #34. Facility census: 89. Findings included: a) Resident #34 Review of Resident #34's physician's orders showed the resident had been receiving the anticoagulation medication apixaban (Eliquis) for atrial fibrillation since 07/19/24. Bleeding is a side effect of anticoagulation medication. Residents receiving anticoagulation medication must be monitored for signs and symptoms of bleeding such as bloody stool or urine, nosebleeds, bruising, or changes in mental status or vital signs. Review of Resident #34's comprehensive care plan showed the care plan did not have a focus related to anticoagulation medication with interventions to monitor for signs and symptoms of bleeding. On 12/17/24 at 1:43 PM, the Clinical Resource Nurse confirmed Resident #34 had not been care planned for the use of anticoagulant medication.

Based on resident interview, family interview, record review, and staff interview, the facility failed to provide oral care to a dependent resident. This deficient practice had the potential to affect one (1) of four (4) residents reviewed for the care area of activities of daily living. Resident identifier: #69. Facility census: 89. Findings included: a) Resident #69 During an interview on 12/15/24 at 3:29 PM, Resident #69 stated she is not getting her teeth brushed twice a day per her wishes. She stated her teeth had not been brushed last night or this morning. The resident's family member was in the room for the interview and stated oral care was addressed at a recent care plan meeting but still was not being done twice a day. A grievance and concern form had been completed on 12/10/24. The form stated, Resident stated teeth not getting brushed at times. The recommended corrective action was for the activities director to ensure each morning that teeth were getting brushed and for the Director of Nursing to spot check this. A note written on the grievance/concern form stated, NHA…

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

Based on record review and staff interview the facility failed to follow physician's orders to obtain weights on a weekly basis and to apply a hand splint. This was true for two (2) of twenty six (26) residents reviewed in the survey sample. Resident identifier #6, #58. Facility Census: #89. a) Resident #6 On 12/17/24 at 10:02 AM record review shows a Physician's order dated 12/10/24 for weekly weights X's four (4) weeks due to weight loss. Review of the documented weights show the facility did not get a weight until 12/16/24. On 12/18/24 at 10:02 AM it was confirmed with the Director of Nursing and the Clinical Resource Nurse #96, who agreed that the weight should have been obtained on 12/10/24 or 12/11/24, depending on the time the order was placed. b) Resident #58 On 12/15/24 at 12:53 PM during an interview with Resident #58 it was observed that her right hand was severely contracted. There was no splint in place. On 12/16/24 at 12:45 PM record review showe Resident #58 had a medical diagnosis of contractures to the right hand and a Physician's order for resting hand splint 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 record review and staff interview the facility failed to ensure the residents maintained acceptable parameters of nutrition to prevent weight loss, by not documenting accurate meal intakes. This failed practice was found true for (1) one of (4) four residents reviewed for nutrition during the Long-Term Care Survey Process. Resident identifier #82. Facility Census 89. Findings Include: a) Resident #82 A record review on 12/15/24 at 3:44 PM, revealed that Resident #82 had the following weights recorded since 09/06/24: 11/28/24-108.8 Pounds (Lbs) 11/26/24 -110.0 Lbs 11/19/24 -110.0 Lbs 11/11/24 -110.0 Lbs 11/7/24 -110.2 Lbs 11/1/24-116.0 Lbs 11/1/24-116.0 Lbs 10/28/24 -115.6 Lbs 10/21/24-116.0 Lbs 10/14/24-118.6 Lbs 10/7/24-120.4 Lbs 9/30/24-122.6 Lbs 9/25/24-122.8 Lbs 9/6/24-140.8 Lbs This averaged out to 22.73% percent weight loss in (2) two months. Further record review of Resident #82's medical record revealed that her Ideal Body weight (IBW) was 125.1 Lbs. A record review on 12/16/24 at 11:33 AM, of Resident #82's meal intake from 09/01/24 to present revealed that out of…

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

Based on record review and staff interview, the facility failed to monitor and treat pain in occurrence with professional standards of practice. This deficient practice had the potential to affect one (1) of five (5) residents reviewed for the care area of unnecessary medications. Resident identifier: #34. Facility census: 89. Findings included: a) Resident #34 The facility's policy titled Pain Management with effective date 01/01/04 and revision date 11/01/23 stated reasons for PRN (as needed) pain medication would be documented. Review of Resident #34's physician's orders showed an order written on 08/04/24 for acetaminophen (Tylenol) 650 milligrams (mg) by mouth every six (6) hours as needed for pain. Review of Resident #34's Medication Administration Record (MAR) showed the resident had received acetaminophen one (1) time, on 12/15/24 at 2:08 PM. The MAR documents the medication was effective in relieving the resident's pain. However, the location and the severity of the resident's pain was not recorded on the MAR or in the nurse's progress notes. On 12/17/24 at 1:42 PM, 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, resident interview and staff interview the facility failed to ensure residents special dietary requirements including preferences were met. This failed practice was a random opportunity for discovery during the Long-Term Care Survey Process. Resident identifier #54. Facility Census 89. Findings Include: a) Resident #54 An observation, on 12/15/24 at 1:04 PM, of Resident #54 eating lunch revealed that Resident #54 was served turkey, stuffing, and peas. Further observation revealed a meal ticket that indicated Resident #54 was to receive a chicken sandwich, lettuce and tomato, chef salad and a baked potato. During an interview on 12/15/24 at 1:04 PM, Resident #54 stated, I am supposed to get a salad. I don't always like what they give me but I try to eat it. During an interview, on 12/15/24 at 1:06 PM, Dietary Aide #30 stated, We don't have the chicken sandwich. I took her a salad and put the baked potato in now. A record review on 12/16/24 at 11:30 AM, revealed a Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/04/24, section C, that 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 record review, resident interview and staff interview, the facility failed to effectively make prompt efforts to resolve grievances made by the residents. This failed practice was a random opportunity for discovery and had the potential to affect more than a limited number of residents living in the facility during the survey process. Facility Census 85. Findings included: a) Call light response time. A review on 11/11/24 at 1:30 PM, of the Grievance/Concerns log revealed that on 10/08/24 The Resident Council made a complaint about call light response time. Further review of the Grievance/Concern log, revealed that the call light response time issue was resolved on 10/14/24. During an interview on 11/11/24 at 2:30 PM, the State Agency (SA) asked Resident #68 if he had to wait for long periods of time to get his call light answered? Resident #68 stated, Yes, sometimes I have to wait an hour or longer. Resident #68 could not specify any particular time that it was worse than others. During an interview on 11/11/24 at 3:00 PM, SA asked Resident #44 if she had to wait for long…

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 interview and resident interview, the facility failed to ensure that it maintained an environment that allowed the residents to receive care and services safely and that the physical layout of the facility maximizes residents independence and does not pose a safety risk. This failed practice was a random opportunity for discovery during the survey process. Resident identifier: #80. Facility Census 85. Findings Included: a) Resident #80 An observation on 11/11/24 at 3:30 PM, found in Resident #80's personal bathroom a hole in the wall on the right side of the sink at the bottom of the wall. Further observation of Resident #80 pulling up to his sink in his wheelchair to wash his hands revealed that he could not get up to the sink properly without putting his foot through the sheet rock. During an interview on 11/11/24 at 3:30 PM, Resident #80 stated, I cannot get in there very good because my right arm is paralyzed. It's hard for me to make the turn so my foot goes through the wall. You should see it when I brush my teeth. A record review on…

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

Based on record review and staff interview, the facility failed to obtain neurological checks for three (3) unwitnessed falls. Resident identifier: #80 Facility Census: #85. Findings Included: Record review on 11/12/24 at 9:15 AM found that Resident #80 has had three (3) unwitnessed falls. They were on 06/03/24, 08/17/24 and 08/28/24. According to the change in condition supplied by the facility, they were all unwitnessed falls. According to the Falls Management Policy #NSG215 (5) Post Fall Management: 5.3 Any patient who has a fall unwitnessed by staff will be observed for neurological abnormalities by performing neurological check, per policy According to the Neurological Evaluation Policy #NSG204 . Neurological evaluations will be performed as indicated or ordered. When a patient sustains an injury to the head or face and/or has an unwitnessed fall, neurological evaluation will be performed: Every 15 minutes x two (2) hours, then Every 30 minutes x two (2) hours, then Every 60 minutes x four(4) hours, then Every eight (8) hours until at least 72 hours has elapsed . On 11/12/24 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 the resident environment was clean, comfortable and homelike. Issues such as black marks, scuffs and pealing paint was found with the interior of the facility (doors, walls,) were found on three (3) of the four (4) hallways of facility. There were also issues with scuffs, black marks and pealing paint on the doors near the nursing station. Facility census: 82. Findings included: a) On 07/03/24 at 2:00 PM a walk trough of the facility with Maintenance Director #59 and Maintenance Assistant #64 issues with scuffs, black marks, and peeling paint was found on several doors on D hall. Issues were identified in Room D #32, D #33, D #35, D #40, D #28 and B #10. The issues identified were black scuff marks, pealing paint around the door frames. A pile of shingles were found outside the B/C hall. Evidence of spiders were found under the heat/air unit in the D wing fine dining area. The Maintenance Director and Assistant both confirmed they were aware of the issues. They both stated they were new at the facility and trying…

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 three (3) residents had been seen by a physician at least once every 30 days for the first 90 days after admission, and at least once every 60 thereafter. Resident identifiers: #28, #72, and #44. Facility census: 82. Findings included: a) Resident #28 During a review of Resident #28's medical record it was determined the physician had not seen the resident every 60 days. The physician had seen the resident on 11/10/23, 08/25/23, 05/19/23, 03/17/23, 01/06/23. The physician assistant had seen the resident on 06/19/24, 04/24/24, 04/19/24, 03/27/24, 03/21/24, 03/04/24, 03/01/24, 02/29/24, 01/26/24, 12/27/24, 11/14/23, 11/13/23, 11/07/23, 10/31/23, 10/29/23, 10/19/23, 10/16/23, 10/15/23, 10/12/23, 10/11/23, 07/14/23. b) Resident #72 During a review of Resident #72's medical record it was determined the physician had not seen the resident every 60 days. The physician had seen the resident on 02/10/24, 11/11/23, 05/26/23, 02/24/23, 12/02/22, 10/01/22, and on 09/09/22. The physician assistant had seen 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 resident and staff interview, the facility failed to provide a safe, clean, homelike environment for Resident #3, 54, 50, 46, 58, and 36. This was a random opportunity for discovery. This has the potential to affect more than a limited number of residents. Resident identifiers: 3, 54, 50, 46, 58, 36. Room identifiers: B10, B14, C26, D31. Facility census: 88. Findings included: A) Room #B10 At approximately 10:45 AM on 04/09/24, an observation was conducted of Room B10, where Resident #3 and 54 reside. During the observation, it was noted that the trim underneath the heating and cooling unit in the room was detached from the wall and was lying flat on the floor, exposing the wall behind the trim. Resident #54 stated It's been like that for a while but no one has come in to fix it yet. At approximately 01:00 PM on 04/10/24, the Administrator acknowledged the trim coming off the wall. At approximately 10:52 AM on 04/09/24, an observation was conducted of Room #B14, where Resident #50 resided. During the observation, a glove was discovered lying on the floor…

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

Based on record review and staff interview the facility failed to provide accurate one (1) resident was provided to the extent possible acceptable parameters of nutrition. Resident identifier: #2. Facility Census: #88 Findings included: a) Resident #2 On 04/09/24 at 10:02 AM record review shows Resident #2 has had a significant weight loss in the last three (3) months and the last six (6) months. Resident #2 had a medical diagnosis of: Eating disorder, feeding difficulties, and a recent diagnosis of Amyotrophic Lateral Sclerosis (ALS). She was on a regular diet, regular texture, finger foods preferred, large portions at all meals. She requires feed assist from staff. She was on monthly weights. According to documented weights, Resident #2 weighed 166.4 pounds as of 03/22/24. On 01/03/24 she weighed 182.2, reflecting a 8.67% weight loss in those three (3) months. Resident #2 weighed 190.2 pounds on 10/30/22, reflecting a 12.1% weight loss in the six (6) months from 10/30/22 until 03/22/24. A significant weight loss is identified as: 5% change in weight in 1 month (30 days) 7.5%…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and staff interview, the facility failed to provide a safe, clean, and homelike environment for Room #D32 which had trash and food laying on the floor, Room #D37 was noted with two (2) dirty and stained nightstands and a soiled blanket with a dry, brown substance on the bed in room [ROOM NUMBER]. The facility's sit to stand lifts were also observed dirty. These were random opportunities of discovery. Facility census: 83. Findings included: a) Room #D32 On 12/19/23 at 9:20 AM, an observation was made in Room #D32. The observation found trash and food lying on the floor under the beds and in the entire room. On 12/19/23 at 9:22 AM, Registered Nurse (RN) #20 stated, We will get this cleaned up right away. On 12/19/23 at 9:50 AM, the Director of Nursing (DON) was notified of the findings. The DON stated, We will get this taken care of right away. b) Room #D37 On 12/19/23 at 9:27 AM, an observation was made in Room D37. The observation found two (2) nightstands which were dirty and stained. On…

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

Based on record review and staff interview the facility failed to administer medications within the physician ordered time frames. Resident # 2, Resident # 27 and Resident #46 had medications administered late on multiple occasions during the month of 12/2023. This was true for three (3) of three (3) residents reviewed for medication administration during a complaint survey. Resident Identifiers: #2, #27, and #46. Facility Census: 83. Findings Included: a) Resident #27 A review of Resident #27's medication administration audit report for the month of 12/2023 found on the following occasions Resident #27 medication was administered more than one (1) and one (1) half hour past the scheduled time of administration: -- Insulin Sliding Scale was scheduled for 11:30 am on 12/03/23 and was not administered until 4:32 PM this was five (5) hours and two (2) minutes late. -- cyanocobalamin tablet was scheduled to be administered at 10:00 AM on 12/06/23 and was not administered until 12:08 PM which was two (2) hours and eight (8) minutes late. -- Duloxetine HCI oral capsule was scheduled to be…

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 implement care plans for one (1) of three (3) Residents whose care plans were reviewed during the long-term care complaint survey process. Resident # 2's care plan was not implemented for placing a radio in closer reach on the left side. Resident identifier: #2. Facility census: 83. Findings included: a) Resident #2 A review of resident #2's care plan found the current care plan, updated on 10/22/23 read as follows: Potential at risk for falls and actual falls: cognitive loss, lack of safety awareness, impaired mobility, history of falls The goal read as follows: Residents will have no falls with major injury requiring hospitalization through the next review. On 12/18/23 at 11:56 AM, an observation found Resident #2 sleeping in his room no radio was found in room within reach on left side of bed. On 12/19/23 at 10:30 AM, the Director of Nursing was interviewed and asked where the radio was that is care planned to be placed close on the left side of the bed. She stated, the family had taken it home.

Based on observation, resident interview and staff interview, the facility failed to ensure respiratory care was provided according to professional standards of practice. These were random opportunities of discovery. Resident Identifier: #2, #76, #28 and #1. Facility Census: 83. Findings Included: a) Resident #2 On 12/19/23 at 9:24 AM, an observation was made of Resident #2's nebulizer mask laying on the nightstand without being in a respiratory bag. On 12/19/23 at 9:25 AM, Licensed Practical Nurse (LPN) #13 was notified and confirmed the nebulizer mask was not stored correctly. LPN #13 stated, I will get a respiratory bag. On 12/19/23 at 10:00 AM, the Director of Nursing (DON) and the Administrator were notified and confirmed the nebulizer mask should have been placed in a respiratory bag. b) Resident #76 On 12/19/23 at 9:24 AM, an observation was made of Resident #2's nebulizer mask laying on the nightstand without being in a respiratory bag. On 12/19/23 at 9:25 AM, Licensed Practical Nurse (LPN) #13 was notified and confirmed the nebulizer mask was not stored correctly. LPN #13…

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 establish a system that determines drug records are in order and an account of all controlled drugs is maintained and periodically reconciled. The facility had controlled substances that had been removed from the medication card and was then taped back into the medication card on two separate medication carts. Also for Resident # 27 his tramadol, a controlled substance was signed out on the Controlled Substance log but was not documented as given on the Medication Administration Record (MAR). These failed practices have the potential to affect more than a limited number of residents. Resident Identifier: #27, #36 and # 75. Facility Census: 83. Findings Included: a) Medication cart for the A hall and D hall. An observation of the medication cart utilized for the A and D hall of the facility with Licensed Practical Nurse (LPN) # 13 on 12/19/23 at 10:41 am, found Resident # 36 had four (4) lorazepam .5 milligram tablets left in her medication card. As LPN #13 pulled it out of the controlled substance out of…

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

Based on observation, resident interview and staff interview, the facility failed to maintain appropriate infection control standards for the disposal of soiled linens in Rooms #D38 and #D32, the storage of a wash basin in Room #C26, the storage of a urinal in Room #C25, and in Room #D31 the storage of a used bed pan. These were random opportunities for discovery. Facility Census: 83. Findings Included: a) Room D38 On 09/19/23 at 9:30 AM, an observation was made of soiled linen in Room #D38 which was in two (2) clear plastic bags left open and untied sitting in floor of the room by the bathroom. Resident #76 stated, Those are from when they cleaned us up. On 09/19/23 at 9:35 AM, Licensed Practical Nurse (LPN) #13 was notified and confirmed the soiled linen bags should have been tied up and removed from the room. On 09/19/23 at 10:15 AM, the Director of Nursing (DON) was notified and confirmed the soiled linen bags should have been tied up and removed from the room. The DON stated, they know better than this .we will get it cleaned up. b) Room D32 On 09/19/23 at 9:45 AM, an…

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

Based on observation, record review, staff interview and random opportunities of discovery, the facility failed to maintain appropriate infection control standards for linen storage and disposal of dirty linen. These were random opportunities for discovery. Facility Census: 83. a) B Hall Linen On 09/19/23 at 1:23 PM, two (2) linen carts were observed on B Hall with the doors open and uncovered. Currently, there is one (1) COVID-19 positive resident residing on this hall. On 09/19/23 at 1:27 PM, two (2) dirty hand towels were observed laying on the floor of room B18. On 09/19/23 at 1:26 PM, Licensed Practical Nurse (LPN) #22 confirmed the two (2) linen carts were not covered and the doors were open. LPN #22 also confirmed the dirty linen was laying on the floor in room B18. LPN #22 stated, Maintanence worked on those carts Friday (09/15/23), I thought they fixed them. LPN #22 stated, okay in reference to the dirty linen laying on the floor in room B18. On 09/19/23 at 1:31 PM, the Administrator was notified and confirmed the linen cart doors should be shut and dirty linen should not…

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 revise a care plan for Resident #15 regarding lift status. This was true for one (1) of five (5) residents reviewed during the survey process. Resident Identifiers: Resident #15. Facility Census: 83. Findings Included: a) Resident #15 On 09/19/23 at 11:00 AM, a record review was completed for Resident #15. The review found a lift assessment dated [DATE] indicating the staff should use a gait belt while transferring the resident instead of a mechanical lift. The care plan was reviewed and the new lift status had not been revised to use the gait belt for transfers. On 09/19/23 at 1:00 PM, the Director of Nursing (DON) confirmed the care plan had not been revised. The DON stated, I take full responsibility .I didn't update the care plan but I did do the lift assessment. No further information was obtained during the survey process. .

Based on observation and staff interview, the facility failed to maintain a safe, functional, sanitary, and comfortable environement for resident #53 and resident #74. This was a random opportunity for discovery. Facility census is 83. Findings include: a) On 09/18/23 at approximately 2:35 p.m., observed some drywall repair work to the outer wall to the right of the window that was unsanded and unpainted in resident room D-38. b) On 09/18/23 at approximatley 2:37 p.m., observed that the cove base has separated from the base of the wall and the lower section of wall located behind the head of bed B appears to have some type damage located in Resident Room D-38. c) On 09/18/23 at approximately 2:55 p.m., observed that the empty bed space in room D-40 appears to have damage on the lower section of wall . d) On 09/19/23 at approximately 10:53 a.m., observed the sink in Resident Room A6 the hand washing sink was loose from the wall and the support leg was leaning inwards. e) Interview with Maintenance Assistant and the Director of Nursing verified these findings and findings were…

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 correctly inform and explain to beneficiaries the Centers for Medicare & Medicaid Services (CMS) Form #10055-Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN) when medicare services were ending for three (3) of three (3) residents reviewed for beneficiary notification. Resident identifiers: #59, #41, and #31. Facility census: 87. Findings included: a) Beneficiary Notification The facility provided a list of Medicare beneficiaries who were discharged from Medicare covered Part A services with benefits days remaining in the past 6 months. Three (3) residents, Resident's #59, #41, and #31 were chosen from the list for review. All 3 residents were provided with the CMS form 10055-a Skilled Nursing Facility Advance Beneficiary notice of non-coverage (SNFABN.) It is important to note that the CMS-10055, is only issued if the beneficiary intends to continue services and the skilled nursing facility believes the services may not be covered under Medicare. It is the facility's responsibility to inform 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, staff interview and policy review the facility failed to provide housekeeping and maintenance services necessary to maintain a sanitary, well-kept resident care area. Resident rooms were absent of clean bed linens, and personalization items that promoted a home-like environment. These failed practices were a random opportunity for discovery and had the potential to affect more than a limited number of residents. Facility census: 87. Findings included: a) Skilled Long Term Care Unit Room #B9: On 03/13/23 at 12:00 PM observation was made of Resident #50 laying on a blue mattress with no sheets covering mattress. Resident #50 was asked where the sheets were? Resident #50 replied, I don't know. Licensed Practical Nurse (LPN) #64 was asked why sheets were not on the Resident's bed? She stated, I don't know, I'll get the aides to put some on there. A light brown/yellow substance was spilled in the floor and at A bed and had ran across the floor under B bed. The bed control for the Resident…

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

Based on observation, policy review, resident interview, and staff interview the facility failed to make grievances forms accessible to all residents and resident representatives. This had the potential to affect more than a limited number of residents living in the Memory Unit. Facility census: 87. Finding Included: A review of the facility policy titled Grievance/Concern-Resident/Family with an effective date of 03/01/02 read as follows. .Purpose -To ensure that any resident or resident representative has the right to express a grievance/concern without fear of interference, coercion, discrimination or reprisal in any form. a) Grievances During the initial tour of facility on 03/13/23, observation found the Grievance forms were in a box on a wall beside the nurses station not accessible for the residents or resident representatives and not at wheelchair level for resident accessibility. During an interview on 03/14/23 at 3:14 PM, Dementia Program Director acknowledged the grievance forms need to be accessible to all residents and their representatives. .

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on record reviews and staff interviews the facility failed to provide Notices of Transfer to the State Ombudsman. This was discovered for three (3) of three (3) residents reviewed for hospitalizations during the Long-Term Care Survey Process. Residents #59, #77 and #87 were transferred to acute care hospitals, and no Notices of Transfer were provided to the State Ombudsman. Resident identifiers: #59, #77 and #87. Facility census: 87. Findings included: a) Policy A review of a facility policy titled Discharge and Transfer with a revision date of 11/15/22 reads as follows. .Written notice must also be provided to the Ombudsman or other required state agency using the NOID or state specific discharge form b) Resident #59 A medical record review on 03/15/23 for Resident #59, revealed the resident was discharged to the hospital on [DATE] and no Notice of Transfer was sent to the State Ombudsman. An interview with the Nursing Home Administrator (NHA) on 03/15/23 at 10:52 AM, reported there was no Notice of…

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

Based on record review and staff interview, the facility failed to track COVID-19 vaccination status for eight (8) of 149 facility employees. This deficient practice was identified during the infection control facility task and had the potential to affect more than a limited number of residents. Facility census: 87. Findings included: a) Staff vaccination tracking A spreadsheet of COVID-19 vaccination status for facility employees was provided by the administrator on 03/14/23 at 10:43 AM. On this spreadsheet, eight (8) employees were indicated to be unvaccinated, without delay or exemptions. These employees were as follows: Licensed Practical Nurse (LPN) #21, LPN #63, CNA (Certified Nursing Assistant) student #61, LPN #86, Bookkeeper #82, Housekeeper #114, Dietary Aid #104, and Laundry Worker #115. The Infection Preventionist subsequently provided documentation that all eight (8) employees were fully vaccinated against COVID-19. During an interview on 03/15/23 at 10:33 AM, the Infection Preventionist stated the spreadsheet was obtained from the corporate office and 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 medical record review, policy review and staff interview the facility failed to notify the resident's representative in a timely manner when Resident #77's was transferred to the hospital. This was true for one (1) of three (3) residents reviewed for hospitalizations. Resident Identifier: Resident #77. Facility census: 87. Findings Included: a) Resident #77 A review of a facility policy titled Change in Condition: Notification of with a revision date of 06/01/21 read as follows. POLICY A Center must immediately inform the resident/patient (hereinafter patient), consult with the patient's physician and notify, consistent with his/her authority, the patient's Health Care Decision Maker (HCDM), where there is: .A decision to transfer or discharge the patient from the Center During a record review on 03/15/23 at 9:18 AM Resident # 77's medical record revealed a Hospital transfer form on 07/13/22. The Resident Representative section was completed with the representative's name and telephone number. A question stated, Notified of transfer? The facility responded with, No. 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on record reviews and staff interviews the facility failed to ensure the required information was conveyed to the receiving providers, to ensure a safe and effective transition of care. This was discovered for two (2) of two (2) residents reviewed for the area of hospitalizations during the Long Term Care Survey Process. Resident identifiers: #59 and #87. Facility census: 87. Findings included: a) Resident #59 On 03/15/23 a medical record review revealed no transfer information was conveyed to the hospital on [DATE] for Resident #59 to ensure a safe and effective transition of care. The transfer information provided must include a minimum of the following: - Contact information of the practitioner responsible for the care of the resident. - Resident representative information including contact information - Advance Directive information - All special instructions or precautions for ongoing care, as appropriate. - Comprehensive care plan goals. During an interview on 03/15/23 at 11:00 AM, with the Nursing…

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 facility failed to obtain laboratory testing as ordered for one (1) of five (5) residents reviewed for the care area of unnecessary medications. Resident identifier: #13. Facility census: 87. Findings included: a) Resident #13 Review of Resident #13's physician's orders showed an order written on 10/10/22 for thyroid stimulating hormone (TSH) laboratory testing every six (6) months, in December and June. The resident had a diagnosis of hypothyroidism and was receiving the medication Levothyroxine as a thyroid replacement. Results for TSH testing in December could not be located in the resident's electronic records. During an interview on 03/15/23 at 3:11 PM, the Director of Nursing (DON) confirmed Resident #13 did not have TSH testing in December as ordered by the physician. No further information was provided through the completion of the survey process. .

Based on record review and staff interview the facility failed to provide an ongoing assessment and oversight for Resident #57 after hemodialysis treatments, that included monitoring the resident's condition for complications. Shared communication between the nursing home and the dialysis facility was not properly implemented. This failed practice was true for one (1) of one (1) resident reviewed for dialysis services with the potential to affect only a limited number of residents. Resident identifier: #57. Facility census: 87. Findings included: a) Resident #57 Record Review showed an order for Resident to attend hemodialysis at a local Dialysis center every Monday, Wednesday, Friday with time of departure to be 5:45 AM transported by local Ambulance service. On 03/13/23 at 2:40 PM, Record review showed no documentation to indicate if the Resident was out of the facility for Hemodialysis services. The Director of Nursing (DON) was asked if the Resident was out to the dialysis center? The DON stated, Yes she should be it is Wednesday. Did they not enter a note? They should have. 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, policy review, Resident Council meeting and staff interview the facility failed to provide Residents with evening snacks. This had the potential to affect a limited number of residents receiving snacks from the nourishment room and the Memory Unit kitchen. Facility Census: 87 Findings Included: a) Policy A review of a facility policy titled Snacks with a revision date of 09/17 read as follows. Snacks and beverages will be provided as identified in the individual plans of care. Bedtime (a.k.a. HS) snacks will be provided for all residents. Additional snacks and beverages will be available upon request for all residents who want to eat at non-traditional times. .4. The dining Services Department will assemble and deliver to each unit the individually planned snacks and bulk snack items to be offered at bedtime. 5. The Dining Service Department provides a listing of the current diet orders and snacks for each resident to each care area. 6. Nursing Services is responsible for delivering the individual snacks to the identified residents and the offering evening…

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

Based on observations and staff interviews, the facility failed to maintain the facility kitchens in a safe and sanitary manner in accordance with professional standards of practice. During the main kitchen tour it was discovered the freezer floor needed to be cleaned, the wall entering the Dish Room was in poor repair and the kitchen on the memory unit needed a deep cleaning. This had the potential to affect a limited number of residents. Facility census: 87. Findings included: a) Main kitchen tour During the main kitchen tour on 03/14/23 at 11:42 AM, it was discovered the floor to the walk-in freezer had a dark substance on the floor, in the back corners. Also the wall to the Dish Room had, missing corner molding, baseboard, and a hole in the wall. An interview with the Dietary Manager (DM) on 03/14/23 at 11:55 AM, verified the floor to the walk-in freezer needed to be cleaned and the wall to the Dish Room needed to be repaired. b) Memory Unit During the initial tour of the Memory Unit kitchen on 03/13/23 at 1:57 PM, with the Dementia Program Director (DPD) observation revealed…

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 reviews and staff interviews the facility failed to ensure complete and accurate medical records. The facility failed to ensure the Physician Orders for Scope of Treatment (POST) forms were completed per directions specified by the [NAME] Virginia Center for End-of-Life Care. This was true for three (3) of 18 residents reviewed for the area of Advance Directives during the Long-Term Care Survey Process. Resident Identifiers: #13, #59. Facility Census: 87. Findings included: a) Resident #13 A medical record review for Resident #13 on 03/14/23, revealed the POST had only a verbal consent witnessed by two (2) persons on 07/08/22 and no signature had been obtained by the Medical Power of Attorney (MPOA). In an interview with the Licensed Social Worker (LSW) on 03/14/23 at 12:09 PM, she verified there was no signature obtained from the Medical Power of attorney (MPOA) for the POST completed on 07/08/22. b) Resident #59 A medical record review for Resident #59 on 03/14/23, revealed the POST had only a verbal consent witnessed by two (2) persons on 07/21/21 and no signature…

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 offer influenza and pneumococcal immunizations to residents as appropriate. This deficient practice had the potential to affect two (2) of five (5) residents reviewed for the care area of immunizations. Resident identifiers: #69, #8. Facility census: 87. Findings included: a) Policy review The facility's policy titled Immunizations: Influenza/Pneumococcal with effective date 12/0/1/06 stated upon admission residents or health care decision makers were to be asked if the resident had ever received pneumovax, and/or annual influenza vaccine. Pneumococcal vaccination was to be encouraged for all residents who had never received the vaccine, for those who have unknown status of vaccination, and those over age [AGE] who were vaccinated five (5) or more years previously and were aged less than 65 at the time of vaccination. Influenza vaccination was to be offered in the fall of each year. b) Resident #69 Review of Resident #69's medical records…

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 document consent and refusal of COVID-19 vaccinations. This deficient practice had the potential to affect two (2) of five (5) residents reviewed for the care area of immunizations. Resident identifiers: #77, #33. Facility census: 87. Findings included: a) Policy review The facility's policy titled COVID-19 Vaccination with effective date 12/14/20 and review date 11/15/22 stated resident COVID-19 vaccination history would be obtained upon admission. Based on the resident's COVID-19 vaccination history, vaccination would be offered. Additionally, a Patient Informed Consent or Declination COVID-19 form was to be used. b) Resident #77 Review of Resident #77's medical records showed the resident had received a COVID-19 booster vaccination on 05/05/22. No COVID-19 vaccination consent form was located in the resident's medical records. During an interview on 03/15/23 at 9:19 AM, Unit Manager (UM) #19 stated she was unable to locate a consent form for Resident #77's COVID-19 vaccination on 05/05/22. UM #19 stated she spoke…

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.