Martinsburg Healthcare Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on review of the concern/grievance forms, review of the facility documentation of reportable occurrences, and staff interview, the facility failed to ensure that all alleged violations of abuse, were reported immediately, to all officials (including to the State Survey Agency and Adult Protective Services (APS), where state law provides for jurisdiction in long-term care facilities) in accordance with State law, through established procedures. This deficient practice was found true for two (2) of four (4) residents reviewed. An allegation of abuse, the staff had knowledge of, was not reported in a timely manner involving Residents #20 and #119. Resident identifiers: Residents #20 and #119. Facility census: 116. Findings included: a) Policy Review A review of the Policy and Procedure, titled: WV Abuse, Neglect and Misappropriation, Policy #NS1018-03, approval date of 05/25/23, noted on page 15 of the policy, under 1. B., if the allegation did not cause serious bodily injury or abuse, the report must 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 and staff interview the facility failed to notify the physician of a significant weight loss to evaluate and manage causes of the resident's nutritional risks and impaired nutritional status. This is true for one (1) of three (3) residents reviewed for weight loss. Resident identifier: # 51. Facility census: 116. Findings included: a) Resident #51 On 09/19/23 during a complaint survey for weight loss and physician notification a record review for Resident #51 revealed a significant weight loss on 09/01/23. Registered Dietician Notes: 9/1/2023 14:27 Weight Change Note Note Text: WEIGHT WARNING: Value: 180.8 -5.0% change over 30 day(s) [ 6.7%, 13.0] -3.0% change over 30 day(s) [ 3.8%, 7.2] -5.0% change [ 6.8% 13.2 ] (Transcribed as Written) 9/18/2023 15:50 Weight Change Note Note Text: WEIGHT WARNING: Value: 179.2 -3.0% change over 30 day(s) [ 4.0%, 7.4] -7.5% change [ 7.6%, 14.8] -10.0% change [ 10.6%, 21.2] (Transcribed as Written) Continued Medical record review found no notification of the Physician for Resident #51's significant weight changes. On 09/19/23…

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

Based on record review and staff interview, the facility failed to administer pain medication as ordered by the physician. This was true for one (1) of five (5) records reviewed for pain management. This failed practice has the potential to affect a limited number of resdents. Resident identifier: #424 Facility census: #115. Findings included: a) Resident #424 On 05/24/23 at 4:08 PM, it was noted the facility did not follow physicians orders for administering pain medication for Resident #424. The physicians order with a revision date of 11/19/22 was for Oxycodone HCL tablet 5 mg give 1.5 tablet by mouth every 6 hours for pain. For the review period of 11/01/22 through 12/31/22 there were nine (9) doses of Oxycodone not administered. Resident #424 was under Hospice care for end of life care during this time period. Further review of the Medication Administration Record (MAR) shows the following: On 11/17/22 at 6:00 AM the medication was signed out of the narcotic count log by Registered Nurse #129 but not documented as being administered. On 11/22/22 at 6:00 PM the medication was…

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

Based on staff interview, medical record review, and policy review, the facility failed to ensure monthly medication regimen reviews (MRR) were completed by a pharmacist and the physician responded to the pharmacy recommendations in a timely manner. This is true for four (4) of five (5) reviewed for unnecessary medications. Resident identifiers: #7, #34, #8, #22. Facility census: 115. Findings include: a) Policy The facility policy titled Medication Regimen Review with a review date of 02/28/23, states non-urgent medication irregularities will be addressed with the attending physician no later than the next routine visit. The attending physician must document in the medical record the identified irregularity reviewed, any action taken to address rational for declining the recommendation. b) Resident (R) #7 Review of the medical record on 05/23/23 revealed there were no MRR for October 2022, November 2022 and February 2023. In addition, the medical record lacks a physician response to the MRR dated 08/27/22. The MRR date 08/27/22 requests a gradual dose reduction for R#7'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 resident interviews during resident council, and staff interview, the facility failed to ensure a substantial/nourishing snack was provided as ordered and/or offered if of ordered between the evening meal and breakfast. This had the ability to affect all residents who did not have a dietary order to receive an evening snack. Resident identifiers: #61, #30, #54, #36, and #9. Facility Census: 115. Findings included: a) Resident Council Meeting During the resident council meeting on 05/23/23 at 1:00 PM, all residents in attendance stated the facility did not offer an evening snack to residents. They went on to say they would like an evening snack and felt the majority of facility residents would enjoy a bedtime snack. One (1) resident stated, They used to do that, but they don't do it anymore. Another resident reported being told by staff that the new ownership doesn't like to provide the snacks and the individual should probably have family bring them. When asked if all residents in the facility had ever been told they could request an evening snack, resident council members…

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 complete labeling and dates on refrigerator and freezer items in accordance with professional standards for food service safety related to storage. This has the ability to affect all Residents that receive their nutrition from the kitchen and pantries. Facility census: 115. Findings included: Record review of the facility's policy titled, Food Storage with revision date 09/2017, showed that All food will be stored wrapped or covered containers, labeled, and dated, and arranged in a manner to prevent cross contamination. a) Kitchen During the initial kitchen tour on 05/22/23 at 9:15 AM, an observation found: --Walk-in Freezer- pork Butcher Box, 2 hamburger patties, large package of hot dogs, chicken crumbles, were not labeled or dated. Walk-in Freezer- Box of sausage patties, Chicken pieces and a pork roast, not closed, open to air. During an interview on 05/22/23 at 9:22 AM, the Dietary Director confirmed the items were not labeled and stated that all food items should be labeled and dated. b) Resident North Pantry'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 and staff interview, the facility failed to store garbage and refuse in a proper manner. One (1) dumpster did not have a lid, the area was polluted with garbage and used medical supplies. This has the potential to affect all residents that reside in the facility. Facility census: 115. Findings included: a) Dumpster area An observation on 05/24/23 found on the ground around the dumpster area was polluted with garbage, bags full of trash, and used medical supplies. On 05/24/23 at 1:57 PM during an interview the Maintenance Director verified the garbage was not disposed of correctly. He stated that the lid to the dumpster has been gone for a while. .

Based on record review and staff interview, the facility failed to maintain a complete and accurate medical record for four (4) of thirty-two (32) records reviewed. Resident identifiers: #88, #421, #91 and #91. Facility census: 115. Findings included: a) Resident #88 On 05/22/23 at 2:32 PM it was noted that there was a transmission based precaution (TBP) donning/doffing station outside of Resident #88's room. There was however, no signage on the door to instruct what kind of precautions or Personal Protective Equipment (PPE) was needed. According to Licensed Practical Nurse (LPN) #4 the resident had nebulizer treatments ordered and the PPE is for treatments. The order states: Albuterol Sulfate inhalation Neulization Solution 2.5 MG/0.5 ML (Albuterol Sulfate) 1 vial inhale orally via nebulizer every 4 hours as needed for COPD. and DuoNeb Solution 0.5-2.5 (3) MG/3 ML (Ipratropium-Albuterol 1 application via mask every 6 hours as needed for COPD. According to the Director of Nursing (DON) on 05/24/23 at 2:00 PM, there should be an order reading: Aerosol Droplet Precautions during…

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

Based on observation, record review, staff interview and policy review, the facility failed to have signage on the door and/or a donning/doffing station available at the door of a resident's room designated as a transmission-based precaution (TBP) room. Resident Identifiers: #88, #114, #111 and #101 Facility census: 115. Findings included: a) Policy review According to the Guidance for Aerosol Generating Procedures dated 02/03/22, An N95 mask, and full PPE must be worn with all aerosol generating procedures.close the door to the resident room before performing treatment. Keep door closed throughout treatment and for one hour post treatment if it is safe to do so . b) Resident #88 On 05/22/23 at 2:32 PM it was noted that there was a donning/doffing transmission based precaution (TBP) station outside of Resident #88's room. There were however, no signage on the door to instruct what kind of precautions or Personal Protective Equipment (PPE) was needed. According to Licensed Practical Nurse (LPN) #4 the resident has nebulizer treatments ordered and the PPE is for treatments. The order…

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

Based on resident interview, record review, and staff interview, the facility failed to protect and promote the rights of Resident #50. The facility failed to issue Resident #50 an invitation to attend two (2) appeals hearings regarding the discharge for nonpayment. This was a random opportunity for discovery. Resident identifier: #50. Facility census: 115. Findings included: a) Resident #50 During an interview on 05/23/23 at 8:11 AM, Resident #50 reported she had been given a discharge notice for nonpayment. Record review, completed on 05/23/23 at 7:10 PM, identified the following details: -A Physician Determination of Capacity, dated 04/21/21, which stated Resident #50 had capacity to make decisions. -A Durable Power of Attorney (DPOA) on file listing resident's family member as DPOA. (A durable power of attorney is a legal document that gives another person the authority to make financial decisions for someone.) -A Social Service Note, dated 02/17/23 at 9:03 AM, stated that the social worker had received notification from the Business Office Manager of a telephone hearing 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 policy review, record review, resident interview and staff interview, the facility failed to immediately inform a resident or the resident representative when there was a need to begin a new form of treatment or a change in care was required for two (2) or 32 residents reviewed. Resident #10's representative was not notified of a facility acquired pressure ulcer or the initiation of treatment for the pressure ulcer and Resident #30 was not notified of a change in a medical appointment. Resident identifiers: Resident #10 and Resident #30. Facility census: 115. Findings included: a) Policy Review A review of the Policy for Notification of Change in Condition, titled Policy #NS1068-01, no date noted, showed under Circumstances requiring notification included but was not limited to, under item 3, Circumstances that require a need to alter treatment which may include a new treatment or discontinuation of a current treatment. Under the section Notifications, when a change in condition was noted, nursing staff would contact the resident and/or representative. b) Resident #10 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on record review and staff interview, the facility failed to provide evidence the required Notification of Medicare Non-Coverage (NOMNC) notice was issued in a timely fashion for one (1) of three (3) residents reviewed for beneficiary protection notification. This failure had the potential to place the resident at risk of not being informed of their rights prior to the end of Medicare Part A covered services. Resident identifier: #370. Facility census: 115. Findings included: a) Beneficiary Notice Review On 05/23/23 at 11:00 AM, a review was completed regarding the beneficiary protection notification liability notice given for the following resident who was discharged home following her last covered day of Medicare Part A services: -Resident #370's last covered day of Part A Services was on 01/02/23. -Resident #370 was not issued a NOMNC. -Resident #370 was discharged to home on [DATE]. The Form Instructions for the Notice of Medicare Non-Coverage (NOMNC) CMS-10123 state: The NOMNC must be delivered 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, record review, and staff interview, the facility failed to honor a resident's right to privacy and confidentiality for all aspects of care and services. This was a random opportunity for discovery. Resident identifier: #50. Facility census: 115 Findings included: a) Resident #50 During an interview on 05/23/23 at 8:11 AM, Resident #50 reported being upset that the facility's Social Worker (SW) discussed private information about her finances and the fact that she was being discharged for nonpayment in front of her roommate. A record review, completed on 05/23/23 at 7:02 PM, revealed the following: - A Social Service Note, dated 4/25/2023 at 10:45 AM, which stated, This writer and Transportation Coordinator spoke with the patient at length regarding discharge planning. Patient reports that if she is unable to secure a HB (hospital bed), lift, and all other supplies/services necessary to ensure her discharge is safe, she states she will not be discharging . Patient's hearing date is 5/16 and she still won't make a decision as to where she's discharging. -…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on resident interview, observation and staff interview, the facility failed to maintain the walls of a resident's room and keep a resident's wheel chair clean and odor free. These were random opportunity for discovery. Resident identifiers: #53 and room [ROOM NUMBER]. Facility census: 115. Findings included: a) Resident (R) #53 During an interview on 05/22/23 at 10:02 AM R#41 reported her roommate R#53 is frequently incontinent, her wheel chair smells of urine and is not cleaned regularly. R#41 pointed to the wheel chair in the hall and acknowledged it smells. An observation noted a strong odor of urine and multiple food crumbs in the seat and foot rest of the high back wheel chair. At 11:03 AM on 05/23/23, Registered Nurse (RN) #10 and Central supply coordinator (CS) #138 confirmed R#53's wheel chair was full of food crumbs and smelled of urine. CS#138 removed the cushioned cover from the wheel chair and carried it to the laundry. After checking with the supervisor, laundry staff reported the cover…

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, electronic medical record review and Operation Policy, the facility failed to follow written policy, thoroughly investigating and reporting to the proper agencies of an allegation of neglect. This has the potential to affect all residents that reside in the facility. Resident identifier: #4. Facility census: 115. Findings Included: A record review of the facility's policy titled, West Virginia Abuse, Neglect & Misappropriation, showed: --Training 1) Provide education and training upon hire, annually and as needed for re-training to include not limited to: a-Recognizing signs of abuse, neglect exploitation, and misappropriation of resident property, such as psychosocial and physical indicators (including injuries of unknown source) --Reporting 1) The Executive Director / designee will report appropriate incidents to Office of Health Facilities Licensure and Certification (OHFLAC), Adult Protective Services (APS), the Regional Ombudsman, and other local authorities, including but not limited to local law enforcement (if appropriate), as required…

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 operation policy the facility failed to report alleged violation related to, neglect, or abuse, and report the results of all investigation to the proper authorities within prescribe time frames. This has the potential to affect all residents that reside in the facility. Facility census: 115. Findings Include: Record review of the facility's policy titled, West Virginia Abuse, Neglect & Misappropriation, showed: --Training 1) Provide education and training upon hire, annually and as needed for re-training to include not limited to: a-Recognizing signs of abuse, neglect exploitation, and misappropriation of resident property, such as psychosocial and physical indicators (including injuries of unknown source) --Reporting 1) The Executive Director / designee will report appropriate incidents to OHFLAC, APS, the Regional Ombudsman, and other local authorities, including but not limited to local law enforcement (if appropriate), as required by the State. a- If the events that cause allegation do not involve abuse and do not result in serious…

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 operation policy the facility failed to take actions to investigate an alleged violation related to, neglect and failed to take corrective actions following an investigation to re-educate staff after a resident injury. This has the potential to affect all residents that reside in the facility. Resident identifiers: #4, #13, #10. Facility census: 115. Findings Included: Record review of the facility's policy titled, West Virginia Abuse, Neglect & Misappropriation, showed: --Training 1) Provide education and training upon hire, annually and as needed for re-training to include not limited to: a-Recognizing signs of abuse, neglect exploitation, and misappropriation of resident property, such as psychosocial and physical indicators (including injuries of unknown source) --Reporting 1) The Executive Director / designee will report appropriate incidents to OHFLAC, APS, the Regional Ombudsman, and other local authorities, including but not limited to local law enforcement (if appropriate), as required by the State. a- If the events that cause…

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 the long-term care Ombudsman was provided a copy of the written Notice of Transfer for two (2) acute hospital transfer/discharges for Resident #92. This was true for one (1) of two (2) residents reviewed for hospitalizations. Resident identifier: #92. Facility census: 115. Findings included: a) Resident #92 A medical record review was completed on 05/23/23 at 11:00 AM. There was no evidence the facility had provided a copy of the written Notice of Transfer/Discharge for Resident #92 to the long-term care Ombudsman for an acute hospital transfer/discharge on [DATE] or for another acute hospital transfer/discharge on [DATE]. In an interview on 05/24/23 at 11:11 AM, the Director of Nursing (DON) reported the facility could not produce evidence that the Ombudsman had been notified.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on medical record review and staff interview, the facility failed to notify the resident/resident representative of the facility bed hold when transferred. This was true for one (1) of two (2) residents reviewed for hospitalizations. Resident identifier: #92. Facility census: 115. Findings included: a) Resident #92 A medical record review was completed on 05/23/23 at 11:00 AM. There was no evidence the facility had provided a bed hold notice for an acute hospital transfer/discharge on [DATE]. In an interview on 05/24/23 at 11:11 AM, the Director of Nursing (DON) reported the facility had not provided a bed hold notice for the 05/10/23 discharge because the facility had initially thought it was discharging Resident #92 to the behavioral health treatment center as opposed to the resident having a short-term stay for stabilization purposes and then returning to their facility. .

Based on observation, policy review and staff interview, the facility failed to develop a comprehensive care plan for Aerosol droplet precautions. This was true for two (2) of thirty two (32) care plan records reviewed. Resident identifiers: #88 and #91. Facility Census: #115. Findings included: a) Resident #88 On 05/22/23 at 2:32 PM during the initial interview phase of the Long Term Care Survey Process it was noted that there was a transmission based precaution (TBP) donning/doffing station outside of Resident #88's room. There was however, no signage on the door to instruct what kind of precautions or what personal protective equipment (PPE) was needed. According to Licensed Practical Nurse (LPN) #4 the resident has nebulizer treatments ordered and the PPE is for treatments. The order states: Albuterol Sulfate inhalation Neulization Solution 2.5 MG/0.5 ML (Albuterol Sulfate) 1 vial inhale orally via nebulizer every 4 hours as needed for COPD. and DuoNeb Solution 0.5-2.5 (3) MG/3 ML (Ipratropium-Albuterol 1 application via mask every 6 hours as needed for COPD. According to the…

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

Based on observation, record review and staff interviews, the facility failed to revise care plans for two (2) of 32 resident's care plans during the Long Term Care Survey Process. Resident #3's had not been revised for a nutritional intervention and Resident #421 had not been revised for hospice services. Resident identifiers: #3 and #42. Facility census: 115. Findings included: a) Resident #3 During a medical record review on 05/22/23 for Resident #3 revealed the care plan had not been revised for the nutritional intervention to add a double entree' portion with meals/per dialysis for protein with a start date of 01/23/23. In an interview with the Director of Nursing (DON) on 05/24/23 at 9:37 AM, verified the care plan was not revised to include the order for double entree portions for meals with a start date of 01/23/23. b) Resident #421 On 05/22/23 at 1:33 PM a record reviewed showed there was no order for hospice care while it was on the facility matrix as an active resident under hospice care. Record review of the care plan and an interview on 05/23/23 at 1:51 PM with the DON…

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 a physician's orders for weekly weights and the administration of pain medication for a Hospice resident was not followed. These were random opportunities for discovery with the potential to affect a limited number of residents. Resident identifiers: #424 and #57. Facility census: 115. Findings included: a) Resident #424 On 05/24/23 at 04:08 PM, it was noted the facility did not follow physicians orders for administering pain medication for Resident #424. The Physicians order with a revision date of 11/19/22 was for Oxycodone HCL tablet 5 mg give 1.5 tablet by mouth every 6 hours for pain. For the review period of 11/01/22 through 12/31/22 there were nine (9) doses of Oxycodone not administered. Resident #424 was under Hospice care for end of life care during this time period. Further record review of the Medication Administration Record (MAR) shows the following: On 11/17/22 at 6:00 AM the medication was signed out of the narcotic count log by Registered Nurse #129 but not documented as being administered. 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 provide care and treatment, based on the comprehensive assessment of the resident, to ensure a resident received care, consistent with professional standards of practice, for pressure ulcer care. This was found true for one (1) of five (5) residents reviewed for pressure ulcer care. Resident #10 developed a facility acquired pressure ulcer, however, there were inconsistencies with the identification and time treatment was started to ensure monitoring of the healing process for the pressure ulcer. Resident Identifier: Resident identifier: #10. Facility census: 115. Findings included: a) Resident #10 An interview, with the Treatment Nurse, on 05/23/23 at 8:24 AM, revealed the facility's policy is to perform weekly measurements of a pressure ulcer. Additionally, the Treatment Nurse confirmed, when a pressure ulcer was identified, the date would be documented the pressure ulcer was identified and treatment initiated. A record review for Resident #10, showed documentation of a skin assessment being completed on 12/12/22,…

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

Based on employee record review and staff interview, the facility failed to ensure Employee #44 and #148 had completed the required annual 12 hours of in-services for dementia and abuse prevention. This deficient practice was found true for two (2) of five (5) employee records reviewed for staffing. Employee identifiers: #44 and #148. Facility Census: 115. Findings included: a) Required annual 12 hour in-services During a review of employee records on 05/23/23, it was discovered employee Nurse Aide (NA) #44 and NA #148 had not completed addressing areas of the required annual in-services to include special resident needs, needs of residents with cognitive impairments, and abuse prevention. In an interview with the Nursing Home Administrator (NHA) 05/24/23, verified NA #44 and #148 had not completed the required annual in-services to include dementia, cognitive impairments and abuse prevention. .

Based on a review of staff postings and staff interview, the facility failed to display the required data on the daily Staff Postings. This was a random opportunity for discovery and affected a limited number of residents and visitors. Facility census: 115. Findings included: During a review of the staff postings on 05/23/23, it was discovered the daily staff postings for 05/01/23 to 05/22/23 had no daily census. The facility must post the following information on a daily basis: 1. Facility name. 2. The current date. 3. The total number . 4. Resident census. In an interview with the Nursing Home Administrator (NHA) on 05/24/23 at 1:20 PM, verified the Staff Postings did not include the daily census. .

Based on medical record review and staff and interview, the facility failed to ensure each resident and/or representative is educated on the risks and benefits and given the opportunity to accept or decline the pneumonia vaccine prior to administration. This is true for one (1) of five (5) residents reviewed for immunizations. Resident identifier: #40 Facility census: 115. Findings include: a) Resident (R) #40 Review of the medical record on 05/22/23, found R#40 received the pneumococcal conjugate 20 (PCV20) vaccine on 09/05/22. The record lacks information related to education given to the resident on the risks and benefits of the vaccine and a consent to receive the PCV20 on 09/05/22. During an interview on 05/22/23 at 3:35 PM, the Infection Preventionist/Registered Nurse #23 acknowledged the medical record lacked a consent for the PCV20 vaccine administered to R#40 on 09/05/22. .

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on observation, interview and record review, the facility failed to serve food to residents at the same table in the north dining room as well as in resident rooms. Resident #1 was put to bed without sheets. Resident identifiers #1. North Dining room and north hall rooms 105, 112 and 115. Facility Census 111. Findings included: a) Resident #1 - No sheets on Bed On 06/07/22 at 12:30 PM, observed resident laying in her bed with no sheets. During an inteview with Registered Nurse (RN) Unit #133 at 12:35 PM verified the resident should not be in bed without any sheets. RN Unit Manager #133 further stated, Resident just got back from getting a shower and then the lunch cart came so the aide who has the resident probably did not have time to make the bed. Not that it changes anything but, yes, I will address it. d) North Hall On 06/07/22 at 12:00 PM during an observation of the noon meal tray pass on the North Hall, rooms 105 to 115 found, staff did not serve each resident in rooms [ROOM NUMBER] at 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, interview, and record review, the facility failed to ensure residents with contractures had interventions in place to prevent further decline. This was true for three (3) of five (5) resident reviewed for the care area of limited range of motion (ROM) during the long-term care survey process. Resident identifiers: #26, #65, and #73. Facility census: 111. Findings included: a) Resident #26 During a resident interview, on 06/06/22 at 6:04 PM, Resident #26 pointed to a splint that was resting on top of the nightstand and stated, I'm supposed to wear that splint on my hand [pointing to her left hand] every day but the staff doesn't always know how to put it on correctly without hurting me, so I just let it go. When asked if she would wear the splint if it was applied appropriately and did not cause her discomfort Resident #26 stated, Yes. I know I should be wearing it every day. When asked how long it ha been since she had worn the splint to her hand Resident #26 replied, It's been months…

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 policy review, record review, and staff interview, the facility failed to ensure a drug regimen of each resident was completed at least once a month by a licensed pharmacist. This was true for four (4) of six (6) residents reviewed for unnecessary medication reviews during the annual long-term care process. Resident identifiers: #93, #75, #59, #73. Facility census: 111. Review of the facility's policy entitled Medication Regimen Review (MRR) Time Frame, with a revision date of 05/03/21, found the following guidance, The medication regimen of each patient is reviewed at least once a month by a licensed Consultant Pharmacist. Findings included: a) Resident #75 A medical record review was completed on 06/09/22 at 8:31 AM. A monthly medication regimen review (MRR) was not on file for the months of July 2021 and August 2021. During an interview, on 06/09/22 at 9:40 AM, the Director of Nursing (DON) reported the facility was in transition switching to Remedi Senior Care (a business that provides pharmacy services to long-term care facilities) and there was no official pharmacist…

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

Based on interview and record review the facility failed to making prompt efforts to resolve a grievance and to keep the resident notified of progress toward resolution. This is true for one (1) of four (4) reviewed for grievances during the Long-Term Care Survey Process (LTCSP). Resident identifiers: #19. Facility census: 111. Findings included: a) Resident #19 On 06/06/22 at 3:58 PM during an interview with Resident #19, she stated that her bible has been stolen/ missing for a week or more. Resident #19 stated that she reported the bible missing and nothing has been done about the item. 06/08/22 a record review of missing items /grievances revealed, no grievance form was filled out. A medical record review of Resident #19's quarterly 3/18/22 Minimum Data Set (MDS), found the resident's brief interview for mental status was twelve (12). A BIMS score of 12 indicates that the resident is considered to be mildly impaired cognitively. A continued medical record review for Resident #19 revealed a progress note dated 6/2/2022 at 4:15 PM: --Activities Note -Note Text: Patient was 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, resident interview, family interview, record review and staff interview the facility failed to ensure residents were free from abuse in the form of mental anguish. The failed practices were random opportunities for discovery. Resident identifiers: #62. Facility census: 111. Findings included: a) Resident #62 During an interview on 06/06/22 at 4:30 PM, Resident #62 stated that there was a problem with another Resident and the problem resulted in a resident to resident altercation on 06/02/22. Resident #62 stated the other resident aggressively claimed Resident #62 stole a Bible. Resident #62 stated the other resident, yelled at me saying you stole my Bible. Resident #62 stated that the door of room had been closed and the resident opened the door to Resident #62's room, walked right in and again began asking where was the Bible. Resident #62 stated she did not report to staff when the resident willfully entered room but stated all staff did after the resident to resident altercation was add an additional anxiety medication so now I am on two (2) anxiety…

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

Based on resident interview, observation, record review and staff interview facility failed to thoroughly investigate a resident to resident altercation to prevent and take corrective action as a result of the investigative findings. The failed practice was a random opportunity for discovery. Resident identifier: #62. Facility census 111. Findings included: Record review of the facility's policy titled, Compliance with Reporting Allegations of Abuse/Neglect/Exploitation , revised on 08/26/19, stated, The Center will investigate all allegations and incidents. a) Resident #62 During an interview on 06/06/22 at 4:30 PM, Resident #62 stated that there was a problem with another Resident and the problem resulted in a resident to resident altercation on 06/02/22. Resident #62 stated the other Resident aggressively claimed Resident #62 stole a Bible. Resident #62 stated the other resident, yelled at me saying you stole my Bible. Resident #62 stated that the door of room once had been closed and the Resident opened the door to Resident #62's room, walked right in and again began asking…

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 one (1) of four (4) residents reviewed for hospitalizations during the long-term care survey process. Resident identifier: #12. Facility census: 111. Findings included: a) Resident #12 An electronic medical record review was completed on 06/07/22 at 10:36 AM. Resident #12 was discharged to the hospital on [DATE]. There was no evidence a written Notice of Transfer/Discharge was provided to Resident #12's legal representative. During an interview on 06/08/22 at 10:40 AM, the Assistant Director of Nursing (ADON) reported the facility was unable to provide evidence a Notice of Transfer Discharge was given to resident's legal representative. Additionally, the facility failed to produce…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on medical record review and staff interview, the facility failed to provide evidence a resident/resident's representative was provided a written Bed Hold Notice for a hospital transfer. This was true for one (1) of four (4) residents reviewed for hospitalizations during the long-term care survey process. Resident identifier: #12. Facility census: 111. Findings included: a) Resident #12 An electronic medical record review was completed on 06/07/22 at 10:36 AM. Resident #12 was discharged to the hospital on [DATE]. There was no evidence a written Bed Hold Notice was provided to Resident #12's legal representative. During an interview on 06/08/22 at 10:40 AM, the Assistant Director of Nursing (ADON) reported the facility was unable to provide evidence a Bed Hold Notice was provided to Resident #12's legal representative. .

Based on record review, and staff interview, the facility failed to follow physician orders related to insulin. This was true for one (1) of six (6) residents reviewed for drug regimen review during the annual long-term care survey process. Resident identifier: #93. Facility census: 111. Findings included: a) Resident #93 A record review was completed on 06/06/22 at 5:43 PM. The record review demonstrated that Resident #93 had a diagnosis of diabetes mellitus and had three (3) different orders for administration of insulin to treat her disease. A review of the Medication Administration Records (MARS) for revealed three different occasions the physician orders were not followed, and the MAR was left blank regarding the administration of insulin for Resident #93. On 03/12/22 the physician order, Lantus SoloStar Solution Pen-injector 100 UNIT/ML (Insulin Glargine) Inject 18 unit subcutaneously two times a day for Diabetes Mellitus was not followed. There was no documentation on the MARS that the 8:00 PM dose was administered. On 06/22/22 the physician order, NovoLOG FlexPen Solution…

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, medical record review, and interview, the facility failed to deliver respiratory care services consistent with professional standards of practice. A physician's order for oxygen was not followed. This was a random opportunity for discovery, during the Long-Term Care Survey Process (LTCSP). Resident Identifier: #70. Facility Census: 111. Findings included: a) Resident #70 An observation of Resident #70, on 06/06/22 at 4:03 PM, revealed the Resident was receiving oxygen at one (1) Liters via nasal cannula (an oxygen delivery device) from an oxygen concentrator. A review of Resident #70's physician order, revealed the order Oxygen at two (2) Liters Per Minute (LPM), for shortness of breath. A second observation of Resident #70, on 06/08/22 at 1:49 PM, revealed the Resident was receiving oxygen at one (1) Liters via nasal cannula from an oxygen concentrator. An interview with Registered Nurse (RN) #133 on 06/08/22 at 1:55 PM, verified the Resident was receiving oxygen One (1) Liter Per Minute. RN #133 confirmand that Resident #70 was ordered oxygen at two (2)…

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

Based on resident interview, observation, record review and staff interview the facility failed to assess for the indications required for the use an antianxiety medication and adequately monitor the medication side effects. This was a random opportunity for discovery. Resident identifier: #62. Facility census: 111. Findings included: a) Resident #62 During an interview on 06/06/22 at 4:30 PM, Resident #62 stated that there was a problem with another Resident and the problem resulted in a resident to resident altercation on 06/02/22. Resident #62 stated the other Resident aggressively claimed Resident #62 stole a Bible. Resident #62 stated the other resident, yelled at me saying you stole my Bible. Resident #62 stated that the door of room had been closed and the Resident opened the door to Resident #62's room, walked right in and again began asking where was the Bible. Resident #62 stated she did not report to staff when the resident willfully entered room but stated all staff did after the resident to resident altercation was add an additional anxiety medication so now I am on 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 resident interview, observation, record review and staff interview the facility failed to accurately document pain levels for pain management and did not documented the administration of an anxiety medication or the side effects of the medication after administration. The failed practice was true for two (2) of 32 sampled residents. Resident identifiers: #13 and #62. Findings included: a) Resident #13 During an interview on 06/06/22 at 3:34 PM, Resident #13 stated, I have pain. I do take Norco and have a prn Tramadol but the Norco does not always cut it . Review of Resident #13's medical record showed a diagnosis of chronic pain due to trauma. A physician order with start date of 03/18/22 stated, Norco Tablet 10-325 MG (Hydrocodone-Acetaminophen) *Controlled Drug*Give 1 tablet by mouth every 6 hours as needed for pain. The Medication administration record (MAR) for June 2022 showed Resident received Norco for a pain level of five (5) on 06/06/22 at 8:16 AM and again for a pain level of four (4) on 06/07/22 at 7:41 AM. The MAR also stated, Is resident currently experiencing…

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.