Morgantown Healthcare Center

Based on record review and staff interview, the facility failed to ensure one (1) of 29 residents reviewed during the long-term care survey process for Physician Orders for Scope of Treatment (POST) forms completed per directions specified by the [NAME] Virginia Center for End-of-Life Care in conjunction with the [NAME] Virginia Health Care Decisions Act (16-30-1). Resident identifiers: #42. Facility census: 116. Findings included: a) Resident #42 Record review on 04/30/25 at 8:55 AM, revealed section for Section D (Signature of Resident, or Guardian /Medical power of Attorney -MPOA Mandatory) was not completed with a MPOA Signature, a verbal signature in place dated 03/03/24 on Resident #42's active Physician Order for Scope of Treatment Form (POST Form). During an interview on 05/01/25 at 10:08 AM, the Director of Nursing (DON), confirmed Resident #42's POST form was incorrect without an MPOA signature in a timely manner.

Based on observation, policy review and staff interview the facility failed to treat residents with dignity and respect by not providing a dignified dining experience and failing to knock on doors before entering. The facility also failed to treat Resident #35 with dignity and respect during a medication administration. These were random opportunities for discoveries. The practice had the potential to affect more than a limited number of residents. Resident Identifiers: #111, #56, #4, #87, #57 and #35. Facility Census: 116. Findings Included: A) Policy Review A review of the facility policy titled Residents Rights with no effective or review date revealed the following. .Procedure: I.i. Knock before entering residents room if door is closed-wait for answer. b) Dignified Dining Experience During a main dining room observation on 06/07/23 at 8:05 am two (2) staff members were assisting residents with their breakfast meal while standing beside and towering over them. During an interview on 06/07/23 at 8:08 AM, the Director of Nursing (DON), acknowledged Nurse Aide (NA) #54 and Payroll…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on observation, resident interview, record review and staff interview the facility failed to develop or implement a comprehensive person-centered care plan with measurable objectives for each resident. This was true for four (4) of 26 residents reviewed during the Long-Term Care Survey Process. Resident Identifiers: Resident #86, Resident #44, Resident #97, Resident #96. Facility Census: 116 Findings Included: a) Resident #86 A record review on [DATE] at 9:17 AM, of Resident #86's medical record revealed an admission date of [DATE]. Further review of the medical record revealed a care plan with an initiated date of [DATE] which read as follows: Focus: The Resident has little activity involvement the resident is a recent admission to center Goal: Resident will participate in activities of choice through review date. Inventions: Assist with transport to activities as needed. Invite resident to schedule activities. Further medical record review revealed the activity preference interview for admission 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on medical record review and staff interview, the facility failed to revise care plans for Resident #15 regarding discontinuation of anticoagulant use, activities for Resident #100 and behavioral interventions for Resident #60. This was true for three (3) of 26 residents reviewed during the long-term survey process. Resident Identifiers: #15, #100 and #60. Facility Census: 116. Findings Included: a) Resident #15 On 06/07/23 at 11:30 AM, a record review was completed for Resident #15. The record review found the care plan stated, the resident is at risk for abnormal bleeding or hemorrhage due to anticoagulant/antiplatelet use (Lovenox). The review found the anticoagulant was discontinued on 03/15/23. On 06/07/23 at 1:00 PM, the Director of Nursing (DON) was notified and stated, I will get it changed right away. No further information was obtained during the long-term survey process. b) Resident #100 A record review on 06/07/23 at 2:00 PM, of Resident #100's medical record revealed a care plan with 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on observation, record review, resident interview and staff interview, the facility failed to implement an ongoing resident centered activities program designed to meet the interest of and support the physical, mental and psychosocial well-being of each resident. This practice was found true for four (4) of ten (10) Residents reviewed for the Activity Care Area during the Long-Term Care Survey Process (LTCSP). Resident Identifier: Resident #86, #44, #100 and #108. Facility Census: 116 Findings Included: a) Resident #86 During the initial tour of the facility on 06/05/23 at 2:15 PM Resident #86 was laying in bed with family present. Family stated Resident watches TV and reads the newspaper and bible daily. But we have not brought his bible here, we thought they would let him borrow one, since he was here for a short stay. They said they receive the newspaper here but have not gotten one to read. During a record review on 06/06/23 at 8:30 PM Resident #86 medical records revealed an activity preference…

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 range of motion (ROM) assistance as ordered to ensure the resident maintains, and/or improves to his/her highest level of ROM. This was true for three (3) of three (3) residents reviewed for ROM. Resident identifiers: #53, #71 and #80. Facility Census: 116 Findings Included: a) Resident #53 Record review on 06/06/23 at 1:53 PM showed Resident #53 had an order for: -- Nursing staff to assist with Passive range of motion (ROM) to bilateral lower extremity for exercise. one time a day, This order was dated 12/28/22. Documentation of the last twenty nine (29) days showed Resident #53 received ROM therapy seven (7) days (for a total of 112 minutes), refused nine (9) days, seven (7) days were documentation as not applicable and no documentation for six (6) days. This was confirmed with the Director of Nursing on 06/06/23 at 3:15 PM. The documentation was as follows: 05/08/23 Not applicable 05/09/23 Not applicable 05/10/23 Resident Refused 05/11/23 Resident Refused 05/12/23 received 8 minutes 05/13/23 Received 3…

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

Based on record review, staff interview and observation, the facility failed to ensure medications were dated upon opening and kept in proper temperature controls in accordance with the accepted professional standards of practice. These were random opportunities for discovery. Facility Census: 116. Findings Included: a) Temperature Log On 06/06/23 at 8:43 AM, a tour of the medication room was completed on A wing. The medication refrigerator temperature log was not complete. The following dates were left blank: --06/01/23 AM check: no initials or title listed --06/01/23 PM check: no temperature, initials or title listed On 06/06/23 at 9:00 AM, the Director of Nursing (DON) was notified and confirmed the temperature log should be complete. b) A wing medication cart On 06/06/23 at 10:05 AM, the A wing medication cart was reviewed. The following medication was found to be undated upon the initial administration: --Lumigan ophthalmic solution for Resident #21 --Flonase nasal spray for Resident #26 --Lispro insulin Kwik pen for Resident #75 --Lispro insulin Kwik pen for Resident #97…

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, resident interview and staff interview the facility failed to provide menu items according to each residents preference. Also the facility failed to provide notification of changes of the menu to residents when the menu needed to be changed. These failed practices had a potential to affect all residents receiving nourishment from the facility kitchen. Resident Identifiers: Resident #27, Resident #80 and Resident #51. Facility Census: 116 Findings Included: a) Menus During a dining observation on 06/06/23 beginning at 12:20 PM on D wing Resident #108's lunch meal ticket revealed they should have had: Spaghetti Caesar Salad Garlic Bread Deluxe Fruit Salad Observations of Resident #108's tray revealed Spaghetti, mixed vegetables, garlic bread and mixed fruit. During an interview on 06/06/23 at 12:50 PM, Nurse Aide (NA) #154 acknowledged there was no Caesar salad on Resident #108 tray. She stated that no one received salad on the tray today. An observation of the menu displayed in the halls for the Residents reads as follows; Spaghetti Caesar Salad Garlic Bread…

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 serve food which was palatable and at an accurate temperature. This failed practice had the potential to affect more than an isolated number of residents. Facility Census: 116. Findings Included: a) Kitchen On 06/08/23 six (6) state surveyors tasted the noon time meal for palatability. The Macaroni and Cheese which was the main entrée tasted of a lot of garlic and left the taste on our palates. The tomato basil salad was tasteless and not palatable and also did not contain the onion and bell pepper. The mashed potatoes were also tasteless and not palatable. The beef steak with onions, the onions were still raw and unable to cut. The sugar cookies were very hard, unable to break in half or unable to chew. On 06/08/23 the CM provided recipes, ~Macaroni and Cheese: -American cheese 48 slices -Swiss Cheese 16 slices -Margarine .25 pound -all purpose flour one (1) cup -Milk two (2) quart -Water one and half (1.5) gallon -Vegetable oil one (1) tablespoon (Tbsp) -Salt .50 teaspoon (Tsp) -Macaroni one and half (1.5) pounds…

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

Based on observation, policy review and staff interview the facility failed to store food in accordance with professional standards for food safety. The facility failed to label and date food items which were open and failed to dispose of expired food items. The facility also stores non resident foods in the nourishment room refrigerator. This failed practice had the potential to affect all residents currently receiving nourishment from the facility's kitchen and the nourishment rooms. Facility Census: 116 Findings Included: A) Policy Review A review of the facility policy titled Food Storage revised date of 09/17 read as following: .Procedures .5. All foods will be stored wrapped or in covered containers, labeled and dated . b) Dry Storage An initial tour of the kitchen with the Culinary Director (CD) beginning on 06/05/23 at 12:16 PM , of the dry storage revealed the following issues: -chili powder- no open/use by date -an open bag of bread crumbs was on the floor. The Culinary Director (CD) acknowledged the failure to label food items with a Date Opened and/or Use by Date. Also…

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, professional board interview, and staff interview the facility failed to ensure Social Service Director (SSD) was licensed with the [NAME] Virginia Board of Social Work in accordance with applicable state laws. This was a random opportunity for discovery and has a potential to affect more than an isolated number of residents. Facility Census: 116. Findings Included: a) Social Service Director On 06/12/23 the facility was asked to provide a professional license or all professional staff including the Social Service Director (SSD) #40. A review of the documentation provided by the facility for SSD #40 found the following: An application for Social Work License (LSW/LGSW/LCSW) this application was completed by SSD #40 on 05/26/23. SSD #40 began working at the facility on 05/04/23 as the SSD. At 3:07 pm on 06/12/23 the [NAME] Virginia Board of Social Work was contacted via telephone. When asked if a person was able to work as social worker prior to their license being approved, the Board Employee indicated you could not start working until your application 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on medical record review and staff interview the facility failed to ensure a complete and accurate medical record. 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 wass true for six (6) of 26 reviewed for the Long-Term Care Survey Process. Resident identifiers: #109, #97, #44, #16, #51 and #26. Facility census: 116. Findings included: a) Resident #109 During a record review on [DATE] at 10:23 AM Resident #109's medical record revealed a Physician Orders for Scope of Treatment (POST) form showed that verbal consent was obtained from the resident's representative on [DATE]. The consent was not witnessed by two (2) staff members. However, the resident representative's actual signature was never obtained. The 2021 POST form guidance titled, Using the POST Form: Guidance for Health Care Professionals, 2021 edition, available on-line, stated, If the incapacitated patient's MPOA…

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 explain the binding arbitration agreement in a form and manner easily understood by residents. This was true for three (3) of three (3) residents reviewed under the care area of arbitration. Resident identifiers: #2, #47, and #44. Facility Census: 116. Findings included: a) Binding Arbitration Agreement On 06/13/23 at 8:30 AM, a review of the facility arbitration agreement was completed. The review found the facility arbitration agreement had all the required information including all definitions of the key words. On 06/13/23 from 8:30 AM to 9:00 AM, three (3) residents (Resident #2, Resident #47 and Resident #44) were interviewed regarding the facility arbitration agreement. All three (3) residents had a Brief Interview of Mental Status (BIMS) of 15, the highest score indicating no cognitive impairment. All three (3) residents stated, I don't know if I signed the agreement and I don't remember what they told me about it. On 06/13/23 at 9:05 AM, an interview was completed with the Admissions…

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 equipment in safe operating conditions. The ice machines did not have a one inch air gap for drainage. This failed practice had the potential to affect all residents currently receiving nutrition from the facility kitchen. Facility Census: 116 Findings included: a) Ice Machine Drain An initial tour of the kitchen with the Culinary Director (CD) beginning on 06/05/23 at 12:16 PM revealed the ice machine water drain was touching the floor drain without a one (1) inch gap allowing for the potential for contaminants to enter the line and travel to the ice machine. During an interview on 06/07/23 at 10:10 AM Director of Plant Maintenance #49 acknowledged the ice machine did not have a one inch gap, stating it would be fixed immediately. .

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on observation, policy review, family interview and staff interview the facility failed to consider a voiced concern of a residents family as a grievance and failed to act promptly to investigate the voiced concern. This was a random opportunity for discovery and was only true for Resident #270. Resident identifier: #270. Facility Census: 116 Findings included: a) Policy Review A review of the facility policy titled Resident Grievance with a review date of 05/30/19 read as follows: .Procedure: 1. Prevent Ongoing Violations a. Upon receipt of an oral, written or anonymous grievance submitted by a resident, the Grievance Official will take immediate action to prevent further potential violation of any resident right while the alleged violation is being investigated, if indicated. .3. Investigation a. The Grievance Official shall complete an investigation of the resident's grievance. b. This may include a review of facility processes, programs and policies, as well as interviews with staff, residents, and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on record review and staff interview, the facility failed to provide a transfer/discharge notice to the resident/resident representative or the ombudsman for one (1) of four (4) residents reviewed for the care area of hospitalization, during the long term care survey. Resident identifier #75. Census 116. Findings Included: a) Resident #75 Record review on 06/05/23 at 4:16 PM, indicated resident #75 was hospitalized on [DATE]. On 06/06/23 at 11:10 AM, a copy of the transfer/discharge form and bed hold policy that was presented regarding resident's hospitalization on 05/23/23 was requested. On 06/12/23 at 12:09 PM, an interview with the Administrator and the Director of Nursing (DON), confirmed they did not have a discharge/transfer form or a bed hold policy for this resident's hospitalization on 05/23/23. .

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on record review and staff interview, the facility failed to provide a bed hold policy to the resident/resident representative for one (1) of four (4) residents reviewed for the care area of hospitalization, during the long term care survey. Resident identifier: #75. Census 116. Findings Included: a) Resident #75 Record review on 06/05/23 at 4:16 PM, indicated Resident #75 was hospitalized on [DATE]. On 06/06/23 at 11:10 AM, a copy of the transfer/discharge form and bed hold policy regarding resident's hospitalization on 05/23/23 was requested. On 06/12/23 at 12:09 PM, an interview with the Administrator and the Director of Nursing (DON), confirmed they did not have a discharge/transfer form or a bed hold policy for this resident's hospitalization on 05/23/23. .

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on record review and staff interview, the facility failed to complete an accurate Minimum Data Set (MDS) for one (1) of 26 sampled residents reviewed during the long term care survey. Resident identifier: #60. Census:116. Findings included: a) Resident #60 On 06/08/23 at 10:30 AM, a medical record review of Resident #60's MDS indicated the resident did not have behaviors under section E of the MDS. The surveyor reviewed all MDSs since the resident's admission: Quarterly MDS ARD 12/18/22 indicated no behaviors Modification of Quarterly MDS ARD 12/18/22 indicated no behaviors On 06/08/23 at 10:45 AM the surveyor requested from the Director of Nursing (DON), copies of all of the resident's progress notes and MDSs. On 06/12/23 at 2:13 PM, record review of the provided progress notes found notes of behaviors the resident has had throughout his stay. A synopsis of the notes regarding behaviors are listed below: 04/29/23 Behavior Note - paranoid behaviors - called family who came to visit 03/28/23 Behavior Note…

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

Based on record review and staff interview, the facility failed to complete a new Pre admission Screening (PAS) when a resident received a new psychiatric diagnosis for one (1) of five (5) residents reviewed for the category of unnecessary medications, psychotropic medications, and medication regimen review, during the long term care survey. Resident identifier #26. Census 116. Findings Included: a) Resident #26 A record review on 06/05/23 at 2:39 PM, provided a completed PAS but no level II needed This PAS was dated 02/23/17 and Section III, number 30 was answered NONE. The Electronic Medical Record (EMR) indicated, during the resident's stay at the facility, he received a diagnosis of Bipolar Disorder, Current Episode Depressed, Mild or Moderate Severity, Unspecified. This diagnosis was given to the resident on 04/18/2023. There was no updated PAS scanned into the EMR. On 06/06/23 at 11:10 AM, the surveyor requested a copy of the most recent PAS from the Director of Nursing (DON). On 06/06/23 at 12:30 PM, a copy of the most recent PAS was provided to the surveyor. The same PAS…

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, medical record review, family interview and staff interview the facility failed to provide care required to maintain hygiene to a resident who was dependent for Activities Of Daily Living (ADL) care. This is true for one (1) of three (3) residents reviewed for ADL care are during the Long Term Care Survey Process. Resident Identifiers: Resident #270. Facility Census: 116 Findings Included: a) Resident #270 During an interview on 06/06/23 at 2:30 PM, Resident #270's representative stated, (Name of Resident # 270's) room smells like urine. Her hair is greasy, and has had no showers since she has been admitted . I spoke to the social worker today about her room and the shower situation. The Social worker stated the resident got two baths a week, If I wanted her to have more I could come in and bathe her. During an observation on 06/06/23 at 3:15 PM, Resident # 270's hair appeared dirty and disheveled. During an observation on 06/07/23 at 8:30 AM, Resident # 270's hair still appeared dirty…

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 follow their suicide prevention policy for one (1) of 26 sampled residents reviewed during the long term care survey process. Resident identifier #75. Census 116. Findings Included: a) Resident #75 On 06/06/23 at 11:10 AM, the surveyor requested a copy of the resident's psychiatric notes/evaluations, copy of care plans, copy of pharmacy recommendations, and a copy of the resident's Pre admission Screening (PAS). Record review revealed the resident had suicidal ideation's since he had been at the facility. Resident #75 was admitted to facility on 10/12/22. On 10/18/2022 at 4:29 PM, Social Worker #172 documented in a progress note, During trauma informed care screening resident stated suicidal ideation multiple times. Resident stated he has thoughts and feelings of not wanting to be alive r/t to feeling like he is not getting progress out of SNF placement. Social worker inquired if he had a plan, and resident held his finger to his head 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 and staff interview, the facility failed to ensure respiratory care was provided according to professional standards of practice. This was a random opportunity for discovery and was only true for Resident #32. Resident Identifier: #32. Facility Census: 116. Findings Included: a) Resident #32 On 06/05/23 at 12:45 PM, an observation was made of a continuous positive airway pressure (CPAP) mask laying on top of the CPAP machine. The CPAP mask was not stored in a respiratory bag. Resident #32 stated, It has never been put in a bag. Registered Nurse (RN) #108 confirmed the CPAP mask was not being stored in a respiratory bag. RN #108 stated, let me get one. On 06/06/23 at 2:40 PM, an additional observation was made of the CPAP mask laying on top of CPAP machine. The CPAP mask was not stored in a respiratory bag. The resident was not present in the room. Licensed Practical Nurse LPN) #145 confirmed the CPAP mask was not being stored in a respiratory bag. LPN #145 stated, I'll go get one. The care plan was reviewed regarding the CPAP machine. 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 record review the facility failed to provide a resident on the memory unit with an alternate meal preference during lunch. This was a random opportunity for discovery and only affected Resident #93. Resident identifier: #93. Facility census: 116. Findings included: a) Resident #93 On 06/05/23 at 1:31 PM, Resident #93 pushed her lunch plate to the side. Resident #93 said to Nurse Aide (NA) #84, They told me I could have a sandwich. NA #84 told the Resident They are not the boss; you eat what you have on your plate. Resident dropped her head, and her bottom lip began to quiver. The Resident got tears in her eyes as she sat and watched her table mates eat their lunch. Activity Director #45 was asked what happens when a resident wants something else to eat? AD #45 stated to NA #84 Are you going to call the kitchen and see if there is something else she can have, maybe a mechanical snack? AD #45 stated due to her diet she could not have a sandwich. AD #45 said, she does this all the time. The diet ticket stated: Regular Dysphasia/Puree Diet. 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, record review and staff interview the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary environment and to help prevent the development and transmission of communicable diseases and infections. Proper infection control procedures were not taken during medication pass on the memory unit. Family was not provided with the proper personal protective equipment during visitation to Resident's room. This failed practice had the potential to affect more than a limited number of residents and was a random opportunity for discovery. Resident identifiers: #35 and #104. Facility census: 116. Findings included: a) Resident #35 On 06/06/23 at 8:52 AM, during observation of medication pass on the memory unit, Licensed Practical Nurse (LPN) #62 placed Resident # 35's eye drops and nasal spray on the seat of a empty cushioned chair in the common living room while she administered the residents oral medications. LPN #35 did not put a barrier down or sanitize the surface prior to placing the multiuse medications on the…

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

Based on observation and staff interview, the facility failed to treat one (1) of the 28 sample residents in the long-term care survey process with dignity and respect. The facility insisted Resident #55 must wear a large blue brief instead of a smaller size. As a result, Resident #55's brief leaked throughout the night resulting in Resident #55's bed being saturated with urine. Resident Identifier: Resident #55. Facility Census: 105. Findings included: a) Resident #55 During an interview, on 10/11/21 at 11:55 AM, Resident #55 stated Nurse Aide (NA) #106 insists resident wear a large brief which does not fit Resident #55 comfortably. Resident #55 weighs approximately 112 pounds, and the large brief is looser fitting and bulges in some areas. Resident #55 then showed surveyor the blue brief the resident was wearing to demonstrate how it fit. Resident #55 stated as a result of wearing large briefs, the brief leaked last night resulting in the bedding becoming wet. Resident #55 reported not only was it embarrassing but it also interrupted quality sleep time needing to wait for the NA…

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 provide a homelike environment by not providing a resident reachable access to a personal telephone. This was a random opportunity for discovery. Resident identifier: #89. Facility census: 105. Findings included: a) Resident #89 During an interview on 10/11/21 at 11:55 AM, Resident #89, stated, I can't reach my phone when I get phone calls. Resident #89 stated that the personal phone was out of reach most days. An observation on 10/11/21 at 11:55 AM found Resident #89's personal phone sat on the nightstand beside the bed. The nightstand was positioned at the head of the bed making the personal phone out of reach for Resident #89. An interview on 10/11/21 at 3:55 PM, the Assistant Director of Nursing (ADON) #139, confirmed Resident #89's phone was out of reach and will care plan that the phone is to be in reach at all times. .

Based on record review and staff interview, the facility failed to ensure one (1) of 28 residents reviewed during the long-term care survey process had a Physician Orders for Scope of Treatment (POST) form completed per directions specified by the [NAME] Virginia Center for End-of-Life Care in conjunction with the [NAME] Virginia Health Care Decisions Act (16-30-1). Resident identifier: Resident #69. Facility census: 105. Findings included: a) Resident #69 A medical record review was completed on 10/11/21 at 1:15 PM. A [NAME] Virginia Physician Orders for Scope of Treatment (POST) form, signed and dated 01/04/21, was in the chart. Section C, entitled Medically Administered Fluids and Nutrition, was left completely blank. Section C offers the patient the opportunity to indicate if they do or do not desire IV fluids as well as the opportunity to indicate if they do or do not wish to have a feeding tube. In 2002, the POST form was incorporated into the [NAME] Virginia Health Care Decisions Act (16-30-25.) POST forms are standardized forms used to reflect orders by a qualified physician…

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, and staff interview, the facility failed to provide one (1) of 28 sample residents a safe, clean, comfortable, and homelike environment. The facility failed to change a soiled privacy curtain in a timely fashion. Resident identifier: #62. Facility census: 105. Findings included: a) Resident #62 During a resident interview, on 10/11/21 at 11:39 AM, Resident #62 pointed out over 20 small, brown stains, ranging from the size of a pencil eraser to a quarter, on the privacy curtain in the middle of the room. Resident #62 stated that the stains have been there for several days and wished it could be cleaned. Registered Nurse (RN) #26 entered Resident #62's room on 10/11/21 at 11:46 AM and stated that she would guess the brown spots were soy sauce, noting they had Chinese food several days ago. RN #26 acknowledged it is the responsibility of all facility staff to create a homelike environment and promptly address any cleaning needs when identified. RN #26 stated the dirty privacy curtain will be changed out for a clean one and then sent to laundry.…

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 a resident fall resulting in a fracture was reported to the required agencies. This was true for one (1) of five (5) falls reviewed. Resident identifier: Resident #304. Facility census: 105. Findings included: a) Resident #304 An electronic health record review was completed on 10/12/21 at 9:23 AM. Resident #304 experienced a fall on 11/25/20 at 9:15 AM. A subsequent x-ray revealed Resident #304 had sustained a hip fracture during the fall. Resident #304 was then transferred to the hospital for treatment. A review of the November 2021 Reportables log revealed the facility had not reported the fall with major injury. During an interview, on 10/12/21 at 1:15 PM, the Administrator reported, We didn't report the fall with fracture. At that time, we weren't reporting falls that were sent out of the building. The Administrator further explained corporate guidance was later provided and clarification given. The facility began reporting falls sent out of the building in May 2021. The Federal regulation 483.12(c)(1)…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on medical record review and staff interview, the facility failed to provide evidence a resident/resident's representative was provided a written Notice of Transfer for an acute hospital transfer. This was true for two (2) of three (3) residents reviewed for hospitalization. Resident identifiers: #69 and #304. Facility census: 105. Findings included: a) Resident #69 A medical record review was completed on 10/12/21 at 11:32 AM. The record review revealed Resident #69 was transferred to the hospital on [DATE]. The record did not reflect the resident/resident's representative was provided a written Notice of Transfer indicating the reason for the transfer, the effective date of transfer, the location to which the resident was being transferred and a statement of the resident's appeal rights. During an interview on 10/12/21 at 1:45 PM, the Medical Records Director reported the facility was unable to provide evidence a written Notice of Transfer was provided to Resident #69. a) Resident #304 A medical 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.

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 upon transfer. This was true for two (2) of three (3) residents reviewed for hospitalization. Resident identifiers: #69 and #304. Facility census: 105. Findings included: a) Resident #69 A medical record review was completed on 10/12/21 at 9:23 AM. The record review revealed Resident #304 was transferred to the hospital on [DATE]. The record did not reflect the resident/resident's representative was provided a written Bed Hold Notice upon transfer. During an interview on 10/12/21 at 1:45 PM, the Medical Records Director reported the facility was unable to provide evidence a written Bed Hold Notice was provided to Resident #69. b) Resident #304 A medical record review was completed on 10/12/21 at 11:32 AM. The record review revealed Resident #304 was transferred to the hospital on [DATE]. The record did not reflect the resident/resident's…

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

Based on observation and staff interview, the facility failed to provide respiratory care consistent with professional standards of practice. A nebulizer mask was on the bedside table with no protective covering. This observation was a random opportunity for discovery. Resident identifier: #57. Facility Census: 105. Findings included: a) Resident #57 An observation on 10/11/21 at 11:38 AM found Resident #57's nebulizer mask on the bedside table with no protective covering. Registered Nurse (RN) #26 confirmed the nebulizer mask was uncovered and stated that facility protocol required the nebulizer mask to be placed in a bag. RN #26 went on to say the nebulizer machine had not been used for over a month and should have been removed from the resident's room. .

Based on observation, record review and staff interview, the facility failed to provide a two (2) handled spouted cup for a resident at meal times. This was a random opportunity for discovery. Resident identifier: #70. Facility census: 105. Findings included: a) Resident #70 An observation on 10/12/21 at 8:10 AM showed Resident #70 had two (2) eight (8) ounce cups of liquid on the breakfast tray. Resident #70 was unable to drink out of the two (2) cups and struggled with one cup not being able to get the drink as desired. Further observation on 10/12/21 at 8:10 AM of Resident #70's food tray showed a tray card that stated, 2 handled cup (1 each). An interview on 10/12/21 at 8:25 AM, Speech Therapist (ST) #169 stated that the two (2) cups on Resident #70's trays were not correct or recommended by therapy. ST #169 stated that the cups on Resident #70's tray should be the two (2) handled spouted cups with handles on both sides. A review of Resident #70's medical recorded verified a care plan that stated, Spouted cups with all meals. The therapy recommendation note also verified…

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, label and date foods in a sanitary manner in accordance with professional standards. This deficient practice had the potential to affect a limited number of residents. Facility Census 105 . Findings included: a) Kitchen/Pantries On 10/11/21 at 11:13 AM initial tour with Food Service Director (FSD) #5, an observation of the walk in refrigerator found no label or date on the following food items: bacon, sausage gravy, egg omelets, cheese slices were wrapped in plastic and opened shredded cheese. The FSD agreed that all items should be discarded due to not being labeled or dated. On 10/11/21 at 11:28 AM observation with FSD in the walk in freezer found veal wrapped in plastic wrap with no date. The FSD agreed the frozen veal should have been thrown away and the FSD discarded the veal. On 10/11/21 at 11:40 AM observation with FSD on PAC unit pantry refrigerator found the following: -one (1) container with no name or date and three (3) small food containers with no name or date. On 10/11/21 at 11:55 AM an observation…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on record review and staff interview, the facility failed to maintain an accurate medical record for one (1) of 28 sample residents reviewed during the Long Term Care Survey. Resident identifier: #97 Facility census: 105. Findings included: a) Resident #97 Resident #97 was admitted on [DATE]. Medical diagnoses included dementia, Alzheimer's, and major depressive disorder. The Brief Interview of Mental Status (BIMS) was scored 00 on the quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) 07/01/21. The BIMS score indicates severe cognitive impairment. In an interview with Resident #97's family member on 10/12/21 at 11:28 AM revealed Resident #97 had dental posts placed with the lower denture inserted in the lower jaw in 2016. A review of the physician orders during this survey found an order dated 04/10/19 for Check dentures for all 0-rings and replace any missing 0-rings three (3) times daily. 0-rings are in nurses cart. (Completed by Nurse Only). In an interview with Resident #97'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 provide a safe environment by the use of an extension cord connected to an electronic device for Resident #100. This was a random opportunity for discovery. Resident identifier: #100. Facility census: 105. Findings included: a) Resident #100 An observation on 10/11/21 at 1:42 PM found an extension cord from the electrical outlet to an electronic tablet device on the bed of Resident #100. Based on an interview on 10/11/21 at 1:43 PM with Licensed Practical Nurse (LPN) #22 stated that no electrical extension cords are permitted for safety reasons. LPN #22 removed the extension cord from the residents room. .