New Martinsville Health & Rehab

Based on record review, resident interview and staff interview, the facility failed to identify verbal complaints/concerns as a grievance. This was a random opportunity for discovery. Findings include: a) On 06/04/24 10:00 AM, review of Resident Council Minutes for the last six (6) months indicated that the resident council voiced concerns about call lights not being answered in a timely manner every month from 12/2023 to 5/2024. On 06/04/24 10:35 AM, During resident council meeting, Resident #31 reported that staff did not answer call lights in a timely manner and that the council has discussed these issues monthly during resident council meetings. On 06/05/24 12:38 PM, during an interview with the administrator regarding call light concerns, the administrator reported the facility was aware of complaints being made in resident council meeting about call lights being answered in a timely manner. She reported that as a result, random Call Light Audits were being performed by nursing staff since 01/21/24 and reported that no issues had been found at this time. She stated that no…

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, record review and staff interview, the facility failed to report allegations of verbal abuse, neglect, and possible crime to all required stated agencies. This deficient practice had the potential to affect three (3) of 11 residents reviewed for the care area of abuse. Resident identifiers: #79, #29, and #86. Facility census: 86. Findings included: a) Resident #79 On 05/24/24, the Office of Health Facility Licensure and Certification (OHFLAC) received a complaint from an employee from a state agency reporting that marijuana, a baggy of pills, and drug paraphernalia had been removed from a resident's room by a police officer. The facility provided a log of facility reported incidences (FRIs) that had been reported to OHFLAC. The log contained no record of a FRI regarding illegal substances found in a resident's room. On 06/10/24 at 11:45 AM, the Regional Director of Operations (RDO) was asked about illegal substances being found in a resident's room. He stated neither he nor the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews, the facility failed to ensure that the resident's Pre-admission Screening (PAS) reflected a pre-admission mental health diagnosis for three (3) of six (6) residents reviewed for the category of PASARR (Pre-admission Screening and Resident Review). The lack of pre-screening resulted in the residents' conditions not being evaluated through the Level II PASARR process. Resident identifier: #79, #61, and #58. Facility census: 86. Findings included: a) Resident #79 A record review, completed on 06/03/24 at 11:07 AM, found the following details: Resident #79 was admitted to the facility on [DATE] with a bipolar disorder diagnosis. There was a Pre-admission Screen (PAS) dated 04/02/24 that was completed by the referring hospital. This PAS failed to include Resident #79's bipolar diagnosis under Section III, Question #30. During an interview on 06/05/24 at 11:17 AM, the Social Worker confirmed Resident #79 had a bipolar diagnosis upon admission, the admission PAS did not…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, the facility failed to ensure each resident had a person-centered comprehensive care plan developed and implemented to meet his or her preferences and goals, and address the resident's medical, physical, mental, and psychosocial needs. This was true for five (5) of 26 residents reviewed in the Long-Term Care Survey Process. Resident identifiers: #82, #190, #191, #54, and #61. Facility census: 86. Findings included: a) Resident #82 A record review, completed on [DATE] at 3:00 PM, revealed Resident #82 was a male admitted to the facility on [DATE]. In Resident #82's care plan the activities department expressed the following goal, I will participate in independent leisure activities of choice daily including word search, cross words, music, tv, sports, going outside through the review date, An intervention listed for this goal was, All staff to converse with her while providing care. The date this intervention was initiated was [DATE]. The care plan had a revision date…

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

Based on resident interview, record review, and staff interview, the facility failed to ensure activities of daily living (ADL) care was provided to dependent residents. This deficient practice had the potential to affect one (1) of three (3) residents reviewed for the care area of activities of daily living. Resident identifier: #29. Facility census: 86. Findings included: a) Resident #29 On 06/03/24 at 1:06 PM, Resident #29 stated she had not been receiving twice weekly showers. Review of Resident #29's comprehensive care plan showed the resident had an ADL self-care performance deficit and required assistance of one (1) for bathing. Review of the facility's shower schedule showed Resident #29 was scheduled to receive showers on Tuesday and Sundays. Review of Resident #29's shower documentation for the past 30 days showed the resident received showers on 05/21/24, 05/23/24, and 05/25/24. No shower refusals were documented. On 06/04/24 at 3:56 PM, Regional Director of Clinical Operations confirmed Resident #29 had not received twice weekly showers. No further information 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 record review and staff interview the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices. This was true for 3 (three) of 11 residents reviewed for the Long-Term Survey Process. Resident identifiers: #39, #41, #191. Facility census: 86. Findings included: a) Resident #39 On 06/04/24 at 09:57 AM a review of Resident #39's medical record was performed. At this time, it was revealed that Resident #39 had a history of frequent falls. Upon further review of Resident #39's medical record, it was noted that Resident #39 had fallen 6 (six) times since January 2024. On 06/10/24 at approximately 10:30 AM, a further review of Resident #39's medical record was performed. Review of Resident #39's care plan noted an intervention that stated, medication per orders for Parkinson's. At this time, it was noted that Resident #39 had a Pharmacist Consultation Report dated 06/30/23…

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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview the facility failed to ensure that a resident received the treatment and care in accordance with professional standards of practice in regard to monitoring pain levels. This was true for two (2) of four (4) residents reviewed for pain during a revisit survey. Resident Identifier: #69 and #80. Facility census: 86. Findings included: a) Resident #69. Medical record review revealed Resident #69's Physician orders for pain management: Hydrocodone-Acetaminophen tablet 7.5-325 MG, give one (1) tablet every four (4) hours as needed for pain use for pain scale 4-10. Order date 04/24/24 with a discontinue date 04/26/24. A continued review of Medication Administration Record (MAR) revealed: --04/26/24 at 9:42 AM pain level 1 - Hydrocodone-Acetaminophen tablet given. Physician Order: Acetaminophen tablet, give 650mg every 6 hours as needed for general discomfort. Give for pain scale 1-3. Order date 04/23/24 with a discontinue date 04/26/24. No Acetaminophen tablet, administered.…

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. The dumpster area was polluted with uncovered garbage and medical supplies. This had the potential to affect all residents that reside in the facility. Facility census: 88. Findings included: a) Dumpster area An observation on 06/10/24 found the dumpster lid open, a trashcan full of trash without a lid and the area was polluted with garbage and medical supplies. On 06/10/24 at about 2:10 PM during an Interview the Maintenance Assistant verified the dumpster lids should be closed. He stated the garbage should not be on the ground. He also stated that he needed help getting the trash can, full of trash over the top of the dumpster. When asked how long it had been sitting there, he replied, I think just today.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, the facility failed to ensure a complete and accurate medical record for residents. The facility failed to maintain an accurate medical record for two (2) of 26 sampled residents reviewed during the Long-Term Care Survey process. The facility failed to ensure Physician Orders for Scope of Treatment (POST) forms were legally valid and matched other physician orders. Resident identifiers: #79, #54, and #3. Facility census: 86. Findings included: a) Resident #79 A record review, on [DATE] at 11:07 AM, revealed a POST form in Resident #79's electronic medical record. The POST form was not dated by Resident #79. The directions for completing the POST form, compiled by the [NAME] Virginia Center for End of Life, state, The patient or incapacitated patient's MPOA (Medical Power of Attorney) representative or health care surrogate must sign and date this section for the form to be legally valid. A review of the original POST form kept at the nurses' station revealed it 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 and staff interview, the facility failed to develop and implement policies and procedures which addressed establishing priorities for performance improvement activities that focused on resident safety, quality of care, and high-volume and/or problem-prone areas. This had the potential to affect an unlimited number of residents. Facility census: 86. Findings included: a) Facility Reported Incidents Review of the eight (8) complaints being investigated concurrently along with the annual Long-Term Care Survey Process revealed that five (5) out of the eight (8) were facility reported incidents involving the allegation of staff verbally abusing residents. During an interview on 06/11/24 at 2:00 PM, the Regional Director of Operations #115 and the Regional Director of Corporate Operations #116 reported that to their knowledge the Quality Assessment and Assurance (QAA) Committee did not identify and/or address the pattern of verbal abuse allegations as an area for improvement. They asked the Assistant Director of Nursing (ADON) and the Infection Preventionist to join…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview the facility failed to maintain essential equipment in safe operating condition according to manufacturer's recommendations. This had the potential to affect all residents who get their nutrition from the kitchen. Facility census: 88. Finding included: a) On 06/10/24 at 11:48 AM an observation of the ice machine in the main dining room found the water drainpipe down in the sewer pipe. There was not a two-inch recommended air gap. Both the drainpipe and sewer pipe were covered with a black substance. On 06/10/24 At 11:50 AM the [NAME] Director of Dietary verified there was no gap between the drainpipe and the sewer pipe and there was at black substance present on both pipes.

Based on observation and staff interview the facility failed to incorporate an effective pest control program. This has the potential to affect all residents residing in the facility. Facility census: 88. Findings included: a) Kitchen area On 6/03/24 at 10:45 AM during a kitchen inspection there were ants in the dish washing room. On 6/03/24 at 10:50 AM during an interview the Maintenance Director verified there were ants in the kitchen area. He stated, everyone has ants, I've had them in my kitchen for about a year. He stated that the facility does not have an exterminator spray for roaches or ants. He clarified that he would spray if insects were observed by the staff. He continued to say that the exterminator only puts bait in traps outside.

Based on record review and staff interview, the facility failed to provide the required Notification of Medicare Non-Coverage (NOMNC) and the Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN) on non-coverage liability notices in a timely fashion for one (1) of three (3) residents reviewed for beneficiary protection notification throughout the Long-Term Care Survey Process. This failure placed the resident at risk of not being informed of her appeal rights prior to the end of Medicare covered services. Resident identifier: #25. Facility census: 86. Findings included: a) Resident #25 On 06/05/24 at 10:43 AM, a review regarding the beneficiary protection notification liability notice process revealed the following details: -Resident #25 remained in the facility after her Skilled Medicare ended. -Resident #25's last covered day of Part A service was 01/11/24. -A NOMNC was issued on 01/15/24 (four days AFTER skilled coverage ended) and signed by resident's representative on 01/17/24. -A SNF ABN was issued on 01/15/24 (four days AFTER skilled coveraged ended) and signed by…

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 implement their abuse policies for reporting neglect. This deficient practice had the potential to affect one (1) of 11 residents reviewed for the care area of abuse. Resident identifier: #29. Facility census: 86. Findings included: a) Resident #29 The facility's policy and procedure titled Abuse Investigation and Reporting with original date 10/01/21 and no revision date stated all alleged violations involving neglect would be reported to the stated licensing/certification agency responsible to for surveying/licensing the facility, the local/state ombudsman, and also Adult Protective Services, if applicable to state law. During an interview on 06/03/24 at 1:39 PM, Resident #29 stated she had been left outside alone in the courtyard four (4) times following smoke breaks. Resident #29 stated she is unable to propel her wheelchair independently due to tremors and was unable to reenter the facility on her own. Resident #29 further stated there was no way to notify staff that she was outside 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 b) Resident #29 During an interview on 06/03/24 at 1:39 PM, Resident #29 stated she had been left outside alone in the courtyard four (4) times following smoke breaks. Resident #29 stated she is unable to propel her wheelchair independently due to tremors and was unable to reenter the facility on her own. Resident #29 further stated there was no way to notify staff that she was outside and wanted to come in. The resident stated she was left out in the hot sun for two (2) hours on one day. Resident #29 also stated she had a history of falling from her wheelchair. Review of facility grievance forms showed a grievance on 05/13/24 which stated, Resident went outside with staff assistance for 1 pm smoke break. At end of smoke break as everyone returned inside [Nursing Assistant (NA) #5] said to this patient, If you can't bring yourself outside or inside, you shouldn't be able to smoke. [NA #5] then entered the building leaving this resident out in the courtyard unattended. Another resident [Resident #79] noted this…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview, the facility failed to provide evidence that a resident/resident's representative was provided a written Notice of Transfer for an acute hospital transfer/discharge and failed to notify the long-term care Ombudsman of the transfer. This was true for two (2) of three (3) residents reviewed under the hospitalization pathway in the annual Long-Term Care Survey Process. Resident identifiers: #191,and #39. Facility census: 86. Findings included: a) Resident #191 A record review, completed on 06/10/24 at 2:24 PM, revealed that Resident #191 had been transferred to the hospital on [DATE]. There was no evidence in the electronic medical record that the facility had provided Resident #191 or his representative with a written Notice of Transfer/Discharge form nor was there evidence the facility had notified the Long-Term Care Ombudsman of resident's transfer to the hospital. During an interview, on 06/11 /24 at 11:20 AM, the Medical Records Director reported the facility…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY b) Resident #34 Medical Record review on 06/10/24 revealed resident #34 was discharged to the hospital on [DATE]. Subsequent review of Resident #34's medical record showed it did not contain documentation that the Notice of Transfer or Discharge was provided to the Resident Representative, or the Ombudsman was notified of the discharges on 06/02/24. On 06/11/24 at 9:50 AM during an interview the Social Worker verified, there was no evidence that the Notice of Transfer or Discharge was completed and provided to the Resident's Representative for the discharges on 06/02/24. The Social Worker also confirmed the Ombudsman was not notified of the discharges on 06/02/24. Based on medical record review and staff interview, the facility failed to provide evidence that a resident/resident's representative was provided a written Bed Hold notice for an acute hospital transfer. This was true for two (2) of three (3) residents reviewed under the hospitalization pathway in the annual Long-Term Care Survey Process. Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, the facility failed to update the PASARR for Resident #3, after the resident was diagnosed with a major mental disorder after admission to the facility. This was true for one (1) of six (6) residents reviewed for PASARRs during the survey process. Resident Identifier: 3. Facility census: 86. Findings include: A) Resident #3 On 06/10/24, a record review was conducted for Resident #3. During record review, it was noted Resident #3 had been admitted to the facility on [DATE]. On 02/25/21, Resident #3 was diagnosed with major depressive disorder and on 10/13/23 was diagnosed with bipolar disorder. Resident #3 had a new PASARR submitted on 11/27/2023, which did not include the new diagnosis of Major Depressive Disorder or bipolar disorder. At approximately 10:04 AM on 06/11/24, an interview was conducted with the social worker concerning the PASARR for Resident #3, she confirmed the absence of major depressive disorder and bipolar disorder on the PASARR.

Based on record review and staff interview the facility failed to obtain laboratory services as ordered by the physician to meet the needs of its residents. This was true for one (1) of 1 resident reviewed for the Long-Term Survey Process. Resident identifier: #41. Facility census: 86. a) Resident #41 On 06/04/24 at 01:00 PM, a review of Resident #41's medical record was performed. During the review of the physician's orders, it was noted that Resident #41 had orders as follows: * Novolog Injection Solution (Insulin Aspart) Inject as per sliding scale: if 201- 250 = 4; 251- 300 = 6; 301- 350 = 8; 351- 400 = 10; 401- 450 = 12; 451 + = 15. Notify Medical Doctor (MD) if blood sugar (BS) is less than 60 or above 450, subcutaneously before meals and at bedtime for Diabetes Mellitus (DM) II. Order date: 01/29/24 * Complete Blood Count (CBC)/Glycated hemoglobin (HgbA 1c) every 6 (six) months. Order date: 08/09/23. Upon further review of the medical record, this Surveyor was unable to locate the most recent results of the CBC and HgbA 1c. On 06/04.24 at 02:06 PM, an interview was conducted…

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 a safe, clean, comfortable, homelike environment. The ceiling in room B6 was damaged. This was a random opportunity for discovery. Facility census: 86. Findings included: a) Room B6 On 06/03/24 at 12:55 PM, Resident #29 asked the surveyor to look at the ceiling in her room. Several brown spots were immediately over the resident's bed. The largest was the size of a plate. In the corner of the room, near but not directly over the resident's bed, contents appearing to be drywall were extruding from a plate-sized hole in the ceiling. On 06/04/24 at 3:33 PM, the Maintenance Supervisor stated the damage in the ceiling of Room #B6 was water damage. He stated the areas would be repaired.

Based on medical record review and staff interview, the facility failed to ensure Advance Directive paperwork was part of Resident #11's medical record. This was a random opportunity for discovery in the complaint process. Resident identifier: #11. Facility census: 78. Findings include: a) Resident #11 An electronic medical record review, completed on 03/18/24 at 1:25 PM, identified there was a Physician Determination of Capacity, dated 09/11/23, indicating Resident #11 lacked capacity to make her own medical decisions. There was no Medical Power of Attorney (MPOA), or Health Care Surrogate (HCS) form scanned in the electronic medical record. There was a Power of Attorney (POA) form, dated 11/23/21, on file. However, the POA failed to authorize the ability to make medical decisions on resident's behalf, it was mainly meant to be a financial power of attorney. During an interview on 03/20/24 at 9:55 AM, the Social Worker confirmed Resident #11 had never completed a Medical Power of Attorney (MPOA) prior to losing capacity. The Social Worker then stated the facility did not have 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 medical record review and staff interview, the facility failed to provide a resident with a well-balanced diet that met her daily nutritional and special dietary needs. The facility failed to offer a diverticulosis diet to Resident #11 who had an identified diagnosis of diverticulosis upon admission to the facility. This was a random opportunity for discovery in the complaint process. Resident identifier: #11. Facility census: 78. Findings include: a) Resident #11 A medical record review was completed for Resident #11 on 03/18/24 at 1:25 PM. Resident #11 was admitted to the facility on [DATE] with a diverticulitis diagnosis as well as a diabetic diagnosis. Resident was placed on a carbohydrate-controlled diet. The Certified Nurse Practitioner (CNP) examined resident on 10/17/2023 and noted the following details, [AGE] year-old female being seen today related to pain/constipation. Patient has had past history of increased pain to left hip and side. X-rays were obtained and were negative for acute…

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 and resident interviews as well as documentation review the facility failed to ensure residents were treated with dignity and respect. Residents complained of staff having poor attitudes and not treating them with respect. Facility census: 82. Findings included: a) On 08/28/23 between the hours of 9:45 a.m. - 10:15 a.m., reviewed residential council meeting minutes from May 2023, June 2023, July 2023, and August 2023. It was noted that every month the issue was discussed regarding staff attitudes. Facility census: 82. b) Resident #46 On 08/29/23 and 08/30/23, conducted an interview with Resident # 46. Resident #46 was asked if staff treated them with dignity and respect. Resident replied, Some of them are aholes. When I ring my call light, they will yell 'What do you want now?' On 08/31/23 at 9:34 AM during the exit conference the administrator and director of nursing had nothing to add to the issues regarding the staff's failure to ensure residents were treated with dignity and respect.

Based on review of facility documents and staff interview, the facility failed to ensure the designated individual acting as the Infection Preventionist completed a specialized training in infection prevention and control. This failed practice had the potential to affect all residents residing in the facility. Census: 89 Findings included: a) Infection Preventionist A review of facility infection control documents, on 09/14/22, showed no evidence of any individual designated to serve as the infection preventionist who had completed a specialized training in infection prevention and control. An interview with the (Director of Nursing) DON, on 09/14/22 at 12:40 PM , revealed the facility had hired a new employee for that role, but the DON had been filling in as the Infection Preventionist. The DON stated neither staff member had a certificate of completion of a required Infection Preventionist course. The DON confirmed, at the present time, no staff members had obtained additional training and were certified as an Infection Preventionist.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and staff interview, the facility failed to ensure residents were served meals in a dignified manner. Residents seated at the same table did not receive meals simultaneously. This failed practice was observed as a random opportunity for discovery and had the potential to affect more than a limited number of residents. Resident Identifiers: Resident #37, #139, and #6. Census: 89 Findings included: a) Observation of the noon meal On 09/12/22 at 12:11 PM , a meal observation was made in the day area adjacent to the A/B nurses station where Resident #23, #37, #139 and #6 were observed sitting at the table. At this time, Resident #23 was eating and had finished most of the meal and had only fruit left on the tray. Residents' #37, #139 and #6 had not received any meal tray at this time. An interview, with Licensed Practical Nurse (LPN) #92, on 09/12/22 at 12:15 PM, revealed she was aware of the dignity issue of residents not being served meals at the same time when seated at the table 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.

Based on a policy review, review of resident council minutes, resident interview and staff interview the facility failed to consider the voiced concerns of residents in resident council. The facility failed to act promptly to investigate resident grievances concerning issues of call lights and staffing attitudes. This practice has the potential to affect more than a limited number of residents living in the facility. Facility census: 89. Findings Included: A review of the facility policy titled Grievance/Concern with a revision date of 06/01/22 found the following. .Policy Center leadership will investigate, document and follow up on all concerns and grievances registered by any patient or patient representative a) Call lights The following Resident Council Meeting Minutes From 01/24/22 to 08/29/22 found the following documentation related to call lights concerns. --The Resident Council Minutes dated on 08/29/22, Our call lights being answered needs improvement. --The Resident Council Minutes dated on 07/25/22, Would like call lights to be answered more quickly. --The Resident…

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

Based on resident interview, observation, resident council meeting and staff interview, the facility failed to provide residents with a safe clean, comfortable and homelike environment. The facility failed to eliminate the institutional practices by the overhead paging of frequent announcements. The facility also failed to provide residents with furniture in good repair and resident walls in good repair . This had a potential to affect an unlimited amount of residents living in the facility. Resident Identifiers: #16 and #119. Facility Census: 89. Findings Included: a) Overhead paging During an interview on 09/12/22 at 11:37 AM Resident #16 stated That thing goes off all the time, (the overhead paging made announcement). I have hearing problems, so I can only imagine how loud it is to the other patients that live here. During a Resident Council meeting held on 09/13/22 begin at 2:38 PM, the overhead paging system interrupted the meeting at 2:55 PM, the announcement was garbled and interrupted one of the residents who was speaking. The residents in attendance of the Resident Council…

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 council meeting, and staff interviews the facility failed to make grievances forms accessible to residents to file a grievance anonymously. This practice has the potential to affect more than a limited number of residents living in the facility. Facility census: 89 Findings Included: a) Grievance Forms Accessibility A review of the facility policy titled Grievance/Concern with a revision date of 06/01/22 found the following. .Process . 2.1 The right to file grievances orally (meaning spoken) or in writing, the right to file grievances anonymously; . During a Resident Council meeting held on 09/13/22 at 2:38 PM by two (2) state surveyors the following question was asked; Do you know how to file a Grievance? --I think there was forms in the dining room, but have not seen them in there. --I unaware there was a form --I was not aware a paper grievance form was an option. On 09/13/22 at 3:45 PM two (2) surveyor observations throughout the facility found no grievance forms for resident accessibility. During an interview on 09/13/22 at 3:50 PM, the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview the facility failed to ensure that resident centered care and services were provided in accordance with professional standards of practice. This was true for six (6) of ten (10) records reviewed for nutrition. Resident Identifiers: #30, #68, #2, #49, #78, #70. Facility Census: 89 Findings Included: a) Resident #30 On 9/14/22 at 11:30 AM record review shows the facility did not re-weigh resident #30 when he had a weight change of five (5) pounds (increase or decrease) from the last weight. According to staff interview with the Director of Nursing (DON) on 9/13/22 at 12:26 PM, staff is to re-weigh the Resident if there is a difference of a five (5) pound increase or decrease in the Residents weight. This was not performed on 3/10/22, 5/31/22, 6/20/22 and 7/06/22. This was confirmed with the DON 9/14/22 at 12:45 PM. The following weights were documented as of 9/14/22. 07/06/2022 13:25 118.6 Lbs 06/20/2022 13:56 109.4 Lbs 05/31/2022 16:15 122.4 Lbs 04/13/2022 10:17 106.0…

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 anonymous resident interviews, anonymous staff interviews, resident council minutes, a resident council meeting held during the long-term care survey, and interviews with Administration, the facility failed to ensure sufficient qualified nursing staff were available at all times to provide nursing and related services to meet the residents' needs safely and in a manner that promoted resident rights, physical, mental and psychosocial well-being. Facility census: 89. Findings Included: a) Anonymous Resident Interviews During an anonymous resident interview on 09/12/22 at 11:06 AM, Resident #301 stated the facility doesn't have enough staff. It would be the resident's preference to get up and be dressed earlier, but there simply isn't enough staff available to honor that preference. During an anonymous resident interview on 09/12/22 at 11:37 AM, Resident #302 stated I am going blind, and need more help, but there is not enough staff. I put my call light on and when they answer it, they turn it off and never come back. The say they don't have time. During an anonymous resident…

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

Based on observation and staff interview the facility failed to employ a clinically qualified nutrition professional on a full time basis to manage the daily function of the kitchen. This had the potential to affect all the residents that receive nutrition from the kitchen. Facility Census: 89. Findings Included: a) a) Qualified Nutrition Professional An observation of the kitchen office on 09/13/22 at 9:04 AM, revealed no certified licensed professional certificates. During an interview on 09/13/22 at 9:04 AM, Dietary Manager #34, stated I am enrolled in the Dietary Mangers class, I will be testing in February. During an interview on 09/13/22 at 9:04 AM interview District Manager of Dietary #112 stated, we do not have a full time certified dietary manager, I am here a few days a month and the dietician is here two (2) to three (3) days a week.

Based on observation and staff interview the facility failed to store food in a safe and sanitary manner in accordance with professional standards for food service safety. The facility failed to keep kitchen equipment clean and rust free. The failed practice had the potential to affect all residents currently receiving nutrition from the facility's kitchen. Facility Census: 89. Findings Included: a) Ice Machine A review of the facility policy titled 4.0 Cleaning Standards with a revision date of 06/15/18 found the following. .Cleaning Procedure Ice Machine ( Bin type) When: Monthly On 09/12/22 at 9:50 AM a tour of the kitchen with Dietician #111, the ice machine in the main dining room revealed to have black substance in the inside of the machine. The Dietician #111 acknowledged the black substance. During an interview on 09/12/22 at 9:55 AM, [NAME] #101 stated the maintenance cleans the ice machine not the dietary department. I don't know the last time it was cleaned. During an interview on 09/12/22 at 10:05 AM the Maintenance Supervisor(MS) #86 stated we clean the ice machine…

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 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: #192. Facility census: 89. Findings included: a) Beneficiary Notice Review On 09/13/22 at 2:04 PM, 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 #192's last covered day of Part A Services was on 06/12/22. -Resident #192 was issued the NOMNC on the next day, 06/13/22. This was also the day of Resident #192's discharge from the facility. The Form Instructions for the Notice of Medicare Non-Coverage (NOMNC) CMS-10123 state: The NOMNC must be delivered at least two calendar days before…

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 one (1) of two (2) residents reviewed for hospitalizations/discharges during the long-term care survey process. Resident identifier: #78. Facility census: 89. Findings included: a) Resident #78 An electronic medical record review was completed on 09/13/22 at 8:49 PM. Resident #78 was discharged to the hospital on [DATE]. There was no evidence a written Notice of Transfer/Discharge was provided to Resident #78 or her legal representative. During an interview on 09/14/22 at 2:13 PM, the Manager of Medical Records stated the facility was unable to locate evidence that a Notice of Transfer/Discharge was given.

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 two (2) of five (5) residents reviewed for hospitalizations during the long-term care survey process. Resident identifiers: #78 and #80. Facility census: 89. Findings included: a) Resident #78 An electronic medical record review was completed on 09/13/22 at 8:49 PM. Resident #78 was discharged to the hospital on [DATE]. There was no evidence a written Bed Hold Notice was provided to Resident #78 or her legal representative. During an interview on 09/14/22 at 2:13 PM, the Manager of Medical Records stated the facility was unable to locate evidence that a written Bed Hold Notice was given. b) Resident #80 A medical record review on 09/12/22 at 1:54 PM, revealed Resident #80 was sent to the hospital on [DATE]. During an interview on 09/13/22 at 11:20 AM the Director of Nursing (DON) stated the bed hold…

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 and staff interview, the facility failed to develop a comprehensive person-centered care plan for each resident to meet the resident's needs that were identified in the comprehensive assessment for one (1) of 29 residents reviewed during the Long Term Care Survey Process (LTCSP). Resident identifier: Resident # 69. Findings included: a) Resident #69 During the initial tour, on 09/12/22 at 10:30 AM, Resident #69 was observed to have both upper and lower dentures on the bedside table in a denture cup. At this time, Resident #69 stated she was needing some help with cleaning her dentures. A record review for Resident #69 showed an oral health assessment dated [DATE], that noted the resident to be edentulous (lacking teeth). Further review of the medical record, showed a care plan addressing Resident #69 as being at risk for dental care problems as evidenced by having own teeth. This care plan problem was developed on 12/22/22 and revised on 06/13/22 to note the same…

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 and staff interview, the facility failed to provide care to residents with pressure ulcers consistent with professional standards of practice to promote healing, prevent infection and prevent new pressure ulcers from developing for one (1) of six (6) residents reviewed for pressure ulcers during the LTCSP. Resident identifier: Resident #81. Findings included: a) Resident #81 A record review for Resident #81, showed the resident to have a pressure ulcer located on the sacrum which was present when the resident was admitted to the facility on [DATE]. A review of the current person-centered care plan addressed the resident as being at risk for skin breakdown related to an unstageable pressure ulcer. An approach on the care plan reviewed, showed staff were required to complete a weekly skin check by a licensed nurse with weekly wound assessments of the wound status. A review of the current physician's orders showed no order for pressure ulcer treatment. Review of the weekly wound…

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 provide appropriate assistive devices to Resident #56 in order for him to drink independently. This was a random opportunity of discovery. Resident Identifier: #56 Facility Census: 89 Findings included: a) Resident #56 On 9/13/22 at 12:25 PM, it was observed that Resident #56 did not have his nosey cup with his meal as ordered by the Physician. This was confirmed on 9/13/22 at 12:26 PM with Licensed Practical Nurse #89.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, the facility failed to ensure two (2) of 26 residents reviewed during the long-term care survey process had a complete and accurate medical record. Resident #75 and #52 had Physician Orders for Scope of Treatment (POST) forms completed incorrectly 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: #75 and #52. Facility census: 89. Findings included: a) Resident # 75 [DATE] 12:52 PM, medical record review found: -A [NAME] Virginia POST form was completed and on file reflecting that resident was to receive Cardiopulmonary Resuscitation (CPR) and Full Treatment. Section E of the POST form entitled E. Signature: Patient or Patient Representative/Surrogate/Guardian was NOT signed but was dated for [DATE]. -The POST form was signed by the attending physician on [DATE]. During an interview on [DATE] 11:30 AM, the Director of Nursing (DON) acknowledged…

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

Based on record review and staff interview, the facility failed to maintain a Quality Assessment and Assurance (QAA) committee consisting, at a minimum, of the Director of Nursing (DON); the Medical Director or his/her designee; and at least three other members of the facility's staff, at least one of who must be the administrator, owner, a board member, or other individual in a leadership role. Facility census: 89. Findings included: a) Quality Assessment and Assurance (QAA) Committee Meeting Attendance On 09/14/22 at 3:00 PM, a review of QAA Committee Meeting sign-in sheets from October 2021 - September 2022 was completed. There was no evidence that the Medical Director or his designee attended any QAA committee meetings in the months of October 2021, November 2021, and December 2021. During an interview on 09/14/22 at 3:39 PM, the Administrator acknowledged the Medical Director was not in attendance at any of the meetings in the October 2021 - December 2021 quarter. The Administrator stated she could not offer an explanation as to why that would have been the case [as 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.