Eagle Pointe Healthcare Center

Based on medical record review and staff interview, the facility failed to update the care plan to reflect a change in diet status. This was a random opportunity for discovery. Resident identifier: #82. Facility census: 108. Findings included: a) Inaccurate Care Plan Resident #82's diet order stated, NPO Diet, NPO texture, NPO consistency for Diet type. The resident's care plan stated: 1) Lid on coffee/hot beverage Date initiated: 06/09/2025 2) Staff to offer nutrition/hydration during checks Date initiated 03/07/2023 3) Patient may be fed pureed foods by caregivers or family as snacks are requested Date initiated 07/06/2023 On 07/01/2025 at 02:30 PM, the Director of Nursing confirmed the inaccurate care plan and stated, She hasn't eaten anything. Corporate Registered Nurse #153 stated, We have a care plan problem.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and record review, the facility failed to ensure patient centered rehabilitative services were provided for Resident #82. This was a random opportunity for discovery and had the potential to affect a limited number of residents. Resident Identifier: #82. Facility Census: 108. Findings included: a) Resident #82 Resident #82 had four (4) plus rehospitalizations per the Minimum Data Set (MDS) and was initially admitted on [DATE]. Speech Therapy (ST) had not screened the patient during her facility stay or upon re-admission to the facility for changes in condition following a hospitalization. The Director of Rehabilitation Services (DOR) stated, Occupational Therapy (OT) and Physical Therapy (PT) usually come from the hospital with orders and the ST need identified by nursing or other therapies. The DOR stated he didn't have speech in the building for awhile. However, interdisciplinary screens had been completed with no ST recommendations by PT and OT. The facility's screening policy 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 record review and staff interview, the facility failed to ensure that the medical record was complete for a Physician Orders for Scope of Treatment (POST) form with no signature for Resident #87. This failed practice was true for one (1) of 28 residents reviewed in the Long-Term Care Survey Process. Resident Identifier: #87. Facility Census: 108. Findings included: a) Resident #87 On 06/30/25 at 09:02 PM, Resident #87's POST form was reviewed by the state surveyor. Verbal Consent was given on 04/16/2025 by the resident's legal representative, however a signed consent was not obtained by the facility. There was no evidence in the medical record to reveal the facility had attempted to follow-up with resident's legal representative to obtain a written signature. On 07/01/2025 at approximately 11:35 AM, the Interim Director of Nursing stated that they were mailing out the POST form today to be signed.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, observations, and record reviews, the facility failed to ensure that staff adhered to infection control protocols while caring for residents classified as requiring Enhanced Barrier Precautions (EBP). Staff failed to wear Personal Protective Equipment (PPE) as specified by the EBP guidelines posted outside the resident's room. This was a random opportunity for discovery. Resident Identifier: #105. Facility Census: 108. Findings Included: a) Resident #105 During an interview on 07/01/25 at approximately 9:40 AM, the resident stated that she had a Foley catheter. Resident was alert, oriented, and had a Brief Interview for Mental Status (BIMS) score of 8. She stated that she had the catheter because she did not have control of her bladder. The resident was under Enhanced [NAME] Precautions, and the notice posted outside Resident #105's room stated the following: ENHANCED BARRIER PRECAUTIONS EVERYONE MUST: -Clean their hands, including before entering and when leaving the room PROVIDERS AND…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and staff interview, the facility failed to maintain bed remote controls in a safe operating condition. This is true for one (1) of five (5) resident beds reviewed. Facility census:108. Findings included: a) room [ROOM NUMBER]B During an interview on 07/01/25 at approximately 2:55 PM, Employee #32. was asked if they were aware of any issues with any exposed electrical wiring. The employee replied, You mean like bed remotes? Yes. One is located in room [ROOM NUMBER]B. On 07/01/25 at approximately 3:10 PM, Surveyor observed electrical tape on the bed control remote on resident bed 123B. On 07/02/25 at approximately 7:53 AM, an interview with the facility Maintenance Director verified that the bed control remote for bed 123 B had electrical tape on the remote. This finding was also acknowledged by the Administrator upon exit on 07/08/25 at approximately 1:00 PM.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and Interviews, the facility failed to ensure that resident's rooms and common areas were maintained at a comfortable temperature. Resident Room Identifiers: room [ROOM NUMBER], #205 and TV room. Facility Census: 109. Findings included: During a walk-through of the locked Alzheimer's unit on 11/19/24 at approximately 9:30 AM, Resident #35 in room [ROOM NUMBER] was observed on his bed, tightly bundled up in a blanket. Investigation revealed the P-tac unit was set to 67 degrees Fahrenheit. Resident did not respond to questions. Further observation revealed that the P-tac unit in room [ROOM NUMBER] was set to 65 degrees Fahrenheit. During an interview with the Director of Plant Maintenance (DPM) #30 at approximately 9:45 AM, a temperature check was requested. The DPM used an ambient air thermometer to check the temperature of room [ROOM NUMBER], and room [ROOM NUMBER]. The DPM confirmed that the ambient air temperature of room [ROOM NUMBER] was observed to be approximately 67 degrees…

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 interview, the facility delayed necessary medical treatment, potentially impacting a resident's health and safety, by failing to address the resident's ongoing complaints of shortness of breath, progressive weight gain, and increasing edema over a period of two weeks. Resident Identifier: Resident #115. Facility Census:109. Findings included: a) Resident #115 A closed record review of Resident #115's records was performed on 11/18/24 at approximately 11:15 AM. Record review revealed that Resident #115 was (age and gender) diagnosed with Dementia, Major Depressive Disorder, Chronic Obstructive Pulmonary Disease (COPD), Congestive Heart Failure (CHF), seizures, and hypertension. During the record review, the facility did not notify the physician of the resident's weight gain of over 12 pounds in two months. Additionally, the facility failed to obtain orders from the physician to address this weight gain. Furthermore, the facility did not inform the physician about the resident's +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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on record review and interview, a resident's necessary medical treatment was delayed due to a lack of ongoing clinical assessment and identification of changes in condition by the facility. This failure resulted in the resident being admitted to the hospital for edema and congestive heart failure. Resident Identifier: Resident #115. Facility Census: 109. Findings included: a) Resident #115 A closed record review of Resident #115's records was performed on 11/18/24 at approximately 11:15 AM. Record review revealed that Resident #115 was a (age and gender) diagnosed with Dementia, Major Depressive Disorder, Chronic Obstructive Pulmonary Disease (COPD), Congestive Heart Failure (CHF), seizures, and hypertension. Record review on 11/19/24 at approximately 10:00 AM revealed a nursing note dated 10/26/224 at 2:48 PM by LPN #130, which stated: Resident sitting in WC in room at this time. Resident feet/ankles/legs have edema, pitting 3+. Resident is noted to be on 80mg of Lasix and can't to drink several drinks…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interview, and observation the facility failed to provide palatable, attractive, and appetizing food. This has the potential to affect all residents that get their nutrition from the kitchen. Facility census: 109. Findings included: a) Meals During a complaint investigation for Residents not being served nutritious and palatable meals found Resident Council Minutes: June 2024 - Concerning the meat is tough, residents not receiving substitutions and eggs not being cooked correctly. No response noted. - Meals do not match the menu. Response We are working to have more consistent offering. We are good as long as the meal matches the tray ticket. August 2024 - Meals are late. Response from the Administrator that meals will be late for various reasons. He encouraged the residents to ask for a snack. October 2024 - Rolls were flat and potatoes were cold. Response education to on temperature of food and presentation of food was given to dietary staff. - Meals are coming late. No response…

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 provide palatable, attractive, and appetizing food at a scheduled time. This has the potential to affect all residents that get their nutrition from the kitchen. Facility census: 109. Findings included: a) Meal times During a complaint investigation for Residents not being served meals on time meals found Resident Council Minutes: August 2024 -Meals are late. Response from the Administrator that meals will be late for various reasons. He encouraged the residents to ask for a snack. October 2024 -Rolls were flat and potatoes were cold. Response education to on temperature of food and presentation of food was given to dietary staff. - Meals are coming late. No response at this time. Review of grievance forms found: -06/10/24 - Time of meals are usually late, meat, fish and eggs are over cooked and tough. Resolution- Posted mealtimes are times meal starting to be served but not all floors /residents/ can receive meals at exact times. Staff educated on keeping meals on schedule. During an interview on…

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

Based on record review, and interviews, the facility failed to ensure they promoted and facilitated resident self determination by failing to assist with transportation to the resident's primary care physician (PCP). Resident identifier: #115. Facility Census:109 Findings included: a) Resident #115 Resident #115 was no longer at the facility. Record review revealed that Resident #115 had been diagnosed with Seizures, Dementia, Major Depressive Disorder (MDD) Congestive Heart Failure (CHF), Chronic Obstructive Pulmonary Disease (COPD), Hypertension (HTN), Hypothyroidism, and Hyperlipidemia. Further record review on 11/19/24 at approximately 10:00 AM revealed that resident had ongoing complaints of shortness of breath, and pain as evidenced by the following progress notes: A nursing note dated 10/26/224 at 2:48 PM by Licensed Practical Nurse (LPN) #130, stated: Resident sitting in WC in room at this time. Resident feet/ankles/legs have edema, pitting 3+. Resident is noted to be on 80 mg of Lasix and can't to drink several drinks at a time as well as not elevating feet throughout the…

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

Based on record review and staff interview, the facility failed to provide care/treatment services in accordance with professional standards of practice. Daily weights were not obtained for Resident #9's cardiac care as directed by the physician. This was a random opportunity for discovery. Resident identifier: #9. Facility Census: 112. Findings Included: a) Resident #9 A review of the facility policy titled Resident Height and Weights with no effective or revision date read as follows. .5. Weight Procedure: .c) Compare weight to previous weight obtained. If a variance of 5(five) pounds or more is noted, reweigh resident to verify weight. .9. Reweigh Parameters: a) A plus/minus of 5 (five) pounds of weight in one (1) week will result in: i) Reweigh within 24 hours (1) Validation with nurse for accurate weight (2) Notify IDT(Interdisciplinary Team)/doctor/family, if indicated. Record review revealed a Physician order, dated 01/17/24, for weight every day. Call (local Cardiology) with weight gain of 3 (three) lbs (pounds) in a day or 5 (five) lbs in a week. During a record review on…

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

Based on observation, record review and staff interview, the facility failed to ensure nutritional adequacy by providing inconsistent portions of the food to maintain perimeters of health. This failed practice had the potential to affect all residents currently receiving nourishment from the facility's kitchen. Facility Census:112. Findings Included: a) Inconsistent Portions During a tour of the kitchen on 02/05/24 beginning at 11:06 AM with the Culinary Director (CD)revealed the following issue: The Diet Guide Sheet directed to use the following serving scoops for the noon meal: Ground Pork Roast #10 Pureed Pork Roast #8 Seasoned Greens ½ (half) cup Seasoned Greens pureed #10 Rice Pilaf ½ cup Rice Pilaf pureed #8 A review of the disher and scoop size chart, reads as follows: #8 Grey 4 ounces (oz) #10 Cream 3.25 oz #16 Blue 2 oz During an observation on 02/05/24 at 12:10 PM of the noon meal being served from the steam table, [NAME] #118 had a blue scoop for pureed greens, which needed to be a cream colored scoop for 3.25 oz. Cook #118 was dispensing the greens by one (1) scoop 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 observation, record review and staff interview, the facility failed to serve food that was palatable and at an accurate temperature. This failed practice had the potential to affect more than an isolated number of residents. Facility Census:112. Findings Included: a) Point of Service During a tour of the Cottage Unit on 02/05/24 at 1:30 PM, the noon meal trays had not arrived on the unit. An immediate interview with the Resident Service Director # 7 stated the noon meal trays usually arrive at 1:00 PM. The noon meal trays arrived on the Cottage unit at 1:43 PM, the staff began serving immediately. At 1:45 PM, the Dietary department was asked to bring a thermometer to take the temperature of the food being served. At the point of service the temperatures were obtained at 1:50 PM, by the Culinary Director (CD) using the facility's thermometer -Pork Roast 80 degrees -Rice 80 degrees -Greens 78 degrees During an immediate interview the CD acknowledged the temperatures were not acceptable. This surveyor heard some residents state, this meat is too tough to cut, I can't eat this.…

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

Based on observation, record review, staff interview and Resident interviews the facility failed to provide Residents with evening snacks. This is true for three (3) of three (3) diabetic Residents reviewed. Resident identifiers: Resident #16, Resident #9 and Resident #11. Facility Census:112. Findings Included: a) Resident #16 During an interview on 02/05/24 at 8:30 PM, Licensed Practical Nurse (LPN) #130 stated the kitchen brings some snacks like ice cream, crackers between 8-9:00, they put them in the nourishment room. The resident has to request them, we don't offer a snack to every resident. During a interview on 02/05/24 at 8:45 PM Nurse Aide (NA) #11 stated we have snacks in the nourishment room sometimes like pudding or applesauce. We don't have a cart full of snacks for each Resident to choose from at night. If the Residents ask for something we can try to find them something. During an interview on 02/05/24 at 8:56 PM, Resident #16 stated, The food sucks here. It is always cold, I mean cold, cold. We had fish again tonight. We just had it Friday and then again tonight it…

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

Based on observation, record review and staff interview the facility failed to ensure foods were stored and prepared in a safe, clean and sanitized environment. The facility also failed to keep the kitchen equipment clean and sanitized. The facility failed to ensure hot foods were held at 135.0 degrees Fahrenheit or higher on the steam table. This deficient practice has the potential to affect all the residents that receive nutrients from the kitchen. Facility Census:112. Finding Included: A review of the facility policy titled Environment with a revision date of 09/17 read sas follows. Procedures: 1. The Dining Services Director will ensure that the kitchen is maintained in a clean and sanitary manner, including floors, walls, ceilings and ventilation. .4. The Dining Service Director will ensure that a routine cleaning schedule is in place for all cooking equipment, food storage areas and surfaces A review of another of the facility policy titled Equipment read as follows. Procedures: 1. All equipment will be routinely cleaned and maintained in accordance with manufacturer'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 staff interview and medical record review, the facility failed to ensure Resident #3 received an adequate amount of nutrition to maintain acceptable parameters of nutrition via feeding tube. This was true for one (1) of three (3) residents reviewed for nutrition from feeding tubes. Resident identifier #3. Facility census 114. Findings included: a) Resident #3 A medical record review for Resident #3 revealed a dietary progress note from 7/21/2023: Note Text: Resident continues to be NPO with all needs met via feeding tube. Current Body Weight (CBW) 157# on 07/05/23. +4.2%x 30 d, +7.2% x 90 d and +9.5% x 180 d. Body Mass Index =marginal obesity. Further weight gain is not desired. Will await next weight to ensure gain is valid. Continued Record review of Resident #3's weights revealed: 9/7/2023 10:09 AM 164.4 pounds Mechanical Lift 9/5/2023 8:03 AM 160.6 pounds Mechanical Lift 8/1/2023 11:17 AM 153.2 pounds Mechanical Lift 7/5/2023 10:28 AM 157.0 pounds Mechanical Lift 6/1/2023 3:28 PM 150.6 pounds Mechanical Lift 5/3/2023 12:49 PM 152.0 pounds Mechanical Lift Continued…

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 conduct testing of staff and residents for COVID-19 in accordance with national standards, to prevent spreading of COVID-19. This was discovered during the completion of the Infection Control Task during the Long-Term Care Survey. This failed practice has the potential to affect all residents currently residing in the facility. Facility Census: 110. Findings included: a) Center of Disease Control CDC A review of the CDC guidelines related COVID 19 testing during an outbreak found the following pertinent information: Negative tests should be repeated in 48-hour intervals, on Day 3 and Day 5 post-exposure. CDC also recommends a series of 3 tests for individuals newly admitted or readmitted to the nursing home in areas where community transmission rates are high. Testing Due to Exposure A series of 3 tests is recommended for individuals in healthcare settings (residents/patients and staff) following SARS-CoV-2 exposure, regardless of the individual's vaccination status. Asymptomatic residents/patients who have had close…

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

Based on resident interviews and staff interviews, the facility failed to uphold a resident's right to privacy by requiring residents to open their packages in front of staff. This was discovered during the resident council meeting and has the potential to affect more than a limited number of residents. Facility Census 110. Findings Included: a) Resident Council Meeting A Resident Council Meeting was held on 05/24/23 at 10:00 AM. During the Resident Council Meeting, the residents were asked if they receive their mail unopened and on Saturdays? All attendees reported they must open packages in front of staff. The members present at the resident council meeting confirmed it was all residents and all packages they receive. b) Staff Interviews On 05/24/23 at 11:10 AM, a staff interview with the Activities Leader (AL) #17 was conducted. The surveyor asked AL #17 what the process for resident mail delivery was. AL #17 responded that the activities department is responsible for delivering the residents' mail to them. The surveyor asked if they open the mail. AL #17 said they do not open…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on observation and staff interview the facility failed to provide a safe, clean comfortable homelike environment. Window blinds in resident rooms were not in good repair. The facility also failed to provide adequate and comfortable lighting levels in the dining area. These were random opportunities for discovery which have the potential to affect more than a limited number of residents who currently reside in the facility. Room identifiers: The Main Dining Room, room [ROOM NUMBER], and room [ROOM NUMBER]. Facility Census: 110 Findings included: a) Main Dining Room During a dining room observation, on 05/23/23 at 11:45 AM, the Main Dining Room had inadequate lighting, several light bulbs were not working making the room dimly lit. During an interview, on 05/23/23 at 11:58 AM, the Executive Director acknowledged the light bulbs were not working properly and several needed to be replaced. b) room [ROOM NUMBER] and room [ROOM NUMBER] An initial tour of the Memory Unit on 05/22/23 at 12:50 PM, revealed the…

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

Based on record review, staff interviews, and resident interviews, the facility failed to implement their abuse policy for one (1) of four (4) residents reviewed for the category of abuse, for one (1) of one (1) resident reviewed for the category of dignity, and for two (2) of two (2) residents reviewed for the category of prompt resolution of grievances, during the long term care survey. Resident identifiers: #97, #75, #220, and #24. Facility Census: 110. Findings included: a) Abuse Policy Communicare's Policies and Standard Procedures for WEST VIRGINIA Abuse, Neglect & Misappropriation, Policy #: NS 1018-03, page five (5) of 20, defines, .Verbal Abuse includes the use of oral, written, or gestured communication, or sounds, to residents within hearing distance, regardless of age, ability to comprehend, or disability. (Examples of mental and verbal abuse include, but are not limited to, harassing a resident; mocking, insulting, ridiculing; yelling or hovering over a resident, with the intent to intimidate; threatening residents, including, but not limited to, depriving a resident of…

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

Based on record review, staff interviews, and resident interviews, the facility failed to immediately report abuse allegations for one (1) of four (4) residents reviewed for the category of abuse, for one (1) of one (1) resident reviewed for the category of dignity, and for two (2) of two (2) residents reviewed for the category of prompt resolution of grievances, during the long term care survey. Resident identifier #97, #75, #220, and #24. Census 110. Findings Included: a) Resident #97 During a resident interview with Resident #12, on 05/22/23 at 1:10 PM, Resident #12 stated her roommate, Resident #97, was verbally abused by an aide named (Nursing Assistant #75 name) one day last week. Resident #12 said she reported this to her roommate's daughter and to staff member (name of #152) who said she would report it. The surveyor asked Resident #12 what did the Nursing Assistant (NA) do that was perceived as abusive and she replied the NA was rude and gruff, had an attitude, when taking her roommate to the restroom. When Resident #97 was interviewed she stated she does not remember…

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 interviews, and resident interviews, the facility failed to prevent further abuse by allowing alleged perpetrator to continue working after obtaining knowledge of an allegation of abuse and failed to complete a thorough investigation for one (1) of four (4) residents reviewed for the category of abuse during the long-term care survey. Resident identifier #97. Facility Census: 110. Findings included: a) Resident #97 During a resident interview with Resident #12, on 05/22/23 at 1:10 PM, Resident #12 stated her roommate, Resident #97, was verbally abused by an aide named (Nursing Assistant #75 name) one day last week. Resident #12 said she reported this to her roommate's daughter and to staff member (name of #152) who said she would report it. The surveyor asked Resident #12 what the Nursing Assistant (NA) did that was perceived as abusive, and she replied the NA was rude and gruff, had an attitude, when taking her roommate to the restroom. When Resident #97 was interviewed she stated she does not remember anything about it. Resident #12 says NA #75 rushed…

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 develop and or implement the comprehensive care plan to meet the resident's needs. This was true for five (5) of 26 residents reviewed in the sample during the Long-Term Care Survey Process. Resident Identifiers: #112, #47, #51, #39 and #66. Facility Census: 110 Findings included: a) Resident #112 A record review of Resident #112's medical record on 05/30/23 at 11:34 AM , found admitting diagnosis included: -anxiety disorder -depression -bipolar disorder -Post-Traumatic Stress Disorder Further review of the medical record revealed a Care Plan with an initiation date of 03/17/23 which reads as follows. Focus: The resident uses, antidepressant medication Depression, Pain Goal: Resident will be without complications of ant-depressant medication side effect, through target date. Inventions included: Encourage resident to voice feelings and discuss coping skills. During an interview on 05/30/23 at 12:53 PM the Minimum Data Set Register Nurse (MDS RN) #57 stated Resident # 112, can tell his coping skills, he…

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 pain management was consistent with professional standards of practice. This deficient practice had the potential to affect one (1) of one (1) resident reviewed for the care area of pain. Resident identifier: #66. Facility census: 110. Findings included: a) Resident #66 Review of Resident #66's physicians' orders showed an order for Acetaminophen (Tylenol), 325 mg tablets, two (2) tablets by mouth every six (6) hours as needed for mild pain and moderate pain. The intensity rating for mild and moderate pain was not specified in the order. Review of Resident #66's Medication Administration Record (MAR) for May 2023 showed the resident had received Acetaminophen for pain seven (7) times in May. The resident's level of pain was only assessed on two (2) occasions, 05/10/23 at 5:39 AM and 05/22/23 at 2:13 PM. The resident's level of pain was not assessed on five (5) occasions, 05/01/23 at 1:53 PM, 05/03/23 at 6:07 am, 05/07/23 at 5:47 AM, 05/17/23 at 3:56 PM, and 05/18/23 and 4:22 AM. Further review of 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 ensure medications were stored and labeled in accordance with currently accepted professional principles. A multi-use tuberculin purified protein derivative (PPD) vial was not dated when opened to determine when the vial should be discarded. This was a random opportunity for discovery that had the potential to affect residents receiving tuberculin PPD injections. Facility census: 110. a) Memory Unit Medication Room On 05/24/23 10:20 AM, inspection of the Memory Unit medication room was made. Licensed Practical Nurse (LPN) #47 was in attendance. In the medication room refrigerator, an opened multi-dose vial of tuberculin purified protein derivative (PPD) was noted to not have been dated when first accessed. Tuberculin purified protein derivative is given by injection to aid in the diagnosis of tuberculosis. A yellow sticker on the medication box stated to discard 30 days after first use. The vial had been delivered from the pharmacy on 4/5/23. LPN #47 confirmed the vial had not been dated when opened to determine when…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . 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 failed to keep accurate temperature records. The facility also failed to keep dishes and utensils in a sanitary area, and to keep kitchen equipment clean. This failed practice had the potential to affect all residents currently receiving nutrition from the facility's kitchen. Facility Census: 110 Findings Included: A review of the facility policy titled Food Storage: Cold Foods with a revision date of 04/18 read as follows. .Procedures .4. A written record of daily temperatures will be recorded. 5. All foods will be stored wrapped or in covered containers, labeled and dated and arranged in a manner to prevent cross contamination. a) Dry Storage On 05/22/23 at 11:30 AM during the initial tour of the kitchen with the Culinary Director (CD)…

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

Based on medical record review, staff interview and resident interview, the facility failed to ensure each residents medical record was complete and accurate medical records. This was true for five (5) of 26 residents reviewed in the sample during the Long-Term Care Survey Process. Resident Identifiers: Resident #101, Resident #47, Resident #34, Resident #51 and Resident #170. Facility Census: 110 Findings Included: a) Resident #101 A record review of Resident #101's medical record on 05/22/23 at 4:41 PM Resident #101's found a Physician Orders for Scope of Treatment (POST) form which indicate verbal consent was obtained from the resident's representative on 09/01/22. The consent was 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 [medical power of attorney] representative or health care surrogate is unavailable at the time of form completion, this…

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

Based on observation and staff interviews the facility failed to maintain equipment in safe operating conditions. Two (2) ice machines did not have a one (1) inch air gap for drainage. This failed practice had the potential to affect all residents currently receiving nutrition from the facility kitchen and the north nourishment room. Facility Census: 110 Findings Included: a) North Nourishment Room Ice Machine During the tour of the North Nourishment Room, on 05/23/23 at 9:42 AM, with the Culinary Director (CD) an observation of the ice machine water drain revealed it was touching the floor drain without a one (1) inch gap. This allowed for the potential for contaminants to enter the line and travel to the ice machine. During an interview on 05/23/23 at 12:32 PM, the Administrator stated I was not aware of the need for a one-inch gap. During an interview on 05/23/23 at 3:12 PM the Director of Plant Maintenance stated, I was not aware of the need of a one-inch gap from the drain, but it will be repaired. b) Main Dining Room Ice Machine A tour of the facility, on 05/23/23 at 10:15 AM,…

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

Based on record review and staff interview the facility failed to notify the representative/family of medical changes. This was true for one (1) out of one (1) resident reviewed for the care area of notification of change during the long-term care survey process. Resident identifiers: Resident # 171. Facility census 110. Findings included: a) Resident #171 A review of the medical record for Resident #171 found the following times a change in care was made and the Power of Attorney was not notified of the changes: On 11/26/22 there was an order for Resident #171 to receive Oxygen via nasal cannula with a flow rate of 2 liters. On 11/18/22 there was an order to change the treatment for a pressure ulcer. On 11/29/22 there was an order to stop the giving Norco (a pain medication). On 05/25/23 at 10:30 AM, the Assistant Director of Nursing (ADON) said there was not any information in the medical to prove the POA for Resident #171 was notified of the order changes listed above. .

Based on resident interview, record review and staff interviews, the facility failed to make prompt efforts to resolve grievances and keep the residents appropriately apprised of progress toward resolution for one (1) of one (1) resident reviewed for the category of personal property, during the long-term care survey. Resident identifier #39. Facility Census 110. Findings Included: a) Resident #39 On 05/24/23 at 10:00 AM, during the Resident Council Meeting, Resident #39 stated her phone was washed and ruined by staff last month and never replaced. Resident #39 stated she reported it to Social Worker (SW) #82 but it has not been replaced and no one has given her an update on when it will be replaced. An Electronic Medical Record (EMR) review conducted on 05/24/23 at 12:45 PM found, A progress note written by Licensed Practical Nurse (LPN) #9, dated 04/30/23 at 12:28 PM which read as follows: While resident was out of room aids went in and cleaned room and changed residents sheets, phone was in the bed sheets and went to laundry, when resident returned she didn't have her phone,…

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

Based on record review and staff interview, the facility failed to notify the State Ombudsman of a transfer to an acute care facility for Resident #55. This was true for one (1) of three (3) residents reviewed under the care area of hospitalization. Resident identifier: #55. Facility Census: 110. Findings included: a) Resident #55 On 05/24/23 at 10:18 AM, a record review was completed for Resident #55. The record review found the resident had been transferred to an acute care facility on 03/24/23. The following progress note dated 03/24/23 at 5:09 AM states the following: At 0430 (4:30 AM) Resident noted to have a temperature of 101.0 (Fahrenheit). Crackles heard in lungs upon auscultation. Resident O2 SAT (oxygen saturation) @ (at) 75%. This nurse applied 2 (two) liters of oxygen. O2 SAT staying at 86-89 (percentage) on 2 (two) liters. Resident was swabbed for COVID 19 with a positive result. BP (blood pressure) 172/78. This nurse left message for (Name of Power of Attorney) @ (at) 0448 (4:48 AM). Resident sent to (Name of acute care facility) @ 0510 (5:10 AM). (Typed as written.)…

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 a bed hold policy to the resident and/or resident representative upon transfer to an acute care facility for Resident #55. This was true for one (1) of three (3) residents reviewed under the care area of hospitalization. Resident #55. Facility Census: 110. Findings Included: a) Resident #55 On 05/24/23 at 10:18 AM, a record review was completed for Resident #55. The record review found the resident had been transferred to an acute care facility on 03/24/23. The following progress note dated 03/24/23 at 5:09 AM states the following: At 0430 (4:30 AM) Resident noted to have a temperature of 101.0 (Fahrenheit). Crackles heard in lungs upon auscultation. Resident O2 SAT (oxygen saturation) @ (at) 75%. This nurse applied 2 (two) liters of oxygen. O2 SAT staying at 86-89 (percentage) on 2 (two) liters. Resident was swabbed for COVID 19 with a positive result. BP (blood pressure) 172/78. This nurse left message for (Name of Power of Attorney) @ (at) 0448 (4:48 AM). Resident sent to (Name of acute care 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.

Based on record review and staff interview, the facility failed to ensure a significant change Minimum Data Set (MDS) assessment was completed when the resident experienced a change in condition. Resident #93 did not have a significant change MDS assessment completed when hospice services were started. This deficient practice had the potential to affect one (1) of 26 residents reviewed in the long-term care survey sample. Resident identifier: #93. Facility census: 110. Findings included: a) Resident #93 Review of Resident #93's medical records showed the resident began receiving hospice services on 04/05/23. No significant change MDS assessment had been completed after the resident began receiving hospice services. During an interview on 05/23/23 at 3:08 PM, MDS nurse #93 confirmed Resident #93 did not have a significant change MDS assessment within 14 days of receiving hospice services. No further information was provided through the completion of the survey.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on record review and staff interviews, the facility failed to ensure a new Pre-admission Screening (PAS) was completed to reflect the resident's new psychiatric diagnosis for one (1) of one (1) resident reviewed for the category of PASARR, during the long-term care survey. Resident identifier #68. Census 110. Findings included: a) Resident #68 Record review conducted on 05/22/23 at 2:08 PM, revealed a PAS dated 03/06/20 did not trigger a Level II evaluation. The record also revealed the resident received a psych diagnosis after admission but did not receive a new PAS to address whether specialized services were needed. The surveyor requested a copy of the most recent PAS from the Administrator. On 05/23/23 at 12:24 PM, a record review of the latest PAS the facility provided to surveyor, was dated for 03/06/20, (resident admitted on [DATE]), the facility completed this PAS. In the electronic record, Medical Diagnosis section, Major Depressive Disorder, recurrent, moderate dated 12/03/20, and Unspecified…

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 the resident's Pre-admission Screening (PAS) reflected pre-admission diagnoses for one (1) of one (1) resident reviewed for the category of PASARR and for one (1) of five (5) residents reviewed for the category of mood/behavior, during the long-term care survey. Resident identifier #68 and #112. Census: 110. Findings included: a) Resident #68 Record review conducted on 05/22/23 at 2:08 PM, revealed a PAS dated 03/06/20 did not trigger a Level II evaluation. The record also revealed the resident received a psych diagnosis after admission but did not receive a new PAS to address whether specialized services were needed. The surveyor requested a copy of the most recent PAS from the Administrator. On 05/23/23 at 12:24 PM, a record review of the latest PAS the facility provided dated 03/06/20, (resident admitted on [DATE]), the facility completed this PAS. In the electronic record, Medical Diagnosis section, Major Depressive Disorder,…

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, family interview, staff interview and record review 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 was true for one (1) of three (3) residents reviewed for the care area of activities during the long-term care survey and had the potential to affect more than an isolated number of residents. Resident identifier: Resident #90. Facility Census: 110 Findings included: a) Resident #90 During the initial tour of the Memory unit on 05/22/23 at 12:49 PM the residents were observed in the dining area, while waiting on the meal, residents became restless and began wandering. The lunch meal started being served at 1:20 PM. During an interview on 05/22/23 at 1:27 PM Resident #90 medical power of attorney stated, we always come at the same time before lunch and there are no activities going on. The other residents are always just wandering around. Mom is just usually sitting there looking out the window or in her room when…

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

Based on record review, observation and staff interview the facility failed to ensure Resident #107 dental status was adequately assessed on admission to the facility. The nurse completing the resident's initial nursing assessment upon admission to the facility noted she did not assess the resident's dental status because the resident was NPO (take nothing by mouth). This was true for one (1) of 26 sampled residents reviewed during the long-term care survey process. Resident identifier: #107. Facility Census: 110. Findings included: a) Resident #107 A review of Resident #107's medical record on 05/24/23 found an admission Initial Evaluation completed by the Director of Nursing (DON) on 12/29/22. Under section 5. Oral status the DON in section 12a. Specify 'other' wrote, Resident NPO unable to determine.' An interview with the Assistant Director of Nursing (ADON) on 05/24/23 at 12:04 PM confirmed, a resident being NPO does not inhibit you from being able to assess their dental status. The ADON performed an oral assessment on Resident #107 at this time and confirmed the resident had…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on record review, staff interview and resident interview the facility failed to ensure a resident who displays or is diagnosed with a mental disorder or psychosocial adjustment difficulty receives appropriate treatment and services to correct the assessed problem or to attain the highest practicable mental and psychosocial well-being. When the facility took Resident #19's right to use her motorized wheelchair the Social Worker indicated the resident voiced she was upset by the situation. The social worker stated, I referred her to (name of psychologist) for psychotherapy to help adjust. The psychologist saw Resident #19 in 02/2023 and noted he would see her every one (1) to three (3) weeks for 12 weeks for psychotherapy. Resident #19 has not seen the psychologist since this occasion in 02/2023. This was a random opportunity for discovery during the Long Term Care Survey Process. This was true for only Resident #19. Resident Identifier: #19. Facility Census: 110. Findings Included: a) Resident #19 On…

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

Based on medical record review and staff interview, the facility failed to ensure a resident's Physician Orders for Scope of Treatment (POST) form was signed and dated by the preparer. This was found for one (1) of 19 advance directives reviewed during the Long-Term Care Survey sample process. Resident identifier: #71. Facility census: 104. Findings included: a) Resident #71 A medical record review for Resident #71 on 02/21/22, revealed the POST form completed on 06/01/21 had not been signed or dated by the preparer. In an interview with the Cooperate Registered Nurse (RN) on 02/21/22 at 1:10 PM, the RN verified the POST form did not include the signature or date of the preparer. .

Based on record review and staff interview, the facility failed to ensure an employee hired had not been found guilty of abuse, neglect, exploitation or mistreatment or misappropriation of property by a court of law. This was true for one (1) of six (6) employees reviewed during the Long-Term Survey Process. Employee Identifier #63. Facility Census: 104. Findings Included: a) Employee #63 A review of Nursing Aide (NA) # 63's employment record reveals a [NAME] Virginia Clearance for Access: Registry and Employment Screening form (WV CARES) dated 09/21/21. There was not a WV CARES Notification of Eligible Fitness Determination. In an interview on 02/22/22 at 10:45 AM, HR (Human Resources) # 52 stated, They had 90 days to get them completed. She must have missed her fingerprinting appointment. She doesn't work that much. When HR#63 was showed the date of 09/21/21 on the WV CARES form she stated there is a letter from the WV CARES that explains the exemption of finger prints. HR #52 produced the following letter dated 01/28/22 from the State of [NAME] Virginia Department of Health 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 medical record review and staff interview, the facility failed to ensure a complete and accurate Minimum Data Set (MDS) Assessment for one (1) of 19 residents reviewed during the long-term care survey process. Resident identifier: #3. Facility census: 104. Findings included: a) Resident #3 Review of Resident #3's medical records revealed a Minimum Data Set (MDS) Assessment with Assessment Reference Date (ARD) of 11/22/21 which coded the resident was taking an anticoagulant for seven (7) days during the look-back period. Review of Resident #3's medical orders for that time period did not show an order for anticoagulant medication. During an interview on 02/22/22, MDS Coordinator #104 confirmed Resident #3 was not taking anticoagulant medication in November 2021 and the MDS was incorrect. No further information was provided through the completion of the survey process. .

Based on record review and staff interview, the facility failed to maintain an environment in which a resident, with an indwelling catheter, receives the appropriate care and services to prevent urinary tract infections. This was true for two (2) of three (3) Residents reviewed during the Long-Term Survey Process. Resident Identifiers #48 and #58 Facility Census 104 Findings Included: a) Facility Policy A review of the Facility Policy titled: Catheter Care Policy, with an implementation date of 11/27/17 and a revision date of 05/03/21, found the following: .1. Catheter care will be performed every shift and as needed by the nursing assistant . b) Resident #48 A review of Resident # 48's medical records found the following task that reads, Catheter / Urine output. Question four (4) of the task reads catheter care provided. A thirty day review from 01/23/22 of question four (4) found staff failed to complete required catheter care on each of the following dates per facility policy: 01/30/22, 02/02/22, 02/09/22, 02/11/22, 02/20/22, and 02/23/22. On 02/23/22 at 8:45 AM, the DON…

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

Based on record review and staff interview the facility failed to maintains the resident's highest practicable level of physical, mental and psychosocial well-being and prevent or minimize adverse consequences related to medication by not maintaining an attending physician review. This was true for one (1) of five (5) Residents reviewed for unnecessary medications during the Long-Term Survey Process. Resident Identifier #102 Facility Census 104 Findings Included: a)Resident #102 A review of Resident # 102's medical record reveals a Consultant Pharmacist's Medication Regimen Review dated 12/19/21 signed by Pharmacist #159 that reads . just a reminder .f/u (follow up) GDR (Gradual Dose Reduction) evaluation . The medications to be reviewed were: Olanzapine 15 mg daily for dementia with behaviors, Depakote ER 1500 mg bedtime, Klonopin 1mg BID (twice a day), Vilazodone 40 mg daily, Trazodone 50 mg daily and 150 mg bedtime. This Consultant Pharmacist's Medication Regimen Review was not signed or addressed by the facility physician. On 02/22/22 at 9:34 AM, the Administrator 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 ensure each resident's drug regimen was free from unnecessary psychotropic medications. Resident #91 received an as needed (PRN) anti-anxiety medications even though they had demonstrated no target behaviors to warrant the use of the PRN medication and the facility failed to attempt non-pharmacological interventions prior to administering the PRN anti-anxiety medication. This was true for one (1) of five (5) residents reviewed for the care area of unnecessary medications during Long-Term Survey Process Survey (LTCSP). Resident identifier: #91. Facility census: 104. Findings include: a) Resident #91 A review of Resident #91's medical record found the following physician's orders for Ativan 0.5 milligrams (mg)- Give 1 tablet by mouth every four (4) hours as needed for anxiety. Review of Medication Administration Record (MAR) for December 2021 and January and February 2022 found Resident #91 was administered this medication on the following dates and times without evidence of non-pharmacological interventions 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.

Based on medical record review and staff interview, the facility failed to ensure medications were stored and labeled in accordance with currently accepted professional principles. One (1) of three (3) opened insulin pens in the Memory Unit medication cart was not dated when first opened. Resident identifier: #41. Facility census: 104. Findings included: a) Memory Unit medication cart On 02/21/22 at 8:05 AM, an inspection was made of the memory unit medication cart. The Lantus SoloStar Solution Pen-injector (insulin) for Resident #41 did not have a date to indicate when the pen had first been opened. This was important to determine when the pen needed to be discarded. According to the Lantus SoloStar Solution Pen-injector package insert available on the Food and Drug Administration Website, Lantus pens should be thrown away 28 days after being opened. The insulin pen had been delivered from the pharmacy on 02/06/22. Licensed Practical Nurse (LPN) #62 confirmed Resident #41's Lantus SoloStar Solution Pen-injector had not been dated when opened. No further information was provided…

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 maintain the kitchen in a safe and sanitary manner in accordance with professional standards of practice. During the kitchen tour it was discovered a dietary aid was not wearing a beard guard while in the kitchen service area. This was a random opportunity for discovery. This deficient practice had the potential to affect a limited number of residents. Facility census: 104 Findings included: a) Kitchen tour During the kitchen tour on 02/21/22 at 11:28 AM, it was discovered Dietary Aide (DA) #30 was not wearing a beard net while in the kitchen service area. During an interview with the Dietary Manager (DM) on 02/23/22 at 12:17 PM, the DM agreed this was not a sanitary practice for DA #30 to be in the kitchen service area without a beard net. .

Based on medical record review and staff interview, the facility failed to ensure the resident and/or the resident's representative has the opportunity to refuse the annual influenza vaccine. This is true for two (2) of five (5) residents reviewed for the influenza immunization during the long term care survey process. Resident identifiers: #52 and #102. Facility census: 104. Findings include: a) R#52 Review of the medical record on 02/22/22, revealed R #52 received the annual influenza vaccine on 10/14/21, 10/16/20, and 10/02/19. The form titled Influenza Vaccination Informed Consent/Declination is dated 09/12/16 and signed by a health care surrogate. The medical record lacks any other consents for the influenza vaccine. The medical record was reviewed with the Infection Preventionist/Registered Nurse (IPRN) #13 on 02/23/2022. The IPRN confirmed a consent for the annual influenza vaccine was only obtained once on 09/12/16. b) Resident (R) #102 Review of the medical record on 02/22/22, revealed R #102 received the annual influenza vaccine on 10/14/21. The form titled Annual…

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.