Parkersburg Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interview and observation, the facility failed to ensure food was stored and served in accordance with professional standards for food service safety This failed practice had the potential to affect more than a limited number of residents. Facility Census: 63.Findings included: a) The facility's policy and procedures for Food Storage: Cold Foods stated, all foods will be stored wrapped or in covered containers, labeled and dated, and arranged in a manner to prevent cross contamination. The facility's policy and procedure for Food Storage: Dry Goods stated, all food would be stored according to the Food and Drug Administration) (FDA) Food Code. and that the food storage areas would be neat, arranged for easy identification and the date marked as appropriate. b) On 12/07/2025 at 11:35 AM, the kitchen investigation was initiated. The following items were found and verified by [NAME] #62: Dry Storage - Beverage cart was sitting in the dry food storage area for lunch. The cart contained…

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 garbage and refuse disposed of properly by blocking trash cans This had the potential to affect more than an isolated number of residents. Facility census: 63. Findings included:a) According to the facility's policy and procedure, garbage and refuse will be disposed of in a safe and efficient manner. The policy and procedure indicated the Dining Service Director (DSD) would ensure lined containers wiould be available within the food service area and garbage and refuse would be removed routinely from the kitchen area during the day and at the end of the workday.b) On 12/07/2025 at 11:35 AM, during the initial kitchen observation, five (5) empty and opened boxes were under the handwashing sink on the floor covering the trash can. A plunger was under the boxes. The boxes had to be moved to dispose of paper towels when the state surveyor's hands were washed. Dietary [NAME] #62 confirmed the boxes on the floor and difficulty disposing of paper towels after hand hygiene was completed.

Based on observation, document review, and staff interviews, the facility failed to maintain an effective infection control program by staff not wearing masks during COVID outbreak and staff leaving ice scoops in ice containers. These were random opportunities for discovery during the survey process. Facility census 63. Findings included: a) On 12/07/25 at approximately 11:30 a.m., upon initial entry observed that the facility was under COVID outbreak and observed Employee #18 and Employee #42 sitting at the nurse's station not wearing any masks. Reviewed the facility's COVID outbreak policy and policy requires all staff to wear masks during outbreak. Interview on 12/07/25 at approximately 11:38 AM with Employee #20 verified that during a COVID outbreak all staff were required to wear masks inside of the facility. b) On 12/07/25 at 12:00 PM, the state surveyor observed no separate container for the ice scoop as drinks were passed on the 200 Hall. The ice scoops were placed in the ice bucket. Nurse Aide (NA) #24 confirmed the scoop was in the ice container during the drink pass 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 ensure the kitchen equipment was maintained in safe operating condition. for the freezer. This failed practice had the potential to affect more than a limited number of residents. Facility Census: 63.Findings included: a) The facility's policy and procedure for Safety as related to kitchen and associated equipment safety stated, the equipment will be properly maintained and the Dining Service Director Will ensure that all equipment is in proper working condition and equipped with safety guards, as appropriate. b) On 12/07/2025 at 12:10 PM, ice and significant frost was observed by the state surveyor on the right side of the freezer door during the initial kitchen inspection. Small ice drips were frozen on the freezer's fan, and a large block of ice was formed under the freezer fan. Dietary [NAME] #62 confirmed the finding and reported there was no frost this morning and that it must have been when the dietary aide was going in and out of the freezer.

Based upon record review and staff interview, the facility failed to ensure twelve hours of in-service education for nurse aides, which includes dementia management training and resident abuse prevention training. This was found to be true for three (3) of five (5) nurse aide personnel reviewed during the long term care recertification process. Staff identifiers: #24, #9, #54, #43, #21. Census: 63 Findings included: A) Nurse Aide (NA) #9 Nurse Aide #9 only had sixteen (16) minutes of dementia management training during the twelve-month period from 12/01/24 to 11/30/25. This falls short of the two hours minimum required annually. B) Nurse Aide (NA) #43 Nurse Aide #43 had a hire date of 09/17/25. She only had twenty-four (24) minutes of dementia management training during the period from 09/17/25 through 11/30/25. This fails to comply with WV regulations of receiving two hours of education within her first 30 days or at next orientation. She also had not been educated on resident abuse prevention, or resident rights. The Nurse Aide had no competencies completed prior to assuming…

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 upon record review, resident interviews, staff interview and observation, the facility failed to honor resident's preferences for showers.This was found to be true for two (2) of eleven (11) residents reviewed during the long term care survey process. Resident identifiers: #6, and #56. Facility census: 63. Findings included: A) Resident #6 During an interview with the resident on 12/07/25 at approximately noon, the resident stated he would like to get a shower. He stated, All they do is give me a bed bath. Resident's hair appeared oily, and hair did not look like it had been combed. He had facial beard growth of a few days length. A review of the resident's current care plan, developed on 03/10/25, documents, It is important to me to shower. The facility's shower/bathing schedule showed Resident #6 was scheduled showers for Wednesdays and Saturdays on day shift. A review of the ADL tasks for showering for the last three (3) months documents the following: 9/9/25 through 9/16/25 no bath or showers documented 9/17/25, Wednesday 1:18 PM shower provided 09/18/25-09/20/25 no bath…

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 all alleged violations involving verbal abuse are reported immediately, but not later than 2 hours after the allegation is made. This failed practice has the potential to affect more than a minimal number of residents residing in the long-term care facility. Resident identifier: #35 Facility census: 63. Findings include:Review on 12/10/25 of a Facility Reported Incident (FRI) revealed the Initial Reporting of Allegations for verbal abuse which should be reported immediately or within two (2) hours had a date and time of 12/18/25 12:00 AM.Further record review of the FRI revealed there no fax or email confirmation of when the incident was reported.Continued record review on 12/10/25 revealed the incident happened on 11/18/25 according to some immediately witness statements taken, however no time of incident was noted in that statement. Other witness statements taken were on 11/25/25 and 11/26/25 which were 6 days after the allegation of verbal abuse was made.During an interview on 12/10/25 at 4:24 PM with 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 the appropriate documentation when a resident was transferred out of the facility to the hospital. This was true for one (1) of one (1) resident reviewed for hospitalizations. Resident Identifier: #9. Facility Census: #63. Findings Include: a) Resident #9On 12/09/25 at 1:15 PM record review of hospitalizations for Resident #9 shows she was transferred to the hospital on the following days.08/20/25 no bed hold documentation available09/15/25 no transfer documentation available09/22/25 no bed hold documentation availableAccording to the Policy OPS404 Discharge and Transfer for a resident being transferred to a hospital includes but is not limited to the following:5.1 For unplanned, acute transfers, the patients must be permitted to return to the Center. Prior to the transfer, the patient and patient representative will be notified verbally followed by written notification using the Notice of Hospital Transfer or state specific transfer form. 5.3 For any hospital transfers, the following will be sent to the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and staff interview the facility failed to ensure the resident's comprehensive care plan was revised relating to a resident using a straw, tube feeding orders, a urinary (Foley) catheter, an actual pressure ulcer and a Peripherally Inserted Central Catheter (PICC) line in place. These were random opportunities of discovery. Resident Identifiers: #9 and #11. Facility Census: #63Findings Include: a) Resident #9 On 12/08/25 at 11:55 AM record review shows that Resident #9 has orders for Enteral Feed Order every shift. Osmolite 1.5 Cal. 60 ml/hr. Runs for 22 hours/day with downtime from 1100-1300 (11:00 AM to 1:00 PM). 25ml H20 flushes every 4 hours. There are no current orders for a Peripherally Inserted Central Catheter (PICC) line, urinary foley catheter or pressure ulcer treatment. Review of the care plan states: Resident at risk for skin breakdown related to actual pressure ulcer, decreased activity, frail fragile skin, impaired sensation, incontinence, Foley catheter in…

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

Based on observations, record review and interview the facility failed to treat a fall for Resident #66 and failed to administer medications in a timely manner as ordered by the physician for Resident #9. These failed practices were random opportunities for discovery during the long term care survey process and had the potential to affect more than a minimal number of residents residing in the long term care facility. Resident identifier #66 and #9 Facility census: 63 Findings include: a) Resident #66 Record review completed on 12/10/25 at 9:38 AM of a facility reported incident (FRI) revealed the facility substantiated that a resident was neglected. As written on the five (5) day follow up – To whom it concerns: While conducting an investigation into an injury of unknown origin regarding the long-term care facility Resident #66, a Certified Nursing Assistant (CNA) reported that she had previously been notified in report resident #66 had sustained a fall on 2/28/2024. Resident #66's roommate, who is alert and oriented, also confirmed that he had a fall on 2/28/24 and a nurse and CNA…

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

Based on record review, staff interview and observation, the facility failed to ensure a safe environment for residents by transporting oxygen without a carrier and not documenting a fall that resulted in a fracture. These were failed practices were random opportunities for discovery and had the potential to affect more than a limited number of residents. Resident Identifier # 66. Facility Census: 63. Findings included: a) The facility's policy and procedure stated, the center staff will report, review and investigate all accidents/incidents which occurred, or allegedly occurred, on or off Center property involving, or allegedly involving, a patient who is receiving services. and the licensed nurse will Report accidents/incidents and assist with completion of a timely investigation to determine root cause. The facility's policy and procedure for Oxygen High Pressure Cylinders stated the cylinders must be properly secured to prevent accidental tipping of the tank and possible rupture causing high pressure release of gasses. and cylinders must be in a secured stand. Full oxygen…

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 nutritional and hydration care and services to a resident that is dependent on tube feed for nutritional and hydration. This was true for one (1) of one (1) resident reviewed for tube feeding. Resident Identifier: #9. Facility Census: 63. Findings Include: a) Resident #9 On 12/07/25 at 2:45 PM it was observed Resident #9 had no tube feeding or water infusing. Upon checking the current orders it was found that Resident #9 was ordered: Enteral Feed Order: every shift Osmolite 1.5 CAL 60 ml/hr. Runs for 22 hours/day with downtime from 1100-1300 and 25 ml of H20 flushes every 4 hours. Order also stated 25 ml of H20 flushes every 4 hours. Hanging on the tube feed pole was Y-tubing which allows simultaneous or separate administration of feedings (formula/nutrition) and water (flushing/hydration) through different ports on the same connection. Upon approaching the Licensed Practical Nurse (LPN) #102 the surveyor asked LPN #102 to check the order for the tube feeding to see when it was to begin. She…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and staff interview the facility failed to manage tube feeding care management as required. This was a random opportunity for discovery. Resident Identifier: #9. Facility Census: #63.Findings Include: a) Resident #9 On 12/07/25 at 2:45 PM it was observed that the tube feeding syringe used during administration did not have the current date on it as required. There was noo date on the syringe.According to the Procedure: Enteral Feeding: Administration by pump under 2) Gather supplies. 2.14 Clean bag or container for storing syringe and administration connector cover (to be changed every 24 hours) labeled with patient's name, date and start time.27. Rinse and dry syringe. Separately store syringe and barrel before storing in labeled and dated plastic bag or container. [NAME] can be used for up to 24 hours. It was confirmed on 12/07/25 at 2:48 PM with the Administrator that the syringe should have the current date on it and only used daily.

Based upon record review and staff interview, the facility failed to post accurate staffing information on 07/05//25, 07/06/25, and 12/07/25.This was found to be true for three (3) of thirteen days reviewed during the long term care survey process. Facility Census: 63 a) Upon entrance to the facility for the recertification survey on 12/07/25 at approximately 11:25 AM, the nursing schedule was posted in a prominent location, and contained the required data elements. However, the data which was posted was for the calendar day of 12/05/25. A review of the time detail report from the facility's timekeeping system documents the posted nurse staffing data hours were not consistent with the data from the time detail report. Discrepancies were as follows: Posted Daily Nurse Staffing Form for 07/05/25 Registered Nurse Hours totaled 24 hoursLicensed Practical Nurse Hours totaled 24 hoursCertified Nurse Aide Hours totaled 96.75 hours Time Detail Reports for 07/05/25 Registered Nurse Hours totaled 23.97 hoursLicensed Nurse Hours totaled 24.93 hoursCertified Nurse Hours totaled 98.97 hours…

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, record review and observation, the facility failed to provide an assistive device as ordered by the physician during the dinner meal. Theis was a random opportunity for discovery and had the potential to affect a limited number of residents. Resident identifier: #17. Facility Census: 63. Findings included: a) Resident #17 The facility's policy and procedure for Assistive Devices stated assistive devices/utensils will be provided as identified on the individualized plan of care to maintain or improve a resident's/patient's ability to eat or drink independently. On 12/08/2025 at 06:2025 PM, Resident #17 was observed during the dinner meal. The resident's tray card stated in all capital letters two (2) times on the tray ticket with one in larger print and one in bold print, FOOD IN BOWLS. The resident did not receive his food in bowls for his entree or side, but did receive his dessert in a bowl. Nursing Assistant #9 confirmed the resident did not receive his food in bowls per his tray ticket. sand order. The resident's dietary order stated, regular diet,…

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 an accurate physician order for thin liquids via straw. This was a random opportunity for discovery and had the potential to affect a limited number of residents. Resident Identifier #11. Facility Census: 63. Findings included: Resident #11 a) On 12/07/2025, a dining room observation was initiated. Resident #52 had a straw in a [NAME] Cup in her wheelchair cup holder in the dining room during the lunch meal and a straw in her water pitcher in her room at bedside. At 1:35 PM, Nurse Aide (NA) #52 verified the resident's tray card for 2 Handled cup w/no lid, Food in mugs, [NAME] Cup, and NO STRAWS The resident and Nursing Aide (NA) #52 the resident had been using straws in the dining room and her room. At 1:35 PM, NA #52 verified the resident's tray card for 2 Handled cup w/no lid, Food in mugs, [NAME] Cup, and NO STRAWS. According to North Coast Medical and Rehabilitation Products, a [NAME] Cup is a Lightweight,…

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 upon record review and staff interview, the facility failed to follow its policy for residents who choose to smoke or vape.This was found to be true for one (1) of one (1) resident reviewed during the long term care survey process. Resident identifier:#56 Census: 63 Findings included:A) Resident #56During the interview with this resident on 12/07/25 at 1:20 PM, the resident was complaining about the facility changing the designated smoking schedule, and having staff accompany her to smoke, as well as use of the smoking apron. A review of her care plan contained the following:Focus area:During my Preferences for Customary Routine Interview, there were daily routine preferences noted as important. The most important things for the center staff to know about my preferred daily routine are: smoking outside. Date initiated: 08/21/24. Surveyor explained to the resident the use of the smoking apron and having staff to accompany the residents outside were for the resident's own safety.A review of the resident's medical record documented a smoking assessment was last completed in…

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 have an infection preventionist. This failed practice had the potential to affect all residents currently residing in the facility. Facility census: 63. Findings include: a) Infection Preventionist During an interview, on 01/22/24 at 12:11 PM, the Director of Nursing (DON), stated, I do the Infection preventionist job. We also have a lady that works down the road, that has had the class that helps me with it. On 01/22/24 at 1:30 PM the DON confirmed there are no staff currently employed at this facility who have completed the specialized training and hold an Infection Preventionist Certificate of training.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and staff interview, the facility failed to provide residents with a dignified dining experience. Residents dining together were not served at the same time. This was a random opportunity for discovery. Resident identifiers: #8, #25, #31, #29, #27, #1, #58, #10, #28, and #38. Facility census: 63. Findings included: a) Dining room observations On 01/16/24 at 12:01 PM, Residents #8, #25, #31, and #29, were observed sitting together at table. #1. Residents #27, #1, #58, and #10 were observed sitting together at table #2 . Resident #28 was sitting at table #3 by themselves. Resident #38 was seated at table #4 by themselves. The trays were served in this order: Resident #29, was served at table #1 Resident #58 was served at table #2 Resident #38 was served at table #4 Resident #8 was served at table #1 Resident #31 served at table #1 Resident #1 served at table #2. Resident #1 required assistance to eat; therefore, the tray was left sitting in front of her while other residents were eating their…

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

Based on observation, record review, staff interview and resident interview, the facility failed to provide a clean, comfortable homelike environment by not cleaning the heater/air conditioning unit filter in Resident #48's room and by not ensuring the dining room chairs are in good repair. This was a random opportunity for discovery, and had the potential to affect more than a limited number of residents. Resident identifier: #48. Facility Census: 63. Findings include: a) Resident #48 An observation of Resident #48's room on 01/16/24 at 2:00 PM, it was discovered the heater had dust flying out of it and the filters were covered with dirt and dust. During an interview on 01/16/24 at 2:30 PM, Resident #48 stated, I haven't been in this room long, who knows when they cleaned it last. They haven't cleaned it since I have been in here. During an interview on 01/16/24 at 03:36 PM, the Maintenance Assistant (MA) #60 stated, Oh my goodness, yes that is dirty. I am gonna go look to see when is the last time it was cleaned. It won't be dirty after today. During a record review on 01/17/24 at…

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

Based on record review, staff interview and observation the facility failed to implement and/or develop care plans for three (3) of 18 sampled residents. For Resident #52 the facility failed to develop a care plan for the resident's use of an anticoagulant medication. Also, Resident #52's fall care plan was not implemented. For Resident #24 the facility failed to implement their dementia care plan. Finally, for Resident #50 the facility failed to implement his catheter care plan. Resident identifiers: #52, #50, and #24. Facility Census: 63. Findings included: a) Resident #52 1. Anticoagulant A review of Resident #52's care plan on 01/22/24, found a physician order for Eliquis (an anticoagulant medication) five (5) milligrams twice a day. This order was written on 07/06/23 and was a current order at the time of this review. A review of Resident #52's care plan found it was void of any focus statements, goals, or interventions related to Resident #52's use of this anticoagulant medication. On 01/23/24 at 9:05 AM, an interview with the Director of Nursing (DON) confirmed Resident #52'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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, staff interview and resident interview the facility failed to develop an activity program to meet the needs and interest of the residents. This failed practice had the potential to affect more than a limited number of residents currently residing in the facility. Resident identifiers: #4, #24, and #14. Facility census 63. Findings include: a) Activity Program During the Resident Council Meeting on 01/17/24 at 2:00 PM the Resident Council members complained there was not much to do at the facility anymore and there was not anything to do in the evening except go to bed. During a record review on 01/18/24 at 10:00 AM of the facilities activity calendars for 10/2023, 11/2023, 12/2023, and 01/2024 a noticeable difference was noted in the amount of activities offered and the type of activities offered. In 10/2023 there were at least 5 activities offered daily and 2 days a week activities were offered at 7:00 PM in the evening. In January 2024 on most days there were only 2…

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

Based on observation and staff interview the facility failed to prepare, distribute and serve food in accordance with professional standards for food service safety. This has the potential to affect more than a limited number of residents residing in the facility. Facility census: 63. Findings include: a) Initial tour of the kitchen On 01/16/24 at 7:40 AM, observation of the stove found the drip pan, oven racks, and the oven floor had a heavy build of a charred black substance. The ovens backsplash also had a build up debris. The metal grates covering the burners also had a build up of black, dried debris. Dietary Manager (DM) #10 stated he had boiled oatmeal earlier this morning which had covered the burner; however, all the burners were littered with charred debris. b) Fruit During an observation on 01/16/24 at 12:14 PM, of the lunch meal it was discovered that none of the individual bowls of fruit cocktail on the Resident's lunch trays were covered. During an interview on 01/16/24 at 12:31 PM, Nursing Assistant (NA) #16 stated, The fruit is usually covered with cellophane or it'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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and staff interview the facility failed to develop and implement an ongoing infection control program aimed at preventing the spread of diseases and infections. This failed practice had the potential to affect all residents residing in the facility. Resident identifiers: #7, #60, #4, #10, #22, #23. Facility Census 63. a) Surveillance Log During a record review, on 01/22/24 at 1:00 PM, of the facilities Infection Control Monthly Line Listing it was revealed that no infections had been tracked for December 2023 and January 2024. During an interview on 01/22/24 at 01:16 PM, the Director of Nursing (DON) stated, Our Nurse Practice Educator (NPE), eft around the 1st of December and our new one started yesterday, our line listing has not been updated since she left at the first of December. During a record review, on 01/22/24 at 3:39 PM, the following residents were listed as examples of residents who had infections, were receiving an antibiotic in December 2023 and/or January 2024,…

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 ensure one (1) of two (2) residents reviewed for the care area of choices received written notice of a room move and an explanation of why the room change was needed. Resident identifier: #14. Facility census: 63. Findings included: a) Resident #14 On 01/16/24 at 8:11 AM, the resident said she recently returned from the hospital and did not return to her original room. She said, I understand I had no bed hold and that was OK, but I got moved to one room when I got back and then 2 days later, I had to go to another room. When asked why she was moved, the resident said she was told she needed to move, and she would have more room if she moved. She said she really didn't want to move, and she frequently gets moved all over the place. Record review found the resident returned to the facility from a hospital admission on [DATE]. She was placed in room [ROOM NUMBER]-A. On 01/04/23 the resident was moved to room [ROOM NUMBER]-B. At…

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

Based on record review and staff interview, the facility failed to ensure Resident #14's grievance related to missing nightgowns was resolved promptly. This was true for one (1) of 18 sampled residents. Resident identifier: #14. Facility Census: 63. Findings included: a) Resident #14 A review of the facility's grievances for the previous year found a grievance form dated 12/13/23. Resident #14 made the grievance because she was missing one (1) pink and one (1) dark purple nightgown. She also indicated there were no lift pads at times. The recommended corrective actions taken by the facility was to replace the gowns and (name of hospice company) providing lift pads. During an interview with the Nursing Home Administrator (NHA) on 01/17/24 at approximately 8:30 AM the surveyor requested documentation showing they had ordered the gowns. On the afternoon of 01/17/24 the NHA provided documentation showing the gowns had been ordered. Review of the computer printout provided by the NHA found the gowns were ordered on 01/17/24 at 9:24 AM which was after surveyor intervention.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and record review, the facility failed to send information which included medications, diagnosis, advance directives, representative contact information, and any other necessary information to ensure a safe and effective transition of care. This was found to be true for two (2) of two (2) residents reviewed for the care area of hospitalization during the long term care survey process. Resident identifiers: #14 and #51. Facility census: 64. Findings include a) Resident #51 On 01/17/24 at 9:45 AM, record review found the resident was admitted to the facility on [DATE]. The resident was discharged to the hospital on [DATE]. Further review of the medical record found a note on 01/09/24, which read a report was called to the emergency room. There was no information indicating if any documentation was sent with the resident at the time of discharge. b) Resident #14 On 12/17/23 the resident was sent to the emergency room due a low oxygen saturation rate of 84%. The facility contacted 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 bed hold notices were completed with accurate information when two (2) of two (2) residents reviewed for the care area of hospitalization were transferred to the hospital. Resident identifiers: #51 and #14. Facility census: 63. Findings included: a) Resident #51 Record review found Resident #51 was sent to the hospital on [DATE]. At 10:00 AM on 01/17/23, the business Office Manager (BOM) #79 provided a completed copy of the bed hold policy sent to the Resident at the time of discharge indicating the resident had no bed hold days available. The BOM confirmed the Resident's payer source was through the Veterans Administration (VA) and the VA would have paid for three (3) bed hold days; however, the form documented the resident had no bed hold days available. b) Resident #14 Record review found the resident was sent to the emergency room on [DATE] due a low oxygen saturation rate of 84%. The facility contacted the hospital on [DATE] and found…

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 a Minimum Data Set (MDS) was completed accurately and reflected one (1) of 18 resident's status. Resident identifier: #3. Facility census: 63. Findings included: a) Resident #3 On 01/16/24 at 8:29 AM, the resident said, I am blind, I see only light. I have fallen several times due to my eyesight. Review of the resident's medical record found the following falls: 04/08/23, the resident fell in his room after his roommate told him to get up and go to the bathroom by himself- he did not take his walker fell to the floor. 04/21/23, the resident fell in his room while staff were assisting him. 05/20/23, the resident fell while his brother was assisting him back from the bathroom. 05/23/23, the resident was found on the floor while ambulating from the bedside commode back to his recliner. 05/26/23, the resident was found sitting on the floor. 07/13/23, the resident fell while trying to find his shoes. An admission MDS with an assessment…

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

Based on record review and staff interview, the facility failed to complete a new Pre-admission Screening and Resident Review (PASARR) with a diagnosis of Paranoid Schizophrenia. This failed practice was found for one (1) of one (1) resident reviewed during the long-term care survey process. Resident identifier: #28. Facility census: 63. Finding included: a) Resident #28 On 01/17/24 at 2:15 PM, record review showed Resident #28 had a diagnosis of Schizophrenia upon admission; however, this was not on the PASARR from the hospital. On 01/17/24 at 2:42 PM, an interview with Social Worker (SW) #32 confirmed the facility did not have PASARR which documented Resident #28 has a diagnosis of Schizophrenia. SW #32 said a new PASARR would be completed today.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, the facility failed to develop a baseline care plan within 48 hours of admission which included current physician's orders for treatment with antibiotics. This was true for one (1) of one (1) new admission. Resident identifier: #23. Facility census: 63. Findings included: a) Resident #23 Record review found Resident #23 was admitted to the facility on [DATE]. At the time of admission, the resident was receiving the antibiotic, Cefdinir, for treatment of a urinary tract infection. In addition, the resident was receiving a topical antibiotic, Mupirocin to the bilateral lower extremities for a diagnosis of cellulitis. At 8:15 AM on 01/23/24, the unit manager Licensed Practical Nurse and the Director of Nursing confirmed the antibiotic usage should have been listed on the 48-hour care plan. On 01/23/24 at 8:22 AM, the above information was discussed with the administrator. No further information was provided by the close of the survey.

Based on record review, observation and staff interview the facility failed to revise Resident #60's care plan when her urinary catheter was removed. This was true for one (1) of 18 sampled residents. Resident Identifier: Resident #60. Facility Census: 63. Findings Included: a) Resident #60 An observation of Resident #60 on the morning of 01/16/24 found she had no indwelling urinary catheter. A review of Resident #60's care plan on 01/17/24 found the following active care plan: Focus Statement: (First Name of Resident #60) requires indwelling Foley catheter due to: other: retention. This focus statement was added to care plan on 12/19/23. The goal associated with this focus statement read: Resident will have no signs and symptoms of Urinary tract infection X 30 days. This goal had a target date of 03/12/24. The interventions included: --Monitor for signs and symptoms of infection and report to physician. -- Monitor output for odor, color, consistency, and amount. -- Provide Privacy and comfort. -- Monitor urine for sediment, cloudy, odor, blood and amount. -- Report to physician…

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

Based on resident interview, record review, and staff interview, the facility failed to ensure one (1) of four (4) residents reviewed for the care area of activities of daily living received services for personal hygiene. Resident identifier: #14. Facility census: 63. Findings included: a) Resident #14 On 01/16/24 at 8:11 AM, the resident said you have to be scheduled to get a shower and you can only have two (2) a week. I would like to get a shower more often than I do, my hair gets matted up in between the few showers I get here. Review of the resident bathing / shower schedule from 11/16/23 through 01/16/24 found the Resident received a shower on 11/19/23 and 01/16/24. The Resident was discharged from the facility on 12/17/23 and returned on 01/03/24. On 01/16/24 at 3:18 PM, the Resident's Nurse Aide (NA) #71, said the Resident receives bed baths because she doesn't like getting a shower. NA #71 said we did have a shower chair that we used to take her to the shower but she started doing bed baths. Sometimes she just says it's too cold in the shower room. On 01/17/24 at 9:10 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and staff interview the facility failed to follow a physician's order in regards to blood sugar monitoring for Resident #10. This failed practice was found true for 1 of 5 residents reviewed for unnecessary medications during the Long Term Care Survey Process. Resident Identifier: #10. Facility Census 63. Findings Include a) Resident #10 A record review on 01/18/24 at 9:30 AM found Resident #10 was ordered NovoLog FlexPen Subcutaneous Solution Pen-injector to be injected per sliding scale. Call the doctor for a blood sugar over 341. Review of Resident #10's Medication Administration Record (MAR) found on 01/17/24 Resident #10's blood sugar was 422. Resident #10's medical record had no mention of the doctor being contacted. During an interview on 01/18/24 at 10:44 AM, with the Director of Nursing (DON), she stated, This was a different doctor and he has a different scale. The other doctor doesn't like to be called unless a resident's blood sugar is over 450. That's no excuse though, they…

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 the residents environment over which it had control of was free from accident hazards. A prescription cream was found at Resident #40's bedside. Interventions for fall prevention were not in place for Resident #52. This failed practice was true for two (2) of five (5) residents reviewed for accidents during the Long Term Care Survey Process. Resident identifiers #40, #52. Facility Census 63. Findings include: a) Resident #40 Observation on 01/16/24 at 8:25 AM, found a tube of prescription Triamcinolone Acetonide Cream at the Resident's bedside. During an interview on 01/16/24 at 9:30 AM with Resident #40, she states, I put the cream on in the morning and in the evening . There is a resident that is confused that wonders in my room, poor thing. But he doesn't bother me. A second observation on 01/16/24 at 03:42 PM, found the Triamcinolone Acetonide Cream continues to be at the Reediest's bedside. A third observation on 01/17/24 at 8:15 AM, found the Triamcinolone Acetonide cream continues to be at…

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

Based on observation, record review and staff interview the facility failed to ensure a resident with an indwelling catheter had a proper medical justification for its use. Also the facility failed to ensure a resident with an indwelling catheter receives the appropriate care and services to prevent urinary tract infections. This was true for two (2) of two (2) residents reviewed for the care area of urinary catheter use. Resident Identifiers: Resident #60 and Resident #50. Facility census: 63. Findings Include: a) Resident #60 An observation of Resident #60 on the morning of 01/16/24 found she had no indwelling urinary catheter. A review of Resident #60's care plan on 01/17/24 found the following active care plan: Focus Statement: (First Name of Resident #60) requires indwelling Foley catheter due to: other: retention. This focus statement was added to care plan on 12/19/23. The goal associated with this focus statement read: Resident will have no signs and symptoms of Urinary tract infection X 30 days. This goal had a target date of 03/12/24. The interventions included: --Monitor…

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 make sure nursing staff had the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. This had the potential to affect a limited number of residents residing in the facility. Staff identifiers: #66 and #14. Facility census: 63. Findings Include: On 01/22/24 at 3:27 PM, review of Nurse Aide #66 and Licensed Practical Nurse #14's personal files did not include any documentation that these staff could demonstrate the skill sets to perform their duties as directed. On 01/23/24 at 8:26 AM, the administrator confirmed she was unable to provide evidence of competency evaluations for NA #66 and LPN #14.

Based on record review and staff interview, the facility failed to complete a performance review of every nurse aide at least once every 12 months. This had the potential to affect a limited number of residents at the facility. Staff identifier: #66. Facility census: 63. Findings Include: a) Nurse Aide (NA) #66 On 01/22/24 at 3:27 PM, review of NA #66's personnel record found no evidence of a yearly performance review. At 8:26 AM on 01/23/24, the Administrator said she was unable to provide a copy of a yearly performance review for NA #66. No further information was provided by the close of the survey.

Based on record review and staff interview the facility failed to establish a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation; and that drug records are in order and that an account of all controlled drugs is maintained and periodically reconciled. The facility failed to ensure Resident #60's controlled substances which were signed out on the controlled substance log were documented as administered on the medication administration record (MAR). This was true for one (1) of five (5) residents reviewed for the care area of unnecessary medications. Resident Identifier: Resident #60. Facility Census: 63. Findings include: a) Resident #60 A review of Resident #60's medical record on 01/22/24 at 1:44 PM, found the resident was ordered oxycodone 10 milligrams (MG) by mouth every six (6) hours as needed for pain. Further review of Resident #60's MAR and the control substances log for Resident #60's oxycodone for the months of 12/2023 and 01/2024 found the following occasions when Resident #60's oxycodone was…

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

Based on record review and staff interview the facility failed to provide a Pneumococcal immunization as required. This failed practice was found true for one (1) of five (5) residents reviewed for immunizations during the Long-Term Care Survey Process. Resident identifier: # 40. Facility Census 63. Findings include: a) Resident #40 During a record review, on 01/22/24 at 1:24 PM, of Resident # 40's vaccines it was found that she had the Prevnar (PCV) 13 vaccine on 11/05/21 and was not given a second vaccination as required. The Center for Disease Control (CDC) recommends: The second dose of PPSV23 be given at least 8 weeks after PCV13 and 5 years after PPSV23 (Pneumococcal Polysaccharide Vaccine.) During an interview, on 01/22/24 at 1:46 PM, the Director of Nursing (DON) stated, I know what happened. Resident #40 was out at the hospital and the order did not get put back in, so I am assuming that is what happened. She has not had the PPSV 23.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on observations, resident interview and staff interview, the facility failed to keep odors maintained, emptying of bedside commodes, repairing of broken pipes in the kitchen, repairing chipped paint in the kitchen, keeping floors clean in the kitchen and not keeping drain odors in bathroom contained. Facility census 62. Findings included: a) Dirty floors On 4/25/22 at 10:35 AM, during initial tour of the kitchen observed floors to be very dirty with brown substance stuck to the floor. Director Food/ Nutrition Services #62 stated, the staff mop after lunch every day. Asked if the kitchen floor is on a deep cleaning schedule and Director Food/Nutrition Services #62 stated when housekeeping can but, they are working behind. On 4/26/21 at 8:45 AM, interview with Cooperate Chef stated, I did not leave the facility until 11 PM on 4/25/22 due to cleaning of dietary department floor. Cooperate Chef stated, I had to pour boiling water on floor to get dirt to lift. The floor was also scrubbed with a scrubbing…

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 record review, the facility failed to ensure care was provided in an environment that promoted dignity for each resident. Based on a random opportunity for discovery, Resident #34 was noted to have a sign above the bed with personal care needs addressed which would be visible to any person entering the resident's room. Resident identifier: Resident #34. Facility census: 62. Findings included: a) Resident #34 An observation, on 04/25/22 at 11:03 AM, revealed a sign posted above Resident #34's bed noting No blood pressure or needle sticks to be performed to the right arm. An interview, on 04/26/22 at 9:48 AM, with the facility's Administrator, verified there was a sign, with resident care information, above the resident's bed. Additionally, the Administrator stated because of dignity issues, no signs should be posted above resident's beds to provide information. .

Based on record review and staff interview, the facility failed to ensure two (2) of 24 residents reviewed during the long-term care survey process had a Physician Orders for Scope of Treatment (POST) form completed per directions specified by the [NAME] Virginia Center for End-of-Life Care in conjunction with the [NAME] Virginia Health Care Decisions Act (16-30-1). The POST forms were unsigned by the Resident or Medical Power of Attorney (MPOA). Resident identifiers: Resident #6 and #40. Facility census: 62. Findings Included: a) Resident #6 Record review on 04/25/22 at 3:01 PM found a POST Form on Resident #6's chart was unsigned by the Resident or MPOA. (Patient/Patient MPOA representative/surrogate signature required). The POST form was dated 07/05/21. During an interview on 04/26/22 at 10:06 AM with the Director of Nursing (DON) confirmed Resident #6's POST form was incomplete without a Resident or MPOA signature. b) Resident #40 Record review on 04/25/22 at 3:05 PM found a POST Form on Resident #40's chart was unsigned by the Resident or MPOA. (Patient/Patient MPOA…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on record review and staff interview, the facility failed to update care plan and [NAME], this is true for (1) one of 20 residents reviewed for care plans. Resident identifier #57. Facility Census 62 Findings included: a) Resident #57 On 04/25/22 at 3:00 PM, review of Care Plan did not show resident receiving a bedside commode and showed one (1) person assist with toileting. [NAME] also did not show bedside commode being utilized and showed independent with toileting. On 4/26/22 at 1:00 PM, interview with IP (infection preventionist) Registered Nurse #22 and verified Care Plan was not updated, Resident #57 utilized bedside commode when resident #57 tested positive for covid six (6) weeks ago and will not let staff take bedside commode out of room now. IP RN #22 stated, information in Care Plan and [NAME] had not been update to reflect current plan of care for resident #57 and will update Care Plan and [NAME] immediately. .

Based on observation , record review and staff interview, the facility failed to ensure that a resident who required respiratory care, was provided that care in accordance with professional standards of practice and in accordance with the resident's plan of care. This deficient practice was identified in one (1) of five (5) residents reviewed during the Long Term Care Survey Process (LTSP) who were receiving oxygen therapy. Resident identifier: Resident #49. Census: 62 Findings included: a) Resident #49 A review of the Policy titled: Oxygen Therapy via Nasal Cannula, with an effective date of 12/01/06, noted that oxygen therapy would be administered as ordered by a physician and would include the correct flow rate, mode of delivery and frequency. A record review for Resident #49 showed a current order which started on 03/29/22, for the resident to receive oxygen therapy at four (4) Liters per minute. An observation of the oxygen administration for Resident #49, on 04/25/22 at 01:52 PM, revealed the oxygen flow rate was set on six (6) Liters per minute. An interview with the Director…

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 identify a pharmacist's recommendations made during the Medication Regimen Review (MRR). The MRR was not reported to the physician or acted upon in a timely manner. This is true for one (1) of five (5) residents reviewed for unnecessary medications. Resident identifier: 51. Facility census: 62. Findings include: a)Resident (R) #51 Review of the medical record on 04/26/22, revealed R #51 was admitted to the facility on [DATE]. The pharmacist progress note written 04/08/22 identifies comments/recommendations made during the monthly MRR and states see report. The medical record is silent for this report. During an interview on 04/26/22 at 1:06 PM, the Director of Nursing (DON) acknowledged she did not download the last medication regimen reviews. The DON reported she was unaware the pharmacists had made any recommendations for R #51 and confirmed the physician was not notified. .

Based on observation and staff interview the facility, failed to label and date foods in the refrigerator and to keep the utensil drawer clean and organized in a sanitary manner. This failed practice had the potential to affect a limited number of residents who receive nutrients from the kitchen. Facility Census 62 Findings included; a) Kitchen On 4/25/22 at 10:35 AM initial tour the kitchen with Director Food/Nutrition Services #62. Observed in walk in refrigerator a pitcher of ice tea not label and dated. Observed an open to air stick of butter not covered and dated. Director Food/Nutrition Services #62 immediately discarded items observed. Continuing with initial tour of the kitchen found utensils drawer to have an excessive amount of debris and utensils were mixed together in no sanitary manner. Director of Food/Nutrition Services #62 agreed that the utensil drawer needed cleaned and organized. .

Based on observation , staff and resident interview, the facility failed to maintain an environment that was sanitary and with functioning equipment. This deficient practice was identified during a random opportunity for discovery and had the potential to affect more than a limited number of residents. Resident #17 did not have a functioning toilet and the portable toilet used was not maintained in a sanitary manner. Resident Identifier #17. Facility census: 62. Findings included: a) Resident #17 A review of the Policy and Procedure titled: Preventive Maintenance: Routine Maintenance, dated with a revision date of 06/01/07, addressed requests for routine maintained on the physical plant, fixtures and equipment would require a work order. The policy further showed once work was completed, the maintenance supervisor or designee would write the action taken on the work order and completed work orders would be filed and maintained for one year. During a resident interview, on 04/25/22 at 10:57 AM, Resident #17 explained the toilet in the room had been broken for approximately a month…

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.