Canterbury Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interviews, the facility failed to maintain a homelike environment by not providing housekeeping and maintenance services to ensure that residents' rooms were being kept in a clean and sanitary condition. Room Identifiers: #103, #104, #108, #110, #302, #304, #307B, #401, #402, #404 #408, 400 Wing hallway, and Shower Room. Resident Identifier: #47. Facility Census: 59. Findings Include: a) Observation of the facility interior upon survey entry on 03/10/25 at 5:30AM: room [ROOM NUMBER] had approximately 3 foot section of section of unfinished drywall above heads of beds The 400 hallway above the resident's room doors had rips in the wall paper borders room [ROOM NUMBER], unfinished dry wall patches on the wall above the head of both resident's beds - Bathroom between rooms [ROOM NUMBERS] had a yellowish stain around base of toilet, and over-flowing trash can. In an interview on 03/10/25 at approximately 5:45 AM, with RN employee identifier #25, he acknowledged the unfinished drywall on the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interviews, the facility failed to ensure the resident environment, over which they had control, was as free from accident hazards as possible in regards to water temperatures. This was a random opportunity for discovery. Room Identifiers: Rooms #101, #107, #202, and #302. Facility census:59. Findings Include: a) Resident #1 During an interview on 03/10/25, at 9:13 AM, Resident #1 stated that the water is too hot for her. She stated that she has never been burnt but must ask the staff to make the water temperature cooler. During an inspection of Resident #1s sink water temperature, this surveyor had to pull my hand back from the sink water due to hot temperatures. b) Water Temperatures During an interview and inspection with the Maintenance Director (MD) #56 on 03/10/25 at approximately 10:30 AM the water temperature was found: -- room [ROOM NUMBER], the sink temperature reading was 128 degrees Fahrenheit. MD #56 stated that once the water had been left running for a while, 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 ensure they had sufficient and competent nurse staffing by failing to complete competency evaluations for Nurse Aides. This is true for five of five Nurse Aide charts reviewed. Findings included: Review of staff files on 03/12/25 at 1:57 PM revealed no competency evaluations for the following staff: #28, #1, #2, #33, #63 Interview with Consulting Administrator on 03/12/25 at approximately 2:30 PM revealed that the facility was behind on competencies and that there were no records for competencies in the last year for the following staff: #28, #1, #2, #33, #63

Based on observation, staff interview, and equipment manual review the facility failed to have a clean, sanitized kitchen, store food in the refrigerator, freezer, and dry storage store food in accordance with professional standards for food service safety. The facility also failed to keep the ice machine in safe operating condition. This has the ability to affect all Residents that get their nutrition from the kitchen, also attends food related activities. Facility Census: 61 Findings included: a) Initial Kitchen tour. During the initial kitchen tour with the Kitchen Account Manager on 03/10/25 at 11:54 AM, an observation found --Walk-in refrigerator - Temperatures not documented -- Walk -in freezer - Temperatures not documented and a large box of cookie dough, open to air. b) Pantry During the resident panty tour on 3/11/25 at 1:12 PM found the drawer was dirty, littered with sugar, salt, and pepper. The upper cabinet had a box of 12 packs of oatmeal expired in April 2024. During an interview on 03/11/25 at 1:20 AM the Infection Preventionist verified that the oatmeal was expired…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, facility staff failed to handle, store, process, or transport linens and laundry in a hygienically clean manner, or clean the laundry machine filters. The facility also failed to follow infection control protocols when handling food trays, and trash. In addition, the facility failed to provide residents with hand hygiene before meals. These failed practices allowed for the potential spread of infection throughout the facility. Facility Census: 59 Findings Include: 1) Handling and storage of clean linen (100 Wing, 300 Wing and 400 Wing): a. During an observation of the 100 Wing linen cart on March 10, 2025, at approximately 7:30 AM, Account Manager (AM) #67 was seen replenishing wall boxes with trash bags. While doing this, she pushed a linen cart out of the way with her foot, causing clean linen from the lower rack of the cart to spill onto the floor. AM #67 was observed picking up the spilled linen and placing it back in the cart. However, RN #62 confirmed that the linen…

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.

b) Resident #58 On 03/10/2025 at 11:03 AM, It was observed Resident #58 in his wheelchair rolling down the hall with his catheter bag in his lap. The catheter bag did not have a bag cover. In an interview with Resident #58, on 03/10/2025 at 11:05 AM, he stated he has never been offered a cover for his catheter bag and would like to have one. In an interview with RN #25 on 03/10/2025, at approximately 11:10 AM, he acknowledged Resident # 58 did not have a cover for his catheter bag. Based on observation and interview, the facility failed to uphold the residents' right to be treated with dignity and respect by leaving urinary catheter bags uncovered and prominently displayed. Resident Identifiers: Residents #28 and #58. Facility Census: 59. Findings Include: a) Resident #28 On 03/10/25, at approximately 1:35 PM, Resident #28 was observed in bed. The resident's catheter bag, which was uncovered and half full of urine, was seen dangling off the foot of the bed in plain view of anyone passing by. At approximately 1:37 PM on 03/10/25, Licensed Practical Nurse (LPN) #38 confirmed that the…

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

Based on observation and interview, the facility failed to ensure that residents had the opportunity to exercise autonomy over important aspects of her life such as choice regarding waking time and morning care. Resident Identifier: Residents #50 and #52 Facility Census: 59. Findings Include: a) Resident #52 During an interview with Resident #52, on 03/10/25, at 1:51 PM, she expressed her preference for waking up early and having her bed made and morning care completed before breakfast. She noted that she does not receive morning care until after 10:00 AM. A family member present during the interview stated that they have raised this issue with the nursing staff multiple times, but no action has been taken. The resident also mentioned that her roommate receives morning care around 7:45 AM each day, while she does not receive assistance until much later. Observations on 03/11/25 revealed that AM care was provided to Resident #52 at approximately 10:20 AM. During an interview with the Director of Nursing (DON) on 03/10/25, at 10:35 AM, the DON confirmed that the resident has the right…

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.

The facility failed to post in a place readily accessible to residents, and family members and legal representatives of residents, the results of the most recent survey of the facility. Random opportunity for discovery. Census 59 Findings included: a) 03/17/25 4:50 PM first observation: A sign located at the receptionist window in the lobby stated that survey results are located on the shelf under the television. However, the state survey results were not located on the book shelf nor anywhere else in the lobby during this observation. b) 03/18/25 11:25 AM second observation: The state survey results were not located on the bookshelf nor anywhere else in the lobby during this observation. c) In an interview with the Administrator 03/18/25 at 11:30 AM she did not find the survey book on the bookshelf and went to locate it. She came back and stated she found it in the business office.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and staff interview, the facility failed to secure and protect residents' personal and medical information. Specifically, private information was not safeguarded and was found in a clear acrylic wall file located in the residents' hallway. This was a random opportunity for discovery. Facility Census: 59. Findings Include: On 03/18/25 at approximately 8:50 AM, a random opportunity for discovery found multiple documents with resident's identifiable health information in an acrylic wall file holder mounted on the wall outside the nursing office on the 300 wing of the facility. A review of the documents on 03/18/25 at 9:15 AM revealed the following: a) Resident names, Room numbers, Diagnoses, Code status, and Vital signs for twenty-nine (29) residents. b) Prescription information for Resident #221. A new resident admitted on [DATE]. c) Medication listings for thirty-one (31) residents d) A controlled drug administration record for Resident #52. The documents also included Shift Change Controlled…

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

Based on policy review, record review, and staff interview, the facility failed to ensure that all written grievance decisions included the steps taken to investigate the grievance, a summary of the pertinent findings or conclusions regarding the resident's concerns(s), a statement as to whether the grievance was confirmed or not confirmed, any corrective action taken or to be taken by the facility as a result of the grievance, and the date the written decision was issued. This was a random opportunity for discovery. Resident identifier: #218. Facility census: 59. a) Resident #218: On 03/17/25 at 03:45 PM, during record review, a grievance form dated 4/10/2024 was not completed for Resident #218. Per the facility's Grievance Policy, the grievance officer will oversee grievances through conclusion leading any necessary investigations by the facility, issuing written decisions to the patient, and coordinating with state and federal agencies. In an interview with the Administrator on 3/17/25, at 2:44 PM, she acknowledged the grievance form for Resident #218 was not completed nor logged…

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

Based on observation, staff interviews, electronic medical record and Operation Policy the facility failed to follow written policy, thorough investigating and reporting to proper agencies of injury of unknow origin and neglect. This is true of two (2) of six (6) residents reviewed for abuse. Resident identifier: #55 and #36. Facility census: 61. Findings include: a) Resident #55 An observation and interview with Resident #55 on 03/10/25 at 8:49 AM revealed a large bruise on her left upper arm. She stated that she did not know where she got it. During an interview on 03/10/25 at 9:01 AM the Director of Nursing (DON) stated she was unaware of the bruise on Resident #55's left upper arm. She continued to state that she would get the bruise check. During an interview on 03/17/25 2:50 PM the DON stated that she had the Nurse Practitioners (NP) assess Resident #55's left upper arm. A record review revealed the Nurse Practitioners skin assessment on 03/11/25: Skin: Old bruises on her hands that were present when she arrived, likely due to previous IV insertion sites. She appears to have…

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

Based on observation, staff interview, and operation policy, the facility failed to report alleged violation related to, neglect, or abuse, and report the results of all investigation to the proper authorities within prescribe time frames. This is true for two (2) of six (6) allegations of abuse. Resident identifier: #55 and #36. Facility census: 61. Findings include: a) Resident #55 An observation and interview with Resident #55 on 03/10/25 at 8:49 AM revealed a large bruise on her left upper arm. She stated that she did not know where she got it. During an interview on 03/10/25 at 9:01 AM the Director of Nursing (DON) stated she was unaware of the bruise on Resident #55's left upper arm. She continued to state that she would get the bruise check. During an interview on 03/17/25 2:50 PM the DON stated that she had the Nurse Practitioners (NP) assess Resident #55's left upper arm. A record review revealed the Nurse Practitioners skin assessment on 03/11/25: Skin: Old bruises on her hands that were present when she arrived, likely due to previous IV insertion sites. She appears to…

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

Based on observation, staff interview, and operation policy, the facility failed to take actions to investigate a large bruise of unknow origin and neglect. This was a random opportunity for discovery. Resident identifier #55. Facility Census 61. Findings include: a) Resident #55: An observation and interview with Resident #55 on 03/10/25 at 8:49 AM revealed a large bruise on her left upper arm. The resident stated that she did not know where she got it. During an interview on 03/10/25, at 9:01 AM, the Director of Nursing (DON) stated she was unaware of the bruise on Resident #55's left upper arm. She continued to state that she would get the bruise checked. During an interview on 03/17/25, at 2:50 PM, the DON stated that she had the Nurse Practitioners (NP) assess Resident #55's left upper arm. A record review revealed the Nurse Practitioners skin assessment on 03/11/25: Skin: Old bruises on her hands that were present when she arrived, likely due to previous IV insertion sites. She appears to have new bruising on her upper arms of unknown cause. She denies pain. Transcribed as…

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 accurately document resident's discharge status in Minimum Data Set assessment (MDS). The assessment must represent an accurate picture of the resident's status during the observation period of the MDS. Resident #62. Findings included: a) Resident #62: An observation on 03/12/24, at 10:58 AM, revealed MDS dated [DATE], Section A, Question A2105 Discharge Status. entered code 4 (four) Short-term General hospital (acute hospital, IPPS). An observation on 03/12/25, of a Social Services Note dated 12/23/24, at 4:40PM, stated Resident's daughter arrived at facility this date and states that she is picking resident up to take him home. She reports that she has arranged for home health services and medical appointment with VA Medical Center. During an interview with MDS Coordinator #54 on 03/12/25, at approximately 12:55 PM, in regards to MDS question A2105 Discharge Status 04.Short-Term General Hospital (acute hospital, IPPS) dated 12/24/24, MDS…

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, resident, staff interview. The facility failed to assist dependent Residents with activities of daily living (ADL's) in accordance with the Residents assessed needs for care. This is true for one (1) of four (4) residents reviewed for ADL care. Resident Identifiers: #50. Facility census: 61. Findings Included: a) Resident #50 showers During an interview and observation on 03/10/25 at 10:20 AM Resident #50 stated that she doesn't get her showers or baths as ordered or her preference. She continued to say that I don't like not having a shower when I get visitors. Her hair was observed to be very oily during this interview. A review of Resident #50's ADL documentation found that there was only one (1) shower on 02/21/25 and two bed baths noted on 02/11/25 and 02/14/25 given in 30 days. During an Interview on 03/11/25, at 12:25AM, the Administrator verified there was no documentation that Resident #50 received showers as scheduled.

Based on observation, interview, and record review, the facility failed to implement protocols ensuring that staff conducted incontinence assessments for dependent residents and provided incontinence care at the required intervals throughout the day. Resident Identifier: #51. Facility Census: 59. Findings Include: a) Resident #51 Observation, interview and record review revealed that a dependent resident was not being provided incontinence care in a timely manner. During an interview on 03/10/25, at approximately 1:15 PM, the Medical Power of Attorney (MPOA) for Resident #51 stated that she visits the resident every day. She mentioned that Resident #51 is incontinent and noted that the facility staff has failed to assess the resident for incontinence at regular intervals. Additionally, she indicated that the resident experiences fecal incontinence, and she often has to clean him up upon her arrival at the facility. Record review revealed documentation that the resident was assessed for incontinence regularly. On 03/12/25, at approximately 11:25 AM, Nursing Assistant (NA) #17, who…

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 interview, the facility failed to follow a physician's order regarding a prescription for oxygen. Resident Identifier: #22. Facility Census: 59 Findings Include: a) Resident #22 During an interview with Resident #22 on 03/10/25, at approximately 9:43 AM, the resident indicated that she was somewhat hard of hearing. She responded to questions about her care, and expressed that she was happy and content with the facility. The resident was observed to be on oxygen therapy. Inspection of the resident's oxygen concentrator revealed that it was set to deliver 4 liters per minute. During record review performed on 03/10/25 at 1:15 PM a physicians order was revealed The physicians order prescribed oxygen at 2 liters per minute by nasal cannula for Resident #22 Ongoing observation of Resident #22 on 03/1025 at 12:55 PM revealed that the oxygen concentrator was still set at 4 liters per minute. Another observation on 03/10/25 at 2:20 PM revealed that the oxygen was still unchanged and set at 4 liters per minute. A follow-up observation on 03/11/25 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 update nurse staff postings to reflect actual hours worked. This is true for five of five days reviewed. Findings included: Review of staff posting on 03/12/25 at 01:57 PM revealed the following Daily Nurse Staffing Forms were not updated to actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift: registered nurses, licensed practical nurses or licensed vocational nurses, and certified nurse aides: 05/28/24 12/18/24 10/21/24 07/05/24 03/05/25 Interview with Consulting Administrator on 03/12/25 at approximately 2:30 PM who acknowledged the Daily Staff Postings were not edited to reflect actual hours worked by direct care staff.

Based on record review and staff interview, the facility was unable to provide evidence that the attending physician reviewed any irregularities identified by the pharmacist and either accepted or rejected the recommendations. This was true for two (2) of five (5) residents reviewed under the Unnecessary Medications pathway in the Long-Term Care Survey Process. Resident identifiers: #24 and #2. Facility census: 59. Findings include: a) Resident #24: On 03/12/25 10:51 AM During record review: -The Pharmacist Medication Regimen Review for 12/15/24 had not been completed. - The Physician did not respond to the BP Recommendations dated 1/18/20 for taking resident's BP daily. 01/18/2025 Recomendation: - 1/18/2025 Pharmacist Medication Regimen Review (MMR) -Metoprolol directions indicate to hold if SBP < 110 please either add daily BP documentation or remove from directions. If hold direction removed from metoprolol, suggest checking blood pressure and pulse weekly (taking metoprolol, losartan, amlodipine) DON Interview: In an interview with DON on 03/17/2025 at 2:42PM, she stated she 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 observation, interview and record review, the facility failed to honor, and implement interventions to meet the resident's preferences, as related to the resident's request to have cereal and oatmeal for breakfast. Resident Identifier #52. Facility Census:59. Findings Include: a) Resident #52 During an interview on 03/10/25 at 1:51 PM, resident stated that she had requested cereal and milk for breakfast, but had not received it. Resident's family member stated that she had spoken to the kitchen staff multiple times, and her mother had still not received any cereal with her breakfast. Resident's daughter stated that she would highlight the cereal on her mother's breakfast menu for the next day. On 03/11/25, at approximately 9:15 AM, when interviewed, Resident #52 stated that no cereal had been served to her. Resident #52's family member produced a picture of a bowl of oatmeal on the resident's bedside table. During an interview with Consulting Administrator (CA) #100 at 10:15 AM, CA #100 was notified that the resident had not received her requested cold cereal and milk. CA…

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 council interview and staff interview the Facility failed to provide evidence that snacks were offered to resident at bedtime. Resident identifiers #47, #30, #2, #46, #49 Findings included: a) Residents #47, #30, #2, #46, #49: On 03/11/25 a Resident council meeting was held at 11:45 AM and the following was discussed: Resident #47 reported that staff do not ask if residents want an evening snack. She stated they (staff) will get one if they are asked for but its usually a gram cracker. She reported that she can remember being offered evening snacks on one occasion and was excited to get the treat. Council members agreed that staff do not offer snacks in the evening but they will bring you an oatmeal cake if you ask for one. Cognitively Intact attendees: Resident #47 had a BIMS of 14- lacked capacity to make medical decisions. Resident #30 had a BIMS of 15- had capacity to make medical decisions. Resident #2 had a BIMS of 15- had capacity to make medical decisions. Resident #46 had a BIMS of 15-had capacity to make medical decisions. Resident #49 had a BIMS of 14-…

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

Based on observation and staff interview the facility failed to store garbage and refuse in a proper manner. The dumpster area was polluted with garbage and used medical supplies. This has the potential to affect all residents that reside in the facility. Facility census: 61. Findings included: a) Garbage dumpster area An observation on 03/12/25, at 2:57 PM, found the dumpster lids open, and the area around the dumpster was polluted with garbage and used medical supplies. On 03/12/25, at 3:16 PM, during an Interview the Maintenance Director verified the trash / medical supplies on the ground around the dumpster.

Based on record review and staff interview the facility failed to ensure all staff had thorough background checks. The state of [NAME] Virginia uses the [NAME] Virginia CARES (Clearance for Access: Registry & Employment Screening) system to determine eligibility to work in a nursing home. Nurse Aide (NA) #17 did not have WV CARES determination on file and had been working at the facility. This was true for one (1) out of five (5) staff reviewed for Nurse Aides reviewed. Staff Identifier: NA #17. Facility census: 58. a) Nurse Aide # 17 A review of the employee file for Nurse Aide (NA) #17 found they do not have a WV Cares eligibility letter on file. NA #17's hire date was 05/08/06. WV CARES became required for all new and current employees beginning in the year 2016. On 04/02/24 at 2:32 PM the Director of Nursing (DON) stated NA #17 had worked at this facility for twenty some years and is now out for an illness. However, he agreed she was working prior to getting ill and there were not any documents to show a WV Cares eligibility screening was completed. At the end of this survey no…

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

Based on record review and staff interview, the facility failed to ensure a Registered Nurse was available 8 consecutive hours a day, 7 days a week. This had the potential to affect all residents at the facility. Facility census: 58. Findings included: a) Eight (8) consecutive hours of RN coverage. A review of the facility staff postings revealed that on 11/19/23 and 12/03/23 no Registered Nurse (RN) was scheduled to work on the above dates. A review of timecards for all staff working on 11/19/23 and 12/03/24 found no RN coverage. During an interview, on 04/03/24 at 8:05 AM, the Director of Nursing reviewed the timecards and stated they were very short staffed.

Based on observation and staff interview the facility failed to retain the original staff postings for a minimum of 18 months as required. This had the potential to affect all residents currently residing at the facility. Facility census 58. Findings include: a) Staff postings On 03/26/24 at 3:45 PM, the Director of Nursing (DON) was asked for the original Staff Posting Sheets for the first quarter of 2024. On 03/27/24 at 9:10 AM, the DON stated the facility is unable to provide the original Staff Posting Sheets because they cannot find them.

Based on observation and staff interview the facility failed to contain waste properly in the dumpster. This had the practice affect more than an isolated number of residents. Facility Census: 58. Findings included: a) On three different observation occasions there was found to be trash around the dumpster and in the community yard between the dumpster and the city road. This consisted of used gloves, masks, and cigarette packages as well as cigarette butts. On 03/25/24 at 1:05 PM there were used gloves, masks, and cigarette packages as well as cigarette butts around the dumpster and behind the dumpster from the fence to the city road. On 03/26/24 at 11:10 AM a second observation of the dumpster found used gloves, masks, and cigarette packages as well as cigarette butts around the dumpster and behind the dumpster from the fence to the city road. On 03/27/24 at 10:45 AM the third observation, with the Administrator, of the dumpster area found trash around the dumpster. Used gloves, masks, cigarette packages and cigarette butts were observed. These items were also found from the fence…

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

Based on record review, resident interview, and staff interview, the facility failed to promote and facilitate resident self-determination through the support of resident choices related to showers. This was true for seven (7) out of seven (7) residents reviewed under choices in the Long-Term Care Survey Process. Resident identifiers: #26, #4, #3, #11, #13, #36, and #1. Facility census: 58. Findings include: a) Resident #26 During an interview with Resident #26 on 3/25/24 at 3:35 PM, the resident reported his showers are every other week, but he would like to have them more often. He reports having told staff this several times. Review of Resident #26's admission minimum data set (MDS), with an Assessment Reference Date (ARD) of 11/21/23 revealed the resident needs partial assistance from staff for his showers. Review of Resident 26's bathing tasks, with a look back period of thirty days revealed the resident had a shower only once on 03/05/24. During an interview on 04/03/24 at approximately 1:00 PM, the Director of Nursing (DON) acknowledged the shower schedules had been an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview the facility failed to develop and implement a comprehensive resident specific care plan. This was true for five (5) of 19 sampled residents. Resident Identifiers: #19, #24, #50, and #33 Facility Census: #58. Findings include: a) Resident #19 (1) fluid restriction On 03/26/24 at 12:40 PM, observation was made of Resident #19 having her lunch meal delivered to her room. She had a sixteen (16) ounce cup of water on her over the bed table. Provided to her from the hydration cart was an additional eight (8) ounces of coffee and eight (8) ounces (oz) of fruit punch. Review of her meal ticket provided with this meal shows Resident #19 is on a fluid restriction of eight (8) ounces of fluid sugar free per meal hydration.' Resident #19 had the following orders: Order Summary: Renal diet Regular Texture Diet Condiments Order Summary: Fluid Restriction Reduce fluid intake to 1000 ml total/24 hours. Breakfast- 8 oz Lunch- 8 oz Dinner- 8 oz Nursing Med Pass- 240 ml with meals for…

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 administer medications as ordered by the physician. Neuro checks were not completed after falls. A critical oxygen level was not reported to the physician. This was found for seven (7) of nineteen residents reviewed. Resident identifiers: #110, #10, #1, #56, #4,#12, and #27. Facility census: 58. Findings included: Facility Policy,Medication Administration revision date: 01/01/22. -Facility should commence medication administration within sixty (60) minutes before the designated times of administration and should be completed by sixty (60) minutes after the designated times of administration. a) Resident #110 Resident #110 was admitted to the facility on [DATE], with the following pertinent diagnosis: -Amputation of gangrene foot. -Diabetic -Vascular disease During a review of the medical record for Resident #110 revealed the following: -Gabapentin 100 milligram (mg) give one (1) capsule three (3) times a day. This was ordered on 03/24/24 at 2:00…

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

Based on observation, staff Interview, and record review the facility failed to ensure the facility was free from accident hazards over which it had control. One (1) medication (med) cart was left unlocked and unattended, allowing access to medications by residents and unauthorized persons. This was a random opportunity for discovery. This deficient practice had the potential to affect more than a limited number of residents. Facility Census: 58. Findings included: a) Unlocked Med Cart On 03/27/24 at 12:20 PM, the Surveyor observed that a med cart on the 400 Hall was unlocked and unattended. The Surveyor remained with the unlocked cart until the Director of Nursing (DON) confirmed medications were in the med cart and that the cart should be locked when unattended. The DON immediately locked the cart. LPN #34 then approached Surveyor and questioned, Was the cart unlocked? I've mentioned in the past that the lock on this cart doesn't always work. You can push it in and think it's locked, but it's not. She then went on to demonstrate what she meant. Review of the facility policy, on…

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

Based on record review and staff interview, the facility failed to monitor for side effects and behaviors associated with an antianxiety (anxiolytic) and antidepressant medication. Resident identifiers: #50, #24 and #10. Facility Census: #58 Findings included: a) Resident #50 On 03/27/24 at 2:15 PM, a record review found Resident #50 had the following medical diagnoses: Alzheimer's disease Dementia with behavior disturbance Anxiety disorder There was a current physician order for buspirone HCL oral tablet five (5) milligrams (mg) (an anxiolytic medication). Give five (5) mg by mouth three times a day for anxiety and restlessness. Observe for side effects: sedation, morning hangover, ataxia, nausea. Record review of the Medication Administration Record and progress notes shows there is no documentation of Resident #50's behaviors or monitoring of side effects as listed above in the physician's order. This was confirmed with the Director of Nursing (DON)on 03/27/24 at 02:50 PM. b) Resident #24 On 03/27/24 at 10:50 AM, a record review found Resident #24 had the following diagnosis:…

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 council meeting, and staff interview, the facility failed to ensure a substantial/nourishing snack was provided between the evening meal and breakfast. This had the ability to affect all residents who did not have a dietary order to receive an evening snack or the cognitive and/or physical ability to make their way to the nurse's station to request something to eat from the nourishment room. Facility Census: 58. Findings included: a) Resident Council Meeting During the resident council meeting with Surveyor on 03/27/24 at 9:48 AM, the six (6) residents in attendance stated the facility did not offer an evening snack to residents. They went on to say they felt most facility residents would enjoy a bedtime snack. Several residents explained if they were hungry before bedtime, they knew they could make their way to the nurse's station and ask for something. When asked if all residents in the facility knew how to acquire a snack from the nursing staff, resident council members were not sure everyone understood. b) Staff interview On 04/02/24 at 3:08 PM, Licensed…

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 establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infection by not following isolation precautions. This was a random opportunity for discovery and had the potential to affect more than a limited number of residents currently residing in the facility. Resident identifiers: #15 and Resident #209. Facility census: 58. Findings include: a) Resident #15 On 03/27/24 at 1:05 PM it was observed Resident #15 had gauze and tape around the left front of the wheelchair. This was pointed out to Registered Nurse (RN) #62. RN #62 stated it was on there to protect the residents' leg from rubbing on the wheelchair. It was explained gauze and tape cannot be cleaned. On 03/27/24 at 3:10 PM, the Director of Nursing (DON) was informed of the above and no further information was provided. b) Resident #209 On 03/27/24 at 1:30 PM, Physical Therapist Assistant (PTA) #83 was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on observation, resident interview, staff interview and record review, the facility failed to treat Resident #7 with respect and dignity and to care for the resident in a manner that promoted maintenance or enhancement of her quality of life. Secondly, the facility failed to provide meals in the dining room to all residents at a table at the same time. Lastly, the facility failed to ensure Resident #11 was given the right to vote. These were random opportunities for discovery. Resident identifiers: #7 and #11. Facility census: 58 Findings include: a) Resident #7 During a dining room observation on 03/27/24 at 12:00 PM, Resident #7 was observed with an abundant amount of facial hair on her upper lip and chin. The facial hair on her lip had the appearance of a very light moustache. The hairs on her chin measured approximately 1/2 - 3/4. The hair was noticeable when standing approximately five (5) feet away from the resident. Resident #7 was sitting at a table by herself. When the Surveyor approached…

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

Based on resident interview, observation, and staff interview, the facility failed to ensure a call light was within reach in Resident #33's room. This was a random opportunity for discovery. Resident identifier: #33. Facility census: 58. Findings include: a) Resident #33 On 03/27/24 at 9:45 AM, Resident #33 stated in a resident council meeting he would like for his call light to be either pinned to his clothing or on the blanket beside him on the right side of his body. The Resident explained his stroke had affected the left side of his body and he has poor mobility. Many times, the nursing assistants leave the room without the call light being within his reach. Resident stated the call light is his lifeline to staff since he is not independent with mobility, and it raises his anxiety levels when he has no way to turn his call light on. A random observation, on 04/02/24 at 11:04 AM, found Resident #33's call light was placed on the left side of his bed, looped around the bed rail and had no clasp. The Resident reported it was out of his reach and expressed his concern that he often…

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 notify the resident's legal representative after the resident experienced a fall. The facility's failure to notify the resident's representative was true for one (1) of four (4) residents sampled for falls in the Long-Term Care Survey Process. Resident identifier: #49. Facility census: 58 Findings included: a) Resident #49 A record review, completed on 04/26/24 at 10:00 AM, revealed the following details: -Resident #49 was admitted to the facility on [DATE]. -A physician determination of capacity, dated 08/02/23, noted the resident lacked capacity to make medical decisions. -There was Legal Guardianship paperwork, dated 08/26/22, scanned into the medical record which reflected that the [NAME] Virginia Department of Health and Human Resources (WV DHHR) had been appointed as a legal guardian for Resident #49. -The guardianship paperwork revealed the WV DHHR would be responsible for all areas of the protected person's (Resident #49's) daily life…

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 Resident #1's personal privacy was maintained during catheter care. Additionally, three (3) residents personal information was left unattended in the lobby and was accessible to the public and other residents . This was true for one (1) out of one (1) reviewed for catheter care and was a random opportunity for discovery. Resident identifiers: Resident # 1, #49, #23, and #50. Facility census: 58 Findings include: a) Resident # 1 While observing catheter care on 04/03/24 at 9:52 AM, it was noted Nurse Aide (NA) #50 failed to close the door and the window blinds before providing catheter care. This was reported to the Director of Nursing (DON) on 04/03/24 at 9:59 AM and no further information was provided. b) Elopement Binder in Lobby Observation, on 03/27/24 at 9:30 AM, found the facility's elopement binder in the front lobby accessible to any passerby. The elopement binder contained resident pictures and an elopement risk identification form completed for each resident who had been deemed an elopement risk. 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, resident interview, and staff interview, the facility failed to identify a verbal complaint/concern as a grievance, failed to make prompt efforts to resolve grievances, and to keep the resident informed of progress toward resolution. This was true for one (1) of 19 residents reviewed in the Long-Term Care Survey Process. Resident identifier: #33. Facility census: 58. Findings include: a) Interview with Social Worker During an interview on 04/02/24 at 10:16 AM, the Social Worker stated it was the social services department that was responsible for overseeing the grievance process, including receiving and tracking grievances through to their conclusions. It was explained that any resident who verbalized they had missing personal property would be assisted by staff in completing a written grievance form. b) Review of Grievance Policy A review of the Grievance Policy, completed on 04/02/24 at 10:29 AM, revealed: -Upon receipt of the grievance/concern, the grievance/concern form would be initiated by the staff member receiving the concern. -The concern/grievance…

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 update Resident #10's Preadmission Screening and Resident Review (PASRR) after they were diagnosed with Major depressive disorder during their stay. This was true for one (1) out of two (2) residents reviewed for Preadmission Screening and Resident Review (PASRR). Resident identifier: #10. Facility censuses 58. Findings included: a) Resident #10 A review of the medical record for Resident #10 on 03/25/24 at 3:08 PM, found the most recent PASARR was dated 01/09/2014, and had no mention of Major Depressive disorder. Resident #1 was diagnosed with major depressive disorder on 11/10/14. PASARR had not been completed since Resident #10 was diagnosed with Major Depressive Disorder. On 04/03/24 at 8:05 AM, the Director of Nursing (DON) verified the PASARR did not have the diagnosis of Major Depressive disorder and a new PASARR should have been completed.

Based on record review and staff interview the facility failed to revise the comprehensive care plan in a timely manner. This was found for one (1) of nineteen residents reviewed during the long-term care survey process. Resident Identifier: #19 Facility Census: #58. Findings Include: a) Resident #19 On 03/26/24 at 01:23 PM, record review shows Resident #19 received dialysis three (3) times a week. The current order stated: Dialysis days: Monday, Wednesday, Friday. Time for pick up: 05:30. Transport to: (Name of dialysis center) Transport: PT (patient) via stretcher. She was care planned for the same. On 03/27/24 at 08:00 AM, the resident was in her room. When Registered Nurse #44 was asked why the resident did not go to dialysis, she responded, she doesn't go until 10:00 AM now, they changed her times. Further conversation on 03/27/24 at 08:30 AM with the Director of Nursing (DON), confirmed the order should state, for pick up at 10:00 AM. He states this changed at the beginning of the year. Review of Resident #19's care plan shows the care plan was not revised to reflect the…

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

Based on observation,record review, and staff interview, the facility failed to ensure a resident received the necessary care and services to maintain good grooming and personal hygiene for dependent residents. Resident #7 had unwanted facial hair. This was a random opportunity for discovery. Resident identifier: #7. Facility census:58. Findings included: a) Resident #7 During a dining room observation on 03/27/24 at 12:00 PM, Resident #7 was observed with an abundant amount of facial hair on her upper lip and chin. The facial hair on her lip had the appearance of a very light moustache. The hairs on her chin measured approximately 1/2 - 3/4. The hair was noticeable when standing approximately five (5) feet away from the resident. Resident #7 was sitting at a table by herself. When the Surveyor approached Resident #7 to inquire about the help she received with grooming, the resident stated, Wait. Wait. I am a mind reader! I would love for someone to help me shave all this off!! as she was pointing to her facial hair. The Administrator confirmed the presence of the facial hair on…

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

Based on record review and staff interview the facility failed to ensure a resident with pressure ulcers received the necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing. Resident Identifier: #27 Facility Census: #58 Findings include: a) Resident #27 On 03/27/24 at 10:17 AM record review shows Resident #27 had the following orders for pressure ulcers or preventative orders with missed treatment dates provided. According to the review of the Treatment Administration Record (TAR) for February and March 2024 the following Physicians treatment orders were not completed as ordered. Apply skin prep and protective cream to right heel Deep Tissue Injury (DTI) every shift for pressure injury. Missed orders on 02/06/24 and 02/14/24 evening shifts. Apply skin prep followed by protective cream to left heel Deep Tissue Injury (DTI) every shift for pressure injury and to prevent skin breakdown. Missed orders on 02/06/24 and 02/14/24 evening shifts. Place two pillows under bilateral feet,…

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, the facility policy, and staff interview the facility failed to use a sterile technique while providing tracheostomy care for Resident #41 and failed to give a breathing treatment to Resident #4 as ordered. This was found for two (2) of four (4) residents reviewed for respiratory care. Resident identifiers; #41 and #4. Facility census: 58. Findings included: a) Resident #41 Facility policy, Tracheostomy Care, revision date: 07/15/21. -Open sterile trach kit using aseptic techniques. -Remove sterile drape from trach care kit and spread on bedside table. Do not touch the inner sterile field. -Empty sterile contents of trach care kit onto the sterile drape. During an observation on Tracheostomy care on 04/02/24 at 11:25 AM with Registered Nurse (RN) #44. RN #44 failed to clear and disinfect the bedside table prior to opening the Tracheostomy kit .RN #44 then removed the sterile drape from the kit and placed it on the chest and abdomen of Resident #41. RN #44 continued to remove the contents of the kit onto the bedside table along with personal…

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 ongoing assessments to ensure the overall quality of care the resident received in regards to dialysis treatment. In addition, the facility failed to follow the physician's order for fluid restriction. Resident identifier: #19. Facility Census: #58. Findings included: a-1) Resident #19 - communication between facility and dialysis center On 03/26/24 at 1:23 PM record review showed Resident #19 received dialysis three (3) times a week Review of the Hemodialysis Communication Record for the following post Hemodialysis treatment assessments were not complete or were missing. This post assessment includes access site, blood pressure, temperature, pulse, Arteriovenous fistula (AV) Shunt for bruit and thrill, any post dialysis complications, any new orders from the dialysis center. 02/02/24 incomplete 02/05/24 incomplete 02/07/24 no Hemodialysis Communication Record 02/09/24 incomplete 02/12/24 no Hemodialysis Communication Record 02/14/24 no Hemodialysis Communication Record 02/16/24 incomplete 02/21/24 incomplete…

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 monitor for side effects and behaviors associated with an antipsychotic medication. Resident identifiers: #50 and #27. Facility Census: #58 Findings included: a) Resident #50 On 03/27/24 at 02:15 PM record review found Resident #50 had the following medical diagnoses: Alzheimer's disease Dementia with behavior disturbance Anxiety disorder There was a current physicians order for an antipsychotic medication: Olanzapine Tablet 2.5 milligrams (MG) Give 2.5 mg by mouth at bedtime every other day for dementia with paranoia. Observe for side effects like sedation, weight gain, dry mouth, blurred vision, tachycardia, Tardive dyskinesia. Record review or the Medication Administration Record and progress notes showed there was no documentation of Resident #50's behaviors or monitoring of side effects as listed above in the physician's order. This was confirmed with the Director of Nursing (DoN) on 03/27/24 at 2:50 PM. b) Resident #27 On 03/27/24 at 11:50 AM, a record review found Resident #27 had the following diagnoses:…

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 interviews and medical record review, the facility failed to develop a discharge plan for a resident. This was true for one (1) of one (1) residents who were reviewed for discharge. Resident identifier: # 17. Facility census: 59. Findings included: a) Resident #17 A review of the discharge record for Resident #17 found the resient was discharged on 08/26/23. A review of the care plan found no discharge plan was completed for this resident In an interview with the Director of Nursing on 09/21/23 at 11:51 AM, the Director of Nursing stated, We missed it and there was no discharge plan on the care plan.