Canterbury Center

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.

Based on resident interview, observation, record review, and staff interview, the facility failed to ensure sufficient nursing staff with the appropriative competencies and skill set were available to provide services to meet resident's needs. Residents did not receive restorative therapy services and showers. This had the potential to affect more than a limited number of residents at the facility. Facility census: 60. Finding included: 1. Restorative Services a) Resident #56 On 07/11/22 at 9:23 AM, the resident said she thought she should be getting hand splints on her hands because they are drawling up. Review of the resident's restorative nursing record found orders for: Restorative 3 times a week for BUE bilateral upper extremities and cervical exercises for muscle strengthening and, RNP (restorative nursing program) 3 weeks for PROM BLE to prevent contractures. Further review found the resident did not receive restorative therapy from 06/10/22 until 06/21/22. On 07/13/22 at 8:34 AM, the Director of Nursing (DON) confirmed therapy was not provided as ordered. When asked why, 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 develop and/or implement the comprehensive care plans for seven (7) of 21 residents reviewed in the long-term care survey sample. This had the potential to affect more than an isolated number of residents. Resident identifiers: #5, #39, #28, #56, #27, #54, #10. Facility census: 60. Findings included: a) Resident #5 Review of Resident #5's physician's orders showed an order written on 04/28/22 for restorative nursing program services for passive range of motion to bilateral upper extremities for 15 minutes, three (3) times a week. Resident #5's comprehensive care plan did not contain a focus or intervention related to restorative nursing program services. During an interview on 07/13/22 at 9:30 AM, Coordinator for Clinical Reimbursement Registered Nurse (RN) #53 confirmed Resident #5 was not care planned for receiving restorative nursing program services. No further information was provided through the completion of the survey. b)…

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 six (6) of ten residents, dependent upon staff for showers, received showers as requested and/or received showers per the shower schedule. Resident identifiers: #3, #12, #28, #56, #37 and #15. Facility census: 60. Findings included: a) Resident #3 Observation of the resident on 07/11/22 at 8:49 AM, found his hair was oily and his shirt was stained with food particles. Review of the showers documented as provided for the past 30 days found the resident was showered on Wednesdays and Saturdays. The resident had the opportunity to receive eight (8) showers. The resident only received four (4) showers on: 06/22/22, 06/25/22, 06/29/22, and 07/4/22. On 07/12/22 at 2:52 PM, the Director of Nursing (DON) reviewed the shower documentation and confirmed the above findings. In addition, the DON acknowledged the resident did not refuse any showers. b) Resident #12 Observation of the resident on 07/11/22 at 9:15 AM, found his hair was disheveled and appeared to be unwashed. Review of the shower documented 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 provide care for residents' as identified on the resident's care plan and physician's orders. This was true for three (3) of 21 (twenty one) records reviewed. Resident Identifiers: #19, #39, #7 Facility Census: 60. Findings included: a) Resident (R) #19 Resident #19 reported missing scheduled doctor appointments outside the facility since her admission, during an interview on 07/11/22. at 11:11 AM. Review of the medical record on 07/12/22, revealed R #19 was readmitted to the facility on [DATE]. The acute care center's discharge instructions include a visit with Dr. (name) a cardiovascular disease cardiologist in ten (10) days. The medical record lacks any information related to this visit. During an interview on 07/13/22 at 11:00 AM, the Director of Nursing confirmed R #19 has not seen the cardiologist as recommended. b) Resident #39 On 07/12/22 at 3:23 PM, a review of the Treatment Administration Record (TAR) for June and July 2022 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.

e) Resident #5 Review of Resident #5's physician's orders showed an order written on 04/28/22 for restorative nursing program services for passive range of motion to bilateral upper extremities for 15 minutes, three (3) times a week. Review of Resident #5's restorative nursing record showed the resident had not received restorative nursing services from 06/09/22 through 06/20/22. During an interview on 07/12/22 at 2:37 PM, the Director of Nursing (DON) confirmed Resident #5's restorative nursing record documented no services from 06/09/22 through 06/20/22. The DON stated Resident #5 may have refused restorative nursing services but acknowledged refusals should have been documented in the record. No further information was provided through the completion of the survey. d) Resident #27 During a medical record review for on 07/13/22 for Resident #27, revealed an order for restorative nursing program three (3) times a week for strengthening exercises and ambulation with a walker. Also reviewed the Restorative Nursing Record, which indicated Resident #27 had not received any restorative…

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, staff interview, and record review the facility failed to ensure a resident with weight loss had meal percentages recorded in the medical record indicating the resident received 3 meals a day. This was found for one (1) of ten (10) residents reviewed for the care area of nutrition. Resident identifier: #56. Facility census: 60. Findings included: a) Resident #56 On 07/11/22 at 09:41 AM, the resident said her food was usually served late and no one would help her eat. On 07/07/22 at 11:59 AM, the registered dietician (RD) wrote the following note: Resident receives a therapeutic-texture modified diet to manage IDDM (insulin dependant diabetes mellitus) and ease chewing related to several missing teeth and swallowing deficit. She has had recent noted pocketing, coughing/choking on solid foods/liquids. SLP (speech) has been referred for a swallowing evaluation. 7.5% weight loss trend over the past 3 months appears r/t (related to) inadequate oral intakes. She has increased protein and calorie needs related to a stage 4 pressure injury and wound infection.…

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 complete the post dialysis communication book once a resident returned from dialysis. This was discovered for one (1) of one (1) residents reviewed for dialysis during the Long Term Care Services Program. Resident identifier: #21 Facility census: 60 Findings included: a) Resident #21 A review of Resident #21's Dialysis Communication Book, revealed eleven (11) post dialysis communication sheets were incomplete on June 3, 8, 10, 13,15, 20, 22, 24, 27, 2022 and July 01 and 08, 2022. An interview with the Director of Nursing (DON) on 07/12/22 at 2:45 PM, verified the dialysis communication post dialysis sheets were incomplete on June 3, 8, 10, 13,15, 20, 22, 24, 27, 2022 and July 01 and 08, 2022. .

Based on observation, record review and staff interview, the facility failed to ensure nursing staff had the appropriate competencies and skill sets to provide resident care. This was a random opportunity for discovery and had the potential to affect more than an isolated number of residents. Resident identifier: #28. Facility census: 60. Findings include: a) Resident #28 On 7/11/22 at 9:20 AM, the residents call light was on. The resident was setting in the doorway of her room in her wheelchair. The Nurse Practioner (NP) passed by the resident, stopped and asked what she needed. The resident said she wanted to go to the bathroom. The NP told the resident she would get her some help. On 07/11/22 at 9:35 AM, Nurse Aide (NA) #37 was observed taking the resident to the bathroom by herself. After review of the resident's medical record, on 07/11/22 at 12:37 PM, the surveyor asked NA #37 with the director of nursing (DON) present how the resident was assisted to the bathroom? NA #37 said she took the resident to the bathroom and used a gait belt during the transfer from the residents…

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 interview, the Quality Assessment and Assurance (QAA) committee failed to identify quality deficiencies of which it should have been aware. This deficient practice had the potential to affect more than a limited number of residents residing in the facility. Facility census: 60. Findings included: 1. Interview On 07/14/22 at 8:28 AM, the Administrator was interviewed on behalf of the Quality Assessment and Assurance (QAA) committee. The Administrator stated the QAA Committee was aware that the Restorative Nursing Program (RNP) aides were sometimes pulled to the floor to perform resident care, rather than being able to perform RNP services. The Administrator stated the QAA Committee has focused extensively on staffing. The Administrator stated the QAA Committee had a project related to documentation of bathing activities. 2. Restorative care a) Resident #56 On 07/11/22 at 9:23 AM, the resident said she thought she should be getting hand splints on her hands because they are drawling up. Review of the resident's restorative nursing record found orders 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.

Based on observation, resident interview, and staff interview, the resident failed to receive his food choice preferences. This failed practice had the potential to affect a limited number of residents. Resident identifier: #33. Facility census: 60. Findings included: a) Resident #33 Observation on 07/11/22 at 1:00 PM, found the resident eating in the dining room of the facility. The resident had an egg salad sandwich, soup, and beets. The resident had not touched the soup or the sandwich, but had eaten the beets. The resident said he did not like egg salad. The resident's tray ticket was laying on the table beside his plate. The tray ticket indicated the resident was to have a grilled cheese sandwich instead of the egg salad sandwich. At 1:06 PM on 07/11/22, the dietary manager (DM) was asked why the resident did not receive the grilled cheese sandwich listed on the tray ticket? The DM said, the resident did not get what's on his ticket because we have a borrowed cook from another facility, and she didn't make any grilled cheese sandwiches. .

Based on observation, staff interview, and record review, the facility failed to ensure a resident, dependent upon staff for transfers, received the required assistance of two (2) staff members for transfers. In addition, the staff member did not have the means to check the information established by the facility regarding the amount of staff assistance required to transfer the resident. This failed practice had the potential to affect more than an isolated number of residents. Resident identifier: #28. Facility census: 60. Findings included: a) Resident #28 On 7/11/22 at 9:20, the residents call light was on. The resident was setting in the doorway of her room. The Nurse Practioner (NP) passed by the resident, stopped and asked what she needed. The resident said she wanted to go to the bathroom. The NP told the resident she would get her some help. On 07/11/22 at 9:35 AM, Nurse Aide (NA) #37 was observed taking the resident to the bathroom by herself. After review of the resident's medical record, on 07/11/22 at 12:37 PM, the surveyor asked NA #37 with the director of nursing (DON)…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on record review and staff interview, the facility failed to notify the ombudsman of discharge to the hospital for one (1) of two (2) residents reviewed for the care area of hospitalizations. This failed practice has the potential to affect a limited number of residents. Resident identifier: #28. Facility census: 60. Findings included: a) Resident #28 Record review on 07/11/22 at 10:39 AM, found the resident was sent to the hospital on [DATE] for rectal bleeding. The resident returned to the facility on [DATE]. On 07/13/22 at 11:45 AM, the administrator said, we tell the ombudsman as soon as a resident goes out, it's on a form. The administrator was asked to provide a copy. On 07/13/22 at 12:19 PM, Registered Nurse (RN) #76 provided a copy of notification of discharge for Resident #28 that was sent to the ombudsman; however, the form was not for the 05/16/22 discharge. RN #76 said this was all she could find and confirmed she was unable to locate the information for the 05/16/22 discharge. On 07/13/22 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 review and revise the care plan when restorative therapy orders were discontinued or changed. This was true for 3 (three) of 21 (twenty one) care plan records reviewed during the survey process. Resident Identifiers: #36, #55, and #37 Facility Census 60. Findings included: a) Resident #36 On 7/11/22 at 11:15 AM during the initial survey interview, Resident #36 stated she is not getting therapy. Upon record review, there are no current orders for Physical, Occupational or Restorative therapy. The care plan states she is to get restorative nursing programs 3 (three) times a week every week for ambulation/stairs for 15 minutes. Resident is weight bearing as tolerated (WBAT) but does not get out of bed. The facility failed to revise the care plan when restorative therapy was discontinued. This was confirmed with the Director of Nursing on 7/11/22 at 1:10 PM. b) Resident #55 Review of Resident #55's comprehensive care plan showed an intervention to implement and deliver restorative program(s) as indicated: RNP [restorative…

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 the attending physician documented the review of identified pharmacy irregularities, the actions taken, and rationales if no actions were taken. This failed practice had the potential to affect two (2) of five (5) residents reviewed for the care area of unnecessary medications. Resident identifiers: #55, #12. Facility census: 60. Findings included: a) Resident #55 Review of Resident #55's medical records showed two (2) consultation reports with recommendations from the pharmacy that did not have a physician or Director of Nursing's signature. Additionally, the actions to be taken in response to the recommendations were not identified. The two (2) consultation reports were as follows: 01/04/22: The pharmacist stated the resident was at a moderate to high risk of falls and received two (2) psychotropic medications that may increase the risk of falls. The medications were quetiapine (Seroquel) 25 mg twice a day and escitalopram (Lexapro) 20 mg daily. The pharmacy stated the quetiapine was due for a gradual dose…

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 gradual dose reduction (GDR) for psychotropic medications or a documented rationale if the GDR was not to be attempted. This deficient practice had the potential to affect two (2) of five (5) residents reviewed for the care area of unnecessary medications. Resident identifiers: #55, #12. Facility census: 60. Findings included: a) Resident #55 Review of Resident #55's medical records showed an order for escitalopram (Lexapro) 20 mg daily for depression. Further review of Resident #55's medical records showed a gradual dose reduction (GDR) for Lexapro was attempted on 06/16/20. No further GDR for Resident #55's Lexapro could be located in the records. During an interview on 07/12/22 at 2:53 PM, the Director of Nursing (DON) confirmed Resident #55's most recent Lexapro GDR was on 06/06/20. The DON stated she was unable to locate a GDR or GDR decline since that time. No further information was provided through the completion of the survey. b) Resident #12 Review of the medical record found the resident has been…

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 medications were kept in proper temperature controls in accordance with accepted professional standards of practice. This failed practice had the potential to affect a limited number of residents. Facility Census: 60. Findings Included: a) Medication Room On 07/13/22 at 9:00 AM, the policy entitled Medication and Vaccine Refrigerator/Freezer Temperatures was reviewed. The policy states, Refrigerators and freezers used to store medications and vaccines will operate within acceptable temperature range and will be checked twice a day for proper temperatures . On 07/12/22 at 8:05 AM, the medication room was reviewed. There were two (2) refrigerators located in the medication room. Licensed Practical Nurse (LPN) #72 provided the temperature log book. The temperature logs were reviewed. The following dates had no temperatures recorded on the June and July 2022 logs: --07/06/22 PM --07/09/22 AM & PM --07/10/22 PM --07/11/22 PM On 07/12/22 at 8:15 AM, the Director of Nursing (DON) was notified of the 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 resident interview, record review, and staff interview, the facility failed to schedule a dental appointment for one (1) resident reviewed for dental care. Resident identifier: #3. Facility census: 60. Findings included: a) Resident #3 On 07/11/22 at 8:50 AM, the said he thought he might need to see a dentist to get some teeth pulled. He said it was scaring him to think about it. Review of the last full Minimum Data Set (MDS) an annual, with a assessment reference date (ARD) of 07/13/21 found the facility was aware of broken teeth and obvious cavities. The assessment noted dental care would be addressed in the care plan. Review of the care plan found the following focus: Resident is at risk for oral health or dental care problems as evidenced by potential caries teeth. Resident is missing dentition to upper and lower jaw. The goal is: Resident will not have any discomfort or chewing problems related to broken, loose or carious teeth over next review as evidence by (abbreviation unknown.) Interventions included: Obtain dental consult as ordered On 07/12/22 at 2:53 PM, the…

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

Based on observations and staff interview the facility failed to store food in accordance with professional standards for food service safety. It was discovered during the kitchen tour several food items were not dated after opening. Also the walk-in cooler/freezer was in poor operational condition. This failed practice had the potential to a limited number of residents. Facility census: 60. Findings included: a) Kitchen tour During the kitchen tour on 07/11/22 at 11:30 AM, it was discovered two (2) ten (10) pound packages of noodles, and a large container of sliced cheese were not dated after opening. The side-by-side cooler and freezer outside thermometers were not operating properly and the floor was rusted and needed to be painted. The doors to the side-by-side cooler/freezer did not seal tightly when closed. The Dietary Manager was present during the tour and verified the food items were not dated after opening and the cooler/freezer unit needed to be replaced. .

Based on medical record review and staff interview the facility failed to maintain correct medical records in accordance with accepted professional standards and practices when documenting weights. This was true for 1 (one) of 10 (ten) records reviewed for nutrition. Resident identifier: #36 Facility census 60. Findings included: a) Resident #36 On 07/12/22 at 9:29 AM, while reviewing the Residents nutrition records it was noted that there was a potential incorrect entry of the residents weight on 01/12/22. This was confirmed with the Director of Nursing on 07/12/22 at 2:45 PM. She confirmed that 1) the resident does not stand and the entry on 01/12/22 was documented as standing and 2) she didn't think the weights were correct based on the three entries documented. The following weights are shown as documented: --02/3/2022 - 12:09 - 116.8 lbs - Wheelchair --01/12/2022 - 16:5 - 122.3 lbs - Standing --012/1/2021 - 14:54 - 117.4 lbs - Wheelchair .

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on observation, record review and interview, the facility failed to maintain appropriate infection control standards for transmission-based precautions and wound care. This failed practice had the potential to affect more than an isolated number of residents. This was true for two (2) of two (2) residents reviewed under the care area of infection control during the long-term survey process. Resident Identifiers: #37 and #56. Facility Census: 60. Findings Included: a) Policy On 07/11/22 the policy entitled Contact Precautions was reviewed. The policy states, In addition to Standard Precautions, Contact Precautions will be used for diseases transmitted by direct and indirect contact with the patient or the patient's environment. State regulations will be followed when applicable. Section 2. Place a STOP. Please see nurse before entering room. sign on door. Section 3. Instruct staff, patient and his/her representative, visitors regarding Precautions and the use of personal protective equipment (PPE).…

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 follow their Antibiotic Stewardship program that includes antibiotic use protocols and a system to monitor antibiotic use. This was true for 1 (one) of 1 (one) resident reviewed for skin conditions unrelated to pressure ulcers. Resident identifier: 36 Facility Census 60. Findings Included: a) Resident #36 On 07/11/22 at 11:10 AM, Resident #36 stated she has an old surgical scar on her right hip that is opening back up and draining. She stated she is waiting on a surgery date to remove the hardware from her right hip. Record review reflects a culture was performed on the wound and a sensitivity for the correct antibiotic. She has been on the antibiotic Clindamycin since 5-18-22 with no stop date. There is no documentation that a stop date has been readdressed nor has the pharmacy called it to the attention of the Physician with a Medical Regimen Review (MRR). On 7/13/22 at 3:45 PM, the Director of Nursing states she has to be on it until her surgery per her Physician. There is currently no surgery scheduled. She does…

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

Based on medical record review and staff interview, the facility failed to ensure the resident or resident's representative was provided current education from the Centers for Disease Control and Prevention (CDC) regarding the benefits and potential side effects of influenza immunization prior to administering the vaccine. This is true for one (1) of five (5) reviewed for immunizations. Resident identifier: #44. Facility census: 60. Findings include: a) Resident #44 Review of the medical record on 07/12/2022, revealed Resident (R) #44's Health Care Decision Maker signed a consent on 09/10/2020 giving the facility permission to administer the annual influenza vaccine. R #44 received the high dose influenza vaccine on 09/29/2021. The vaccine information statement (VIS) from CDC located in the chart is dated 08/15/2019. *CDC's current VIS for the Influenza vaccine is dated 08/06/2021. During an interview on 07/12/22 the Director of Nursing (DON) and the Infection Preventionist (IP) confirmed R #44 received the influenza vaccine on 09/29/21. The DON acknowledged the medical record…

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