Sistersville Center

Based on record review and staff interview, the facility failed to ensure required members of the Quality Assurance and Performance Improvement (QAPI) team were present to hold the required quarterly meeting. Facility Census: 65. a) QAPI members On 04/03/25 at 1:10 PM, a review of the sign in sheets for QAPI was completed. The review found the Director of Nursing (DON) position was empty during the dates of 02/19/24 through 04/08/24. There was no one filling in the DON position. Therefore, for the dates of 02/19/24 through 04/08/24, the required members did not attend. On 04/03/25 at 2:30 PM, this time frame was confirmed by the Administrator and the current DON. b) QAPI meetings On 04/03/25 at 2:40 PM, a review of the sign in sheets for QAPI was completed. The review found there were no meetings held in the months of 01/2025, 02/2025 or 03/2025. On 04/03/25 at 3:00 PM, the Administrator confirmed there were no meetings held in 01/2025, 02/2025 or 03/2025.

Based on observation, record review and staff interview, the facility failed to provide care in a manner and environment that promoted a dignified dining experience for the residents. This failed practice had the potential to affect more than a limited number of residents. Resident identifiers: #61, #50, #22, #57, #1, #2, #29. Facility Census: 65. Findings included: a) On 03/31/25 at 12:55 PM, during the dining observation, resident's were not seated at the same time at tables, the lunch meal did not arrive at the same time for resident's at the same table, six (6) residents were left seated in the center of the dining room while the other resident's were at their tables and served beverages and lunch meals and clothing protectors were placed on residents without asking their preference. At 1:05 PM, Resident #61 tried multiple times to feed Resident #50 from their tray. The state surveyor intervened for staff to re-direct the resident. Resident #50 received the lunch tray at 1:13 PM. Resident #1 was fed at 01:32 PM after the tablemate's lunch had been fed beginning at 1:12 PM. Staff…

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

Based on record review and staff interview, the facility failed to complete a change in condition (CIC) for Resident #22's development of a pressure ulcer on the right heel. This was a random opportunity for discovery. Resident Identifier: #22. Facility Census: 65. Findings Include: a) Resident #22 On 03/31/25 at 2:30 PM, a progress note was reviewed. The progress note dated 03/31/25 at 1:16 PM stated, Resident has a blister to her right heel. NP (Nurse Practitioner) in facility this morning and visited resident. New order for Sure Prep to right heel BID (twice daily). POA (Power of Attorney) notified and in agreement with order. (Typed as written.) Upon further review, no change in condition was found for Resident #22. On 04/01/25 at 2:00 PM, an interview was held with the Director of Nursing (DON). The DON confirmed the resident did have a blister to the right heel and no change in condition had been completed.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and staff interview, the facility failed to implement or develop comprehensive, person-centered care plans for four (4) of 22 residents. Resident #22's care plan was not implemented regarding a dietary restriction, documenting meal intakes, and for the risk of limited engagement. Resident #31's care plan was not implemented for monitoring of medication side effects and behaviors, pain assessments,and anticoagulation monitoring. The facility failed to develop a care plan for Resident #57 and #59 to include all diagnoses. Resident Identifiers: #22, #31, #57, #59, #25. and #51. Facility Census: 65. Findings included: a) Resident #22 On 03/31/25 at 12:38 PM, the lunch trays arrived at the dining room on A hall. Resident #22 was sitting with another resident. Nurse Aide (NA) #66 sat Resident #22's food in front of her. The resident was sitting in a geri-chair with a clothing protector on, which was covering up her hands. The resident was tearful throughout the entire dining…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, the facility failed to ensure care plans were revised for Residents #42 fall, #22 dependent for meals, #57 independent for mobility, #4 full code, #23 give fluids when NPO, and #28 hospice when not ordered. These failed practices affected more than a limited number of residents. Resident identifiers: #42, #22, #57, #4, #23, and #28. Facility census: 65. Findings included: a) Resident #42 On [DATE] at approximately 11:00 AM, a record review was completed for Resident #42. The review found the resident had a fall on [DATE]. An x-ray was completed with no abnormalities found. However, the resident continued to complain with pain upon movement. A computed tomography scan (CT ) was ordered by the facility physician on [DATE]. The CT results were received on [DATE], with the following finding:There are fractures of the left superior and inferior rami, there is also a fracture through the left side of the sacrum. The care plan was reviewed on [DATE] at 11:15 AM. The care plan…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, the facility failed to ensure physician orders were followed. medications were administered timely, behaviors, and pain were monitored. This had the potential to affect more than a limited number of residents. Resident identifiers: #31, #22, #59, #57, #25, #51 and facility late mdications, #28, #49, #37, #23, #36, #8, #7, $41, #50, #9, #41, #50, #20, #63, #42, #58, #61, #23, #10, #15, #17, #267, and #268. Facility census: 65. Findings included: a) Resident #31 On 04/01/25 at 9:30 AM, a record review was completed for Resident #31. The review found the physician's orders were not being followed on the 01/2025 and 02/2025 medication administration records (MARs). The following physician's orders and dates are as follows: --Anticoagulant Medication Monitoring: --01/09/25 day shift --01/13/25 day shift --01/14/25 day shift --01/15/24 day shift --01/16/25 day shift --01/17/25 night shift --01/28/25 day shift --02/11/25 day shift --02/12/25 day shift --Monitor for Behaviors:…

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 have sufficient staffing for the B hall on 03/29/25 and 03/30/25. This failure has the potential to affect more than a limited number of residents. Facility Census: 65. Findings Include: a) B hall residents On 04/03/25 at 11:30 AM, the daily staff postings were reviewed for 03/29/25 and 03/30/25. The review found only two (2) nurses scheduled for both dates; one (1) on the red hall and one (1) on the blue hall. The red hall has 26 beds and the blue hall had a census of 42 residents. No other nurse was scheduled on the blue hall during day shift. The nurse schedule provided had noted a need for day shift on 03/29/25 and 03/30/25. The daily nursing hours per patient day were above the minimum; but, multiple medications were late and multiple treatment orders were incomplete. The acuity of the residents was higher on these days with only one (1) nurse on the blue hall. The following list of late medications for each resident is as follows:…

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 daily menus were followed. This was a random opportunity for discovery and had the potential to affect more than a limited number of residents. FACILITY:FACILITY. Facility Census: 65. Findings included: a) The facility's menu for 03/31/25 was BBQ Pork on Roll, Gelatin Cubes with Whipped Topping and Potato Chips. The BBQ was served on white sandwich bread in the Dining Room and on the hallways per states surveyors' observations. Resident #10, #56 and #26 were on regular diets and all three residents received light bread in place of a roll. Resident #26 demonstrated difficulty picking up and eating the BBQ on light bread. On 04/01/25 at 12:00 PM, the Corporate Dietary Manager #83 confirmed there were no buns/rolls served for the BBQ yesterday. The Corporate Dietary Manager #83 stated, No, we did not. and that the bread truck ran this date. b) The facility's menu for 04/01/25 was Breaded Fish Filet on Roll, Tartar Sauce, Lettuce and Tomato Garnish, Sliced Peaches and Seasoned Potato Wedges. Lettuce…

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

Based on record review, staff interview, resident interview and observation, the facility failed to prepare and serve food at a safe and appetizing temperature. This failed practice had the potential to affect more than a limited number of residents. FACILITY:FACILITY. Facility Census: 65. Findings included: a) The facility's policy and procedure stated, All foods will be held at appropriate temperatures, greater than 135 (degrees) F (or as state regulation requires) for hot holding, and less than 41(degrees) F for cold food holding. b) On 04/01/25 at 12:00 PM, the food holding temperature were taken by the Corporate Dietary Manager #83. The following temperatures were obtained: -Holding Temperatures for lunch meal: Lettuce 51.8 - put in freezer Shredded Lettuce 50 - put in freezer Fish - 164.2 Potato Wedges - 183.7 Ground Fish - 181.5 Advanced Mechanical Soft potato wedges - 191.1 (skin off) Meatballs - 195.2 Pureed peaches - 40.3 Rice - 184.2 Pureed rice - 182.1 Pureed fish - 194.7 Peaches - 40.9 Cottage cheese - 39.4 Pureed rice - 172.4 Pureed bread - 170 Fortified pudding - 39.4…

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 food was stored properly and food preparation equipment was clean. This failed practice had the potential to affect more than a limited number of residents. FACILITY:FACILITY. Facility Census: 65. Findings included: a) The facility's policy and procedure stated, All foods are labeled and dated with the name of the product and the date received and use by date once opened. Manufacturer use by dates are used unit opened. Prepared foods are labeled and dated with the name of product, date opened, and use by date. b) On 03/31/25 at 11:25 PM, the Kitchen Investigation was initiated with the Corporate Dietary Manager #83. The following items were observed and confirmed: Frozen chicken breast in an opened ziploc with no dates on the package. Imperial Beef Base was opened and not dated. Celery and Lettuce were opened, uncovered in a box and not dated. Sandwich bread was opened and not dated. The Corporate Dietary Manager #83 asked, Do we need a use by date? c) On 04/01/25 at 10:40 AM, the pantry 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 record review and staff interview, the facility failed to maintain complete, accurate, and timely medical records. This deficient practice had the potential to affect five (5) of 22 residents reviewed in the long-term care survey sample. Resident Identifiers: #5, #58, #25, #51, and #3. Facility census: 65. Findings included: a) Resident #5 On 04/01/25 at 8:48 AM, Licensed Practical Nurse (LPN) #11 was observed administering morning medications to Resident #5. One of the medications administered to the resident was Zyrtec (cetirizine hydrochloride) 10 mg. Review of Resident #11's physicians' orders showed on 03/29/25 the resident was ordered Zyrtec allergy oral tablet (Cetirizine HCl [hydrochloride], give 1 tablet by mouth one time a day for sinusitis. The order did not specify the dosage for the medication. On 04/01/25 at 9:50 AM, the Director of Nursing confirmed Resident #5's Zyrtec didn't have a dosage ordered. She stated the pharmacy only supplies one dosage of Zyrtec to the facility. She stated she…

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

Based on observation, record review, and staff interview, the facility failed to establish and maintain an infection prevention and control program designed to help prevent the development and transmission of communicable diseases and infections. These were random opportunities for discovery that had the potential to affect more than a limited number of residents. The facility failed to ensure Enhanced Barrier Precautions (EBP) signage was appropriately placed outside Resident #3's room. The facility failed to follow EBP for Resident #7. The facility also failed to provide resident hand hygiene in the dining room. Resident Identifiers: #3 and #7. Facility census: 65. Findings included: a) Resident #3 The facility's policy titled Enhanced Barrier Precautions, with effective date 01/06/20 and revision date 12/16/24, stated Enhanced Barrier Precautions (EBP) would be implemented for residents with wounds or indwelling medical devices. On 04/01/25 at 8:43 AM, Licensed Practical Nurse (LPN #11) stated where the EBP signage is placed outside the residents' room notifies staff which…

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 and resident interview, the facility failed to ensure a resident with limited Range of Motion (ROM) was able to reach the call light to call for assistance. This was a random opportunity for discovery and had the potential to affect a limited number of residents. Resident Identifier: #38. Facility Census: 65 Findings included: a) Resident #38 During the initial interview process, Resident #38 was observed sitting upright in bed and leaning toward the left. The resident attempted to position himself, but was unable. The patient attempted to use the call light, but was unable to reach it. The patient has a diagnosis of hemiplegia and hemiparesis following cerebral infarction affecting the left non-dominant side. The state surveyor pushed the call light for the resident at the resident's request. Nurse Aide (NA) #36 answered the call light promptly and asked the Director of Nursing (DON) for assistance with repositioning the resident. b) NA #36 reported the patient will use his call light and stated, When he has it, he usually does. The DON…

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

Based on observation and record review, the facility failed to provide a home-like environment during the dining experience. This failed practice had the potential to affect more than a limited number of residents. FACILITY:FACILITY. Facility Census: 65. Findings included: a)The facility's policy and procedure stated, All items are removed from trays and are appropriately placed in front of the resident, packages are opened, and lids are removed. b) On 03/31/25 at 12:55 PM during the facility's dining observation, the staff left a resident's food on their tray when during the lunch meal. An additional resident's tray was left on the table beside the resident's meal while they ate lunch.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, the facility failed to ensure documentation that the appropriate information was communicated to the receiving health care institution or provider upon resident transfer. This deficient practice had the potential to affect one (1) of two (2) residents reviewed for the care area of hospitalization. Resident identifier: #66. Facility census: 65. Findings included: a) Resident #66 Review of the facility's policy titled, Discharge and Transfer, with effective date 06/01/96 and revision date 03/24/25, showed for hospital transfers, the following would be sent to the hospital with the resident: - eInteract Nursing Home to Hospital Transfer From (in states where no state specific form is required) - medication list - Advance Directives - Physician's Orders for Scope of Treatment (POST) form or equivalent The policy and procedure also stated a copy of the eInteract form would be placed in the resident's medical record. Review of Resident #66's progress notes stated the…

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

Based on record review and staff interview, the facility failed to ensure an accurate Minimum Data Set (MDS) regarding weight loss. This was true for one (1) of two (2) residents reviewed under the care area of tube feeding. Resident Identifier: #61. Facility Census: 65. Findings Include: a) Resident #61 On 03/31/25 at 4:51 PM, a record review identified the resident was noted with significant weight loss. The resident's weight on 02/05/25 was 176.8 pounds. The resident's weight on 03/07/25 was 167.2 pounds. This is a significant weight loss of -5.43% in 30 days. A review of the MDS significant change dated 03/10/25 section K regarding weight loss was reviewed on 03/31/25 at 7:00 PM. The MDS stated no or unknown for the question K0300 for loss of 5% or more in the last month or loss of 10% or more in 6 months. On 04/02/25 at 3:40 PM, the Director of Nursing (DON) confirmed the MDS was incorrect regarding significant weight loss.

Based on record review and staff interview, the facility failed to prevent the development of an avoidable pressure ulcer to the right heel for Resident #22. This was true for one (1) of three (3) records reviewed under the care area of pressure ulcers. Resident Identifier: #22. Facility Census: 65. Findings include: a) Resident #22 On 04/01/25 at 11:30 AM, a record review was completed for Resident #22. A progress note dated 03/31/25 at 1:41 PM stated, Note: Resident has a blister to her right heel. NP (Nurse Practitioner) in facility this morning and visited resident. New order for Sure Prep to right heel BID (twice daily). POA (Power of Attorney) notified and in agreement with order. On 04/01/25 at 12:19 PM, the Director of Nursing confirmed the resident had developed a pressure ulcer on her right heel.

Based on observation, record review, and staff interview, the facility failed to transfer oxygen tanks in a safe manner. This was a random opportunity for discovery. Facility Census: 65. Findings Include: a) Oxygen tanks On 04/03/25 at 12:32 PM, an observation of the Maintenance Director carrying four (4) oxygen tanks, with no carrier used. The Maintanence Director had two (2) oxygen tanks in each hand, as he walked around the building the tanks were clanking together. On 04/03/25 at 12:34 PM, an interview was held with the Maintanence Director. the Maintanence Director stated, I know I'm not supposed to carry them this way .I'm trying to help her (referring to the oxygen delivery person) and she is tired. On 04/03/25 at 12:48 PM, the Corporate RN was notified. The Corporate RN shook her head in agreement and confirmed the oxygen tanks should not be transported without a carrier.

Based on record review and staff interview, the facility failed to provide pneumococcal immunizations according to standards of practice. This deficient practice had the potential to affect one (1) of five (5) residents reviewed for the care area of immunizations. Resident identifier: #59. Facility census: 65. Findings included: a) Resident #59 Review of the facility's policy titled, Pneumococcal Vaccination, with effective date 05/04/15 and revision date 09/13/24, gave the following instructions: - Obtain patient/representative consent for pneumococcal vaccination - Administer the vaccine Review of Resident #59's electronic health records showed the resident's Medical Power of Attorney (MPOA) consented on 10/28/24 for the resident to receive the pneumococcal vaccination. Resident #59's Medication Administration Records (MARs) for October and November 2024 contained no documentation the resident received pneumococcal vaccination. On 04/02/25 at 1:55 PM, the Director of Nursing (DON) confirmed the facility had no documentation Resident #59 had received pneumococcal vaccination after…

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 two (2) allegations of resident-to-resident sexual abuse were reported in a timely fashion and/or to the appropriate state agencies. Resident identifiers: #27 and #23. Facility census: 55. The Office of Health Facility Licensure and Certification (OHFLAC) Long-Term Care Reporting Requirements guidance, dated December 4, 2019, instructs that OHFLAC and Adult Protective Services (APS) should receive an immediate fax report of allegations within two (2) hours. Findings included: a) Resident #27 and Resident #23 Alleged Victims of Resident-to-Resident Sexual Abuse. A review of facility reportables revealed a facility reportable, dated 03/11/24 that revealed Resident #27 had been an alleged victim of sexual abuse by Resident #24, noting Resident #27 was walking past Resident #24 in the hallway and he grabbed her buttocks. The incident in question was reported to the Office of Health Facility Licensure and Certification (OHFLAC)and the long-term care Ombudsman. Adult Protective Services (APS) did NOT receive a faxed…

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

Based on record review and staff interview, the facility failed to develop and implement a comprehensive person -centered care plan for one (1) of three (3) residents reviewed in the complaint survey process. The facility failed to address Resident #24's inappropriate sexual behaviors towards residents. Facility identifier: #24. Facility census: 55. Findings included: a.) Resident #24 A review of the comprehensive person -centered care plan for Resident #24 showed a focused area of Resident #24 having a history of exhibiting sexually inappropriate behavior toward staff. Review of the following facility reportables noted inappropriate sexual behaviors toward other residents on the following dates: -03/11/24 -03/21/24 -06/24/24 -08/07/24 During an interview on 10/07/24 at 2:40 PM, the Social Worker confirmed had been exhibiting sexually inappropriate behaviors towards residents and that his care plan should have been updated.

Based on medical record review and staff interview, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice. This deficient practice was true for one (1) out of three (3) residents reviewed during a complaint survey process. Resident identifier: #3. Facility census: 55. Findings included: a) 04/15/24 Monthly Medication Regimen Review On 10/08/24 at 9:00 AM, an electronic medical review was completed on Resident #3. When reviewing the pharmacist's monthly medication review it was noted that on 04/15/24 the pharmacist noted Resident #3 receives Divalproex Sodium Dr. The current diagnosis is dementia with behaviors. The recommendation went on to request, Please monitor valproic acid trough concentration on the next convenient lab day, one (1) week after any dosage change, and annually thereafter to rule out toxicity. The electronic medical record revealed that the Nurse Practitioner (NP) had seen the monthly medication regimen review and had agreed to the recommendation on 05/02/24 noting I accept 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 medical record review and staff interview, the facility failed to ensure the attending physician documented in the resident's medical record that an identified irregularity had been reviewed and what, if any, action was to be taken to address it. This deficient practice was true for one (1) out of three (3) residents reviewed during a complaint survey process. Resident identifier: #3. Facility census: 55. Findings included: a) 04/15/24 Monthly Medication Regimen Review On 10/08/24 at 9:00 AM, an electronic medical review was completed on Resident #3. When reviewing the pharmacist's monthly medication review it was noted that on 04/15/24 the pharmacist noted Resident #3 receives Divalproex Sodium Dr. The current diagnosis is dementia with behaviors. The recommendation went on to request, Please monitor valproic acid trough concentration on the next convenient lab day, one (1) week after any dosage change, and annually thereafter to rule out toxicity. The electronic medical record revealed that the Nurse Practitioner had seen the monthly medication regimen review and had…

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

Based on observation and staff interview the facility failed to ensure the resident environment was clean and sanitary. The dementia care unit dining area was unclean, a vitals machine had a brown splattered substance on the bottom, and there was a smeared brown substance on a hand sanitizer dispenser . This failed practice has the potential to effect all residents currently residing in the dementia care unit. Facility Census: 65 Findings Include: a) A tour of the dementia care unit on 04/01/24 beginning at 12:30 PM found the floor in the dining room to be littered with food debris the walls in the dining room had what appeared to be food splatters on several spots on the walls throughout the dining room. By the sink there was food splatters on the wall and several gnats were noted to be positioned on the wall around the food splatters. An additional tour of the dining room on 04/01/24 at 1:58 PM with the Market President found the dining room had been freshly mopped however there was spread red jello on the floor and food particles were still noted on the floor throughout the…

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

Based on observations, record review, resident interviews and staff interviews, the facility failed to implement an ongoing resident centered activities program designed to meet the interest of and support the physical, mental and psychosocial well-being of each resident. This was a random opportunity for discovery. This failed practice had the potential to affect more than a limited number of residents residing in the facility. Resident identifiers: Resident #26, Resident #15, and Resident #32. Facility Census: 65. Findings Include: a) Observations: During several observations throughout the complaint revisit survey on 04/01/24 to 04/02/24, several group activities were not being conducted as scheduled. The monthly activity calendar for the Blue Hall scheduled events were as follows: -04/01/24 2:00 PM Getting to Know me (3) three residents were in attendance 4:00 PM Meaningful Moments was not conducted -04/02/24 9:30 AM Sensory Group was not conducted 10:30 AM Move and Grove was not conducted 2:00 PM PB&J Day (Peanut Butter and Jelly) The monthly activity calendar for the Red Hall…

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 interviews the facility failed to ensure the activities program is directed by a qualified professional. This had a potential to affect all residents residing in the facility. Facility Census: 65 Findings Include: a) Activity Professional During several observations throughout the complaint revisit survey on 04/01/24 to 04/02/24, several group activities were not being conducted as scheduled. The monthly activity calendar for the Blue Hall scheduled events were as follows: -04/01/24 2:00 PM Getting to Know me (3) three residents were in attendance 4:00 PM Meaningful Moments was not conducted -04/02/24 9:30 AM Sensory Group was not conducted 10:30 AM Move and Grove was not conducted The monthly activity calendar for the Red Hall (Memory Unit) was dated for the month of February. During several observations of the Memory Unit, no activities were being conducted. During an interview on 04/02/24 at 10:43 PM the Recreation Director (RD) stated I am not certified, I started this position in January and I have one week of classes. The RD stated I complete…

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, water temperature measurement and staff interview the facility failed to ensure the resident environment over which it had control was as free from accident hazards as possible. The water temperature was found to be 119 degrees and the medication and treatment cart were discovered unlocked and unattended on the night of 04/01/24. This failed practice had the potential to affect more than an isolated number of residents. Facility Census: 65. Findings Include: a) Water Temperature An observation on 04/01/24 at 4:00 PM found the hot water in the restroom in the front lobby of the building was too warm to the touch. At 4:45 PM on 04/01/24 a visiting Maintenance Director came to the restroom and obtained the temperature. He stated, This will be in Celsius we will convert it Fahrenheit. The temperature obtained was 48.7 degrees Celsius. This converts to 119.7 degrees Fahrenheit. The state operations manual (SOM) page 340 contained the following in regards to water temperatures: Water Temperature Time Required for a 3rd Degree Burn to Occur 155°F 68°C 1 sec 148°F…

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 maintain the resident's highest practicable level of physical, mental, and psychosocial well-being and the ability to prevent or minimize adverse consequences related to medication therapy to the extent possible. The facility failed to act upon the pharmacist medication regimen review reports for comments and recommendations identified for three (3) of three (3) residents reviewed during the complaint survey. Resident identifiers: Resident #50, Resident #66, and Resident #67. Census: 64. Findings included: a) Resident #50 On 02/13/23 at approximately 4:55 PM during a medical record review of Resident #50's medication regimen reviews, a progress note report was ran to identify any DRR (drug regimen review) reports received from 08/01/23 to 02/13/24. Two (2) drug regimen reports dated 09/25/23 and 10/20/23 were identified with Note: A medication regimen review was performed- see report for comments/ recommendation(s) noted. No reports were provided for 09/25/23 or 10/20/23. During an interview with Director of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review and staff interview, the facility failed to develop and implement a baseline care plan within 48 hours of admission for resident #41 that included the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. This was true for one (1) of three (3) residents reviewed during a complaint survey. Resident identifier: #41. Facility Census 64. a) Resident #41 During a medical record review on 02/14/24 at 10:28 AM, Resident #41 was identified to have a BIMS of 10 and lacked capacity. The baseline care plan, dated 02/02/24, reviewed for Resident #41 identified only one (1) focus that was incomplete, one (1) incomplete goal, and outlined only two (2) interventions for the incomplete focus. - FOCUS: Resident/Patient requires assistance/is dependent for mobility related to: _____. - GOAL: Resident will utilize_____bed rail(s) _____ (indicate one: independently; with assistance) for _____ (indicate: turning…

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 two (2) residents received treatment and care in accordance with professional standards of practice. The facility failed to ensure neurological checks were completed for Resident #66 and Resident #67. This failed practice was true for two (2) of three (3) residents reviewed in the complaint care survey process. Resident identifier: #66, #67. Facility Census: 64. Findings included: a) Resident #66 During a record review, on 02/13/24 at 11:07 AM, an unwitnessed fall was identified for Resident #66 on 09/13/23. The unwitnessed fall required neurological checks to be completed. During a review of the 09/13/23 initiated neurological checks form Neurological Evaluation Flow Sheet, under the section to be completed After First 8 Hours Completed Above, Evaluate Every 8 Hours for At Least 64 Additional Hours the following two (2) neurological checks were not completed per the dates and times documented on the form; * 09/14/23 at 1800 * 09/15/23 at 0200 During an interview on 02/13/24 at 3:47 with the DON, the DON…

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

Based on observation, record review, and staff interviews the facility failed to ensure they maintained medical records that were complete, accurately documented, readily accessible and systematically organized in the resident's medical record. This was true for one (1) of three (3) residents reviewed for falls during the complaint survey. Resident identifier: #50. Facility Census: 64. a) Resident #50 During a medical record review for Resident #50 on 02/13/24 at 9:56 AM a fall was identified to have happened on 09/02/23 and documented as incident #737 on the fall list that was provided by the facility. During the review of the resident's medical record for 09/02/23 there was no changes in condition documented in her chart, there were no nurses' notes, no care plan updates, or any other pertinent documentation correlated to the documented fall that was referenced as incident #737 for Resident #50 on 09/02/23. On 02/14/24 at 11:37 AM during an interview with the Assistant Director of Nursing (ADON) #23, the ADON acknowledged that Resident #50 was documented to have fallen on 09/02/23…

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

Based on staff interview, resident council meeting, and record review the facility failed to provide residents a confidential way to file a grievance. This failed practice has the potential to affect more than an isolated number of residents currently residing in the facility. Facility census: 60. Findings Included: a) Grievances On 04/05/23 at 10:23 AM, during a Resident Council meeting it was revealed there was no confidential way for the residents and/or family members to file a grievance without involving a staff member. On 04/05/23 at 1:45 PM, an observation throughout the facility found no grievance forms available throughout the facility. During an interview on 04/11/23 at 8:56 AM, with the Social Work Director #44 stated the Residents must come to a staff member to file the grievance on the computer. She stated that there are no grievance forms available for residents to file a grievance anonymously. .

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on record review and staff interview the facility failed to provide Notice of Discharge to the Office of the State Long Term Care (LTC) Ombudsman during a discharge / transfer or the Resident Representative. This was true for three (3) of three (3) Hospitalizations reviewed. Resident Identifier #60, #51 and # 45. Facility Census 60. Findings Included: a) Resident #60 A medical record review on 09/13/22 at 1:27 PM, revealed resident #60 was discharged to the hospital on [DATE]. Subsequent review of Resident #60's medical record showed it did not contain documentation the Notice of Transfer or Discharge was provided to the Resident Representative, or the Ombudsman of the discharges on 03/31/23. During an interview 04/04/23 at 2:30 PM the Social Service Director stated she does not send out discharge and transfer notices to the ombudsman or send a bed hold notice if they are not above 90 % capacity. On 04/04/23 at 2:48 PM Corporate Business Development #79 verified, the ombudsman should have been notified…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on medical record review and staff interview, the facility failed to provide evidence the resident and/or the resident's representative was provided a written Bed Hold Notice for a hospital transfer. This was true for three (3) of three (3) residents reviewed for hospitalizations during the Long-Term Care Survey Process. Resident identifiers: #51, #45, and #60. Facility census: 60. Findings included: a) #60 A medical record review on 09/13/22 at 1:27 PM revealed resident #60 was discharged to the hospital on [DATE]. Subsequent review of resident #60's medical record showed it did not contain documentation that the resident / resident's representative was provided a written Bed Hold Notice for a hospital transfer of the discharges on 03/31/23. During an interview 04/04/23 at 2:30 PM the Social Service Director, stated she does not send a bed hold notice if they are not above 90 % capacity. On 04/04/23 at 2:48 PM Corporate Business Development #79 verified both a bed hold policy should have been sent with…

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, medical record review and staff interview, the facility failed to implement comprehensive person-centered care plans for residents with wounds. In addition, the facility failed to include in the care plan the side effects of psychotropic medications which staff should watch for. This was found for one (1) of five (5) residents reviewed for unnecessary medications, one (1) of two (2) reviewed for pressure ulcers and one (1) of one (1) reviewed for wounds. Resident identifiers: #23, #17 and #43. Facility census: 60. Findings include: a) Resident (R) #23 Review of the medical record on 04/03/23, revealed R#23 developed an in house pressure ulcer on his coccyx on 02/15/22. The skin and wound evaluation forms dated 11/11/22 states there is a Stage 2 pressure ulcer with partial thickness skin loss, exposed dermis, and 80% epithelial tissue in the wound on the sacrum. The medical record lacks any weekly wound assessments until surveyor intervention on 04/03/23. A wound assessment dated [DATE]…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on medical record review and staff interview, the facility failed to ensure residents receive treatment and care in accordance with professional standards of practice. Resident #38's antibiotics were not given as ordered, Resident #17's wound changes were not documented, Vancomycin trough levels were not drawn correctly causing a resident to miss his antibiotic and a resident was allowed to self administer a medication without a physician's order. These findings are true for one (1) of one (1) residents reviewed for wounds and one (1) of two (2) residents reviewed for infections. The remainder were random opportunities for discovery. Resident identifiers: #38, #63, #17 and #45. Facility census: 60. Findings include: a) Resident (R) #38 On 04/04/23 at 3:39 PM, a medical record review displayed the following physician order with a start date of 02/10/23, Cefdinir Capsule 300 MG Give 1 capsule by mouth two times a day for right pleural effusion for 7 Days. The Medication Administration Record (MAR), 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 Nurse Aides (NA) were able to demonstrate competencies on an annual basis. This was true for four (4) of five (5) nurse aides reviewed for staffing during the Long-Term Survey Process (LTCSP). Staff Identifiers: Nurse Aide (NA) #50,#35, #42, and #52. Facility census: 60. Findings included: a) Staff Competencies A facility records review revealed NA #50, NA #35, NA #42, and NA #52 did not receive their 12-month Competency review. During an interview on 04/06/23 at 2:51 PM the Corporate Administrator confirmed there were no annual competency / skills check completed for NA #50, NA #35, NA #42, and NA #52. He stated the NA evaluations were something the facility was working on getting completed. .

Based on record review and staff interview the facility failed to complete yearly performance evaluation for all Nurse Aides (NA). This was true for five (5) of five (5) nurse aides reviewed for staffing during the Long-Term Survey Process (LTCSP). Employee Identifiers: Nurse Aide (NA) #50, #35, #42, #2, amd NA #52. Facility census: 60. Findings included: a) Facility NA's Annual Evaluations A facility records review revealed NA #50, NA #35, NA #42, NA #2, and NA #52 did not receive their 12-month evaluation. During an interview on 04/06/23 at 2:51 PM the Corporate Administrator confirmed there were no annual evaluations completed for NA #50, NA #35, NA #42, NA #2, and NA #52. He stated NA evaluations were something the facility was working on getting completed. .

The facility failed to ensure the daily nurse staff posting was completed accurately for three (3) days throughout the long-term care survey process. This was a random opportunity for discovery and has the potential to affect all residents currently residing in the facility. Facility census: #60. Findings included: a) Nurse Staff Posting An observation on 04/03/23, 04/04/23, and 04/05/23 of the facility posted staffing data, found the required Resident census was not documented. During an interview on 04/06/23 at 10:08 AM the Administrator verified the census was not documented. She stated she would add the census now. .

Based on observation, record review and staff interview, the facility failed to ensure prescribed medications were available to be administered as ordered and staff failed to document the administration of controlled substances in the narcotic drug count book at the time of disposition. This is true for one (1) of five (5) residents and one (1) of two (2) nurses observed during medication administration. Resident identifiers: #15, #18, and #37. Facility census: 60. Findings include: a) Resident (R) #15 A medication administration observation was conducted with Registered Nurse (RN) #76 on 04/04/23 at 9:10 AM. RN #76 reported, R#15's Dorzolamide HCL eye drops (for glaucoma) were not available for administration. A medical record review on 04/05/23 confirmed R#15 missed one of two daily prescribed doses of Dorzolamide HCL eye drops. The nurse documented the medication was not available. b) Narcotic Administration Medication observations with RN #76 on 04/04/23, revealed the following: --At 8:44 AM RN #76 administered Gabapentin 400 milligrams (mg) (a Schedule V controlled substance)…

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 physician responded to monthly drug regimen reviews. This was true for four (4) of five (5) reviewed for unnecessary medications. Resident identifier #1, #51, #43 and #36. Facility census: 60. Findings included: a) Resident #1 A medical record review for Resident #1 revealed the following monthly drug regimen reviews unsigned or responded to by the physician. --09/28/22 Recommendation to initate Senna 8.2 MG two tablets once daily at bed time due to opioid analgesic use. --09/28/22 Recommendation to reevaluate the three or more Central Nervous System (CNS) depressants. --03/13/23 Recommendation clarify the as needed analgesic order to include Pain, Site, and sequence. -03/13/23 Recommendation potential drug -drug interaction -03/28/23 Recommendation to initate Senna 8.2 MG. During an interview on 04/11/23 at 11:02 AM Corporate Administrator #77 verified the physician or the DON did not sign all recommendations or follow up timely. b) Resident #51 A medical record review for Resident #51 revealed the…

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

Based on medical record review and staff interview, the facility failed to monitor residents for side effects of psychotropic medications. This is true for three (3) of five (5) residents reviewed for unnecessary medications. Resident identifiers: #43, #36, #51. Facility census: 60. Findings include: a) Resident (R) #43 Review of the medical record on 04/11/23, revealed R#43's diagnoses included Alzheimer's disease, dementia with agitation, anxiety and wandering. Her current medications include: --Clonazepam (benzodiazepine used for panic disorders and mania) 0.5 milligrams (mg) twice a day for restlessness, agitation, repetitive chatter and cursing --Risperidone (atypical antipsychotic) 1 mg twice a day for dementia with behavioral disturbance pacing, aggression, agitation, and repetitive chatter --Trazodone hydrochloride (antidepressant) 75 mg at bedtime for depression The pharmacist's monthly medication regimen review (MMR) dated 01/23/23, notes R#43 receives Risperdal which may cause involuntary movements including tardive dyskinesia. An Abnormal Involuntary Movement Scale…

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 provide food services in accordance with professional standards. The facility failed to ensure food was labeled and dated, domed lids were visibly stained / whitened with what the Food Service Director identified as lime / calcium buildup, a ceiling vent was covered in dust, and various repairs were needed. This practice had the potential to affect more than a limited number of residents. Facility census: 60. Findings included: a) Tour of the Kitchen and the Nourishment Room on the Blue Hall. During an initial tour of the kitchen on 04/03/23 at 10:10 AM with the Food Service Director, the following issues were identified: -There were two (2) two-pound clear bags of what was identified as [NAME] Crispy cereal that was unlabeled. There was also a third bag of what was identified as [NAME] Crispy cereal that was unlabeled and with approximately 1/4 of the bag remaining. The Food Service Director acknowledged the dietary staff failed to follow protocol when they did not label the food. -One (1) of four (4) ceiling vents…

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 Medical Director attended quarterly Quality Assurance and Performance Improvement Committee Meetings (QAPI). This has the potential to affect more than a limited number of residents currently residing in the facility. Facility census: 60. Findings included: a) QAPI meetings A facility record review on 04/05/23 at 10:21 AM of QAPI committee meeting sign-in sheet revealed the Medical Director did not attend any meetings from 06/2022 until 03/28/23. During an Interview on 04/05/23 at 10:41 AM the Administrator verified the Medical Director did not attend quarterly QAPI meetings as required. .

Based on observation, staff interview and policy review, the facility failed to establish and maintain an effective infection prevention and control program designed to prevent the development and transmission of communicable diseases and infections. Staff failed to perform adequate hand hygiene and used their thumb nail to open pill blisters during medication pass. Gloves were not changed timely during wound care. Bed pans were not covered and labeled. A food cart was in disrepair and a resident consumed the remainder of another resident's lunch. This is true for one (1) of two (2) nurses observed during medication administration, one (1) of one (1) observed for wound care and one (1) of three (3) food carts. The remainder were random opportunities for discovery. Resident identifier: #18, #15, #35, #23, and #11. Facility census: 60. Findings include: a) Resident #35 On 04/03/23 at 12:04 PM, Resident #35 finished eating his meal and stood up in the dining room. He walked over to the sink and washed his hands. When finished, he sat back down at a different table. He sat in Resident…

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

Based on observation and staff interview, the facility failed to provide care to residents in a manner that promoted the right to a dignified existence and failed to protect a residents privacy during care. These were random opportunities for discovery. Resident identifier: #43 and #23. Facility census: 60. Findings included: a) Resident #43 On 04/03/23 at 11:50 AM, Resident #43 was observed asleep in the television room/day room of the memory care unit. Readily visible was an uncovered urinary catheter leg bag hanging below Resident's left pants leg. The urinary catheter bag had no covering, and it was instantly noticeable the bag was approximately 1/3 full of urine. On 04/03/23 at 12:00 PM, Resident #43 was escorted into the dining room by staff for the lunch time meal. Resident #43 was seated in the dining room with approximately 15 other residents. During an interview on 04/03/23 at 12:24 PM, Licensed Practical Nurse (LPN) #78 agreed the noticeably visible urinary catheter bag should have been identified as a dignity issue and addressed prior to them being escorted into the…

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

Based on record review and staff interview, the facility failed to report incidents resulting in serious bodily injury in a timely manner to the appropriate state agencies. This was true for one (1) of three (3) residents reviewed for falls and one (1) of six (6) residents reviewed for accidents during the Long-Term Care Survey Process. Resident identifiers: #51 and #11. Facility census: 60. Findings included: a) Resident #51 A record review, completed on 04/05/23 at 9:30 AM, revealed the following details: -Resident #51 experienced a fall on 01/16/23 and was sent to the hospital. -A General nursing note, on 01/17/23 at 8:20 AM, noted Patient returned from hospital with 12 sutures to wound to scalp. -The facility's reportables log did not reflect the incident had been reported to the appropriate state agencies. During an interview on 04/05/23 at 10:38 AM, Social Worker #44 stated the fall resulting in 12 sutures to Resident #51's scalp had not been reported as a fall with serious bodily injury. Social Worker #44 explained the facility had been using different guidelines at that time…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on medical record review and staff interview, the facility failed to complete an accurate comprehensive assessment for one (1) of two (2) residents reviewed for pressure ulcers. The comprehensive assessment does not identify Resident #23's pressure ulcer. This is true for one (1) of two (2) residents reviewed for pressure ulcers. Resident identifier: #23. Facility census: 60. Findings include: a) Resident (R) #23 Review of the medical record on 04/03/23, revealed R#23 developed an in house acquired pressure ulcer on his coccyx on 02/15/22. The skin and wound evaluation forms dated 11/11/22 states there is a Stage 2 pressure ulcer with partial thickness skin loss, exposed dermis, and 80% epithelial tissue in the wound on the sacrum. The medical record lacks weekly wound assessments until surveyor intervention on 04/03/23. A wound assessment dated [DATE] notes the Stage 2 pressure ulcer on the sacrum remains. The comprehensive minimum data set (MDS) assessment with an assessment reference date (ARD) of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on medical record review and staff interview, the facility staff failed to accurately complete the significant change comprehensive assessment for a resident with a pressure ulcer. This is true for one (1) of two (2) reviewed for pressure ulcers. Resident identifiers: 23. Facility census: 60. Findings include: a) Review of the medical record on 04/03/23, revealed R#23 developed an in house acquired pressure ulcer on his coccyx on 02/15/22. The skin and wound evaluation forms dated 11/11/22 states there is a Stage 2 pressure ulcer with partial thickness skin loss, exposed dermis, and 80% epithelial tissue in the wound on the sacrum. The medical record lacks weekly wound assessments until surveyor intervention on 04/03/23. A wound assessment dated [DATE] notes the Stage 2 pressure ulcer on the sacrum remains. The quarterly minimum data set assessments (MDS) with assessment reference dates (ARD) of 09/13/22 and 12/08/22 are coded incorrectly under section M0210 and fail to identify R#23's pressure ulcer.…

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 #55's care plan to reflect a change in nutritional status. This is true for one (1) of six (6) residents reviewed for the care area of nutrition. Resident identifier: #55. Facility census: 60. Findings included: a) Resident (R) #55 A review of the medical record on 04/11/23 revealed an active diagnosis of Adult Failure to Thrive (AFTT) on R#55's quarterly minimum data set (MDS) assessment with an assessment reference date (ARD) of 02/10/23. R#55's last weight was 134.5 pounds. The care plan identifies the diagnosis of AFTT, but was not updated to reflect this change. The nutritional Focus states Resident has low risk for decline in nutritional status with weight loss. The goals include meal consumption of greater than 75% of three (3) meals a day and maintain a weight of 150 to 160 pounds. The care plan lacks measurable goals and intervention for R#55's AFTT diagnosis. On 04/11/23 at 9:25 AM, R#55's record was reviewed with Registered Nurse Consultant #83 and the Senior Nursing Home…

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 assess pressure ulcers weekly to promote the healing of pressure areas. This was true for two (2) of two (2) residents reviewed for pressure areas. Resident identifiers #46 and #23. Facility census 60. Findings Included: a) Resident #46 A medical record review for Resident #46 revealed the following physician orders: -- Apply HYDRA Guard two times a day and as needed to sacrum to maintain skin integrity every day and night shift for to maintain skin integrity. -- Wash coccyx/buttocks with wound wash, pat dry. Apply foam dressing. Change every other day and as needed as soiled every night shift every two 2 day(s) for wound healing. -- Apply skin prep to bilateral heels and ensure that heels are offloaded. Monitor skin for any changes to skin integrity. Continued review of Resident #46's medical record found the following Care plan: Focus: Resident #46 is at risk for skin breakdown related to impaired cognition, impaired mobility, incontinence,…

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 each resident was afforded the amount of supervision required to prevent accidents during the lunch time hour. This was true for one (1) of three (3) residents reviewed for falls in the Long-Term Care Survey process. Resident identifier: #42. Facility census: 60. a) Resident #42 Review of the facility matrix, on 04/03/23 at 10:43 AM, revealed Resident #43 had a history of falls with injury. Review of the physician orders, on 04/03/23 at 10:44 AM, found the following order, Nonskid footwear for resident safety as resident allows which was given on 04/19/21. Review of Resident #42's care plan, on 04/03/23 at 10:45 AM, found the following focus area: [Resident's First Name] is at risk for falls: cognitive loss, lack of safety awareness, hx [history] of falls with injury. An intervention associated with the focus area was listed as: Encourage nonskid shoes when out of bed. A dining room observation, on 04/03/23 at 12:12 PM, revealed: -11 residents were in the dining room eating. -CNA #34 was the only…

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

Based on record review and staff interview, the facility failed to maintain a complete and accurate medical record for one (1) of 24 sampled residents during the Long-Term Care Survey Process. Specifically, the facility failed to accurately accept verbal consent on a Physician Orders for Scope of Treatment (POST) form by using only one (1) witness to the consent. Resident identifiers: #43. Facility census: 60. Findings Included: a) Resident #43 A medical record review, completed on 04/03/23 at 1:52 PM, revealed the following details: -There was a Physician Orders for Scope of Treatment (POST) form on file for Resident #43. - Liscensed Practical Nurse (LPN) #46 had accepted verbal consent from Resident #43's Health Care Surrogate (HCS). The verbal consent was accepted on 11/22/22. LPN #46 was the only witness to the verbal consent. Review of instructions on how to complete the POST form from Using the POST Form: Guidance for Healthcare Professionals 2021 Edition, page 20, outlined: If the incapacitated patient's MPOA [Medical Power of Attorney] representative or Health Care Surrogate…

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.