Majestic Care of Hopemont

Based on observation, record review and staff interviews, the facility failed to ensure care was promoted in a manner that maintained or enhanced the resident's dignity and respect during the dining experience. This failed practice had the potential to affect more than a limited number of residents. Resident Identifiers: #18 and #24. Facility Census: 47.Findings included:a) Resident #18On 02/16/2026, Resident #18 was served by the staff,. The resident requested silverware from the State Surveyor as he was attempting to use his table mates dirty soiled napkin. The resident was served a piece of whole chicken breast and a salad. Nurse Aide #60 confirmed the resident did not receive silverware and got a black plastic spoon for the resident to use. Resident #24 was observed eating his lunch meal with plastic silverware.The resident's desserts were served in plastic bags and not on a regular dessert plate. On 02/16/2026 at 12:33 PM, the Administrator confirmed the desserts were served in a plastic bag.On 02/16/2026, during the initial dining room investigation, the State Surveyor…

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 interviews, the facility failed to monitor, evaluate and document restraints for residents. This was discovered during the Long Term Survey Process and had the ability to effect more than a limited number of residents. Resident Identifier: #6. Facility census: 47. Findings Include: a) Resident #6 On 02/16/2026 at approximatley 4:00 PM a record review was done on Resident #6. The record review revealed it stated that Resident #6 had a diagnosis of Huntington's Disease. This disease can limit a person's functional status and control of limbs. For Resident #6 safety they had orders to have a wheel chair restraint belt on while in a wheel chair at all times. Resident #6 also had orders for limb restraint for Inter-Muscular (IM) Injections, due to the disease process making it hard to stay still during these procedures. The orders from the medical record were as follows: Broda Chair with quick release pelvic restraints while out of bed to maintain optimal upright position. Monitor Q 30 minutes and release Q 2 hours x 15 minutes for ROM, toileting and…

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

Based on staff interview and documentation review the Facility failed to complete [NAME] Virginia Pre-admission Screening with new diagnosis of Major Depressive Disorder. This is true for Resident #3. Facility Census 47. Findings Included:a) Resident #3 On 02/16/26, a review wascompleted of a document titled [NAME] Virginia Department of Health and Human Resources Pre-admission Screening (PAS) dated for 11/13/24. For Resident #3, on Question #30 the answer was marked a. None. Upon Review of Resident #3's diagnosis list, resident was diagnosed with Major Depressive Disorder, Recurrent, Moderate on 11/15/24. Interview with Administrator on 02/17/26 at 5:25 PM who acknowledged Resident #3 did not have a new PAS did not contain his new diagnosis of Major Depressive Disorder.

Based on observation, record review and staff interview, the facility failed to provide a well -balanced diet taking into consideration preferences. The failed practice had the potential to affect a limited number of residents. Resident Identifier: #30. Facility Census: 47. Findings included: a) Resident #30 Resident #30's diet order stated, Consistent Carbohydrate, Regular, Thin, and no added salt, no beef or pork ,yogurt at Breakfast and Lunch.: On 02/17/2026 at 12:31 PM, [NAME] #98 served the resident ham on her tray. Following state surveyor intervention, Dietary Aide #97 removed Resident #30's tray from delivery cart and confirmed the tray card stated food allergy for milk and no beef or pork. [NAME] #98 stated, I ain't got anything .only pork. and It depends on her mood. - referring to if the resident eats pork or not. The resident received a peanut butter and jelly sandwich. The facility does not provide an alternate menu, but resident's can choose something from the always available menu according to Account Manager #91.

Based on observation, record review, staff interview and resident interview, the facilitate failed to ensure the resident received food that accommodated allergies, intolerances and preferences. This failed practice had the potential to affect a limited number of residents. Resident Identifier: #30. Facility Census: 47. Findings included: a) Resident #30's diet order stated, Consistent Carbohydrate, Regular, Thin, and no added salt, no beef or pork ,yogurt at Breakfast and Lunch. On 02/17/26 at 12:31 PM, [NAME] #98 served the resident ham on her tray. Following state surveyor intervention, Dietary Aide #97 removed Resident #30's tray from delivery cart and confirmed the tray card stated food allergy for milk and no beef or pork. [NAME] #98 stated, I ain't got anything .only pork. and It depends on her mood. - referring to if the resident eats pork or not. The resident received a peanut butter and jelly sandwich. The facility does not provide an alternate menu, but resident's can choose something from the always available menu according to Account Manager #91. On 02/16/2026 at 12:50,…

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

Based on observation and staff interviews, the facility failed to follow prescribed dietary order for liquid consistency for the residents. Resident identifier: #4. Facility census: 47. Findings Include: a) Resident #4 On 02/16/26 at approximately 12:00 PM a meal tray was delivered to Resident #4 room. It was placed down and when opened the tray was observed to contain the following:Tray contained Full chicken breast (not cut up and not diet appropriate)Polenta Summer squash was missing and was subbed w/ spinach (not diet appropriate)Roll (not diet appropriate)Malt vinegar - missingMargarine - missingChocolate pudding was missing and subbed out w/ brownie CoffeeSoy milk The Residents diet was Minced and moist with nectar thick liquids. This was a requirement per Speech therapy #77, who confirmed Resident #4 was a high aspiration risk and pocketed their food. This tray was delivered by LPN #21 and when called back into the room to confirm the contents did not meet the prescribed dietary requirements, she stated that The chicken should not have been a whole piece, should be shredded.…

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 a resident with an assistive device during meals by not providing nosey cup. This was a random opportunity for discovery. Resident identifierz: #6. Facility Census: 47. Findings Included:a) Resident #6 On 02/17/26 at approximately 12:50 PM, Resident #6 was observed dining in the dining room with assistance from Nurse Aide #74. Observation of Resident #6's tray card revealed he was to have one nosey cup, not present on his tray. He did have cold tea, orange juice and and milk all served in regular clear plastic cups. An interview with Nurse Aide #74 was conducted 02/17/26 at 12:55 PM revealed they were not familiar with a nosey cup and these were the cups that resident normally used at meals. Review of Care Plan for Resident #6 stated the following: Focus: Resident presented with potential for nutritional risk related to diagnosis major depressive disorder, vitamin D deficiency. Receiving a mechanically altered diet with thickened liquids to ease chewing/swallowing concerns secondary to dx of Huntington's…

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

Based on record review and staff interview the Facility failed to provide accurate documentation by listing inaccurate diagnosis of Post Traumatic Stress Disorder for a resident. This was a random opportunity for discovery. Resident Identifier: #1. Facility census: 47. Findings included: a) Resident #1 On 02/16/26 during documentation review, it was observed that Resident #1 had a diagnosis of Post Traumatic Stress Disorder (PTSD) onset of 09/7/23 on his diagnosis list. Upon further review of his records, this diagnosis nor treatment for said diagnosis could be found. An interview with Social Services Director (SSD) on 02/17/26 at 4:11 PM revealed the diagnosis had been taken off the Matrix and Minimum Data Set (MDS) assessment per suggestion of their corporate MDS coordinator due to lack of proof resident had this diagnosis. SSD reported Resident #1's intake information nor in-house diagnostic information suggested Resident #1 had a diagnosis of PTSD. An interview with Administrator on 02/18/26 at approximately 2:00 PM, he relayed per the facility's Corporate MDS Coordinator, the…

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

Based on observation, and staff interview, the facility failed to provide food at a palatable and appetizing temperature as determined by the type of food to ensure resident satisfaction. This failed practice had the potential to affect more than a limited number of residents. Facility Census: 51. Findingd included: a) A tray on A-Hall was tested by DM #100 and temperatures were as follows: Pureed Pork - 122 degrees Mashed Potatoes - 126 degrees Pureed Peas - 102 degrees Pureed Bread - 100 degrees b) Temperatures were confirmed by DM #100. DM #100 reported pork should have been at 130 degrees and the vegetable's temperature was low. DM #100 stated the bread could be served hot or cold. The facility's Policy and Procedure stated, Hot foods will be served at a temperature 120 degrees F or higher. These findings confirmed by Dietary Manager (DM) #100 on 11/19/24 at 12:25 PM.

Based on observation, record review and staff interview, the facility failed to store and label food in accordance with professional standards for food service safety. This failed practice had the potential to affect more than a limited number of residents. Facility Census: 51. Findings included: Findings confirmed by the Dietary Manager (DM) #100 and the Chief Operating Officer (COO) #35 on 11/18/24 during the investigation initiated at 11:42 AM included the following items in the pantry: a) An opened can of Shasta. b) Undated sandwiches in fold over bags. c) Unlabeled and undated drink in a cup -tea. d) Undated bowl of broth. e) Opened and used container of Boost in the freezer. f) Undated hamburger in the freezer. g) Undated package of lasagna in freezer. DM #100 asked, Is that me? and stated, I'm going to throw it away. COO #35 stated the refrigerators were the dietary department's responsibility. According to the 2013 US Publilc Health Service Food and Durg Administration Food Code: 3-202.15 Package Integrity: Food packages shall be in good condition and protect the integrity…

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

Based on record review and staff interview, the facility failed to ensure that an alleged violation involving resident-to-resident sexual abuse was reported within two (2) hours of the event/allegation being brought to the facility's attention, to appropriate state agencies as required. This was a random opportunity for discovery throughout the facility reportable incident (FRI) investigative process. Resident identifier: #48. Facility census: 51. Findings included: a) Resident #48 During a record review, on 11/19/24 at 7:30 PM, it was noted there was a written reporting form outlining a resident-to-resident sexual altercation between Resident #48 and Resident #8. There was no evidence that the Office of Health Facility Licensure and Certification (OHFLAC) had been notified of this incident within the required two (2) hour time frame. On 11/20/24 at 8:30 AM, a review of the facility's Abuse and Neglect policy revealed that an allegation must be reported within (2) hours if it involved abuse During an interview on 11/20/24 at approximately 9:00 AM, the Chief Operating Officer…

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 facility record review and staff interview the facility failed to use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week. This was true for two (2) of five (5) days identified during the long-term care survey process. This had the ability to affect all the residents. Facility census: 49. Findings included: a) 05/28/23 On 05/29/24 at approximately 11:00 AM during a review of the facilities payroll transaction report of all direct care hours for 05/28/23, no direct care Registered Nurse (RN) hours were identified for 05/28/23. On 05/29/24 at approximately 11:05 AM during a further review of the facility Nursing Staff Information Sheet (also known as the Nursing Staffing Posting form), the total number of Registered Nurse staff for 05/28/23 was handwritten in at one (1) and the total number of hours for the Registered Nurse Staff hours was also handwritten in at eight (8). During an interview with the Director of Nursing (DON) on 05/29/24 at approximately 12:15 PM, he stated he had found an agency Timesheet for Agency RN #95 and that he…

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

Based on facility record review and staff interview the facility failed to conduct and document a complete facility-wide assessment to determine what resources were necessary to care for its residents competently during both day-to-day operations and emergencies. The facility did not assess the physical environment, equipment, services, and other physical plant considerations that are necessary to care for the resident population. This was a random opportunity for discovery during the long-term care survey. Census: 49. Findings included: a) Gas leak On 05/29/24 at approximately 11:30 AM during a review of the facility assessment revealed on Page 14 under number 3.12 to provide your facility-based and community-based risk assessment, utilizing an all-hazards approach (an integrated approach focusing on capacities and capabilities critical to preparedness for a full spectrum of emergencies and natural disasters). It was further identified on Page 24 of the facility assessment that the following were the identified facility risks and or community risks/disasters listed that have 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 resident observation, record review and staff interview, the facility failed to ensure the resident and or representative was informed in advance by the physician, other practitioner or health professional of the risks and benefits of proposed care, of treatment alternatives or treatment options and to choose the alternative option preferred. This was true for 1 (one) of 18 residents reviewed in the Long-Term Care Survey Process. Resident identifier: #36. Facility census: 49. Findings include: a) Resident #36 On 05/28/24 at 12:30 AM, a review of Resident #36's medical record was conducted. A fall care plan was noted with interventions stating, Encourage resident to wear hipsters at all times for safety. and Encourage resident to wear soft helmet while ambulating for safety. On 05/28/24 at 01:07 PM an observation of Resident #36 was conducted. Resident #36 was noted to be in bed, no hipsters were noted to be on Resident #36 and no helmet was noted to be present. On 5/29/24 at 11:25 AM an interview with Employee #72 was conducted. Employee #72 stated, He refuses to wear 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 resident council meeting interviews, observation and staff interview the facility failed to ensure residents were able to submit grievances anonymously. This had the potential to affect more than an isolated number of residents. Facility census: 49. Findings included: a) 05/28/24 12:30 PM, Observed a sign in the front lobby stating there were grievance forms available at the front desk. 05/29/24 10:45 AM, During resident council meeting, Resident #24 stated in order to file a grievance residents and family must ask for a form at the front desk. She stated that staff will assist residents in filing out the paper. Resident #24 stated there was no place to get the forms anonymously or to submit them anonymously. 05/29/24 11:12 AM during an interview with Social Worker (SW) #9 the SW explained that the process of completing a grievance was to ask a staff member for a form and that she or other staff would assist in completing the form if asked. She stated there was no place to get a form anonymously and/or submit it anonymously.

Based on record review, resident observation and staff interview the facility failed to ensure that the comprehensive care plan is reviewed and revised by an interdisciplinary team composed of individuals who have knowledge of the resident and his/her needs.This was true for 3 (three) of 18 residents reviewed during the Long Term Care Survey Process. Resident identifiers: Resident #36, Resident #25 and Resident #45. Facility census: 49. Findings Include: Resident #36 On 05/28/24 at 12:30 AM, a review of Resident #36 ' s medical record was conducted. A fall care plan was noted with interventions stating, Encourage resident to wear hipsters at all times for safety. and Encourage resident to wear soft helmet while ambulating for safety. On 05/28/24 at 01:07 PM an observation of Resident #36 was conducted. Resident #36 was noted to be in bed, no hipsters were noted to be on Resident #36 and no helmet was noted to be present. A further review of Resident #36 ' s medical record was conducted on 05/28/24 at approximately 01:25 PM, which noted Resident #36 had 19 documented falls from…

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 residents received treatment and care in accordance with professional standards of practice which would allow the residents to achieve their highest practicable physical, mental, and psychosocial well-being. This was true for two (2) out of four (4) residents reviewed for restorative nursing services. Resident identifiers: #5 and #37. Facility census: 49. Findings included: a) Resident #5 Record review on 05/30/24 at 11:51 AM, revealed that Resident #5's physician had prescribed Range of Motion (ROM)/stretching protocol global 1 (one) time daily, up to 5 (five) times a week for contracture management on 12/15/21. During an interview on 05/30/24 at 10:46 AM, Physical Therapist (PT) #15 and PT # 22 , and also confirmed by record review, revealed the resident received twelve (12) treatments out of a prescribed twenty-five (25) treatments, during the period 04/01/24 to 04/31/24. b) Resident #37 Record review for Resident #37 revealed that his physician had prescribed Moist Heat to L LE (Left Lower Extremity) and…

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

Based on record review, staff interview and resident observation the facility failed to provide supervision, implementation, monitoring and modifying of interventions to prevent avoidable accidents. This was true for 2 (two) of 7 (seven) residents reviewed during the Long-Term Care Survey Process. Resident identifiers: Resident #36 and Resident #25. Facility census: 49. Findings include: a) Resident #36 On 05/28/24 at 12:30 PM, a review of Resident #36 ' s medical record was conducted. A fall care plan was noted with interventions stating, Encourage resident to wear hipsters at all times for safety. Encourage resident to wear soft helmet while ambulating for safety. On 05/28/24 at 1:07 PM an observation of Resident #36 was conducted. Resident #36 was noted to be in bed, no hipsters were noted to be on Resident #36 and no helmet was noted to be present. A further review of Resident #36's medical record was conducted on 05/28/24 at approximately 1:25 PM, which noted Resident #36 had 19 documented falls from 01/01/24 through 05/26/24. The falls occurred on: 01/15/24, 01/22/24,…

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 facility record review and staff interview the facility failed to provide the accurate data on the nurse staffing information form. The daily census was not accurate for 4 of 5 daily of the nurse staffing information forms reviewed during the long-term care process. This issue had the ability to affect more than a limited number of residents. Census: 49. Findings included: The facilities available and occupied beds report review on 05/29/24 at 11:00 AM revealed the following: a) 05/28/23 On 05/28/23 the daily census was identified to be 46 and the staffing posting form was a handwritten census of 49. b) 07/05/23 On 07/05/23 the daily census was identified to be 47 and the staffing posting form was a handwritten census of 48. c) 01/01/24 On 01/01/24 the daily census was identified to be 43 and the staffing posting form was a handwritten census of 44. d) 05/27/24 On 05/27/24 the daily census was identified to be 49 and the staffing posting form was a handwritten census of 50. During an interview with the Director of Nursing (DON) on 05/29/24 at approximately 12:20 PM, he…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, the facility failed to ensure behavior monitoring and medication side effect monitoring was documented for a resident receiving psychotropic meds. This deficient practice affected one (1) of five (5) residents reviewed for the care area of unnecessary medications. Resident identifier: #12. Facility census: 49. Resident identifier: a) Resident #12 Review of the facility's policy titled Behavioral Assessment, Intervention, and Monitoring with no implementation date specified, stated the following: - If a resident was being treated for altered behavior and mood, the Interdisciplinary Team (IDT) would document any improvements or worsening in the resident's behavior, mood, and function. - The IDT would monitor for side-effects related to psychoactive medications. Review of Resident #12's medical records showed the resident had been admitted to the facility on [DATE]. Resident #12 had diagnoses of anxiety, depression, and mood disorder. The resident was prescribed the…

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

Based on observation and staff interview the facility failed to provide hand washing to residents on B hall before their lunch meal. Resident #33 had a pool noodle type piped foam taped around the head and foot board of the bed. This foam could not be effectively cleaned. These practices were random opportunities for discovery during the Long-Term Care Survey Process. Facility Census: 49. Findings included: a) B-hall An observation on 05/29/24 at 12:35 PM, revealed (7) seven lunch trays were passed on B hall with no hand hygiene provided. During an interview on 05/29/24 at 12:35 PM, with Nurse Aide (NA) #29 she stated, I'll be honest, we normally don't do it on the hallway. We do in the dining room but not on the hallway During an interview on 05/29/24 at 1:30 PM, with The Director of Nursing (DON) he confirmed that handwashing should be completed with residents before they receive their tray. b) Resident #33 05/29/24 at 1:38 PM during a tour of resident room the black pipe foam that resembled a pool noodle was seen to be tapped with black tape along the headboard and the foot board…

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 observation the facility failed to provide a dignified dining service. This failed practice was found true for (1) one random resident observed during the lunch dining in the Long-Term Care Survey Process. Resident identifier #44. Facility Census 49. Findings Include: a) Resident #44 During an observation on 05/29/24 at 12:15 PM, Resident #44 was sitting at a table with (3) three other residents. The other (3) three residents got their lunch tray at 12:15PM. (9) nine other residents at different tables were served before Resident #44 received her lunch tray at 12:25 PM. Further observation showed that (1) one of the residents seated at the table with Resident #44 was finished eating when Resident # 44 got her lunch tray. During an interview, on 05/29/24 at 12:25 PM, with Nurse aide (NA) #87 she stated, We are supposed to pass them out in order, but they don't come out in order. We must find them. We have not come to [Resident # 44 name} tray yet.

Based on staff interview and facility documentation, the facility failed to provide reasonable accommodation in regard to activities of daily living (ADLs). This was true for one (1) of eighteen (18) residents reviewed under the ADL pathway. Resident identifier: #43. Facility Census: 49 Findings included: a) Gas Leak Resulting in No Hot Water Facility staff had reported signs of a gas leak on 05/26/24. The gas company technician had noted a positive test for gas in the kitchen area, and, as a precaution, recommended turning off the gas supply to the facility. As a result, no hot water had been available for the residents since 05/26/24. a) Resident #43 During staff interviews on 05/30/24 at 11:03 AM, with Nurse Aide (NA) #29, Registered Nurse (RN) #83 and Licensed Practical Nurse (LPN) #73, stated the bath wipes used for bed baths were to be warmed for 20 seconds in a microwave before being used on residents. However, staff were unable to warm the bath wipes because the microwave ovens had been removed due to safety concerns. This resulted in residents being wiped down with cold…

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 resident interview the facility failed to provide a homelike environment by not allowing Resident # 29 access to his personal belongings by his own freewill. Resident #33's room had personal health information taped on the bed and had cosmetic imperfections that could pose a safety hazzard in the bathroom. This failed practice was found true for two (2) of two (2) residents reviewed for environment during the Long-Term Care Survey Process. Resident identifiers: #29, #33. Facility Census: 49. Findings Include: a) Resident # 29 During the initial interview on 05/28/24 at 1:46 PM, Resident # 29 stated, I want stuff out of my closet, and I can't get to it because there is a lock on it. When surveyor asked if he had a key to it Resident #29 stated, No, the nurse or NA has it and I have to have them come and unlock. It takes them a long time. A record review on 05/28/24 at 2:00 PM revealed that Resident # 29 has a Brief Interview of Mental Status (BIMS) score of 14. During an interview, on 05/28/24 at 3:30 PM, the Administrator stated, I'm sure…

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, in response to allegations of abuse, the facility failed to have evidence that all alleged violations are thoroughly investigated. This was true for 1 (one) of 7 (seven) residents reviewed in the Long Term Care Survey Process. Resident identifier: Resident #25. Facility census: 49. Findings include: Resident #25 On 05/29/24 at 09:00 PM, a review of Facility Reported Incident (FRI) dated 05/16/24, was conducted. It was reported on 05/16/24 that on 05/15/24 at 10:00 PM, while facility staff was providing care to Resident #25, a 10cm x 5cm bruise, right upper thigh was noted and that it was estimated to be approximately 2-3 days old. A review of the facility ' s investigation noted that statements were obtained from 12 from staff members. However upon reviewing the statements obtained it was noted that 7 (seven) of the 12 statements were from employees not working on the unit at the time of the occurrence. At that time this Surveyor requested a copy of the schedule from the date and time of the occurrence. It was then noted that statements…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, the facility failed to ensure a complete and accurate Preadmission Screening and Resident Review (PASRR) and failed to complete a new PASRR when a PASRR expired. This deficient practice had the potential to affect two (2) of two (2) residents reviewed for the care area of PASRR. Resident identifiers: #27 and #41. Facility census: 49. Findings included: a) Resident #27 Review of Resident 27's medical records showed the resident was admitted on [DATE]. The resident had a diagnosis of unspecified psychosis not due to a substance or known physiological condition at the time of admission to the facility. Resident #27 had been transferred from another long-term care facility who documented that the resident had a diagnosis of psychosis. Further review of Resident #27's medical records showed a PASSR completed [DATE]. The PASSR did not indicate the resident had a diagnosis of psychotic disorder. On [DATE] at 2:00 PM, Social Worker #65 confirmed Resident #27's admission PASSR…

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

Based on staff interview and facility documentation, the facility failed to provide accurate and complete medical records in regard to activities of daily living (ADLs). This was true for one (1) of eighteen (18) residents reviewed under the ADL pathway. Resident identifier: #43. Facility Census: 49 Findings included: a) Gas Leak Resulting in No Hot Water Facility staff had reported signs of a gas leak on 05/26/24. The gas company technician had noted a positive test for gas in the kitchen area, and, as a precaution, recommended turning off the gas supply to the facility. As a result, no hot water had been available for the residents since 05/26/24. a) Resident #43 During a review of Bath/Shower Temperature Logs at the nursing station on 05/30/24 at 11:17 AM, RN #83 and LPN #73 showed a shower being completed for Resident #43 on the evening of 05/26/24. Submission of a request for Bath/Shower Temperature Logs completed on 05/30/24 at 11:17 AM. These logs revealed no completed sheets. Upon interview with the Director of Nursing (DON) - on 05/30/24 at 12:47 PM, DON stated there were…

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 reportable allegation review, staff interview and policy review the facility failed to ensure they implemented their abuse/neglect policy as it relates to thoroughly investigating allegations of abuse. Resident identifier: #34, #28. Facility census: 48. Findings included: a) Resident #34 The facility received allegations through a social media account that alleged that on night shift on hallway B1 the nurse aides were telling an obese patient that she needs to come to the desk to get water because she's too fat. The facility investigated an allegation of abuse/neglect involving Resident #34 on 01/08/24. During this investigation Social Worker #22 and Social Worker #40 both interviewed Resident #34. They both asked the resident how she got access to water for drinking. When Social Worker #40 asked this question the resident responded, They don't bring me water in my bedroom. They tell me that I need to go to the bathroom and then get my water. When Social Worker #22 asked the question the resident said, I ask for it and they bring it. The social workers did not interview…

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 reportable allegation review, staff interview and policy review the facility failed to ensure they thoroughly investigated allegations of abuse. Resident identifier: #34, #28. These were random opportunities for discovery. Facility census: 48. Findings included: a) Resident #34 The facility received allegations through a social media account that alleged that on night shift on hallway B1 the nurse aides were telling an obese patient that she needs to come to the desk to get water because she's too fat. The facility investigated an allegation of abuse/neglect involving Resident #34 on 01/08/24. During this investigation Social Worker #22 and Social Worker #40 both interviewed Resident #34. They both asked the resident how she got access to water for drinking. When Social Worker #40 asked this question the resident responded, They don't bring me water in my bedroom. They tell me that I need to go to the bathroom and then get my water. When Social Worker #22 asked the question the resident said, I ask for it and they bring it. The social workers did not interview staff 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 medical record review and staff interview the facility failed to ensure one (1) of three (3) residents were free from significant medication errors. Resident #54 received two (2) medications that were intended for his roommate. Resident #54 received a sulfonylureas (Glipizide) and an anticonvulsant (Dilantin). The resident did not have diagnoses that supported the need for these two (2) classes of medications. Resident identifier: #54. Facility census: 48. Findings included: a) Resident #54 A medication error report dated 12/27/23 regarding Resident #54 revealed the facility administered Glipizide 10 mg (milligram) po (by mouth) and Diazepam 5 mg po. These medications were both administered on 12/19/24 at 10:00 PM. The medication error report revealed the medication belonged to Resident #54's roommate. Registered Nurse (RN) #29 administered the medication. The report revealed the physician was contacted and the resident was to be monitored, a snack given and glucose monitored every 3-4 hours. Further medical record review revealed this did not happen. There was 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 medication error report review, policy review, medical record review and staff interview the facility failed to ensure their quality assurance committee analyses a significant medication errors to determine a root cause analysis and prevent the possible recurrence. Resident #54 received two (2) medications that were intended for his roommate. Resident #54 was one (1) of three (3) residents who were reviewed for significant medication errors. Resident #54 received a sulfonylureas (Glipizide) and an anticonvulsant (Dilantin). Resident identifier: #54. Facility census: 48. Findings included: a) Resident #54 On 03/27/24 at approximately 9:10 a.m., interview with Registered Nurse (RN)/QAPI (Quality Assurance and Performance Improvement) #47 she was asked to describe how medication administration errors are reported to the QAPI committee. RN/QAPI #47 replied I get the med error numbers and report them out in the meeting. RN/QAPI #47 was asked if a root cause analysis of medication administration errors are performed with each error. RN/QAPI #47 replied, No, I do not do one each…

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

Based on observation and staff interviews, the facility failed to ensure the activities program is directed by a qualified professional. This had a potential to affect more than a limited number of residents residing in the facility. Facility census: 44. Findings Included: a) Qualified Activity Professional During an observation on 08/22/22 at 12:05 PM the Activity Department was void of a certificate for a qualified activity professional. During an interview on 08/23/22 at 9:10 AM, the Social Worker #82 stated, We don't have an activity director we have not had one in months, I have told them we needed one, I am doing the best I can but I am not certified and really don't know what I am doing. During an interview on 08/23/22 at 10:39 AM, the Administrator stated, The Activity Director has been gone since August 2021. The Division of Personnel will not let us hire due to not knowing if its a Supervisor 2 or 1 position. I have been telling them we were going to get a tag for not having an Activity Director. .

Based on employee record reviews and staff interview, the facility failed to complete the annual performance evaluations for nurse aides. This was true for five (5) of five (5) agency nurse aides reviewed during the sufficient and competent nurse staffing. Employee #23, #32, #46, #57, and #61 had not received their annual nurse aide performance reviews. Facility census: 44 Findings included: a) Performance reviews for agency nurse aides During a review of employee records on 08/24/22, it was discovered Employee #23, #32, #46, #57, and #61 agency nurse aides (NA) had not had their annual performance reviews completed on or before their annual date of hire. In an interview with the interim Director of Nursing (DON) on 08/23/22 at 1:00 PM, reported he had never completed annual performance reviews for any agency NA staff. .

Based on observation and staff interviews, the facility failed to store food in sanitary conditions by not labeling foods appropriately and not discarding when foods expired in the kitchen. The facility also failed to correctly document temperatures for all the dietary equipment requiring temperature logs. This deficient practice had the potential to affect more than a limited number of residents that receive nutrients from the kitchen. Facility Census:44 Findings Included: A facility policy titled Food Storage Labeling with a revision date of 04/2018 stated (Typed as written) .Procedures 4. An accurate thermometer will be kept in each refrigerator and freezer. A written record or daily temperatures will be recorded. 5. All foods will be stored wrapped or in covered containers, labeled and dated and arranged in a manner to prevent cross contamination. a) Reach In Freezer An initial tour of the kitchen with the Food Service Worker (FSW)#209 beginning on 08/22/22 at 11:17 AM, the reach in freezer found the following items : -An opened box of Hamburger Patties: no opened date -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.

Based on medical record review and staff interview, the facility failed to ensure a complete and accurate Minimum Data Set (MDS) assessment in the area of psychiatric/mood disorders for one (1) of five (5) residents reviewed for the care area of unnecessary medications. Resident identifier: #23. Facility census: 44. Findings included: a) Resident #23 Review of Resident #23's medical records showed a diagnosis of schizoaffective disorder. The resident was taking the medication iloperidone for schizoaffective disorder. Review of Resident #23's Minimum Data Set (MDS) assessment with Assessment Reference Date (ARD) 06/23/22 showed the resident was not coded as having schizophrenia, which included schizoaffective disorder. During an interview on 08/24/22 at 11:01 AM, the Minimum Data Set Coordinator confirmed Resident #23 had a diagnosis of schizoaffective disorder and the MDS with ARD 06/23/22 was incorrect. No further information was provided through the completion of the survey. .

Based on record review staff interview, the facility failed to ensure pressure ulcer care was provided in accordance with professional standards of practice. Resident #4's pressure ulcer treatment to the coccyx was not on the treatment administration record. This deficient practice had the potential to affect one (1) of two (2) residents reviewed for the care area of pressure ulcers. Resident identifier: #4. Facility census: 44. Findings included: a) Resident #4 Review of Resident #4's physician's orders showed the following orders written on 06/01/22 for pressure ulcer care: --Cleanse left hip with mild soap and water, pat dry. Apply daikon's to the fluffed tip of 2x2 gauze and gently insert into the tunneled area on side of the wound going approximately 1 cm, pack gently and loosely, do not force 2x2 gauze into area, cover with 2x2 gauze into area, cover with 2x2 gauze and paper tape. Change daily and PRN (as needed). --Cleanse coccyx with mild soap and water, pat dry. Apply fluffed dry 2x2 gauze in the coccyx area, tape not needed. Change every day and PRN. On 08/24/22 at 9:13…

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 temperature checks were completed daily for one (1) of the two (2) refrigerators used for medication storage. This failed practice had the potential to affect a limited number of residents. Facility census:44. Findings included: a) Medication Temperatures During an observation of the A1 medication storage room (located on A Hall) on 08/23/22 at 9:15 AM, the temperature log for the medication refrigerator was found to incomplete for August 2022. The following dates were blank on the temperature log: 08/04/22, 08/09/22, 08/13/22, 08/17/22, and 08/18/22. Licensed Practical Nurse (LPN) #80 verified the temperature log was incomplete and stated that night shift usually completes the temperature log and stated, We've hired so many new people on nights they probably forgot. LPN #80 further stated that the medications routinely kept in the refrigerator were vaccines, insulin, suppositories, eye drops in addition to a vial Ativan for intramuscular injections at that moment. Record review of the facility's…

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