Weirton Geriatric Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on observation and staff interview, the facility failed to ensure resident rooms were designed or equipped to assure full visual privacy for each resident. This was true for five (5) out of five (5) resident rooms during the long-term care survey process. Resident identifiers: #108, #57, #55, #12, and #103. Facility census: 119. Findings included: a) room [ROOM NUMBER] Observation, on 03/27/23 at 2:11 PM, revealed there was one (1) privacy curtain in the room that could extend in a straight line between the two (2) resident beds in the room. Resident #12 was placed in the A-bed, which is the bed closest to the door. During a second observation, on 03/28/23 at 10:17 AM, LPN #128 acknowledged there was nothing that would afford Resident #12 full privacy should her roommate enter the room in an attempt to get to the B-bed, which is the bed closest to the window. b) room [ROOM NUMBER] Observation, on 03/27/23 at 2:26 PM, revealed there was one (1) privacy curtain in the room that could extend in a straight…

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 maintain a resident's room in a clean and homelike manner. Feeding tube supplies were in an open box on the floor and filling up the visitor chair in the room. This is true for one (1) of two (2) residents reviewed for feeding tubes. Resident identifier: #18. Facility census: 119. Findings included: a) Resident (R)#18 An observation on 03/27/23 at 10:23 AM, revealed an open box on the floor in R#18's room containing five unused feeding tube bags. In addition, the chair in the room contained two open and one closed case of Glucerna tube feeding bottles, leaving no place for a visitor to sit. At 10:25 AM on 03/27/23, Registered Nurse (RN) #26 confirmed these findings and immediately picked the feeding bags up off the floor and cleared the chair for visitors. .

Based on Resident Council Meeting, observations and staff interview, the facility failed to post grievance forms in prominent locations throughout the facility. A resident or resident representative should have access to grievance forms, and freedom to file grievances anonymously. This had the potential to affect a limited number of residents. Facility census: 119. Findings included: a) Posting grievance forms The Resident Council President 03/28/23 at 11:05 AM, reported she was not aware of any grievance forms being available in the facility. She also reported if you wanted to file a grievance you needed to go through staff. During observations after the Resident Council Meeting, it was discovered the grievance forms were not accessible to residents or family in prominent locations on either the second or third floor. In an interview on 03/28/23 at 11:55 AM, with the Director of Social Services, verified the grievance forms were not located throughout the facility and were not accessible to residents and family. .

Based on record review and staff interview the facility failed to develop a person-centered care plan to address the resident's medical, physical, mental and psychosocial needs. This was discovered for one (1) of five (5) residents reviewed for the area of unnecessary medications. The care plan for Resident #11 was not developed for the use of psychotropic medication. Resident identifier: #11. Facility census: 119. Findings included: a) Resident #11 A medical record review on 03/29/23, revealed Resident #11 had orders for Seroquel 25 milligrams (mg) once daily for paranoid thoughts and agitation, Zoloft 50 mg once daily for major depression, and Buspirone 5 mg twice daily for anxiety. Further medical record review, found there was no care plan developed for use of psychotropic medications. In an interview with the Director of Nursing on 03/29/23 at 11:21 AM, they verified there was no care plan developed for the psychotropic medications for Resident #11. .

Based on record review, staff interview and policy review the facility failed to ensure residents receive treatment and care in accordance with professional standards of practice. The facility failed to complete neurological checks for an unwitnessed fall. This was true for one (1) of three (3) residents reviewed for falls during the Long Term Care Survey Process. Resident identifier: #72 Facility Census: 119 Findings Included: a) Resident #72 Record review on 3/29/23 at 11:31 AM shows Resident #72 had an unwitnessed fall on 11/26/22 at 7:00 PM. She obtained a left leg skin tear which was treated at the center with first aid. Upon review of the neurological policy and medical record documentation the facility did not complete any neurological checks until 11/26/22 at 11 PM, four (4) hours after the fall. The facility policy (not dated) for Events of a Fall states: . Neurological Assessment MUST be performed immediately and then every four (4) hours for seventy two (72) hours following the fall . This was confirmed with the Director of Nursing on 3/29/23 at 10:45 AM. .

Based on observation, medical record review, and interview, the facility failed to deliver respiratory care services consistent with professional standards of practice. Oxygen supplies were not properly stored. This was a random opportunity for discovery, during the Long-Term Care Survey Process. Resident identifiers: #64, and #42. Facility census: 119. Findings Included: a) Resident #64 An observation on 03/27/23 at 11:23 AM found Resident #64's face mask for his bilevel positive airway pressure (BIPAP) laying on a shelf without being placed in a protective bag. An interview on 03/27/23 at 11:35 AM with License Practical Nurse (LPN) #145 confirmed that Resident #64's's BIPAP Mask should be placed and stored in a protective bag when not in use. Resident #42 b) On 3/27/23 at 1:40 PM, an observation was made of Resident #42's BiPap mask sitting on the bedside table, not in a protective storage bag. At this time Registered Nurse (RN) #102 confirmed the Bipap was not in the proper storage bag. .

Based on record review and staff interview, the facility failed to ensure each medication order included an adequate indication for use. This is true for two (2) of nine (9) residents reviewed for medications during the long term care survey process. Resident identifiers: #111, #91. Facility census: 119. Findings include: a) Resident (R) #111 A review of the medical record on 03/28/23 at 9:00 AM revealed R#111 had physician orders and medication administration record lacked diagnoses or a reason for medication administration for the following drugs: Augmentin (antibiotic) 500-125 milligrams (mg) once a day Flomax (alpha-blocker used to treat benign prostatic hyperplasia) 0.4 mg once a day Gabapentin (controlled substance used to treat nerve pain) 100 mg three times a day Prilosec (proton-pump inhibitor for heart burn) delayed release 20 mg once a day Risperdal (antipsychotic) 0.5 mg once a day Tylenol 650 mg twice a day During an interview at 9:40 AM on 03/28/23, Licensed Practical Nurse (LPN) #108 reviewed the medical record including the electronic medication administration record…

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

Based on record review and staff interview, the facility failed to ensure each medication order included an adequate indication for use for psychotropic medications. Resident identifiers: #42 and #104. Facility Census: 119 Findings Included: a) Resident #42 Resident #42 has a diagnosis of anxiety and major depressive disorder. She has an order for Buspirone (anti anxiety) tablet 5 milligrams, oral, twice a day at 6:00 AM and 6:00 PM start date 11/09/22, and was current order at the time of this review. There was no diagnosis for this medication. This was confirmed with the Director of Nursing on 3/28/23 at 1:30 PM. b) Resident #104 Resident #104 has a diagnosis of major depressive disorder. She has an order for Citalopram (anti depressant) tablet 20 milligrams, oral, once a day at 6:00 AM for a diagnosis of Acute embolism and thrombosis of unspecified deep veins of the right distal lower extremity). This is an inappropriate diagnosis for this medication. Citalopram is used for depression , not deep vein thrombosis (DVT). This was confirmed with the Director of Nursing on 3/28/23 at…

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

Based on Interview and record review the facility failed to ensure all qualified staff had their food handler's card. This has the ability to affect all Residents that get their nutrition from the kitchen. Facility census: 119. Findings included: a) Kitchen On 03/28/23 at 1:23 PM a review of training certificate for food handlers found: Dietary staff #65 - No documentation of Food Handlers Training prior to 03/27/23. During an Interview with the Assistant Administrator on 03/29/23 at 11:45 AM, verified the staff in question did not have Food Handlers Training until 03/27/23. .

Based on observation and staff interview the facility failed to monitor temperatures on a resident's refrigerator. This was a random opportunity for discovery. Resident identifier: #18. Facility census: 119. Findings include: a) Resident (R) #18 An observation at 10:23 AM on 03/27/23 revealed an incomplete daily temperature log on the side of R#18's refrigerator. The last temperature documented was on 03/23/23. Registered Nurse #26 confirmed R#18's refrigerator temperature log was not up to date during an interview at 10:30 AM on 03/27/23. .

Based on observation and staff interview the facility failed to store garbage and refuse in a proper manner. The compactor areas were polluted with garbage, debris and medical supplies with the potential to attract pests and vermin. This has the potential to affect a limited number of residents that reside in the facility. Facility census: 119. Findings included: a) Compactor areas An observation on 03/29/23 at 1:45 PM found the nursing compactor area had used medical supplies laying on the ground around the compactor. A continued observation on 03/29/23 at 1:53 PM found the kitchen compactor lid was open and the area was littered with kitchen debris, on the ground around the compactor. On 03/29/23 at 1:54 PM during an Interview the maintenance staff #150 they verified the trash and medical supplies should not be laying on the ground around the facility compactors. .

Based on record review and staff interview, the facility failed to maintain a complete and accurate medical record for two (2) of 29 sampled residents during the Long-Term Care Survey Process. Specifically, the facility failed accurately record a written physician order in the electronic medical record for Resident #57 and Resident #108. The facility also failed to maintain a complete and accurate medical record for one (1) of two (2) residents reviewed for the area of dialysis during the Long-Term Care Survey Process. Resident identifiers: #57, #108, and #73. Facility census: 119. Findings included: a) Resident #57 A record review, completed on 03/28/23 at 1:34 PM, revealed the following: -Resident is prescribed Miralax. -The written physician order, dated 10/07/22, read Miralax, 17 gram/dose PO [by mouth] QD [once a day] for constipation. -The physician order in the electronic medical record, failed to include the medical diagnosis of constipation. During an interview, on 03/28/23 at 1:38 PM, the Director of Nursing (DON) stated when the order was placed in the electronic medical…

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 maintain resident's equipment in safe operating condition. During a random opportunity for discovery during the Long Term Care Survey Process, Resident #17's wheelchair was identified to be unsafe. Resident identifier #17. Facility census: 119. Findings included: a) Resident #17 During a random opportunity for discovery on 03/27/23 at 10:30 AM, revealed the wheelchair for Resident #17 had an exposed metal brake handle with a sharp edge, and foam padding taped on the right arm rest. In an interview with Unit Manager #102 on 03/28/23 at 9:40 AM, verified the wheelchair had an exposed metal sharp edge on the brake handle, which could cause injury for Resident #17. Also foam padding on the right arm rest was not easy to clean.

Based on record review and interview, the facility failed to ensure the Drug Regimen Review Policy addressed the time frame in which the physician must respond to the pharmacist's recommendations. This failed practice had the potential to affect all residents residing in the facility. Facility census: 115. Findings included: a) Drug Regimen Review Policy The facility's policy titled Drug Regimen Review, with no implementation date given, was reviewed. The policy did not address the time frame in which the physician must respond to the pharmacist's recommendations. During an interview on at 11/17/21 at 12:07 PM, the Assistant Administrator was informed the facility's Drug Regimen Review Policy did not give a time frame in which the physician must respond to the pharmacist's recommendations. The Assistant Administrator stated the policy would be revised to include this. No further information was provided through the completion of the survey. .

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on record review and interview, the facility failed to provide evidence residents and/or resident representatives were provided a written Notice of Transfer for three (3) of three (3) records reviewed for an acute hospital transfer. The facility also failed to provide evidence the long-term care Ombudsman had been notified of the transfers. This had the potential to affect more than a limited number of residents transferred or discharged . Resident identifiers: #27, #102, and #107. Facility census: 115. a) Resident #27 A medical record review was completed on 11/16/21 at 11:15 AM. The record review revealed Resident #27 was transferred to the hospital on [DATE]. The record did not reflect the resident/resident's representative was provided a Notice of Transfer, nor did the record reflect the Notice of Transfer was sent to the Ombudsman. On 11/17/21 at 10:00 AM, Business Office Employee #166 reported the Notice of Transfer was not provided to resident / resident representative upon transfer or sent to the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on record review and interview, the facility failed to develop and/or implement person-centered comprehensive care plans for six of 30 residents reviewed during the long term care survey process. Nutritional needs were not addressed for Resident's #46, #71, and #69. Catheter care was not addressed for Resident #64. Behavioral/emotional needs were not addressed for Resident #43. Resident identifiers: #46, #64, #71, #69, and #43. Facility census: 115. Findings included: a) Resident #46 Review of the current physician's orders found orders dated 01/22/21: --Soft diet with puree fruits and vegetables, thin liquids, staff supervision at meals; no Jello mixed with fruit. --Patient to use red built up handle for silverware and soup bowl; scoop plate and two handled cup with lid for meals. Review of the current care plan with the Director of Nursing (DON) on 11/18/21 at 7:53 AM found the care plan did not include any mention of the above orders related to meal service. b) Resident #64 During an interview 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.

Based on observation, resident review, and staff interview, the facility failed to follow physician's orders for six (6) of 30 residents reviewed during the long-term care survey process. Resident identifiers: #107, #69, #85, #83, #46, #71. Facility census: 115. Findings included: a) Resident #107 Review of Resident #107's medical record showed an order written on 11/02/21 for six (6) ounces of nutritional supplement if 50% or less of the meal or snack was consumed. The order stated the amount of supplement given was to be charted. The type of nutritional supplement was not specified. Review of Resident #107's consumption records since 11/02/21 showed the resident had consumed 50% or less for dinner on the following dates: - 11/03/21: 26-50% of meal taken - 11/04/21: refusal of meal - 11/05/21: refusal of meal - 11/07/21: 26-50% of meal taken - 11/08/21: 26-50% of meal taken - 11/09/21: 26-50% of meal taken - 11/11/21: 26-50% of meal taken - 11/15/21: 26-50% of meal taken On 11/05/21 at 6:29 PM, Resident #107 was documented as taking 120 milliliters of a supplement. On 11/09/21 at…

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

b.) Resident #105 An observation on 11/15/21 at 01:42 PM, revealed no operable call system was available in the bathroom for Resident #105. An interview, with Employee #325, on 11/15/21 at 01:51 PM, confirmed there was no functioning call system in Resident #105's bathroom and verified Resident #105 did go in the bathroom and could access a call system if available. An interview with RN # 67, on 11/15/21 at 01:56 PM, verified there should be a functioning call system in the residents bathroom and there was no functioning call light for Resident #105 to activate in case assistance was needed while in the bathroom. A review of the resident centered care plan, dated 11/10/21, for Resident #105, showed the resident was at risk for falls and noted the resident was to use the call light as a fall prevention measure. c.) Resident #72 An observation, on 11/16/21 at 02;23 PM, revealed a tube of Calmoseptine cream on the shelf by the resident's sink. An interview, with RN #38, verified the Calmoseptine cream was on the shelf in the Resident #72's room and there was no order for the cream.…

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 have food items labeled and dated correctly, unclean equipment in the kitchen, one pantry on enchanted garden refrigerator with spillage and temperature logs in the kitchen were incomplete. This failed practice had the potential to affect a limited amount of residents who receive nutrients from the kitchen and pantry. Facility Census 115. Findings included; a) Kitchen and Pantry On 11/15/21 at 11:56 AM initial tour with Certified Dietary Manager (CDM) #168 found the following items in the reach in refrigerator with no label and/or date: --40 ice tea glasses with no label or date --one (1) bag of french fries open with no date --one (1) bag of carrots open no dates --one (1) bag of Brussels sprouts open with no date. --one (1) onion stored in small bag with no label and date. --mixer stand had debris around rim as well as the back of mixer stand CDM removed items found and discarded and also addressed to cook #73 needed to clean mixer stand. CDM agreed all issued found should have not been like that. 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 observation, policy review, medical record review and staff interview, the facility failed to establish and maintain an infection prevention program to help prevent the development and transmission of communicable diseases and infections including Covid-19 in regard to, precaution signage and laundry services. This failed practice had the potential to affect more than a limited number of residents in the facility. Resident identifier: #263. Facility census: 115. Findings Included: a) Resident #263 On 11/15/21 at 12:37 AM, found no precaution signs on Resident #263's door. Medical record review on 11/16/21 at 10:38 AM, revealed, Resident #263 was in Covid isolation, Respiratory Droplet Precautions related to being new admission. During an interview on 11/16/21 at 10:41 AM, with the Nurse Aide (NA) revealed, Resident #263, was in modified droplet Precautions. On 11/16/21 at 10:48 AM, Registered Nurse (RN) #27 confirmed, there was no precautionary signage on Resident #263's door. RN #27 placed a sign for respiratory droplet isolation sign in Resident #263's door. 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, interview, and record review, the facility failed to ensure a resident's right to self-determination, and the reassessment of mental capacity as evidenced by the resident's improved cognition. This failed practice was true for one (1) of 30 residents reviewed during the long-term care process. Resident identifier: #94. Facility census: 115. Findings included: a) Resident #94 During an interview on 11/15/21 at 1:43 PM, Resident #94 reported having a cerebral aneurysm and cerebrovascular accident (CVA) prior to being admitted to the facility. Resident reported she has come a long way since her admission a few years ago and has regained a lot of her physical abilities as well as experiencing a marked increase in her cognitive abilities. Resident #94 reported a family member had been appointed to act on her behalf when she was first admitted and that she is very close to that family member. Resident #94 expressed the fact that she and the appointed family member discuss her care openly and there has never been a time she has ever disagreed with her legal…

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

Based on observation and interview, the facility failed to provide reasonable accommodation in regards to a call light being accessible to the resident. This failed practice had the potential to affect a limited number of residents. Resident identifiers: #39. Facility census: 115. Finding included: a) Resident #39 An observation on 11/15/21 at 2:00 PM found Resident #39 lying in bed without a call light in reach. This failure would make Resident #39 unable to call for help or assistance. On 11/15/21 at 2:15 PM with Registered Nurse (RN) #20 verified, Resident #39's call light was not in reach of resident and stated residents should always have their call system in reach. RN #20 placed the call light in reach at this time. On 11/18/21 at 9:15 AM, the findings were discussed with the Administrator. No other information was provided prior to the end of survey on 11/18/21 at 12:30 PM. .

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on record review and interview, the facility failed to ensure two (2) of (30) residents reviewed during the long-term care survey process had a Physician Orders for Scope of Treatment (POST) form completed per directions specified by the [NAME] Virginia Center for End-of-Life Care in conjunction with the [NAME] Virginia Health Care Decisions Act (16-30-1). Resident identifiers: #45 and #104. Facility census: 115. Findings included: a) Resident #45 Record review on [DATE] at 03:16 PM, revealed section for Patient Information, Section D - (signature of Patient /Resident, Guardian/MPOA Representative/Surrogate -Mandatory) and Date on Resident #20's active Physician Order for Scope of Treatment Form (POST Form) was not completed. During an interview on [DATE] at 01:22 PM with Social Worker (SW) #180, confirmed Resident #45's POST form D was incomplete. b) Resident #104 Record review on [DATE] at 03:24 PM, revealed section A for Cardiopulmonary Resuscitation (CPR) -Marked Attempt Resuscitation/CPR) on…

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

Based on record review and staff interview, the facility failed to ensure a Minimum Data Set (MDS) was accurately completed. This is true for one (1) of 30 residents reviewed. Facility census 115. Resident identifier #52. Findings included: a) Resident #52 On 11/15/21 at 1:40 PM review of the MDS for Resident #52 found on 10/01/21 the accurate diet was not captured on MDS. Interview with MDS coordinator #36 on 11/16/21 at 2:17 PM in section K of MDS on 10/01/21 did not capture a therapeutic diet. MDS coordinator #36 reviewed MDS on that date and diet from that MDS review and agreed that it was not accurate and stated, I will have to modify the MDS. .

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on observation, record review, and staff interview, the facility failed to revise the comprehensive care plan when a change in condition occurred. This failed practice had the potential to affect two (2) of 30 residents reviewed during the long-term care survey process. Resident identifiers: #85 and #8. Facility census: 115. Findings included: a) Resident #85 Review of Resident #85's medical records showed the resident experienced weight loss while in the hospital from [DATE] to 11/1/21. On 10/07/2021, the resident weighed 142 lbs. On 11/02/2021, the resident weighed 132 pounds which is a 7% weight loss. On 11/09/21, Resident #85 continued to weigh 132 pounds. On 11/16/21 at 12:40 PM, Resident #85 was noted to be sitting in a chair with her lunch tray in front of her. The resident was not eating. The resident did not respond to the surveyor's questions. During an interview on 11/16/21 at 12:50 PM, Employee #151, who was noted to be distributing trays to residents, stated Resident #85 was independent in…

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

Based on observation, record review and interview, the facility failed to ensure one of two residents reviewed for the care area of position/mobility received the equipment necessary to maintain proper positioning while using a geri-chair. Resident identifier: #83. Facility census: 115. Findings included: a) Resident #83. Observation of the Resident on 11/15/21 at 1:00 PM found the Resident in his room seated in a geri-chair. The Residents feet were dangling at least a foot above the floor. The chair had no leg rests. A second observation on 11/16/21 at 11:38 AM, with Unit Manager, Registered Nurse (RN) #7 found the resident was again in his room seated in his geri-chair with his feet dangling about 1 foot above the floor. RN #7 confirmed the Resident feet and ankles were swollen with edema. The Resident receives the medication, Lasix for edema. RN #7 said therapy would be contacted to assess the Resident for foot rests for the geri-chair. On 11/16/21 at 12:26 PM, observation found the manager of rehabilitation, certified occupational therapy assistant (COTA) #218 applying a foot…

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, observation, and record review, the facility failed to ensure tubing and drainage bags were not resting on the floor of the facility for two of four residents reviewed for catheter care. Resident identifiers: #64 and #104. Facility census: 115. Findings included: a) Resident #64 During an interview with the Resident at 1:42 PM on 11/15/21, the Resident said she had a super pubic catheter which she had for about 10 years. She said, I had this before I came to the facility. The Resident was setting in her wheelchair in her room. Observation found the catheter drainage bag was hooked under the seat of her wheelchair. The bottom of the drainage bag and part of the tubing were resting on the floor. A second observation on 11/17/21 at 10:38 AM, found the Resident was setting in her wheelchair in her room. Observation found the catheter drainage bag was hooked under the seat of her wheelchair. The bottom of the drainage bag and part of the tubing were resting on the floor. Unit Manager, Registered Nurse (RN) #67 observed the resident and said, Its supposed to be…

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, medical record review and interview, the facility failed to deliver respiratory care services consistent with professional standards of practice. A physician's order for oxygen was not followed. This is true for one of two reviewed during the Long-Term Care Survey Process (LTCSP). Resident Identifier: #93. Facility Census: 115. Findings included: a) Resident #93 An observation of Resident #93, on 11/15/21 at 10:15 AM, revealed the Resident #93 was receiving oxygen at three (3) Liters via nasal cannula (an oxygen delivery device) from an oxygen concentrator. A review of Resident #93's physician order, revealed the order Wear Oxygen at two (2) Liters Per Minute (LPM), via Nasal Cannula continuously, with an order date of 06/10/21. A second observation of Resident #93, on 11/17/21 at 10:50 AM, revealed the Resident was receiving oxygen at three (3) Liters via nasal cannula from an oxygen concentrator. An interview with Licensed Practical Nurse (LPN) #125 on 11/17/21 at 11:00 AM, verified the Resident was receiving oxygen at three (3) Liter Per Minute. LPN #125…

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

Based on observation, interview and record review, the facility failed to ensure one of one resident reviewed for dental services received assistance with obtaining repairs to broken dentures. Resident identifier: #57. Facility census: 115. Findings included: a) Resident #57 On 11/15/21 at 12:25 PM, the resident said his dentures were broken and they needed repaired. He stated, I can't afford to buy a new pair. The resident said his teeth had been broken for quite some time. He believed they were broken while he was at the hospital, when a nurse dropped the denture cup by accident. He stated he had a good looking sandwich for lunch piled high with lettuce, tomato, and meat but he could not bite down on it due to not having his dentures. He said he took the sandwich apart to eat it but it would have been easier if he had his teeth in. The resident retrieved the dentures from his denture cup setting beside the sink. The dentures were soaking in water. A half moon shaped chunk the size of a quarter was missing from the upper denture, just above the teeth area of the denture. 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 observation, record review and staff interview, the facility failed to provide food in a form to meet the needs of residents. This failed practice had the potential to affect two of six residents reviewed for the care area of nutrition. Resident identifiers: #69, #46. Facility census: 115. Findings included: a) Resident #69 Review of Resident #69's medical records showed an order written on 09/10/21 for soft diet with chopped meat with gravy/sauce. On 11/16/21 at 12:20 PM, Resident #69 was observed eating in the third-floor dining area. He had been served from the satellite kitchen on the third floor. Resident #69 was eating turkey with gravy on bread. Some of the turkey was cut into smaller pieces but two (2) pieces of turkey were intact and had not been cut into smaller pieces. The resident left the dining area without eating all the turkey that had already been cut into the smaller pieces. During an interview on 11/16/21 at 12:30 PM, Dietary Aide #41 stated she thought the turkey was soft enough to not need chopped into pieces. During an interview on 11/16/21 at 4:00 PM,…

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 adaptive eating equipment ordered by the physician was provided to the resident. This was a random opportunity for discovery. Resident identifier: #46. Facility census: 115. Findings included: a) Resident #46 Review of the physician's orders found an order, dated 01/21/21 for: Patient to use red built up handle for silverware and soup bowl, scoop plate and two handled cup with lid for meals. On 11/17/21 at 7:55 AM, observation found nursing assistant (NA) #167 serving the Resident a tray. The food was not in a scooped plate and no built up silverware was present on the tray. This observation was confirmed by Nursing assistant (NA) #167 and Unit Manager, Registered Nurse (RN) #67. The Resident received food in the wrong consistency, RN #67 stopped the tray service and obtained a second tray. Observation of the second tray served on 11/17/21 at 8:03 AM, found food was now served in a scooped plate but the Resident only had 1 red built up handle which was placed on the Residents fork. The 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 record review and staff interview, the facility failed to ensure each resident's medical record was complete and accurately documented for two (2) of 30 residents records reviewed during the Long Term Care Survey Process (LTCSP). Resident identifiers: Resident # 72 and #14. Census: 115 Findings included: a) Resident #72 A review of the Minimum Data Set (MDS) dated , 10/21/21, noted Resident #72 transferred independently. A review of therapy progress notes dated ,10/21/21, noted Resident #72 to be independent for transfers in the room and bathroom and resident was able to take self to toilet. A review of the Nursing Assistant care plan (Kardex) showed Resident #72 required two (2) person assist for mobility. An interview with Registered Nurse (RN#67), on 22/26/21 at 02:44 PM, verified the Kardex is what the nursing assistants would utilize to provide care , however, the resident is now transferring independently and confirmed the directive was not correct. RN #67 stated further, the Kardex should have been updated to reflect current orders and current plan of care for the…

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

Based on observation and interview, the facility failed to ensure all rooms in the facility were adequately equipped to allow residents to call for staff assistance. This was a random opportunity for discovery during the initial tour of the Long Term Care Survey Process (LTCSP) and affected resident #105. Resident identifier: #105. Facility census: 115. Findings included: a.) Resident #105 An observation on 11/15/21 at 01:42 PM, revealed no operable call system was available in the bathroom for Resident #105. An interview, with Employee #325, on 11/15/21 at 01:51 PM, confirmed there was no functioning call system in Resident #105's bathroom and verified Resident #105 did go in the bathroom and could access a call system if available. An interview with RN # 67, on 11/15/21 at 01:56 PM, verified there should be a functioning call system in the residents bathroom and there was no functioning call light for Resident #105 to activate in case assistance was needed while in the bathroom. .