White Sulphur Springs Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and staff interview, the facility failed to store and prepare food in a sanitary manner, due to having items that were out of date and not dated in the refrigerators, items exposed to the elements, having dirty equipment, and failing to monitor refrigerator temperatures of personal refrigerators in resident rooms. This has the potential to affect all residents receiving food from the kitchen and all residents with personal refrigerators in their rooms. Facility census: 64. Findings include: A) Outdated, undated, and exposed items At approximately 11:20 AM on 07/08/2024 a tour of the kitchen in the facility was conducted. During the tour, the following were found in the walk-in refrigerator: Three (3) trays of cake with no date. A plastic container of beef based with no lid on it. A plastic container of strawberries with no date on it. A cardboard box containing squash with a discard date of 07/01/2024. Twenty (20) individual cookies placed in plastic sleeves were in the dry stock room 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 and staff interview, the facility failed to dispose of refuse in a manner to prevent attracting vermin. This has the potential to affect all residents residing in the facility. Facility census: 64. Findings include: a) At approximately 2:00 PM on 07/10/2024, a tour was conducted of the rear of the facility where the facility kept their dumpsters. Upon arriving at the dumpsters, an empty potato chip bag, multiple clear gloves, pieces of food, and clear plastic garbage bags were scattered around and underneath the dumpsters. Three (3) of the four (4) dumpsters had the lids opened, with one missing a lead entirely. One dumpster was leaking a white substance out of the bottom, onto the pavement. At approximately 2:09 PM on 07/10/2024, the Dining Services District Manager acknowledged the trash on the ground and the state of the dumpsters.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview the facility failed to review and revise the care plan for Resident #61's psychotropic medication, dementia, and behaviors. In addition the facility failed to revise the care plan to reflect weights no longer be obtained for Resident #59 and the care plan to reflect the surrogate for Resident #29. This was true for 3 (three) of 19 residents reviewed for the Long Term Care Survey process. Facility census: 64. Resident identifiers: #61,#59 and #29. Findings include: a) Resident #61 Psychotropic Medication On 07/08/24 at 9:11 PM a review of Resident #61's medical record was performed. It revealed there were several notes in the documentation related to, refusal of care, physical and verbal aggression towards staff and other residents. During the review, a progress note dated 07/06/24 at 6:05 PM read as follows : This resident was wondering [SIC] in and out of other residents rooms this morning. He was sitting on another residents bed and refused to leave. Multiple attempts…

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 interview, the facility failed to provide medically related social services for Resident #61 or residents that suffered abuse from Resident #61. This was true for 1 (one) of 3 (three) residents reviewed during the Long-Term Survey Process. Facility census: 64. Resident identifiers: Resident #61 and Resident #42. Findings include: a) Resident #61 On 07/08/24 at 1:30 PM an interview was conducted with Resident #42. At that time, Resident #42 stated, I don't sleep much at night due to Resident #61 coming into my room at night. I nap during the day so I don't wake up to find him in my room. It scares me. That's why I had the staff put up the stop sign in my door. On 07/08/24 at 9:11 PM a review of Resident #61's medical record was performed. It revealed there were several notes in the documentation related to physical and verbal aggression towards staff and other residents. During the review, a progress note dated 07/06/24 at 6:05 PM read as follows : This resident was wondering [SIC] in and out of other residents rooms this morning.…

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 accurately document medication administration times on the Medication Administration Record (MAR) and medication sign out and administration times on the narcotic count sheet for Resident #28 ' s Morphine Sulphate. This was a random opportunity for discovery. Facility census: 64. Findings include: A) Resident #28 Resident #28 was admitted to the facility with the diagnoses of Chronic Obstructive Pulmonary Disease (COPD) and Liver Cell Carcinoma. He had a Brief Interview for Mental Status (BIMS) score of 14, suggesting he was cognitively intact, and was determined to have capacity. Upon review of the resident matrix after arrival to the facility at approximately 11:00 AM on 07/08/2024, it was noted Resident #28 was marked for end of life/palliative care/comfort measures along with 25 other residents in the facility. At approximately 2:15 PM on 07/08/2024, Resident #28 was observed sitting on the side of his bed, bent over at the waist, with his hands almost touching the floor. Staff members then came into the room to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and staff interview, the facility failed to practice proper infection control to prevent the spread of communicable diseases during lunch service. This was a random opportunity for discovery. This has the potential to affect all residents residing in the facility. Facility census: 64. Findings included: At approximately 12:12 PM on 07/08/2024, an observation was made during lunch service in the 400 hallway of the facility. Nurse Aide (NA) #10 took a tray off the delivery cart, took it to room [ROOM NUMBER] and brought it back to the cart upon realizing the resident was out of the facility. Upon returning to the delivery cart, NA #10 placed the tray back onto the cart with the clean, undelivered trays. NA #10 acknowledged they should not have placed the tray back onto the cart and stated I ' m not sure why I did.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and staff interview the facility failed to provide a safe, comfortable, homelike environment for residents, staff and the public. Issues were found with dead flowers and items being stored over on top of the over bed light fixture. In addition the facility did not have record of fire drills being completed as required. These were random opportunities for discovery during the long term care survey and has the potential to affect all of the residents. Room identifiers: #304, #307. Census: 64. Findings included: a) Exit door window pane across of dining room On 07/08/24 at approximately 2:30 PM during a tour of the facility, the exit door to the court yard located across the hallway from the dining room was observed. This door has a glass insert that would provide a full view of the court yard outside. The glass appeared to have the seal broken with moisture trapped between the panes. The window glass that covered approximately 75% was extremely cloudy, making it impossible to enjoy the view…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview, the facility failed to confer with the appointed resident representative regarding the physician recommendation for medical treatment (biopsy of thyroid nodules) and the recommendation of the Registered Dietitian for nutritional support. This was true for one (1) of four (4)residents whose rights were reviewed during the long-term care process. Resident identifier: #29. Census: 64. Findings included: a) Resident #29 ENT referral A medical record review on [DATE] at approximately 10:00 AM identified the resident had a Brief Interview for Mental Status (BIMS) of 06. It was further identified that the physician note completed on [DATE] stated the patient was alert and oriented x1 with no acute distress and that Resident #29 did not have capacity. It was further identified that the Nurse Practitioner (NP) assisted Resident #29 to complete Physician Orders for Scope of Treatment (POST) form on [DATE]. The POST form was for no cardiopulmonary resuscitation (CPR) 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 record review and staff interview, the facility failed to allow Resident #28 to participate in his care and make treatment decisions, by failing to inform him of his right to participate in hospice care. The facility also failed to notify the responsible party for Resident #61 of the potential side effects of a psychotropic medication before administration. This was true for two (2) of three (3) residents reviewed for the right to make informed decisions during the survey process. Resident identifiers: #28, #61. Facility census: 64. Findings included: a) Resident #28 Resident #28 was admitted to the facility with the diagnosis of Chronic Obstructive Pulmonary Disease (COPD) and Liver Cell Carcinoma. He had a Brief Interview for Mental Status (BIMS) score of 14, suggesting he was cognitively intact, and was determined to have capacity. Upon review of the resident matrix after arrival to the facility at approximately 11:00 AM on 07/08/2024, it was noted Resident #28 was marked for end of life/palliative care/comfort measures along with 25 other residents in the facility. 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 observation, staff interviews and record reviews, the facility failed to implement two (2) of 19 resident's care plans. Resident #7's care plan was not implemented in the area of nutritional assistance. Resident #7 was not monitored or assisted with her meal for over one (1) hour after her meal was delivered. Resident #61 had no nutritional care plan developed despite having experienced weight loss. Resident identifiers: #7, #61. Facility census: 64. Findings include: a) Resident #7 07/08/2024 based on record review the flow chart revealed Resident #7's lunch was delivered to her room at 12:00 PM. Before surveyor entered resident's room at 1:05 PM. 07/08/24 at 1:05 PM the surveyor observed resident's tray was not eaten. Her hands appeared constricted, and she was holding her tea between her knuckles and could not place it back on her tray. The resident's roommate stated Resident #7 needed help and could not feed herself. This surveyor asked Resident #7 if she needed help with her food and drink and she said yes. This surveyor went into the hall and found Registered Nurse…

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 The facility failed to address the needs of residents at risk or already experiencing impaired nutrition and hydration. The facility declined the Registered Dietician dietary recommendations without notifying the surrogate and failed to obtain weights. This was true for two (2) of four (4) residents reviewed for nutritional needs during the long term care survey process. Resident identifiers: Resident #29 and Resident #61. Census. 64. a) Resident #29- nutritional support During a medical record review on [DATE] at approximately 10:00 AM of Resident #29's medical record, it is identified that the resident has a Brief Interview for Mental Status (BIMS) of 06. It is further identified that the physician note completed on [DATE] stated that the patient was alert and oriented x 1 with no acute distress and that Resident #29 does not have capacity at this time. It is further identified that the Nurse Practitioner (NP) assisted Resident #29 to complete the Physician Orders for Scope of Treatment (POST) form on [DATE].…

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

Based on record review, staff interview and observation, the facility failed to follow physician's order related to volume of feeding to be administered to Resident #52. This was true for 1 (one) of 1 (one) resident reviewed for the Long-Term Care Survey Process. Facility census: 64. Resident identifier: #52. Findings include: a) Resident #52 On 07/10/24 at approximately 12:30 PM, a review of Resident #52's medical record was completed which revealed that in the physician's orders, the following order was present: Order: five times a day for Nutrition Jevity 1.5 CAL Administer bolus via gravity 320 ML 5 times per day FLUSH tube with 30 ML of water prior to feeding, and a final 30 ML flush of water at the end of each feeding. Total volume of flush = 300 ML/24 hrs (excluding medication flushes). Total volume of nutrient + this flush = 380 ml (1900 ML/24 hrs.) On 07/10/24 at 12:53 PM, a tube feeding administration observation was completed for Resident #52 with LPN #46. When LPN #46 was preparing the feeding at the cart to take into the room, LPN #46 poured feeding from a 1000…

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 complete the Nurse staffing information accurately. Some of the data required was not completed, the direct care staff and the total actual hours worked by the direct care staff was inaccurate. This was true for nine (9) of ten (10) Nurse Staffing forms reviewed during the long term care survey process. Census: 24. Findings included: a) 03/19/23 During a review of the Daily Staffing form on 07/09/24 at approximately 7:30 PM, the total direct care staffing hours identified was 148 hours with a hours per patient day (hppd) for a census of 65 at 2.28. During a review of the Genstar daily staffing sheet and the Genstar daily time detail, the actual total direct care staffing hours were 164.65 with an HPPD of 2.53. 07/10/24 at 08:58 AM during an interview with the Administrator, the Administrator agreed that the total direct care staffing hours identified was not correct for 03/19/23. b) 05/14/23 During a review of the Daily Staffing form on 07/09/24 at approximately 07:30 PM, the total direct care staffing hours…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, the facility failed to provide the necessary behavioral health care and psychiatric services to Resident #61. This was true for 1 (one) of 3 (three) residents reviewed for the Long Term Survey Process. Facility census: 64. Resident identifier: Resident #61. Findings include: a) Resident #61 On 07/08/24 at 9:11 PM a review of Resident #61's medical record was performed. It revealed there were several notes in the documentation related to, refusal of care, physical and verbal aggression towards staff and other residents. During the review, a progress note dated 07/06/24 at 6:05 PM read as follows : This resident was wondering [SIC] in and out of other residents rooms this morning. He was sitting on another residents bed and refused to leave. Multiple attempts to talk with resident and offer food drinks and to go to the bathroom were unsuccessful. Resident was attempting to hit at staff and the residents of the room he had entered. Resident eventually left this residents…

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

Based on record review and staff interview, the facility failed to provide necessary appropriate person-centerd care and individualized treatment and services to meet Resident #61's behavioral and psychosocial needs. This was true for 1 (one) of 3 (three) residents reviewed for the Long Term Survey Process. Facility census: 64. Resident identifiers: Resident #61. Findings include: a) Resident #61 On 07/08/24 at 9:11 PM a review of Resident #61's medical record was performed. It revealed there were several notes in the documentation related to physical and verbal aggression towards staff and other residents. During the review, the following documentation was revealed to be entered into Resident #61's medical record: On 07/06/24 at 6:05 PM a progress note read as follows : This resident was wondering [SIC] in and out of other residents rooms this morning. He was sitting on another residents bed and refused to leave. Multiple attempts to talk with resident and offer food drinks and to go to the bathroom were unsuccessful. Resident was attempting to hit at staff and the residents of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, the facility failed to provide an interdisciplinary approach to address Resident #61's needs and to provide the necessary services related to the diagnosis of dementia. This was true for 1 (one) of 3 (three) residents reviewed during the Long Term Care Survey Process. Facility census: 64. Resident identifier: Resident #61. Findings include: a) Resident #61 On 07/08/24 at 9:11 PM a review of Resident #61's medical record was performed. It revealed there were several notes in the documentation related to, refusal of care, physical and verbal aggression towards staff and other residents. During the review, a progress note dated 07/06/24 at 6:05 PM read as follows : This resident was wondering [SIC] in and out of other residents rooms this morning. He was sitting on another residents bed and refused to leave. Multiple attempts to talk with resident and offer food drinks and to go to the bathroom were unsuccessful. Resident was attempting to hit at staff and the residents…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, the facility failed to monitor Resident #61 for side effects of psychotropic medication after administration of Zyprexa 10mg Intramuscularly (IM). This was true for 1(one) of 5 (five) residents reviewed for the Long Term Care Survey Process. Facility census: 64. Resident identifier: Resident #61. Findings include: a) Resident #61 On 07/08/24 at approximately 9:11 PM, a review of Resident #61's medical record was performed. It revealed that on 05/19/24 at 11:15 PM the following progress note was entered into Resident #61's medical record: Resident continues to be very restless with poor safety awareness. Attempted again to contact provider at Vis a Vis. Vis a Vis provider's microphone not working. Contacted Dr. [NAME] and instructed to administer 10 milligram (mg) Zyprexa IM. Medication administered as ordered and resident assisted back to bed. Resting in bed at this time with 0 (zero) complaints of (c/o) pain/discomfort. This note was revealed to be a follow up to a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview the facility failed to administer a as needed (PRN) psychotropic for a specifically diagnosed condition for Resident #61. This was true for 1 (one) of 5 (five) residents reviewed for the Long-Term Care Survey Process. Facility census: 64. Resident identifier: #61. Findings include: a) Resident #61 On 07/08/24 at approximately 9:11 PM, a review of Resident #61's medical record was performed. It revealed that on 05/19/24 at 11:15 PM the following progress note was entered into Resident #61's medical record: Resident continues to be very restless with poor safety awareness. Attempted again to contact provider at Vis a Vis. Vis a Vis provider's microphone not working. Contacted Dr. [NAME] and instructed to administer 10 milligram (mg) Zyprexa IM. Medication administered as ordered and resident assisted back to bed. Resting in bed at this time with 0 (zero) complaints of (c/o) pain/discomfort. This note was revealed to be a follow up to a Change in Condition Evaluation 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.

The facility failed to make good faith attempts to identify deficiencies of which they had or should have had knowledge of. The Quality Assurance and Performance Improvement (QAPI) program implemented to correct the [NAME] Virginia Portable Order for Scope of Treatment (POST) form completions was not being modified correctly. This has the potential to affect all the residents residing in the facility that completes a POST form. This was identified during the long term care survey process. Identifier: POST forms. Census: 64 a) Post forms During a POST form document review of on 07/12/24 at approximately 04:00 PM it was identified that a post form cannot be modified. It is stated on the form that if changes are needed you are to void the form and complete a new POST form. It is further noted that to void a POST form the following must be completed; If a patient or MPOA representative/surrogate (for patients lacking capacity) wants to void the form: destroy paper form and contact patients health care provider and the WV e-Directive Registry to void orders in patient's medical record…

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

Based on medical records, facility records and staff interview the facility Quality Assurance and Performance Improvement committee failed to develop corrective actions to effectively change systems level to prevent quality of care and or quality of life problems. The POST forms were not being accurately completed and or modified based on the physician's determination of capacity. All residents had the potential to be affected by this practice. This was discovered during the facilities long term care survey process. Census: 64. a) Post forms During a POST form document review of on 07/12/24 at approximately 4:00 PM it was identified that a post form cannot be modified. It is stated on the form that if changes are needed you are to void the form and complete a new POST form. It is further noted that to void a POST form the following must be completed; If a patient or MPOA representative/surrogate (for patients lacking capacity) wants to void the form: destroy paper form and contact patients' health care provider and the WV e-Directive Registry to void orders in patient's 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 resident interviews, staff interviews, and record review the facility failed to ensure sufficient qualified nursing staff are available at all times to provide nursing and related services to meet the residents' needs safely and in a manner that promotes each resident's rights, physical, mental and psychosocial well-being. This has the potential to affect more than a minimal number of residents at the facility. Census 65. Findings Included: a) Anonymous Resident Interviews On 03/06/23 at 12:19 PM, an anonymous resident complained about having to wait a long time last night to get cleaned up and being left in urine for hours. On 03/06/23 at 1:57 PM, another anonymous resident stated he/she has to sit in their poo for hours, especially if it is meal time. The staff make residents wait until trays are served and picked back up before they will change the residents. This resident also stated, Nurses only want to pass meds and won't help you get cleaned up either. Sometimes I wait for hours for someone to answer. On 03/06/23 at 12:43 PM, an anonymous resident stated that the…

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

Based on observation, resident interview, resident council meeting and staff interview, the facility failed to serve food which was palatable and appetizing in appearance. The failed practice had the potential to affect all residents currently receiving nutrition from the facility's kitchen. Resident identifiers: Resident #17, Resident #21, Resident #40, Resident #56 and Resident #5. Facility Census: 65. Findings Included: a) Resident #17 During the initial tour on 03/06/23 at 11:54 AM, Resident # 17 stated the food sucks, I eat the food that my friend brings me. You can not eat the food that is prepared here it is terrible. b) Resident #21 During the initial tour on 03/06/23 at 11:38 AM, Resident # 21 stated the food is bad, I am not offered a substitute if I don't like my meal. I just don't eat it. I have lost weight, because I don't eat. c) Resident #40 During the initial tour 03/06/23 at 11:29 AM, Resident # 40 stated the food is nasty, I am not offered a substitute if I don't like it I just don't eat. d) Resident Identifier #56 Resident interview on 03/06/23 at 12:43 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, resident interview, resident council meeting and previous minutes from resident council, the facility failed to provide Residents with evening snacks. This had the potential to affect more than a limited numbers of residents living in the facility that could receive snacks from the kitchen. Facility Census: 65. Findings Included: a) Nourishment Rooms During the tour of the Nourishment Room on 400 hall with the Account Manager (AM) on 03/07/23 at 8:13 AM the following snacks were reveled: -three (3) bags of chips left over from last night snack pass -eight (8) half sandwiches -pitches of purple drink, red drink and tea During the tour of the Nourishment Room on 200 hall with the AM on 03/07/23 at 8:18 AM the following snacks were revealed: -1 can of tomato soup -6 half sandwiches -a pitcher of grape drink During an interview on 03/07/23 at 8:19 AM the Account Manager (AM) stated I deliver the snacks between breakfast and lunch, that is just what is left over from snack pass last night. During an interview on 03/07/23 at 10:14 AM, the AM stated…

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 and staff interview, the facility failed to ensure foods were stored and prepared in a safe, clean, and sanitary environment. The facility failed to ensure kitchen equipment, kitchen area and ice machine were clean and sanitary in a manner in accordance with professional standards for food service safety. The facility also failed to correctly document temperatures for the dish machine. This failed practice had the potential to affect more than a limited number of residents currently receiving nourishment from the facility's kitchen. Facility Census: 65 Findings Included: a) The improper sanitization of kitchen equipment A review of a facility policy titled Equipment with a revised date 09/17 stated (typed a written): Procedures 1. All equipment will be routinely cleaned and maintained in accordance with manufacture's directions and training materials. 2. All staff members will be properly trained in the cleaning and sanitized after every use. 3. All food contact equipment will be cleaned and sanitized after every use. 4. All non food contact…

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 maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. The facility failed to place residents with active Multidrug-resistant organisms (MDRO) in Transmission Based Precautions (TBP) and provide proper hand washing practices during catheter care. Resident identifiers: R#4, #35, #22, #56, #1, and #117. Facility census 65. Findings included: a) Resident #4 While reviewing the line listing provided by the facility Infection Preventionist (IP), it was noted Resident #4 had extended-spectrum beta-lactamases (ESBLs) in urine on 12/11/22 and was being treated with antibiotic. Resident #4 was not placed in any type of TBP. aa) Resident #4 During an observation of catheter care on 03/07/23 at 1:25 PM, NA #42 provided catheter care for Resident # 4. While performing hand hygiene NA #42 failed to use a paper towel to turn off the sink. The above was also…

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 an effective pest control program so the facility is free of rodents. This was a random opportunity for discovery. This failed practice had the potential to affect more than a limited number of residents currently receiving nourishment from the facility's kitchen. Facility Census: 65. Findings Included: a) Kitchen Tour An initial tour of the kitchen with the Account Manager(AM) #77 beginning on 03/06/23 at 10:31 AM, revealed the following: - A sticky mouse trap with a piece of fudge cake was found in the dry storage area. - A sticky mouse trap with a piece of fudge cake was found beside an upright cooler. The AM stated, we have mice in the building, I just put the new sticky traps out this morning with fresh fudge cakes. - A shelf about the stove had small black rodent pellets. b) Staff Interviews During an interview on 03/06/23 at 11:00 AM, the Administrator stated we did have a mice issue, we have had the exterminator here every two weeks and we use the sticky traps. We have not seen any sign of mice 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on record review, resident interview and staff interviews, the facility failed to accurately complete the Minimal Data Set (MDS) assessment for dialysis services for one (1) of one (1) resident reviewed for the care area of dialysis, and for one (1) of one (1) resident reviewed for the care area of discharge, during the long term care survey. Resident Identifiers: #5 and #62. Census 65. Findings Included: a) Resident #5 On 03/06/23 an electronic record review found the quarterly MDS, with an Assessment Reference Date (ARD) of 02/09/23, section O, letter J, Dialysis was marked No, indicating the resident did not receive dialysis. The electronic record contained a physician's order for dialysis dated March 2021. On 03/06/23 at 1:05 PM, the resident said he has been receiving dialysis for years, including February of 2023. Staff interviews on 03/07/23 at 8:39 AM, with the minimum data set coordinators (#46 and #31), confirmed the MDS with the ARD of 02/09/23 was marked incorrectly on section O, letter J,…

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

Based on record review and staff interview, the facility failed to complete a new Pre admission Screening And Resident Review (PASARR) for a resident with a newly evident or possible serious mental disorder for one (1) of four (4) residents reviewed for the category of PASARR, during the long term care survey. Resident identifier #5. Census 65. Findings Included: a) Resident #5 On 03/07/23 the Director of Nursing (DON) was asked to provide the most recent PASARR for Resident #5. The DON presented a PASARR for resident #5, dated 09/10/10. The review of this PASARR, section III MI/MR (Mental Illness / Mental Retardation) Assessment, #30 Current Diagnosis, letter n. Other related conditions (Specify:), was answered, Adjustment Disorder. All other choices on this section were not checked. On 03/07/23 at 10:48 AM an electronic medical record review, finds the resident was diagnosed with the following diagnosis on the following dates: Major Depressive Disorder Single Episode on 02/02/11 Anxiety Disorder on 07/11/11 Psychotic Disorder with Hallucinations due to known Psychological…

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 pressure ulcer care and treatments consistent with the professional standards of care for one (1) of one (1) resident reviewed for the care area of pressure ulcers during the long term care survey process. Resident identifier: #1. Facility census: 65. Findings included: a) Resident #25 Record review found the resident was readmitted to the facility after a hospital stay on 03/04/23. Review of the progress notes found the following: 03/04/2023 00:32 Nursing Documentation Note General: Patient was admitted /readmitted for the following reason(s): Exacerbation of Respiratory Condition Therapy Infection Management of Diabetes Management of Renal Disease Pain Management readmission The pt. had been hospitalized for greater then 5 days Additional details about this note: Integumentary System reviewed Skin Check completed: resident is experiencing foot pain: Left foot pain- heel protector boot in place No skin injury/wound(s) were noted. On 03/06/23, two days after admission, a nurse completed a skin and wound…

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 catheter care with current professional standards of practice. This was true for one (1) of one (1) resident reviewed for catheter care. Resident identifier: #4. Facility census 65. Findings included: a) Resident #4 Observation on 03/07/23 at 1:25 PM, found nurse aide (NA) #42 providing catheter care for Resident #4. Observation found there was no anchor device on the resident to secure the Foley catheter and prevent accidental remover and/or tissue damage. NA#42 said she was told at the beginning of her shift Resident #4 needed a secure device. NA #42 cleansed the inside of the vagina and the buttock area. NA #42 failed to cleanse the Foley tubing. While performing hand hygiene NA #42 failed to use a paper towel to turn off the sink. The above was also witnessed by Registered Nurse (RN) #58. RN #58 said she will re-educate NA#42. .