Beckley Healthcare Center

Inspectors wroteBased on observation, record review, and staff interview, the facility failed to develop and/or implement residents' comprehensive care plans. This deficient practice affected four (4) of 33 residents reviewed in the long-term care survey sample. Resident identifiers: #93, #43, #15, and #1. Facility census: 138.

Inspectors wroteBased on observation, record review and staff interview the facility failed to ensure a resident who was dependent on staff for Activities Of Daily Living received the care they needed to maintain and/or attain the highest practicable physical, mental and psychosocial well being. Resident #15 was not provided assistance with eating as required. Resident #51 did not receive the assistance with bathing they required This was true for two (2) of four (4) residents reviewed during the long term care survey process. Resident Identifier: #15 and #51. Facility Census: 138.

Inspectors wroteBased on observation, record review, staff interview and resident interview the facility failed to ensure Resident #15 received care to enable them to maintain and or attain acceptable parameters of hydration and nutrition status. The facility failed to ensure Resident #15 had access to water and/or fluid of his preference at bedside and accessible at all times. In addition the facility has failed to provide Resident #15 with assistance with meals to ensure the best possible meal consumption. This is true for one (1) of six (6) residents reviewed for the care areas of hydration and/or nutritional status during the long term care survey process. Resident Identifier: #15. Facility Census: 138. a) Resident #15 a1) Hydration On 01/05/26 at 3:00 pm Resident #15 was observed in his bed with his lunch tray still present. No additional fluid other than what was on his tray was observed. [...]

Inspectors wroteBased on Record review and staff interview, the facility failed to ensure medications were administered in accordance with physician orders. Specifically, a resident was ordered lorazepam 0.5 mg every six (6) hours; however, the resident received lorazepam 2 mg per dose on seven (7) occasions. The facility failed to identify and correct the medication administration error in a timely manner. This failed practice represented a pattern of noncompliance and had the potential for more than minimal harm, as the resident received a dosage of lorazepam significantly greater than ordered on multiple occasions. The incorrect administration placed the resident at risk for adverse effects including excessive sedation, altered mental status, and respiratory depression. [...]

Inspectors wroteBased on record review and staff interviews, the facility failed to ensure accurate and complete medical records for the five (5) of 33 residents. Resident #73, 1:1 documentation incorrect, Resident #149's post-event form was missing, and a fall assessment time was incorrect. Resident #6's feeding and water flush entries were mixed up. Resident #12's weights recorded incorrectly, and Resident #8's readmission assessment missed the identification of wounds. This was found true for five (5) of 33 residents' medical records being reviewed during the long-term care survey process. Resident identifiers: #73, #149, #6, #12, and #8. Facility census: 138.a) Resident #73 Record Review: On 01/07/26, review of Resident #743's activity participation records showed no documentation of 1:1 visits. [...]

Inspectors wroteBased on record review and staff interview, the facility failed to ensure appropriate information was communicated to the receiving healthcare institution when a resident was transferred to the hospital in order to ensure a safe and effective transition of care. This deficient practice had the potential to affect one (1) of seven (7) residents reviewed for the care area of hospitalization. Resident Identifier: #8. Facility census: 138.

Inspectors wroteBased on record review, observation and staff interview the facility failed to ensure Resident #9 who was fed by enteral means received the enteral feeding in accordance with the physician's orders. This was true for one (1) of two (2) residents reviewed for the care area of Tube Feeding during the long term care survey process. Resident Identifier: #9. Facility Census: 138. Findings Include: a) Resident #9 A review of Resident #9's medical record on 01/07/26 found the following physician orders: -- Enteral feed order in the morning turn off tube feeding at 8:00 am if the total volume of 1400 ml has infused, clear pump and document total. The start date of this order was 09/26/25 and was the current order at the time of this review. -- Enteral Feed order one time a day Jevity 1.5 at 70/ml/hr. via enteral pump start time 12:00 pm and run until 1400 Ml has been infused. [...]

Inspectors wroteBased on observation, record review, and staff interview, the facility failed to ensure oxygen was administered according to physician orders. This deficient practice was identified as a random opportunity for discovery. Resident Identifiers: #149 and #8. Facility census: 138.

Inspectors wroteBased on resident interview, staff interview, record review, and observations the facility failed to ensure one resident received timely, consistent, and effective pain management in accordance with physician orders, and resident assessments, This practice was found true for one (1) of two (2) resident's reviewed for pain. Resident identifier: #149. Facility Census: 138.a) Resident #149On 01/06/2026 at 9:39 AM, Resident #149 reported uncontrolled pain and stated: They don't give me my pain medication. I hurt. The resident reported having cancer and stated he may have three (3) to four (4) months left to live. The resident expressed a desire to read his Bible and get closer to the Lord, but stated his pain prevented him from doing so. [...]

Inspectors wroteBased on observation, record review, and staff interview, the facility failed to have a system to account for the receipt, usage, disposition, and reconciliation of all controlled medications. This was a random opportunity for discovery. Resident identifier: #21. Facility census: 138.

Inspectors wroteBased on observation, record review, and staff interview, the facility failed to ensure medications were labeled properly. A multi-dose vial of insulin had two (2) different dates to indicate when the vial had been opened and two (2) different dates to indicate when the vial would expire. This was a random opportunity for discovery. Resident Identifier: #90. Facility Census: 138.

Inspectors wroteBased on record review and staff interview, the facility failed to offer the pneumococcal vaccination to Resident #4. This was true for one (1) of five residents reviewed under the care area of infection control. Resident Identifier: #4. Facility Census: 138. Findings Include: a) Resident #4 On 01/05/26 at 2:30 PM, a record review was completed for Resident #4. The review found Resident #4 was eligible for a pneumococcal 20 vaccination in 09/2025. However, the resident was not offered the pneumococcal vaccination. On 01/06/26, at 1:30 PM, Corporate Nurse #220 confirmed the vaccination was not offered to the resident.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure enteral (tube) feeding was provided in accordance with professional standards of practice. Documentation of the amount of enteral feeding infused was not accurately recorded. This deficient practice had the potential to affect (2) of (2) residents reviewed for the care area of tube feeding. Resident identifiers: #1 and #8. Facility census: 139.

Inspectors wroteBased on observation, staff interview, the facility failed to ensure that baking pans were stored in a sanitary manner by stacking them while still wet (wet nesting). This practice had the potential to contaminate food-contact surfaces and cause foodborne illness. This failed practice had the potential to affect more than a minimal number of residents residing in the facility. Facility census: 139.

Inspectors wroteBased on observation and staff interview, the facility failed to ensure safe infection control practices were followed to prevent the spread of diseases and infections. This was a random opportunity for discovery and has the potential to affect more than a limited number of residents. Facility Census: 139. a) Ice Chest On 9/08/25 at 3:30 PM an observation of the ice chest on F wing of the facility found the scoop for the Ice was stored in the chest with the clean Ice. An immediate interview with Registered Nurse #300 confirmed the scoop was not stored properly to prevent the spread of infection.

Inspectors wroteBased on record review and staff interview the facility failed to ensure Resident #151's physician orders reflected her wishes concerning the end of life care. This was true for one (1) of five (5) residents reviewed for the care area of advance directives during the long term care survey process. Resident identifier: #151. Facility census: 139. a) Resident #151 A review of Resident #151's medical record on [DATE] found a Physician Orders for Scope of Treatment (POST) form which was completed by the resident on [DATE] and signed by the Nurse Practitioner on [DATE]. On this form Resident #151 indicated she did not want Cardiopulmonary Resuscitation (CPR) should her heart stop. She also indicated she would want full intervention prior to her heart stopping. Further review of the medical record found a physician's order dated [DATE] which read CPR. [...]

Inspectors wroteBased on record review, staff interview and policy review the facility failed to implement their Abuse Prohibition policy in regards tot he reporting of neglect. This was a random opportunity for discovery and was true for Resident #145. Resident Identifier: #145. Facility Census: 139. a) Policy Review A review of the facility's policy titled, Abuse, Neglect, and Misappropriation found the following pertaining to the identification and reporting of abuse: IV Identification of Incidents and allegations 1. The accurate and timely identification of any even which would place our residents at risk is a primary concern of the facility. 2. The following procedures will assist the staff in the identification of incidents and direct them to the appropriate steps of intervention. a. [...]

Inspectors wroteBased on record review and staff interview the facility failed to identify and report a situation of potential neglect. This was a random opportunity for discovery found during the long term care survey process. This was true for Resident #145. Resident Identifier: #145. Facility Census: 139. a) Resident #145 Resident #145 was selected as a closed record review for the care area of hospitalization during the long term care survey process. A record review completed during the investigation of this care area found the resident was sent to the emergency room (ER) on 07/18/25. The transfer form completed by the facility indicated the resident was sent to the local hospitals ER at 1:10 pm on 07/18/25. The reason for the transfer was listed as, unresponsive. [...]

Inspectors wroteBased on resident interview, record review, and staff interview, the facility failed to ensure a complete and accurate Minimum Data Set (MDS) assessment in the area of dialysis for one (1) of one (1) residents reviewed for the care area of dialysis. Resident Identifier: #135. Facility census: 139.

Inspectors wroteBased on record review, observation and staff interview the facility failed to ensure Resident #16's care plan in regards to falls was implemented. This was true for one (1) of five (5) residents reviewed for the care area of accidents during the long term care survey process. Resident Identifier; #16. Facility Census: 139. a) Resident #16 A review of Resident #16's medical record found the following care plan: Focus Statement (First Name of Resident #16) has had falls and is at risk for further falls secondary to dementia with severe impaired cognitive function, unsteadiness on feet, muscle weakness, episodes of incontinence, difficulty hearing, episodes of pain. (Resident #16) has hypertension, panic disorder, anxiety, osteoarthritis, anemia, depression, hx of CVA. She has use of medications that carry side effects that increase risk for falling. Resident has poor safety awareness. [...]

Inspectors wroteBased on observation, record review and staff interview, the facility failed to store medications in accordance with accepted standards of practice. A multiuse vial of Tuberculin Purified Protein Derivative was not dated when opened. Facility census: 139.

Inspectors wroteBased on record review and staff interview the facility failed to notify Resident #114's attending physician of a urine culture which identified the resident of having ESBL in her urine. This was true for one (1) of five (5) residents reviewed for the use of a catheter during a complaint survey. Resident identifier: #114. Facility Census: 145. a) Resident #114 A review of Resident #114 medical record found since 01/01/25 Resident #114 had two (2) urine cultures ordered. The first was ordered on 02/26/25 and was obtained on 02/28/25 as directed by the order. A review of the results for this urine culture found the following, .ATTN. ESBL !!! Follow Contact Precautions. The results of this culture were verified on 03/03/25 and had a print date and time of 03/04/25 at 6:03 am. Handwritten on the lab result was the following, 03/18/25 5:30 PM DR. [...]

Inspectors wroteBased on observation, and staff interview the facility failed to ensure they implemented their infection control policy to prevent the spread of disease. This was found during the investigation of a complaint and had the potential effect more than an isolated number of residents currently residing in the facility. Resident Identifier: #32. Facility Census: 45. Findings Include: a) Resident#32 At approximately 3:15 PM on 06/16/25, Nurse Aide #1 and Nurse Aide #3 was observed entering the room of Resident #32. Nurse Aide #1 was overheard telling Resident #32 they were going to assist her to bed. On Resident #32's door was a sign which indicated someone in the room was ordered enhanced barrier precautions. Beside Resident #32's name on the name plate of the room was a yellow sticker. The yellow sticker identified which of the two residents in the room was ordered EBP. [...]

Inspectors wroteBased on record review and staff interview the facility failed to thoroughly investigate all allegations of neglect thoroughly. This was true for one (1) of 10 reportable incidents reviewed. Resident Identifier: #19. Facility Census: 144. Findings Include: a) Resident #19 A review of a facility reported incident dated 05/22/25 revealed Resident #19's sister had alleged the resident left the facility for a medical appointment and was dirty (socks had not been changed for several days and he was not cleaned up for his appointment). The facility reported the incident involving Resident #19 immediately when it was brought to their attention by the resident's sister. The investigation was reviewed. Statements were taken from the staff who were working with the resident prior to him leaving for his appointment. They indicated the resident was clean and dry when he left the facility. [...]

Inspectors wroteBased on record review and staff interview the facility failed to ensure Resident #114's lab work was addressed and acted upon timely. In addition the failure to treat the Urinary Tract Infection (UTI) identified by the lab testing caused a delay in Resident #114 receiving a required procedure to remove kidney stones. This was true for one (1) of five (5) residents reviewed for the use of a catheter during a complaint survey. Resident #114. Facility Census: 145. a) Resident #114 A review of Resident #114 medical record found since 01/01/25 Resident #114 had two (2) urine cultures ordered. The first was ordered on 02/26/25 and was obtained on 02/28/25 as directed by the order. A review of the results for this urine culture found the following, .ATTN. ESBL !!! Follow Contact Precautions. [...]

Inspectors wroteBased on record review, observation, and staff interview the facility failed to ensure the resident environment was as free from accident hazards as possible. This was true for Resident #1 and was a random opportunity for discovery. Nurse Aide (NA) #20 and NA #21 had completed Resident#1's shower. They returned her to the hall and without surveyor intervention NA #20 and NA #21 would have used the total mechanical lift as a transport device to transport Resident #1 from the hallway to her bed which was by the window in her room. The surveyor intervened and prevented this from happening due to the risk of serious harm and/or death associated with using the lift as a transport device. The State Agency (SA) determined this practice placed Resident #1 in an immediate jeopardy (IJ) situation. The facility was notified of the IJ at 6:49AM on 05/19/25. [...]

Inspectors wroteBased on observation and staff interviews, the facility failed to ensure Resident #2 was treated with respect and dignity. This was a random opportunity for discovery. Resident identifier: #2. Facility Census: 145.

Inspectors wroteBased on record review, resident representative interview, and staff interview, the facility failed to allow the resident's representative to make decisions regarding the resident. This was true for one (1) of one (1) resident reviewed for the care area of elopement. The incident was determined to be past non-compliance. The incident occurred on 12/25/24. Staff education to prevent reoccurrences of the incident was completed on 04/07/25. Resident identifier: #78. Facility Census: 145.

Inspectors wroteBased on record review and resident, staff, and family interview, the facility failed to report an allegation of abuse against Resident #48. This was true for one (1) of seven (7) residents reviewed for abuse during the survey process. Resident identifier: 48. Facility census: 145.

Inspectors wroteBased on resident interview, record review and staff interview the facility failed to ensure Resident #139 received proper treatment and assistive devices to maintain vision and hearing abilities. This was true for one (1) of one (1) resident reviewed for the vision and hearing care area during the long-term care survey. Resident identifier: #139. Facility Census: 145. Findings Include: a) Resident #139 During an interview with Resident #139 on 04/07/25 at 1:14 pm she stated that she needed new glasses, and she had been waiting a long time to get them, and she did not understand why it was taking so long. An interview with Social Worker #51 on 04/09/25 in the morning found the resident had seen the eye doctor on 01/28/25. Social Worker #51 stated, (Name of the eye doctor) is old school and he mailed the consults back. [...]

Inspectors wroteBased on observation, record review, and staff interview, the facility failed to follow the physician-prescribed therapeutic diet for one (1) of 14 residents reviewed for the care area of food. Resident identifier: #78. Facility census: 145.

Inspectors wroteBased on record review and staff interview, the facility failed to maintain an accurate medical record pertaining to a diagnosis. This was true for 1 (one) of 38 (thirty-eight) records reviewed during this survey process. Resident identifier: #118. Facility census: 145.

Inspectors wroteBased on observation and resident, family, and staff interviews, the facility failed to deploy sufficient nursing staff to meet the needs of the residents residing there. This has the potential to affect more than a limited number of residents. Resident identifiers: #139, #23, #6. Facility census: 181.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure the environment remains as free of accident hazards as is possible and that each resident receives adequate assistance and devices to prevent accidents. put proper interventions in place to prevent falls with injury for Resident #93, such as upon return from hospitalization status post fall, therapy determined Resident #93 needed maximum assistance with transfers however Resident #93's independent functional status for transfers. This is true for (5) five of seven (7) residents reviewed for falls during the survey process. Resident identifier: Resident #93,#163, #240, #88, and #141. Facility census: 181.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure Resident #61 was free from abuse which includes freedom from physical restraints to restrict movement. This is true for one (1) of one (1) residents reviewed during the survey. This will be cited as past non compliance because the facility identified what had happened and took immediate steps to correct the failure to ensure it does not reoccur. All components of the of plan of correction were completed prior to this survey beginning. This did occur and because Resident #61 did not have the cognitive ability to indicate how this affected her the reasonable person standard was applied. A reasonable person would suffer psychosocial harm from being tied to a chair and being unable to move against their will therefore this will be cited as actual harm at past non compliance. Resident Identifier: #61. Facility Census: [...]

Inspectors wroteBased on record review and staff interview, the facility failed to ensure Resident #61 was free from restraints, which includes freedom from physical restraints to restrict movement. This is true for one (1) of one (1) residents reviewed during the survey. This will be cited as past non compliance because the facility identified what had happened and took immediate steps to correct the failure to ensure it does not reoccur. All components of the of plan of correction were completed prior to this survey beginning. This did occur and because Resident #61 did not have the cognitive ability to indicate how this affected her the reasonable person standard was applied. A reasonable person would suffer psychosocial harm from being tied to a chair and being unable to move against their will therefore this will be cited as actual harm at past non compliance. Resident Identifier: #61. [...]

Inspectors wroteBased on record review and staff interview the facility failed to develop and implement the individualized comprehensive care plan. This was true for five (5) of twelve (12) residents reviewed for history of illicit drug usage. Resident Identifiers: Resident #40, #52, #70, #91, and #93. Facility Census: 195. Findings Include: a) Resident #40 On 04/15/24 at approximately 10:00 AM during a review of the facility identified residents with a diagnosis of illicit drug use, Resident #40 was identified to have a diagnosis of other psychoactive substance abuse in remission, onset of 08/23/23. During a review of Resident #40's care plan dated 08/24/23, it was identified that the facility failed to develop or implement an individualized comprehensive care plan for this diagnosis. [...]

Inspectors wroteBased on observation, record review and staff interview, the facility failed to maintain appropriate infection control standards during a COVID-19 outbreak. This failed practice had the potential to affect more than an isolated number of residents. These were random opportunities for discovery. Facility Census: 195. Findings Include: Upon arrival to the facility on [DATE] at 9:30 PM, Receptionist #8 advised the surveyors the facility was in a COVID outbreak. Receptionist #8 stated, everyone has to wear a surgical mask while in the facility. The Administrator confirmed the COVID outbreak began on 04/04/24. On 04/16/24 at approximately 10:45 AM, a tour of the facility units was conducted. During the tour of the units, nurses' station 1 (one) was approached at approximately 11:10 AM. Two (2) employees were observed with their surgical masks pulled down below their noses. [...]

Inspectors wroteBased on observation and staff interviews the facility failed to provide a safe, clean comfortable, and homelike environment. A resident room door entrance rubber threshold was partially unadhered from floor and presenting a trip hazard. Room Identifier #E9. Census: 195. Findings Include: During a tour of the facility on 04/16/24 at approximately 12:29 PM the rubber threshold at the door entrance of Room #E9 was observed to be partially unadhered from the floor and laying out in the egress presenting a trip hazard. During an interview with Maintenance Technician (MT) #106 on 04/16/24 at approximately 12:30 PM, he agreed this presented a trip hazard and began to repair the rubber threshold.

Inspectors wroteBased on policy review, staff interview, and record review, the facility failed to protect from neglect after a fire on 02/24/24 and after illegal drug activity was identified. Both situations created immediate jeopardy for more than a limited number of residents. Fire Local media reported a structure fire at the facility on 02/24/24. The facility also reported the fire by fax to the State Agency (SA) on 02/25/24. A total of 18 minutes elapsed from the time the fire alarm activated on the A-Wing, and the time the facility began to evacuate residents. The facility failed to identify the need to evacuate residents in a timely manner. They only began the evacuation of the residents after they were told to do so by emergency responders. [...]

Inspectors wroteBased on policy review, staff interview, and record review, the facility failed to ensure the resident environment remained as free of accident hazards as is possible and that each resident received adequate supervision and assistance to prevent accidents. A structure fire resulted in the activation of the facility fire alarm system. The facility staff did not begin evacuation after seeing smoke and hearing the fire alarm system. Two (2) residents were using illegal substances inside the facility. These substances include opiates that were not prescribed. The residents required Narcan due to overdose. Fire A total of 18 minutes elapsed from the time the fire alarm activated on the A-Wing, and the time the facility began to evacuate. The facility did not begin to evacuate until told to do so by emergency responders. [...]

Inspectors wroteBased on observation and staff interview, the facility failed to ensure each resident was afforded the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences. The call light system device was not accessible for a resident while in bed. This was a random opportunity for discovery and was true for Resident #109. Resident identifier: # 109. Facility Census: 191.

Inspectors wroteBased on observation and staff interviews, the facility failed to provide a safe, clean, comfortable, and homelike environment. A closet door was broken, and a Packaged Terminal Air Conditioner (PTAC) unit had several broken grids on top of the unit. This was a random opportunity for discovery. Room identifiers: #C11 and #G7. Facility Census:

Inspectors wroteBased on record review and staff interview the facility failed to implement the individualized comprehensive care plan. This was true for two (2) of four (4) resident care plans reviewed for wound care. Resident Identifier: #30 and #201. Facility Census:

Inspectors wroteBased on record review and staff interview the facility failed to revise the individualized comprehensive care plan. This was true for one (1) of four (4) resident care plans reviewed for wound care. Resident identifier: #65. Facility Census: #191 a) Resident #65 On 02/27/24 at 9:30 AM, a record review for Resident #65 found an active order to cleanse stage 4 to sacrum with in house wound cleanser (IHWC), pat dry, apply santyl, mupirocin, Hydrofera blue, and cover with border dressing every Tuesday, Thursday, Saturday and PRN as needed. The facility Skin Care and Wound Management Policy #NS 1400-00 stated: The facility staff strives to prevent resident/patient skin impairment and to promote the healing of existing wounds . [...]

Inspectors wroteBased on record review and staff interview the facility failed to provide treatment and services to prevent or heal pressure ulcers in accordance with professional standards of care. This was true for three (3) of four (4) residents reviewed for wound care. Resident identifiers: #30, #65 and #201. Facility Census:

Inspectors wroteBased on staff interviews and medical record review, the facility administration (Administrator and Director of Nursing) who knew illegal drugs were being used and brought into the facility, failed to administer the facility in such a manner as to protect other residents and promote their highest practicable level of mental and physical well-being. In addition, two (2) residents had to be administered Narcan and sent to the local hospital after using illegal drugs. Resident identifiers: #300 and #301. Facility census: 191.

Inspectors wroteBased on observation and staff interview, the facility failed to ensure the resident call system was operable. This was a random opportunity for discovery. Resident identifier: #125. Facility census: 191.

Inspectors wroteBased on observation and staff interview, the facility failed to provide a safe, clean, comfortable, and homelike environment, by failing to maintain a sanitary, orderly, and comfortable interior. This has the potential to affect more than a limited number of residents. This was a random opportunity for discovery. Rooms: A1,A2,A3,A13, B10, C7, D1, D5, E4 E6, E14, E15,F2 ,G1, G3, G Hallway . Facility census:

Inspectors wroteBased on observation, record review, and staff interview, the facility failed to ensure the resident environment remains as free of accident hazards as possible, by failing to keep treatment carts locked when they were not in use and out of sight of nursing staff. The had the potential to affect more than a limited number of residents. This was a random opportunity for discovery. Facility census:

Inspectors wroteBased on observation and staff interview, the facility failed to maintain appropriate infection control standards for the storage of a urinary drainage bag for Resident #142, not placing gloves on while preparing a sandwich for Resident #69, and failure to complete hand hygiene during medication administration for Resident #85 and placing a dirty food tray for Resident #142 back on the clean food cart. This was a random opportunity for discovery. Resident identifiers: #142, #69, #85 and #142. Facility Census: 199.

Inspectors wroteBased on observation and staff interview, the facility failed to treat each resident with dignity and respect by failing to serve meals to Residents #58 and #108 at the same time. Residents #58 and #108 were roommates. This was true for two (2) of two (2) residents observed for dignity and respect. This was a random opportunity for discovery. Resident identifiers: #58, #108. Facility census:

Inspectors wroteBased on record review and staff interview, the facility failed to notify the Medical Power of Attorney (MPOA) of a new physician's order for medication for Resident #54. This was true for one (1) of 12 residents reviewed during the survey process. Resident Identifier: #54. Facility Census:199. Findings Included: On 01/08/24 at 1:00 PM, a list of the facility reportables were reviewed. The review found a reportable dated 01/04/24 regarding Resident #54 stating,Healthcare Surrogate reports that facility gave incorrect medication and that facility is creating unnecessary emergency room visits. (Typed as written.) Upon reviewing the current physician's orders, the medication Trazodone (antidepressant) was restarted on 01/05/24 when the resident returned from hospital leave. However, the physician's determination of capacity for Resident #54 was completed on 12/21/23. [...]

Inspectors wroteBased on record review and staff interview, the facility failed to develop a comprehensive care plan regarding dialysis for Resident #45 and a new medication for Resident #54. This was true for two (2) of 12 residents reviewed during the survey process. Resident identifiers: #45 and #54. Facility Census: 199.

Inspectors wroteBased on observation, record review, and staff interview, the facility failed to ensure the care plans of Residents #4 and #164 were followed or revised to reflect dialysis orders and to address meals while at dialysis. The facility failed to ensure proper equipment was available for residents based on care plans and dialysis orders. This was true for two (2) of two (2) residents reviewed for care plans. Resident identifiers: 4, 164. Facility Census: 199 A) Resident #4 On 01/08/24 at approximately 2:00 PM, a record review was conducted for Resident #4. The review indicated there were no orders for a meal while at dialysis, even though the care plan indicates they should get a meal on Tuesdays, Thursdays, and Saturdays for dialysis appointments. [...]

Inspectors wroteBased on record review and staff interview, the facility failed to follow physician's orders regarding medication administration for Resident #53, #54, and #108. This was true for three (3) of three (3) residents reviewed during the complaint survey. Resident identifiers: #53, #54, #108. Facility census: 199.

Inspectors wroteBased on observation and staff interview, the facility failed to maintain professional standards of care for residents receiving dialysis. This was true for three (3) of three (3) residents reviewed under the care area of dialysis. Resident Identifiers: #4, #164 and #45. Facility Census: 199. Findings Included: a) Resident #4 On 01/09/24 at 11:30 AM, a record review was completed for Resident #4. The review found the resident received renal dialysis weekly on Tuesday, Thursday, and Saturday at 11:45 AM. The review also, found the resident had a port for dialysis and not an arteriovenous (AV) fistula. Resident #4 was interviewed on 01/10/24 at 9:00 AM. The resident was asked do they always keep hemostats available in case of an emergency. The resident responded, I have never seen any. [...]

Inspectors wroteBased on observation, record review and staff interview, the facility failed to maintain professional standards of practice during medication administration. These were random opportunities for discovery. Resident identifiers: #163, #161 and #28. Facility Census: 199.

Inspectors wroteBased on observation and staff interview, the facility failed to ensure the call lights were within reach of Resident #92, #129 and #108 for safety measures. These were random opportunities of discovery. Resident identifiers: #92, #129 and #108. Facility Census: 199.

Inspectors wroteBased on record review, and staff interview the facility failed to ensure Resident # 196 who was discharged from the facility with the expectation of returning to the facility was readmitted to the first available bed. Resident #196 was sent to a local psychiatric hospital on [DATE]. When he was stabilized and ready to be discharged back to the facility the facility denied his readmission stating they could not handle his behavioral problems. This failed practice resulted in actual harm to Resident #196 who suffered increased frustration, irritability, and depression related to not being allowed to return to the facility and having to remain a patient at the psychiatric hospital for a prolonged period of time. This was true for one (1) of three (3) discharged residents reviewed during a complaint survey. Resident Identifiers: #196. Facility Census: 191. Findings Include: [...]

Inspectors wroteBased on observation and staff interview, the facility failed to provide a dignified dining experience for Resident #160. This was a random opportunity for discovery. Resident Identifier: #160. Facility Census: 191. Findings Included: a) Resident #160 On 11/27/23 at 1:00 PM, Resident #160 was lying in bed. Licensed Practical Nurse (LPN) #170 was observed standing while feeding Resident #160. On 11/27/23 at 3:55 PM, the Director of Nursing (DON) was notified and confirmed the staff should not be standing while feeding a resident. No further information was obtained during the survey process.

Inspectors wroteBased on observation and staff interview, the facility failed to maintain appropriate infection control standards for the disposal of soiled linen. This was a random opportunity for discovery. Resident Identifier: #50. Facility Census: 191. Findings Included: a) Resident #50 On 11/28/23 at 9:13 AM, soiled linens were observed laying on the floor next to bed F-12A. On 11/28/23 at 9:15 AM, Nurse Aide (NA) #129 confirmed the soiled linens were laying on the floor. NA #129 stated, I'm getting ready to pick them up. On 11/28/23 at approximately 9:20 AM, the Director of Nursing (DON) was notified and confirmed soiled linens should not be on the floor. No further information was obtained during the survey process.

Inspectors wroteBased on record review, and staff interviews the facility failed to ensure two (2) of Resident #193 and Resident #194 received care and services in accordance with professional standards of practice, to ensure their highest practicable level of well-being. Resident #193 sustained physical harm when the facility failed to ensure a resident was properly assessed for care needed after an incident involving her foot. In addition, the facility failed to ensure Resident #194's orthopedic surgeon was contacted before providing treatment to a surgical wound created by the surgeon. Resident identifiers: #193. Census: 192.

Inspectors wroteBased on observation and staff interview the facility failed to ensure a safe, functional, sanitary environment for residents. This had the potential to affect more than an isolated number of residents. Resident identifiers: #31, #53, and #56. Facility census: 192.

Inspectors wroteBased on observation, care plan review and minimum data set review the facility failed to ensure residents who needed assistance with activities of daily living (ADLs) received the assistance needed for good grooming and hygiene. Resident identifiers: #76, #129, #68, and #145, and #165. Facility census: 92.

Inspectors wroteBased on interviews and observations the facility failed to make sure all scales in the building were calibrated to measure residents' weights. In the areas of Hall B and E areas of the facility. This affected 192 residents. Census:

Inspectors wroteBased on observation and staff interview the facility failed to ensure they had sufficient dietary staff to support the functions of the dietary department. This had the potential to affect residents on oral diets. Facility census: 192.

Inspectors wroteBased on observations and interviews the facility failed to adhere to the standard infection control guidelines such as hand hygiene and resident hygiene. This affected 192 residents. Census:

Inspectors wroteBased on observations and interview the facility failed to maintain all patient care equipment in safe operating condition. This practice had the potential to affect more than an isolated number of residents. Census: 192.

Inspectors wroteBased on observation and staff interview the facility failed to ensure residents were treated with dignity and respect. Observations were made of an that related to not respecting a residents dignity. This was a random opportunity for discovery. Resident identifier: #37. Facility census: 192.

Inspectors wroteBased on record review and interview the facility failed to notify the resident's change of condition to the physician. This affected one (1) out of six (6) residents. Resident identifier: #195. Census 192.