Marmet Center

Inspectors wroteBased on record review and staff interview, the facility failed to designate a qualified Infection Preventionist. This deficient practice had the potential to affect all residents residing in the building. Facility Census: 88.

Inspectors wroteBased on record review, resident interview, and staff interview. The facility failed to develop and implement a comprehensive care plan for activities. This was found during the Long Term Care Annual Survey process. (Facility census 88) (Resident indicators, #2, and #12.) c1) Resident #69 - AIMS The facility's policy titled, Behaviors: Management of Symptoms, with an effective date of 08/01/99 and a revision date of 09/15/25, stated the Abnormal Involuntary Movement Scale (AIMS) would be completed per nursing schedule for patients receiving antipsychotic medications. Review of Resident #69's comprehensive care plan showed the following focus, Resident is at risk for complications related to the use of psychotropic drugs for schizophrenia. Antipsychotic and antidepressant medications. The focus was initiated on 09/23/19 and revised on 01/11/24. [...]

Inspectors wroteBased on record review, staff interviews, and policy review the facility failed to provide care and services within accepted standards of practice. Timely and consistent Abnormal Involuntary Movement scale (AIMS) assessments were not completed, and they failed to monitor peripheral intravenous (IV) access. This deficient practice applied to five (5) four of (5) five residents reviewed for unnecessary medication and (1) one of (1) one residents for antibiotic usage during the Long-Term Care Survey Process. Resident identifiers: #76, #69, #56. Facility Census: 88. Findings Include: a) Resident #76 A record review on 04/21/26 at 10:41 AM, showed Resident #76 was prescribed Zyprexa from 07/10/23 to 09/20/25. Further record review found that the only AIMS assessment completed for Resident #76 was on 01/10/24. [...]

Inspectors wroteBased on record review and staff interview, the facility failed to document the percentage of a house supplement a resident consumed when that resident was experiencing weight loss. This deficient practice had the potential to affect one (1) of seven (7) residents reviewed for the care area of nutrition. Resident Identifier: #29. Facility Census: 88.

Inspectors wroteBased on observation, record review and staff interview, the facility failed to store and label medications within accepted standards of care. A multi-use vial of Purified protein derivative (PPD) was not dated when accessed. Multi-use insulin pens were not discarded when they expired and were not dated when they were first opened. These deficient practices were discovered during investigation for the medication storage and labeling facility task. Resident Identifiers: #59, #44, #32, and #6. Facility census: 88.

Inspectors wroteBased on observation, resident interviews and staff interview. The facility failed to ensure meals were served in an appealing manner for residents to consume. This was found during the Annual Long Term Care survey. (Resident indicators # 2,16, 24,and47) (Facility census 88)

Inspectors wroteBased on observation, and staff interviews. The facility failed to ensure meals were served in a sanitary manner to prevent potential foodborne illness, and that equipment was kept clean. This was found during the Annual Long Term Care Survey and had the potentail to affect all residents who received nutrition from the kitchen. Facility Census: 88.

Inspectors wroteBased on observation, record review, and staff interview, the facility failed to maintain an infection prevention and control program designed to help prevent the development and transmission of communicable diseases and infections. The facility failed to perform appropriate infection surveillance, which had the potential to affect more than a limited number of residents. Also, the facility failed to ensure enhanced barrier precautions were followed during one (1) of one (1) dressing change observations. Additionally, the facility failed to store bedpans appropriately. This was a random opportunity for discovery. Resident Identifiers: #42 and #30. Facility Census: 88.

Inspectors wroteBased on record review, resident interviews, and staff interviews, the facility failed to ensure residents had a choice in room assignments and that they were notified of the room change in a timely manner. This failed practice was found true for (1) one of (4) four residents reviewed for choices during the Long-Term Care Survey Process. Resident identifier #63. Facility Census: 88. Findings Include:a) Resident #63A review on 04/23/25 at 10:00 AM, of the facilities room moves for the last month, revealed that (8) eight residents had room changes indicated as clinical need. Further record review showed that Resident #63 who has a Brief Interview for Mental Status (BIMS) of 14, was moved from room A3 B to room D32 A.During an interview on 04/22/26 at 11:20 AM, Resident #63 stated, I was not told the reason my room was changed. [...]

Inspectors wroteBased on record review, and staff interviews the facility failed to document behavioral monitoring and the effectiveness of non-pharmacological interventions for Resident #69, who was receiving psychotropic medications. Additionally, the facility failed to ensure Resident #10 was not overly medicated, which caused drowsiness and restraint. This failed practice was found true for one (1) of five (5) residents reviewed for unnecessary medications during the Long-Term Care Survey Process. Resident identifier: #69. Facility Census: 88. a) Resident #69 The facility's policy titled, Behaviors: Management of Symptoms, with effective date 08/01/99 and review date 09/15/25, stated as follows: - Staff will observe and monitor for behavioral symptoms and document these symptoms in the medical records. - Individualized, person-centered, non-pharmacologic interventions would be implemented. [...]

Inspectors wroteBased on record review and staff interview, the facility failed to ensure complete and accurate Minimum Data Set (MDS) assessments. This deficient practice had the potential to affect one (1) of three (3) residents reviewed for the care area of resident assessment and one (1) of five (5) residents reviewed for the care area of unnecessary medications. Resident Identifiers: #7 and #69. Facility census: 88.

Inspectors wroteBased on observation, record review, and staff interview the facility failed to ensure that the administration of enteral nutrition is consistent with and follows physician orders. This failed practice was found true for (1) one of (2) residents reviewed for the care area of tube feeding during the Long-Term Care Survey Process. Resident identifier #59. Facility Census: 88. a) Resident #59A record review on 04/19/26 at 11:30 PM, revealed an order for Resident #59 that read as follows:One time a day Isosource 1.5 @60ml/hr X18 hrs. Volume 1080ml. Instructions for the 18-hour tube feeding were to start at 12:00 PM, and end at 6:00 AM.An observation on 04/19/26 at 12:10 PM, found Resident #59 asleep in bed. No tube feeding was being administered. [...]

Inspectors wroteBased on observation, record review, and staff interview, the facility failed to ensure a resident received double entree portions as ordered by the facility. This was a random opportunity for discovery. Resident Identifier: #69. Facility Census: 88.

Inspectors wroteBased on record review and staff interview, the facility failed to administer COVID-19 vaccinations in accordance with professional standards of care. This deficient practice had the potential to affect one (1) of five (5) residents reviewed for the care area of COVID-19 vaccination. Resident Identifier: #1. Facility Census: 88.

Inspectors wroteBased on interviews conducted and observation, the facility failed to maintain a safe, functional, sanitary, and comfortable environment. This practice had the potential to affect more than an isolated number of residents. Facility census 89.

Inspectors wroteBased on observation, document review, and staff interviews, the facility failed to ensure they stored food in accordance with professional standards for food quality. The facility failed to maintain proper refrigerator temperatures of the refrigerator located in the Rehab pantry room. This deficiency has the potential to affect more than an isolated number of residents, staff and visitors within the Facility census: 84.

Inspectors wroteBased on observation and staff interviews, the facility failed to maintain a sanitary environment related to gnats and a damaged countertop located in the Rehab pantry room. This deficiency has the potential to affect more than an isolated number of residents. Facility census: 84.

Inspectors wroteBased on observation, policy review and staff interview the facility failed to establish and 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. This had the potential to affect more than an isolated number of residents. Facility census: 88. Findings Include: a) Upon entry of the facility on 02/03/25 there was a sign in place on the main entrance door that indicated the facility was in a COVID outbreak. This was confirmed with the Administrator. On 02/03/25 at 12:20 PM Nurse Aides #40 and #51 were seen on C Hall with their N-95 mask off their face and down under their chin. According to the facility policy for Infection Control (IC405 COVID-19) revision date of 07/01/24 under General Standard Precautions: [...]

Inspectors wroteBased on observation, record review, resident interview and staff interview the facility failed to provide a dignified and respectful existence for Resident #84. This was true for one (1) resident of one (1) residents reviewed during the survey process. Resident identifier: #84. Facility census: 88.

Inspectors wroteBased on record review and staff interview, the facility failed to report two (2) changes in conditions for reasonable suspicion of a crime to the appropriate State agencies for Resident #84. This was true for one (1) of one (1) residents reviewed during the survey process. Resident identifier: #84. Facility Census: 88.

Inspectors wroteBased on record review and staff interview the facility failed to obtain a Physicians order to place a resident on one-on-one observation status. There was also no indication the facility updated the physician when the resident refused to go out for evaluation. These issues were found for one (1) of one (1) residents reviewed. Resident identifier: #84 Facility census: 88 Findings Include a) Resident #84 On 01/17/25 at 6:00 PM the facility placed Resident #84 on a one-on-one observation status due to behavior. This continued to be in place as of 02/03/25 at the time of the complaint investigation. The incident on 01/17/25 was related to resident trashed his room, kicking heater, letting water run in his sink trying to flood room, cursing, throwing razors all over his room. [...]

Inspectors wroteBased on record review and staff interview, the facility failed to maintain accurate and complete medical records for Resident #84. This was true for one (1) of one (1) residents reviewed during the survey. Resident identifier: #84. Facility Census: 88. Findings Include: a) Resident #84 On 02/03/25 at 10:00 AM, a record review was completed for Resident #84. The review found the [NAME] Virginia (WV) Physician Order for Scope of Treatment (POST) form did not have documentation of the preparer's signature or date. On 02/03/25 at 10:10 AM, the Administrator stated, We will get this corrected.

Inspectors wroteBased on observation and staff interview, the facility failed to ensure the resident environment over which it had control was as free from accident hazards as possible when a medication cart was left unlocked and unattended and razors were found at the bedside. This was a random opportunity for discovery. This deficient practice had the potential to affect more than a limited number of residents. Resident identifiers: #69 and Facility. Facility Census:

Inspectors wroteBased on record review and staff interview, the facility failed to ensure the pharmacist completed monthly medication regimen reviews and that the physician addressed recommendations made by the pharmacist. This deficient practice had the potential to affect three (3) of five (5) residents reviewed for the care area of unnecessary medications. Resident identifiers: #34, #16, #54. Facility census: 89.

Inspectors wroteBased on observation and staff interview, the facility failed to store medications in accordance with professional standards of practice. Multi-use vials of medications stored in the D hallway med cart were past the manufacturer's expiration dates. Additionally, insulin pens for three (3) residents were not dated when first accessed. These were random opportunities for discovery during the medication storage and labeling facility task investigation. Resident identifiers: #390, #34, #7. Facility census: 89.

Inspectors wroteBased on observation, policy review, and staff interview the facility failed to follow the menus by not providing the appropriate serving size to residents. This failed practice was a random opportunity for discovery and had the potential to affect more than a limited number of residents during the Long-Term Care Survey Process. Facility Census 89. Findings Include: a) Food service in the Alzheimer's unit A dining observation on 12/15/24 at 12:30 PM, in the Alzheimer's unit, revealed that the Activity Directory (AD) was in a kitchen area fixing the plates for the lunch meal for the residents on that unit. Further observation revealed that the AD was serving the turkey with a mouth sized fork, serving the stuffing with a spatula, and serving the peas with a ladle. During an interview on 12/15/24 at 12:32 PM, the AD stated, I don't have the right size utensils over here. [...]

Inspectors wroteBased on observation, staff interview, and policy review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. This was a random opportunity for discovery and had the potential to affect more than a limited number of residents during the Long-Term Care Survey Process. Facility Census 89. Findings Include: a) Alzheimer's unit refrigerator The initial tour of the Alzheimer's unit on 12/15/24 at 11:44 AM, revealed a kitchen area with a refrigerator that had 14 apple crisp in it on a tray with no date. During an interview on 12/15/24 at 11:45 AM, Licensed Practical Nurse (LPN) #33 stated, I am not sure when the Apple crisp was put in here. Maybe this morning. I really don't know. LPN #33 confirmed that the apple crisp did not have a date on them. [...]

Inspectors wroteBased on record review, staff interview, and observation the facility failed to operate and provide services in compliance with all applicable Federal, State, and local laws, regulations and codes by not ensuring staff serving food had a food handlers card. This failed practice was a random opportunity for discovery and had the potential to affect more than a limited number of residents. Facility Census 89. Findings Include: a) Food Handlers Card A dining observation on 12/15/24 at 12:30 PM, in the Alzheimer's unit, revealed that the Activity Directory (AD) was in a kitchen area fixing the plates for the lunch meal for the residents on that unit. During an interview on 12/15/24 at 12:32 PM, the surveyor asked the AD if she had a food handlers card. The AD replied, No, I do not. [...]

Inspectors wroteBased on record review and staff interview, the facility failed to ensure medical records were complete and accurate. This deficient practice had the potential to affect two (2) of 26 residents in the long-term care survey sample. Resident #34's skilled nursing evaluations were inaccurate in the area of genitourinary status. Resident #10's Physician Orders for Scope of Treatment form was not signed by the resident's representative. Resident identifiers: #34, #10. Facility census: 89.

Inspectors wroteBased on observation, record review and staff interview, the facility failed to implement Enhanced Barrier precautions in accordance with professional standards of care and the facility's policies and procedures. These were random opportunities for discovery that had the potential to affect more than a limited number of residents. Resident identifiers: #22, #37. Facility census: 89.

Inspectors wroteBased on observation, staff interview, and policy review the facility failed to maintain all electrical equipment in safe operating condition. This failed practice was a random opportunity for discovery and had the potential to affect more than a limited number of residents. Facility census 89.

Inspectors wroteBased on observation and staff interview the facility failed to ensure a physical environment with an effective pest control program. Observations were made of gnats in two (2) different resident rooms. Room identifiers: #A01, #B11. Facility census: 89.

Inspectors wroteBased on record review and staff interview the facility failed to ensure a resident's Preadmission Screening and Resident Review (PASARR) reflected the pre admission diagnoses sheet for schizophrenia and anxiety disorder, This was true for one (1) of three (3) PASRR's reviewed. Resident identifier: #37. Facility Census: #89.

Inspectors wroteBased on record review and staff interview, the facility failed to develop a comprehensive care plan in the area of anticoagulant medication for one (1) of five (5) residents reviewed for the care area of unnecessary medications. Resident identifier: #34. Facility census: 89.

Inspectors wroteBased on resident interview, family interview, record review, and staff interview, the facility failed to provide oral care to a dependent resident. This deficient practice had the potential to affect one (1) of four (4) residents reviewed for the care area of activities of daily living. Resident identifier: #69. Facility census: 89.

Inspectors wroteBased on record review and staff interview the facility failed to follow physician's orders to obtain weights on a weekly basis and to apply a hand splint. This was true for two (2) of twenty six (26) residents reviewed in the survey sample. Resident identifier #6, #58. Facility Census: #89. a) Resident #6 On 12/17/24 at 10:02 AM record review shows a Physician's order dated 12/10/24 for weekly weights X's four (4) weeks due to weight loss. Review of the documented weights show the facility did not get a weight until 12/16/24. On 12/18/24 at 10:02 AM it was confirmed with the Director of Nursing and the Clinical Resource Nurse #96, who agreed that the weight should have been obtained on 12/10/24 or 12/11/24, depending on the time the order was placed. b) Resident #58 On 12/15/24 at 12:53 PM during an interview with Resident #58 it was observed that her right hand was severely contracted. [...]

Inspectors wroteBased on record review and staff interview the facility failed to ensure the residents maintained acceptable parameters of nutrition to prevent weight loss, by not documenting accurate meal intakes. This failed practice was found true for (1) one of (4) four residents reviewed for nutrition during the Long-Term Care Survey Process. Resident identifier #82. Facility Census 89. Findings Include: a) Resident #82 A record review on 12/15/24 at 3:44 PM, revealed that Resident #82 had the following weights recorded since 09/06/24: 11/28/24-108.8 Pounds (Lbs) 11/26/24 -110.0 Lbs 11/19/24 -110.0 Lbs 11/11/24 -110.0 Lbs 11/7/24 -110.2 Lbs 11/1/24-116.0 Lbs 11/1/24-116.0 Lbs 10/28/24 -115.6 Lbs 10/21/24-116.0 Lbs 10/14/24-118.6 Lbs 10/7/24-120.4 Lbs 9/30/24-122.6 Lbs 9/25/24-122.8 Lbs 9/6/24-140.8 Lbs This averaged out to 22.73% percent weight loss in (2) two months. [...]

Inspectors wroteBased on record review and staff interview, the facility failed to monitor and treat pain in occurrence with professional standards of practice. This deficient practice had the potential to affect one (1) of five (5) residents reviewed for the care area of unnecessary medications. Resident identifier: #34. Facility census: 89.

Inspectors wroteBased on observation, resident interview and staff interview the facility failed to ensure residents special dietary requirements including preferences were met. This failed practice was a random opportunity for discovery during the Long-Term Care Survey Process. Resident identifier #54. Facility Census 89. Findings Include: a) Resident #54 An observation, on 12/15/24 at 1:04 PM, of Resident #54 eating lunch revealed that Resident #54 was served turkey, stuffing, and peas. Further observation revealed a meal ticket that indicated Resident #54 was to receive a chicken sandwich, lettuce and tomato, chef salad and a baked potato. During an interview on 12/15/24 at 1:04 PM, Resident #54 stated, I am supposed to get a salad. I don't always like what they give me but I try to eat it. During an interview, on 12/15/24 at 1:06 PM, Dietary Aide #30 stated, We don't have the chicken sandwich. [...]

Inspectors wroteBased on record review, resident interview and staff interview, the facility failed to effectively make prompt efforts to resolve grievances made by the residents. This failed practice was a random opportunity for discovery and had the potential to affect more than a limited number of residents living in the facility during the survey process. Facility Census 85.

Inspectors wroteBased on observation, record review, staff interview and resident interview, the facility failed to ensure that it maintained an environment that allowed the residents to receive care and services safely and that the physical layout of the facility maximizes residents independence and does not pose a safety risk. This failed practice was a random opportunity for discovery during the survey process. Resident identifier: #80. Facility Census 85. Findings Included: a) Resident #80 An observation on 11/11/24 at 3:30 PM, found in Resident #80's personal bathroom a hole in the wall on the right side of the sink at the bottom of the wall. Further observation of Resident #80 pulling up to his sink in his wheelchair to wash his hands revealed that he could not get up to the sink properly without putting his foot through the sheet rock. [...]

Inspectors wroteBased on record review and staff interview, the facility failed to obtain neurological checks for three (3) unwitnessed falls. Resident identifier: #80 Facility Census: #85. Findings Included: Record review on 11/12/24 at 9:15 AM found that Resident #80 has had three (3) unwitnessed falls. They were on 06/03/24, 08/17/24 and 08/28/24. According to the change in condition supplied by the facility, they were all unwitnessed falls. According to the Falls Management Policy #NSG215 (5) Post Fall Management: 5.3 Any patient who has a fall unwitnessed by staff will be observed for neurological abnormalities by performing neurological check, per policy According to the Neurological Evaluation Policy #NSG204 . Neurological evaluations will be performed as indicated or ordered. [...]

Inspectors wroteBased on record review and staff interview the facility failed to ensure one (1) of seven (7) residents did not receive doses of medications that had errors in the dose ordered by the physician assistant. Resident #201 received a larger dose of morphine sulfate than what the physician assistant intended to prescribe. This created an immediate jeopardy situation. Resident identifier: #82. Facility census: 82.

Inspectors wroteBased on observation and staff interview the facility failed to ensure the resident environment was clean, comfortable and homelike. Issues such as black marks, scuffs and pealing paint was found with the interior of the facility (doors, walls,) were found on three (3) of the four (4) hallways of facility. There were also issues with scuffs, black marks and pealing paint on the doors near the nursing station. Facility census: 82.

Inspectors wroteBased on medical record review and staff interview the facility failed to ensure three (3) residents had been seen by a physician at least once every 30 days for the first 90 days after admission, and at least once every 60 thereafter. Resident identifiers: #28, #72, and #44. Facility census: 82.

Inspectors wroteBased on observation and resident and staff interview, the facility failed to provide a safe, clean, homelike environment for Resident #3, 54, 50, 46, 58, and 36. This was a random opportunity for discovery. This has the potential to affect more than a limited number of residents. Resident identifiers: 3, 54, 50, 46, 58, 36. Room identifiers: B10, B14, C26, D31. Facility census: 88.

Inspectors wroteBased on record review and staff interview the facility failed to provide accurate one (1) resident was provided to the extent possible acceptable parameters of nutrition. Resident identifier: #2. Facility Census:

Inspectors wroteBased on observation and staff interview, the facility failed to provide a safe, clean, and homelike environment for Room #D32 which had trash and food laying on the floor, Room #D37 was noted with two (2) dirty and stained nightstands and a soiled blanket with a dry, brown substance on the bed in room [ROOM NUMBER]. The facility's sit to stand lifts were also observed dirty. These were random opportunities of discovery. Facility census: 83.

Inspectors wroteBased on record review and staff interview the facility failed to administer medications within the physician ordered time frames. Resident # 2, Resident # 27 and Resident #46 had medications administered late on multiple occasions during the month of 12/2023. This was true for three (3) of three (3) residents reviewed for medication administration during a complaint survey. Resident Identifiers: #2, #27, and #46. Facility Census: 83. Findings Included: a) Resident #27 A review of Resident #27's medication administration audit report for the month of 12/2023 found on the following occasions Resident #27 medication was administered more than one (1) and one (1) half hour past the scheduled time of administration: -- Insulin Sliding Scale was scheduled for 11:30 am on 12/03/23 and was not administered until 4:32 PM this was five (5) hours and two (2) minutes late. [...]

Inspectors wroteBased on record review, observation and staff interview the facility failed to implement care plans for one (1) of three (3) Residents whose care plans were reviewed during the long-term care complaint survey process. Resident # 2's care plan was not implemented for placing a radio in closer reach on the left side. Resident identifier: #2. Facility census: 83.

Inspectors wroteBased on observation, resident interview and staff interview, the facility failed to ensure respiratory care was provided according to professional standards of practice. These were random opportunities of discovery. Resident Identifier: #2, #76, #28 and #1. Facility Census: 83. Findings Included: a) Resident #2 On 12/19/23 at 9:24 AM, an observation was made of Resident #2's nebulizer mask laying on the nightstand without being in a respiratory bag. On 12/19/23 at 9:25 AM, Licensed Practical Nurse (LPN) #13 was notified and confirmed the nebulizer mask was not stored correctly. LPN #13 stated, I will get a respiratory bag. On 12/19/23 at 10:00 AM, the Director of Nursing (DON) and the Administrator were notified and confirmed the nebulizer mask should have been placed in a respiratory bag. [...]

Inspectors wroteBased on observation, record review and staff interview the facility failed to establish a system that determines drug records are in order and an account of all controlled drugs is maintained and periodically reconciled. The facility had controlled substances that had been removed from the medication card and was then taped back into the medication card on two separate medication carts. Also for Resident # 27 his tramadol, a controlled substance was signed out on the Controlled Substance log but was not documented as given on the Medication Administration Record (MAR). These failed practices have the potential to affect more than a limited number of residents. Resident Identifier: #27, #36 and # 75. Facility Census: 83. Findings Included: a) Medication cart for the A hall and D hall. [...]

Inspectors wroteBased on observation, resident interview and staff interview, the facility failed to maintain appropriate infection control standards for the disposal of soiled linens in Rooms #D38 and #D32, the storage of a wash basin in Room #C26, the storage of a urinal in Room #C25, and in Room #D31 the storage of a used bed pan. These were random opportunities for discovery. Facility Census: 83. Findings Included: a) Room D38 On 09/19/23 at 9:30 AM, an observation was made of soiled linen in Room #D38 which was in two (2) clear plastic bags left open and untied sitting in floor of the room by the bathroom. Resident #76 stated, Those are from when they cleaned us up. On 09/19/23 at 9:35 AM, Licensed Practical Nurse (LPN) #13 was notified and confirmed the soiled linen bags should have been tied up and removed from the room. [...]

Inspectors wroteBased on observation, record review, staff interview and random opportunities of discovery, the facility failed to maintain appropriate infection control standards for linen storage and disposal of dirty linen. These were random opportunities for discovery. Facility Census: 83. a) B Hall Linen On 09/19/23 at 1:23 PM, two (2) linen carts were observed on B Hall with the doors open and uncovered. Currently, there is one (1) COVID-19 positive resident residing on this hall. On 09/19/23 at 1:27 PM, two (2) dirty hand towels were observed laying on the floor of room B18. On 09/19/23 at 1:26 PM, Licensed Practical Nurse (LPN) #22 confirmed the two (2) linen carts were not covered and the doors were open. LPN #22 also confirmed the dirty linen was laying on the floor in room B18. LPN #22 stated, Maintanence worked on those carts Friday (09/15/23), I thought they fixed them. [...]

Inspectors wroteBased on record review and staff interview, the facility failed to revise a care plan for Resident #15 regarding lift status. This was true for one (1) of five (5) residents reviewed during the survey process. Resident Identifiers: Resident #15. Facility Census: 83. Findings Included: a) Resident #15 On 09/19/23 at 11:00 AM, a record review was completed for Resident #15. The review found a lift assessment dated [DATE] indicating the staff should use a gait belt while transferring the resident instead of a mechanical lift. The care plan was reviewed and the new lift status had not been revised to use the gait belt for transfers. On 09/19/23 at 1:00 PM, the Director of Nursing (DON) confirmed the care plan had not been revised. The DON stated, I take full responsibility .I didn't update the care plan but I did do the lift assessment. [...]

Inspectors wroteBased on observation and staff interview, the facility failed to maintain a safe, functional, sanitary, and comfortable environement for resident #53 and resident #74. This was a random opportunity for discovery. Facility census is 83.

Inspectors wroteBased on observation and staff interview, the facility failed to correctly inform and explain to beneficiaries the Centers for Medicare & Medicaid Services (CMS) Form #10055-Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN) when medicare services were ending for three (3) of three (3) residents reviewed for beneficiary notification. Resident identifiers: #59, #41, and #31. Facility census: 87.

Inspectors wroteBased on observation, staff interview and policy review the facility failed to provide housekeeping and maintenance services necessary to maintain a sanitary, well-kept resident care area. Resident rooms were absent of clean bed linens, and personalization items that promoted a home-like environment. These failed practices were a random opportunity for discovery and had the potential to affect more than a limited number of residents. Facility census: 87.

Inspectors wroteBased on observation, policy review, resident interview, and staff interview the facility failed to make grievances forms accessible to all residents and resident representatives. This had the potential to affect more than a limited number of residents living in the Memory Unit. Facility census: 87. Finding Included: A review of the facility policy titled Grievance/Concern-Resident/Family with an effective date of 03/01/02 read as follows. .Purpose -To ensure that any resident or resident representative has the right to express a grievance/concern without fear of interference, coercion, discrimination or reprisal in any form. [...]

Inspectors wroteBased on record reviews and staff interviews the facility failed to provide Notices of Transfer to the State Ombudsman. This was discovered for three (3) of three (3) residents reviewed for hospitalizations during the Long-Term Care Survey Process. Residents #59, #77 and #87 were transferred to acute care hospitals, and no Notices of Transfer were provided to the State Ombudsman. Resident identifiers: #59, #77 and #87. Facility census: 87.

Inspectors wroteBased on record review and staff interview, the facility failed to track COVID-19 vaccination status for eight (8) of 149 facility employees. This deficient practice was identified during the infection control facility task and had the potential to affect more than a limited number of residents. Facility census: 87.

Inspectors wroteBased on medical record review, policy review and staff interview the facility failed to notify the resident's representative in a timely manner when Resident #77's was transferred to the hospital. This was true for one (1) of three (3) residents reviewed for hospitalizations. Resident Identifier: Resident #77. Facility census: 87. Findings Included: a) Resident #77 A review of a facility policy titled Change in Condition: Notification of with a revision date of 06/01/21 read as follows. POLICY A Center must immediately inform the resident/patient (hereinafter patient), consult with the patient's physician and notify, consistent with his/her authority, the patient's Health Care Decision Maker (HCDM), where there is: [...]

Inspectors wroteBased on record reviews and staff interviews the facility failed to ensure the required information was conveyed to the receiving providers, to ensure a safe and effective transition of care. This was discovered for two (2) of two (2) residents reviewed for the area of hospitalizations during the Long Term Care Survey Process. Resident identifiers: #59 and #87. Facility census: 87.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice. The facility failed to obtain laboratory testing as ordered for one (1) of five (5) residents reviewed for the care area of unnecessary medications. Resident identifier: #13. Facility census: 87.

Inspectors wroteBased on record review and staff interview the facility failed to provide an ongoing assessment and oversight for Resident #57 after hemodialysis treatments, that included monitoring the resident's condition for complications. Shared communication between the nursing home and the dialysis facility was not properly implemented. This failed practice was true for one (1) of one (1) resident reviewed for dialysis services with the potential to affect only a limited number of residents. Resident identifier: #57. Facility census: 87.

Inspectors wroteBased on observation, policy review, Resident Council meeting and staff interview the facility failed to provide Residents with evening snacks. This had the potential to affect a limited number of residents receiving snacks from the nourishment room and the Memory Unit kitchen. Facility Census: 87 Findings Included: a) Policy A review of a facility policy titled Snacks with a revision date of 09/17 read as follows. Snacks and beverages will be provided as identified in the individual plans of care. Bedtime (a.k.a. HS) snacks will be provided for all residents. Additional snacks and beverages will be available upon request for all residents who want to eat at non-traditional times. .4. The dining Services Department will assemble and deliver to each unit the individually planned snacks and bulk snack items to be offered at bedtime. 5. [...]

Inspectors wroteBased on observations and staff interviews, the facility failed to maintain the facility kitchens in a safe and sanitary manner in accordance with professional standards of practice. During the main kitchen tour it was discovered the freezer floor needed to be cleaned, the wall entering the Dish Room was in poor repair and the kitchen on the memory unit needed a deep cleaning. This had the potential to affect a limited number of residents. Facility census: 87.

Inspectors wroteBased on record reviews and staff interviews the facility failed to ensure complete and accurate medical records. The facility failed to ensure the Physician Orders for Scope of Treatment (POST) forms were completed per directions specified by the [NAME] Virginia Center for End-of-Life Care. This was true for three (3) of 18 residents reviewed for the area of Advance Directives during the Long-Term Care Survey Process. Resident Identifiers: #13, #59. Facility Census: 87.

Inspectors wroteBased on record review and staff interview, the facility failed to offer influenza and pneumococcal immunizations to residents as appropriate. This deficient practice had the potential to affect two (2) of five (5) residents reviewed for the care area of immunizations. Resident identifiers: #69, #8. Facility census: 87.

Inspectors wroteBased on record review and staff interview, the facility failed to document consent and refusal of COVID-19 vaccinations. This deficient practice had the potential to affect two (2) of five (5) residents reviewed for the care area of immunizations. Resident identifiers: #77, #33. Facility census: 87.