Mercer Healthcare Center

Inspectors wroteBased on observation, record review and staff interviews the facility failed to develop and/or implement plans of care related to Post-Traumatic Stress Syndrome (PTSD), Oxygen, Dementia interventions, and Epilepsy. This failure was found to be true for four (4) of 30 residents reviewed for care plan accuracy during the Long-Term Care Survey Process. Resident identifiers: #82, , #79, #5, and #9. Facility Census: 116. a) Resident #5 On 06/15/26 at approximately 3:54 PM, observation of Resident #5 revealed oxygen being administered via nasal cannula at 3.5 liters per minute. Review of the physician's order indicated the resident was prescribed oxygen at 2 liters per minute. The discrepancy was immediately brought to the attention of facility staff. At approximately 3:52 PM, RN #5 confirmed that the physician's order was for oxygen administration at 2 liters per minute. [...]

Inspectors wroteBased on resident interview, record review, and staff interview, the facility failed to provide a program of activities to meet the needs and interest of each resident. This deficient practice had the potential to affect three (3) of six (6) residents reviewed for the care area of activities. Resident Identifiers: #35, #9, and #101. Facility Census: 116.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure Resident #83's [NAME] Virginia Physician's Orders for Scope of Treatment (POST) form was signed by his medical power of attorney (MPOA) while Resident was lacking capacity. This was true for one (1) of nine (9) residents sampled for advance directives during the Long-Term Care Survey process. Census: 116 Resident identifier: #83Findings included: a) Resident #83 The POST form dated [DATE] was signed by Resident #83. The last capacity evaluation dated [DATE] showed Resident #83 did not have [NAME] to make decisions based on disorientation and an inability to process information due to dementia. An interview with Director of Nursing (DON) on [DATE] at approximately 11:00AM confirms Resident #83 did not have capacity on [DATE] but signed his POST form changing his end of life wishes. [...]

Inspectors wroteBased on record review and staff interview, the facility failed to provide adequate notice of last covered Medicare A days to Resident #127's Medical Power of Attorney (MPOA). This was true for one (1) of three (3) residents sampled for beneficiary notification during the Long-Term Care Survey process. Census: 116 Resident identifier: #127Findings included: a) Resident #127 A policy titled Policies and Standard Procedures states, this notice [NOMNC] will be provided at least [two] 2 days in advance of the last covered day to allow for adequate time to appeal, if the beneficiary so chooses. The Notice of Medicare Non-Coverage (NOMNC) reads as follows: Medicare coverage of your current skilled services will end on date: 03/04/26. The telephone notification per the NOMNC was made on 03/06/26 at 10:00AM to the Medical Power of Attorney (MPOA). [...]

Inspectors wroteBased on record review and staff interview, the facility failed to provide required information for continuity and coordination of care when a resident was transfered, including a list of resident's medication and when it was last given. This was found to be true for two (2) of three (3) residents reviewed during the long term care survey process. Resident identifiers: #10, #120. Facility census: 116.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure the Minimum Data Set (MDS) included a diagnosis of Epilepsy. This was found to be true for one (1) of 30 residents reviewed during the long term care survey process. Resident identifer: #82. Facility census: 116.

Inspectors wroteBased on record review and staff interview, the facility failed to include a diagnosis of major depressive disorder on the most recent Preadmission Screening and Resident Review (PASARR). Failure to coordinate the PASARR and the Minimum Data Set (MDS) can lead to duplicative effort and treatment. This was found to be true for two (2) of seven (7) residents reviewed during the long term care survey process. Resident identifiers: #52, #82. Facility census: 116.

Inspectors wroteBased on record review and staff interview, the facility failed to notify the physician when Resident #130's blood sugars were outside of the ordered parameters. This was found during a complaint investigation. Census: 116 Resident identifier: #130Findings included:a) Resident #130A review of the orders reveals an order with a start date of 06/04/25 that reads: notify [Medical Doctor] MD if blood sugar is less than 60 and/or greater than 400. During a review of the Medication Administration Record for June 2025, the following dates had blood sugars outside of the parameters and the physician was not notified according to the progress notes:06/07/25-42406/11/25 -4806/20/25-47606/21/25-431During an interview with the Director of Nursing on 06/18/26 at 1:30PM, she confirmed according to the progress notes, the physician was not notified of blood sugars outside of the ordered parameters.

Inspectors wroteThe facility failed to ensure oxygen therapy was administered in accordance with physician orders and the resident's care plan for 1 of 1 resident reviewed for oxygen administration Resident #5. Facility census: 116.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure Resident #83's medical record was accurately completed. This was true for one (1) of nine (9) residents reviewed for advance directives and two (2) of five (5) residents. Resident identifiers: #83 and #9. Census: 116. Resident identifier: #83.a) Resident #83 A Physician's Determination of Capacity form dated 11/18/25 showed Resident #83 lacked capacity due to a diagnosis of dementia and disorientation and inability to process information. Resident #83 has a surrogacy selection form designating a Medical Power of Attorney (MPOA) as his healthcare surrogate that was dated 11/17/25. Resident #83 was admitted to hospice care on 12/3/25 and the hospice Long Term Care Status Form was signed by Emergency Contact #2, the resident's sister. [...]

Inspectors wroteb) Resident #56 An observation on 01/22/25 at 11:00 PM, revealed a bottle of Povidone Iodine Prep Solution setting on the dresser in Resident #56's room. During an interview on 01/22/25 at 11:00 PM, Resident #56 stated, They leave all kinds of stuff in here. An observation on 01/22/25 at 11:10 PM, with the Director of Nursing (DON) revealed that Resident #56's room door was shut. The state agency (SA) knocked on the door. A Nursing Assistant (NA) came to the door and stated, We are doing wound care. Give us just a few minutes. During an observation, and interview on 01/22/25 at 11:25 PM, the DON in Resident #56's room showed that the Povidone Iodine Prep Solution was no longer on the dresser. The DON opened the dresser drawers and found the solution in the drawer with 6 bottles of skin prep solution and several unwrapped gauze pads. [...]

Inspectors wroteBased on record review, resident interview and staff interview the facility failed to monitor the effectiveness of pain medications in accordance with professional standards of practice. This failed practice was found true for (1) one of (7) seven residents reviewed for pain during the Long-Term Care Survey Process. Resident identifier: #31. Facility census: 120. Findings Include: a) Resident #31 During an interview on 01/28/24 at 9:15 AM, Resident #31 stated, I hurt all the time. They are waiting on something from the pharmacy. A record review on 01/28/24 of Resident #31's current orders revealed an order for Oxycodone-Acetaminophen oral tablet 5-325 to give (1) one tablet by mouth every (8) eight hours as needed for pain. The order had a start date of 11/04/24. [...]

Inspectors wroteBased on observation, record review, and staff interview, the facility failed to store and label medications in accordance with professional standards of care. Multiuse vials of insulin had not been dated when opened. Additionally, multiuse vials of insulin had not been discarded 28 days after opening. These were random opportunities for discovery. Resident identifiers: #83, #85, #80, #62, #51, #61, and #57. Facility census: 120.

Inspectors wroteBased on observation and record review the facility failed to ensure food is prepared in a form designed to meet the individual needs of each resident. This was a random opportunity for discovery and has the potential to affect more than a limited number of residents. Resident identifiers: #37, #47, #76, #51, #29, #79, #98, and #88. Facility Census: 113. Findings Include: a) On 01/27/25 at 12:37 PM during the noontime meal service it was noted the facility was serving kielbasa sausage. At 12:37 PM on 01/27/25 Employee #162 the district food manager (DFM) was overheard asking [NAME] #146 if she had ground kielbasa. She replied, no. She indicated she thought the kielbasa meet the requirement for the mechanical and advanced diets. Employee #162 advised [NAME] #146 that it needed to be ground. By this point in service the entire A unit of the facility had been served. [...]

Inspectors wroteBased on observation and staff interview, the facility failed to ensure the ice machines in the A and B hall pantries were clean and sanitary. In addition, the microwave in the B-hall nutrition pantry was rusted. This failed practice had the potential effect more than an isolated number of residents. Facility Census: 120. Findings Include: a) A and B hall pantries During an observation of the A hall pantry at 11:10 am on 01/20/25, found the ice machine was not clean. The grate were the cups or containers would sit was covered in white scaly substance. The certified dietary manager (CDM) removed the grate and under the grate there was an accumulation of water and a brown slimy like substance. The CDM agreed the ice machine needed to be cleaned. During an observation of the B hall pantry at 11:15 am on 01/20/25, found the ice machine was not clean. [...]

Inspectors wroteBased on record review and staff interview, the facility failed to make good faith attempts to correct quality deficiencies related to complete and thorough investigations, despite being cited multiple times in the past and identifying issues related to the investigations. This has the potential to affect more than a limited number of residents. Facility census: 120.

Inspectors wroteBased on observation and staff interview, the facility failed to ensure they honored the residents right to receive meal trays in a dignified manner. This was a random opportunity for discovery during the Long-Term Care Survey process. Facility Census:113. Resident identifier: #71.

Inspectors wroteBased on record review and staff interview, the facility failed to thoroughly investigate an allegation of abuse of Resident #319. This was true for one (1) of nine (9) residents reviewed for abuse during the survey process. Resident identifiers: #319, #320, #46, #50, #54, #40, and #8. Facility census: 120.

Inspectors wroteBased on record review and staff interview the facility failed to ensure Resident #108's Discharge Minimum Data set was coded to accurately reflect the location where the resident was discharged to. This was true for one (1) of 36 sampled residents reviewed during the long-term care survey process. Resident Identifier: #108. Facility Census: 113.

Inspectors wroteBased upon record review and staff interviews, the facility failed to refer one (1) of eight (8) residents who had a newly evident serious mental health disorder diagnsis for a level II review. This was true for one (1) of eight (8) records reviewed. Resident identifier: #85. Facility census: 120.

Inspectors wroteBased on observation, record review and staff interview, the facility failed to implement Resident #47's care plan regarding accident hazards in his room and failed to implement Resident #99's care plan in regard to same sex caregivers. This was true for two (2) of 36 resident care plans reviewed during the survey process. Resident identifiers: #47, #99. Facility census: 120.

Inspectors wroteBased on record review and staff interview the facility failed to revise care plan after placing resident on a Q one (1) hour checks for three (days). This was a random opportunity for discovery during the Long-Term Care survey process. Facility identifier: #96. Facility Census: 113.

Inspectors wroteBased on record review and staff interviews the facility failed to ensure they provided an ongoing program of activities of support the needs of each resident. One resident (1) did not have an Activity Preference Assessment (ADA) within in seven (7) Days of Admission. This was a random opportunity for discovery during the long-term care survey process. Resident identifier: #368. Facility census: 113.

Inspectors wroteBased on observation, record review, and staff interview, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice. A medication dosage was not specified in a physician's order for Resident #42. A physician's order for no straws was not followed for Resident #88. This deficient practice had the potential to affect two (2) of 36 residents reviewed in the long-term care survey sample. Resident identifiers: #42 and #36. Facility census: 120.

Inspectors wroteBased on record review and staff interview the facility failed to provide necessary behavioral health care and services to attain or maintain the highest practicable physical, mental and psychocial well-being. This failed practice was found true for (1) one of (2) two residents reviewed for mood/behavior during the Long-Term Care Survey Process. Resident identifier: #99. Facility census: 120. Findings Include: a) Resident #99 A record review on 01/21/25 at 10:00 AM, revealed that Resident #99 had diagnoses that included the following: Dementia with mood disturbance Dementia with anxiety Generalized anxiety disorder Major Depressive disorder, Recurrent severe with psychotic features Further record review of Resident #99's, Behavior Monitoring and Interventions report, revealed that from 10/01/24 to present Resident 99 had 15 days that he was marked for behaviors. [...]

Inspectors wroteBased on record review and staff interview the facility failed to provide medically related social services necessary to attain or maintain the highest practicable physical, mental and psychocial well-being. This failed practice was found true for (1) one of (2) two residents reviewed for mood/behavior during the Long-Term Care Survey Process. Resident identifier: #99. Facility Census: 120. Findings Include: a) Resident #99 A record review on 01/21/25 at 10:00 AM, revealed that Resident #99 had diagnoses that include the following: Dementia with mood disturbance Dementia with anxiety Generalized anxiety disorder Major Depressive disorder, Recurrent severe with psychotic features Further record review of Resident #99's, Behavior Monitoring and Interventions report, revealed that from 10/01/24 to present Resident #99 had 15 days marked for behaviors. [...]

Inspectors wroteBased on observation, record review and staff interview, the facility failed to ensure residents were free from significant medication errors. This deficient practice had the potential to affect (1) of four (4) residents reviewed during the medication administration facility task. Resident identifier: #73. Facility census: 120.

Inspectors wroteBased on resident interview, record reviews and staff interview's the facility failed to ensure residents were provided with needed dental services. This failed practice was found true for one (1) of four (4) residents reviewed for dental services during the Long-Term Care Survey process. Resident identifier: #55. Facility census: 120.

Inspectors wroteBased on observation, staff interview and resident interview the facility failed to serve food at palatable temperatures. This was a random opportunity for discovery during the Long-Term Care Survey Process. Resident identifier #29. Facility census: 120.

Inspectors wroteBased on observation, resident interview, record review, and staff interview, the facility failed to provide ordered assistive eating devices. This was a random opportunity for discovery. Resident identifier: #51. Facility census: 120.

Inspectors wroteBased upon record review and staff interviews, the facility failed to accurately record the DNR status of Resident #32, in the electronic medical record. This was a random opportunity for discovery. Resident identifier: #32. Facility census: 120.

Inspectors wroteBased on observation, record review, and staff interview, the facility failed to establish and maintain an infection prevention and control program designed to help prevent the development and transmission of communicable diseases and infections. The facility failed to ensure Enhanced Barrier Precautions (EBP) were appropriately initiated. This was a random opportunity for discovery. The facility also failed to ensure appropriate hand hygiene was performed during pressure ulcer dressing changes for one (1) of one (1) residents observed for pressure ulcer dressing changes. Resident identifiers: #51 and #31. Facility census: 120.

Inspectors wroteBased on record review and staff Interviews the facility failed to ensure residents were being served a meal free from allergens. Resident #10 had a fish oil allergy and was served a fish sandwich. This past non-compliance had the potential to affect more than a limited number of residents. The state agency (SA) determined this failed practice put Resident #10 in immediate jeopardy by being served a fish sandwich. Fish oil allergies have the potential to cause stomach pain or diarrhea, swelling in the throat, difficulty breathing, dizziness or fainting, very low blood pressure, and shock. All those symptoms had the potential to severely impair residents' health and lead up to causing death. This also has the potential to cause resident #10 to have emotional and psychological impact. [...]

Inspectors wroteBased on staff interview and record review the facility failed to ensure two (2) of five 5 residents resident received treatment as ordered by their physician. The facility failed to follow physician's orders for wound treatments for Resident #54 and #66. Resident identifiers: #54 and #66. Facility Census: 104.

Inspectors wroteBased on observation, record review and staff interview, the facility failed to maintain appropriate infection control standards for foley catheter care storage and/or disposal of a bed pan and timely removal of a meal tray. These were random opportunities for discovery. Resident identifier: #8, #37. Room identifier: #A19. Facility Census: 104.

Inspectors wroteBased on document review, staff interview, and resident interview, the facility failed to identify each resident's allergies and provide an appropriate alternative. This resulted in an immediate jeopardy (IJ) for Resident #73, who was allergic to shrimp. This deficient practice was true for one (1) of three (3) residents reviewed for food allergies. Resident Identifier: #73. Facility census: 107. Resident #73 was served pureed Shrimp and Sausage Jambalaya for lunch on 01/19/24 at approximately 1:00 PM, had an allergic reaction, and required physician-prescribed medication to alleviate facial swelling. The facility immediately began to implement corrective measures and the deficient practice was corrected on 01/19/24 by 11:00 PM, prior to the start of the survey, therefore making it Past Noncompliance. The Administrator was notified of the Past Noncompliance IJ on 05/06/24 at 4:18 PM.

Inspectors wroteBased on record review and resident and staff interview, the facility failed to provide a safe, comfortable, and homelike environment by failing to ensure the availability of clean washcloths. This has the potential to affect more than a limited number of residents. Resident identifier: 57. Facility census: 107.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure that all alleged violations involving abuse and neglect were reported, to the appropriate state agencies as required. This was a random opportunity for discovery and a deficient practice identified during complaint investigation. The deficient practice was true for five (5) out of five (5) resident records sampled under the abuse/neglect category. Resident identifiers: #73, #77, #10, #57, and #112. Facility census: 107.

Inspectors wroteBased on observation and staff interviews, the facility failed to provide reasonable accommodation in regards to a call light being out of reach. This was a random opportunity for discovery. Resident Identifiers: #1 and #65. Facility Census:

Inspectors wroteBased on record review and resident and staff interview, the facility failed to ensure allegations of neglect were thoroughly investigated by concluding personal care was provided to a resident in a timely manner, but failing to establish how long the resident waited to receive care. This was true for one (1) of three (3) residents reviewed for allegations of neglect during the survey process. Resident identifier: 57. Facility census: 107.

Inspectors wroteBased on record review and resident and staff interview, the facility failed to ensure personal care was provided to a resident in a timely manner, by making a resident wait to be cleaned and assisted out of bed because there were no clean linens. This was true for one (1) of one (1) residents reviewed for ADL care during the survey process. Resident identifier: 57. Facility census: 107.

Inspectors wroteBased on observation and staff interview, the facility failed to ensure the Daily Staffing Posting information was accurate and the facility failed to maintain the Daily Staffing Posting data for a minimum of 18 months. This was a random opportunity for discovery and had the potential to affect all residents. Facility Census: 97.

Inspectors wroteBased on medical record review, policy review, resident interview and staff interview, the facility failed to ensure three (3) of three (3) residents and/or residents representatives reviewed were afforded the right to participate in the care planning process. Resident identifiers: #6, #12 and #69. Facility Census: 97.

Inspectors wroteFindings Included: c) Resident #11 On 1/30/24 at 11:35 AM record review of Resident #11s' wound care orders and review of the Treatment Administration Report (TAR) for Resident #11 for the last three (3) months shows the following treatments orders were not completed: [...]

Inspectors wroteBased on record review and staff interview the facility failed to establish a system of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation and determined drug records were in order and that an account of all controlled drugs was maintained and periodically reconciled. This was a random opportunity for discovery and had the potential to affect a limited number of residents who currently reside at the facility. Resident identifier: #100. Facility census 97.

Inspectors wroteBased on record review and staff interview the facility failed to ensure the dietary staff had the appropriate competencies and skills sets to carry out the functions of the food and nutrition services. This was a random opportunity for discovery. Facility Census:

Inspectors wroteBased on observation and staff interviews the facility failed to ensure menus were followed and residents received the correct serving of food items. This has the potential to affect all residents who receive nutrition from the kitchen. Facility census:

Inspectors wroteBased on observation, staff interview and resident interview, the facility failed to serve and prepare food in a palatable, attractive, and appetizing manner. This had the potential to affect more than a minimal number of residents at the facility. Resident identifiers: #50 and #68. Facility Census: 97.

Inspectors wroteBased on observation, record review, and staff interview, the facility failed to procure, store, prepare, and serve food in a sanitary manner, by failing to store food containers in a sanitary manner, and by failing to record refrigerator temperatures. This was a random opportunity for discovery. This had the potential to affect more than a limited number of residents. Facility Census: 97. a) Kitchen observation At approximately 1:07 PM on 01/29/24, a plastic food container was removed from the dishwasher and placed on the drying rack in the dish room. The container was sealed with the lid, with water inside, failing to allow it to properly air dry. Culinary Director (CD) #98 and Regional Dietary Manager (RDM) #220 witnessed the container on the drying rack, sealed with water inside, unable to properly air dry. [...]

Inspectors wroteBased on observation 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 to help prevent the development and transmission of communicable diseases and infections. This was a random opportunity for discovery and had the potential to affect more than a limited number of residents. Facility Census: 97.

Inspectors wroteBased on record review and staff interview the facility failed to provide notice for resident room changes, including the reason for the change, before the resident's room or roommate in the facility is changed. This is true for four (4) of five (5) residents reviewed for room changes during a complaint survey. Resident Identifiers: #29, #10, #84 and #101. Resident Census: 97.

Inspectors wroteBased on observation and staff interview the facility failed maintain the residents right to personal privacy and confidentiality of their personal and medical records. This was a random opportunity of discovery. Resident Identifiers: #69 and #95. Facility Census: 97 Findings Included: a) Resident #69 On 01/29/24 at 08:09 PM it was observed that Licensed Practical Nurse (LPN) #122 had left the computer screen opened on the medication cart. The LPN was in a residents' room and the medication cart and computer screen were left unattended. The personal and medical records for Resident #69 were exposed and available to anyone walking past the medication cart. This was confirmed with LPN #122 on 01/29/24 at 8:13 PM and the Administrator at 8:28 PM. [...]

Inspectors wroteBased on record review and staff interview, the facility failed to complete a thorough investigation of a verbal abuse allegation and report the results to the appropriate State Agencies within a five (5) day follow up of the incident in accordance with State law. Resident identifier: Resident #67. Facility Census: 97. Findings Include: a) Resident #67 A review of the facility reportable log on 01/29/24 at 2:25 PM, revealed the following verbal abuse allegation: The alleged victim (Resident #67's name) Alleged Perpetrator name: Housekeeper #12 name Date of incident: 10/16/23 Brief description of the incident: Resident reported that when she ask for a roll of toilet paper (Housekeeper #12 name) replied hell, I gave you two (2) rolls yesterday. The reporting forms were void of any documentation that a thorough investigation of the verbal abuse allegation had occurred. [...]

Inspectors wroteBased on record review and staff interview, the facility failed to implement a comprehensive person-centered care plan for wound care treatments. This was found for one (1) of three (3) respidents reviewed for pressure ulcers. Resident Identifiers: #11 and #63. Facility Census: 97 Findings Included: a) Resident #11 On 1/30/24 at 11:35 AM record review of Resident #11s' comprehensive personal-centered care plan: Focus: .has impaired skin integrity related to limited physical mobility, incontinence, morbid obesity, has pressure ulcers to left posterior thigh X 3 areas, sacrum and right buttock. Intervention/tasks: Administer treatments as ordered by medical provider. Apply barrier creams post incontinent episodes. Complete skin at risk assessment upon admission, quarterly, and as needed, complete weekly skin checks, Resident #11 had Physician orders for multiple pressure ulcer wound care. [...]

Inspectors wroteBased on observation and staff interview the facility failed to ensure that the resident environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistance devices to prevent accidents. This was a random opportunity for discovery. Facility census: #97 Findings Included: a) B1 Hall medication cart On 01/29/24 at 08:09 PM observation of the medication cart on B1 hall was unlocked and left unattended by Licensed Practical Nurse (LPN) #122. There were six (6) residents sitting near the medication cart. According to a Resident Response Analyzer report of wandering residents provided by the Director of Nursing on 01/29/24, there were sixteen (16) residents that wandered throughout the facility. The LPN was away from the medication cart for four (4) minutes. [...]

Inspectors wroteBased on observation, record review and staff interview the facility failed to offer sufficient fluid intake to maintain proper hydration and health. This failed practice was found true for (1) one of (3) three residents reviewed for hydration. Resident identifier: #91. Facility census: 97.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure that residents who require dialysis receive such services, consistent with professional standards of practice and the comprehensive person-centered care plan. The facility failed to follow the physician's order and the comprehensive care plan intervention to document the post-dialysis weight provided by the dialysis center weekly. This deficient practice had the potential to affect one (1) of three (3) residents reviewed for receiving dialysis treatments. Resident identifier: #4. Facility census: 97.

Inspectors wroteBased on resident interviews, observation and staff interview the facility failed to provide the appropriate nutritive content as prescribed for a renal diet. This was a random opportunity for discovery. Facility Census: 97.

Inspectors wroteBased on facility documentation and staff interview the facility failed to have the minimum quarterly Quality Assessment and Assurance (QAA) meetings to identify and correct Quality deficiencies. This had the potential to affect more than an isolated number of residents that reside at the facility. Facility census: 71. a) QAA meetings Record review of the facility's undated policy titled, Quality Assurance performance Improvement (QAPI),showed the facility will have a QAPI meeting every month. On 08/22/23 at 9:45 AM a review of QAPI plan, policy and meeting sign in sheets revealed no documentation for QAA / QAPI meetings were available from 02/28/23 through 07/11/23. On 08/22/23 at 9:51 AM the Administrator stated that they don't have documentation of a QAA / QAPI meeting from 2/28/23 until 07/11/23.

Inspectors wroteBased on observation, record review, resident interview and staff interview, the facility failed to thoroughly investigate allegations of abuse and/or neglect for four (4) of four (4) residents reviewed for the care area of abuse. Resident #51's elopement, Resident #3's wound care not being provided, missing rings for Resident #10 and allegations of verbal and physical abuse by a nursing assistant (NA) during repositioning of Resident #229 were not thoroughly investigated. Resident identifiers: #51, #3, #10 and #229. Facility Census: 71. Findings Included: a) Resident #51 On 08/21/23 at 3:00 PM, the facility reportable log was reviewed. Resident #51 was listed as an elopement from the facility on 07/28/23. The immediate reporting of allegations stated, SW (Social Worker) and DON (Director of Nursing) alerted to resident elopement by staff on the floor. [...]

Inspectors wroteBased on record review and staff interview, the facility failed to revise a care plan for Resident #51's actual elopement, discontinuation of fall precautions for Resident #50, current diagnoses for Resident #31, discontinuation of a urinary catheter for Resident #329 and an accrual of actual falls for Resident #278. This was true for five (5) of 24 residents reviewed during the long-term survey. Resident Identifiers: #51, #50, #31, #329 and #278. Facility Census: 71. a) Resident #51 On 08/21/23 at 9:00 AM, the care plan was reviewed for Resident #51. The resident was noted with an actual elopement on 07/28/23. However, the care plan listed risk for elopement on the care plan. The care plan had not been revised to reflect an actual elopement had taken place. [...]

Inspectors wroteBased on record review, policy review and staff interview the facility failed to follow physicians orders. This was true in the care areas of late medication administration, missed medications, following orders for fall precautions, rechecking blood glucose level, performing neurological checks and reviewing laboratory results. Resident Identifiers: #20, #32, #38, #50, #51, #229, #278, #329. Facility Census: 71 Findings Included: a) Resident #38 1. Missed order to recheck blood glucose On 05/12/23 at 12:00 noon, the blood glucose level read HI on the glucometer. Indicating the blood glucose was over 500. According to the progress note on 05/12/23 at 13:48 PM, the provider was notified with a new order to administer 16 units of Novolog and recheck in 1 hour. The Novolog was administered as ordered, however there was no recheck on the blood glucose in one hour. [...]

Inspectors wroteBased on observations, Resident interviews, staff interviews, and record reviews the facility failed to ensure all staff had appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident.

Inspectors wroteBased on observation and staff interview, the facility failed to maintain the kitchen in a safe and sanitary manner in accordance with professional standards of practice. During the kitchen tour it was discovered the walk-in cooler had debris on the floor. The threshold seal was missing to the walk-in cooler and the serving lids for the steam table were stored on a dirty shelf, and the ice machine was not draining properly. This had the potential to affect all residents receiving nutrition from the kitchen. Facility census: 71.

Inspectors wroteBased on staff interview and facility documentation the facility failed to explain the arbitration agreement to residents or their representatives to understand the terms of the agreement. This has the potential to affect all residents residing in the facility. Facility census: 71.

Inspectors wroteBased on observations 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. The facility failed with to maintain a separation between the clean and soiled area of the laundry room to prevent contamination of airflow. This practice had the potential to affect more than an isolated number of residents. Facility census: 71.

Inspectors wroteBased on observation and staff interview, the facility failed to ensure each resident received privacy during care. This was based on a random opportunity for discovery and was true for Resident #37, who was not provided privacy during an injection. Resident Identifier: Resident #37. Census: 71.

Inspectors wroteBased on resident interview, observation, staff interview the facility failed to Promptly resolve a grievance concerning a non-working television (TV.) This was a random opportunity for discovery. Resident identifier: #229. Facility census: 71.

Inspectors wroteBased on resident interview, facility documents review, and staff interviews, the facility failed to implement written policies and procedures for reporting an allegation of abuse in a timely manner. This was true of one (2) out of three (3) residents reviewed in the care area of abuse and misappropriation of property. Resident Identifiers: Resident #229, #10. Facility census 71.

Inspectors wroteBased on record review, facility documentation of reportable occurrences review, resident and staff interview, the facility failed to ensure that all alleged violations of abuse, were reported immediately, and failed to ensure the results of an investigation was reported within five (5) working days of the occurrence, to all officials (including to the State Survey Agency and Adult Protective Services (APS), where state law provides for jurisdiction in long-term care facilities) in accordance with State law, through established procedures. This deficient practice was found true for two (2) of three (3) residents reviewed. An allegation of abuse, the staff had knowledge of, was not reported, in a timely manner, involving Resident #229. An allegation of misappropriation of personal items, the facility had knowledge of, was not reported in a timely manner, for Resident #10. [...]

Inspectors wroteBased on record review and staff interview, the facility failed to provide an accurate and complete Minimum Data Set (MDS) assessment for Resident #31. This was true for one (1) of five (5) residents reviewed for the care area of unnecessary medications. Resident Identifier: #31. Facility Census: 71. Findings Included: a) Resident #31 On 08/15/23 at 12:53 PM, the MDS modification of admission MDS dated [DATE] was reviewed. Under section I Active diagnoses, two (2) diagnoses were not indicated under the psychiatric/mood disorder section. The two (2) diagnoses that were not listed were anxiety disorder and depression. On 08/15/23 at 1:18 PM, MDS Registered Nurse (RN) #86 confirmed the diagnoses of anxiety disorder and depression were not included on the MDS. No further information was obtained during the long-term survey process. .

Inspectors wroteBased on observation, record review, and staff interview, the facility failed to develop and/or implement the care plan with fall and pressure ulcer precautions for Resident #50 and dialysis instructions for dialysis for Resident #11. This was true for two (2) of 24 residents reviewed during the long-term survey. Resident Identifiers: #50 and #11. Facility Census: 71. Findings Included: a) Resident #50 On 08/14/23 at 3:07 PM, a record review was completed for Resident #50. A physician's order dated 05/13/23 stated, heel protectors when up every shift and a physician's order dated 08/13/23 also stated, resident to have elastic tubular stockings to BLE (bilateral lower extremities) as tolerated every shift. The care plan pressure ulcer precautions were reviewed and did list the intervention of tubular stockings to BLE as tolerated. [...]

Inspectors wroteBased on medical record review and staff interview the facility failed to have a complete discharge plan / recapitulation of stay. This is true for 1 of 3 Residents reviewed for discharge. Resident identifier #76. Facility census 71. Findings Included: a) Resident #76 Medical record review of Resident #76's discharge from the facility on 06/09/23 Revealed a Discharge summary / Recapitulation of stay completed 06/09/23 at 9:12 AM. Continued review found section D. Activities Director was incomplete. Section C. Dietary Services final summary was completed and signed by the Culinary Director 07/05/23. No Resident or Representative Signature in section E. Subsequent review of Resident #76's medical record showed no further information on the discharge / discharge planning. [...]

Inspectors wroteBased on resident interview, staff interview and record review the facility failed to provide a service for daily oral care for a dependent resident. This failed practice was true for One (1) out of one (1) reviewed for ADL care. Resident identifier: # 229. Facility census 71.

Inspectors wroteBased on resident interview, staff interview and record review the facility failed to recognize, evaluate, and address the needs of a resident to ensure the resident was provided a bag lunch prior to going to dialysis three (3) days a week. This was true for two (2) of two (2) residents reviewed for dialysis services. Resident Identifier: #11 Facility Census:

Inspectors wroteBased on observation, Centers for Disease Control and Prevention (CDC) website review, and staff interview the facility failed to provide dressing changes that meet the professional standards of care. This was true for one (1) out of one (1) resident observed for peripherally inserted central catheter (PICC). Resident identifier: #229. Facility census 71.

Inspectors wroteBased on record review, policy review and staff interview the facility failed to provide ongoing communication and collaboration with the dialysis facility regarding dialysis care and services. This was true for one (1) of two (2) residents reviewed for dialysis services. Resident identifier: #11 Facility Census: 71 Findings Included: a) Resident #11 On 08/16/23 at 11:55 AM record review found several Pre and Post Dialysis Evaluations were missing. This was confirmed with the Regional Director of Clinical Operations (RDCO) #159 at this time. According to the facility Hemodialysis Care and Monitoring Policy and Procedure the facility will provide a method for on-going communications and collaboration for the development and implementation of the dialysis care plan. VIII Pre Dialysis a. [...]

Inspectors wroteBased on record review and staff interview, the facility failed to complete the monthly medication reviews for Resident #51. This was true for one (1) of five (5) residents reviewed under the care area of unnecessary medications. Resident #51. Facility Census: 71. Findings Included: a) Resident #51 On 08/16/23 at 10:30 AM, a review of the monthly medication reviews from the pharmacy was completed. The review found a monthly review dated 05/07/23 recommending a gradual dose reduction (GDR) for Melatonin 3mg (milligrams) at HS (hours of sleep) was not completed or signed by the physician. On 08/16/23 at 12:10 PM, the Director of Nursing (DON) stated, May's was not done .I'm not sure why. No further information was obtained during the long-term survey process.

Inspectors wroteBased on observation, record review, facility documentation review and staff interview, the facility failed to ensure the facility provided medications with an error rate of five (5) percent or less. This was found true for one (1) of four (4) residents observed during the medication administration task of the Long Term- Care Survey Process (LTCSP). The facility medication error rate was 7.69. Resident identifier: Resident #48. Census:

Inspectors wroteBased on record review and staff interview the facility must obtain laboratory services to meet the needs of the residents. The facility was responsible for the quality and timeliness of the laboratory services. This was true for one (1) of seven (7) residents reviewed for laboratory services during the Long-Term Care Survey Process. Resident identifier: #32 Facility census: 71.

Inspectors wroteBased on record review and staff interview the facility failed to ensure the physician was promptly notified of laboratory results that fell outside of clincial reference ranges. This resulted in a delay of treatment for a resident who had a urinary tract infection. This was true for one (1) of seven (7) residents reviewed for laboratory services during the Long-Term Care Survey Process. Resident identifier: #32 Facility census: 71.

Inspectors wroteBased on medical record review and staff interviews the facility failed to ensure documentation was accurate and correct. This was true for one (1) out of two (2) reviewed for dialysis. Resident identifier: #229, Facility census 71.