Sistersville Center

Inspectors wroteBased on medical record review, observation, and staff interview, the facility failed to ensure Resident's received treatment and care in accordance with professional standards of practice. Specifically, physician's orders were not followed for Neurological checks (neuro checks) . This practice affected one (1) of one (1) residents reviewed, during the Long-Term Care Survey Process (LTCSP). Resident identifier #13. Facility census: 60. a) Resident #13 The facility's policy titled Falls Management, with effective date 09/15/01 and revision date 01/15/26, stated any resident who had a fall unwitnessed by staff would be observed for neurological abnormalities by performing neurological checks per policy. [...]

Inspectors wroteBased on staff interview and surveyor intervention, the facility failed to provide feeding of meals in a timely manner after serving the trays to residents with no drink or meal assistance. This was true for two (2) of two (2) residents in the care area of Resident Rights/Exercise of Rights. Resident Identifiers: Resident #55 and Resident # 57. Facility census: 60.

Inspectors wroteThe facility failed to honor resident choices regarding the things that are important in her life in regards to getting out of bed before lunch. This is true for two (2) of two (2) residents reviewed for choices. Resident identifier: #54. Facility census: 60. Findings Included: a) Resident #54 During an interview with Resident #4 on 03/30/26 at 11:32 AM, the resident expressed frustration regarding a delay in assistance with getting out of bed. She stated that she had been waiting for approximately one (1) hour and noted that her aide had previously mentioned they would return with help but had not yet done so. She stated she must get them early or she don't get up in time. During an interview on 03/30/26 at 11:45 AM with Registered Nurse #30 she stated she would get Resident #54's aide to get her out of bed for lunch. An observation at 12:10 PM found Resident #54 still in bed. [...]

Inspectors wroteBased on record review and staff interview, the facility failed to implement their abuse prohibition policy regarding the reporting of allegations of potential verbal abuse. This was true for one (1) of four (4) residents reviewed for the care area of abuse. Additionally, a random opportunity for discovery showed other allegations of potential verbal abuse had not been reported. Resident Identifier: #7. Facility Census: 60.

Inspectors wroteBased on record review and staff interview, the facility failed to report allegations of potential verbal abuse within a timely manner. This was true for one (1) of four (4) residents reviewed for the care area of abuse. Additionally, a random opportunity for discovery showed other allegations of potential verbal abuse had not been reported. Resident Identifier: #7. Facility Census: 60.

Inspectors wroteBased on record review and staff interview, the facility failed to investigate allegations of potential abuse. This was a random opportunity for discovery. Facility Census: 60.

Inspectors wroteBased on record review and staff interview, the facility failed to complete a yearly performance appraisal for direct care staff. This is true for one of five nurse aide performance appraisal's reviewed during this survey. Nurse Aide #52. Facility Census: 60Findings included: a) On 04/01/26 at approximately 4:00 PM, Administrator #47 was asked for Nurse Aide (NA) #52's Performance Appraisal for this year and she reported it is not in the chart. The surveyor asked if they could have the most recent one completed. The performance review delivered to the surveyor was dated 09/16/24. On 4/01/26 at 4:02 PM, a reviewed of Employee Performance Appraisal Form for NA #52 who was hired on 12/14/15 revealed her last performance review was completed on 09/16/24. Review of facility title, HR616 Performance Appraisal states: [...]

Inspectors wroteBased on record review and staff interview, the facility failed to ensure complete and accurate medical records. This deficient practice had the potential to affect two (2) of three (3) residents reviewed for the care area of advance directives. Resident Identifiers: #2 and #13. Facility Census: 60.

Inspectors wroteBased on staff interview and surveyor intervention, the facility failed to ensure pre meal hand hygiene was performed on one (1) of two (2) residents reviewed for the care area of infection prevention and control. Resident Identifier #55. Facility Census: 60.

Inspectors wroteBased on staff interview and observation, the facility to ensure garbage was disposed of properly. This failed practice had the potential to affect more than a limited number of residents. Facility Census: 65.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure required members of the Quality Assurance and Performance Improvement (QAPI) team were present to hold the required quarterly meeting. Facility Census: 65. a) QAPI members On 04/03/25 at 1:10 PM, a review of the sign in sheets for QAPI was completed. The review found the Director of Nursing (DON) position was empty during the dates of 02/19/24 through 04/08/24. There was no one filling in the DON position. Therefore, for the dates of 02/19/24 through 04/08/24, the required members did not attend. On 04/03/25 at 2:30 PM, this time frame was confirmed by the Administrator and the current DON. b) QAPI meetings On 04/03/25 at 2:40 PM, a review of the sign in sheets for QAPI was completed. The review found there were no meetings held in the months of 01/2025, 02/2025 or 03/2025. [...]

Inspectors wroteBased on observation, record review and staff interview, the facility failed to provide care in a manner and environment that promoted a dignified dining experience for the residents. This failed practice had the potential to affect more than a limited number of residents. Resident identifiers: #61, #50, #22, #57, #1, #2, #29. Facility Census: 65.

Inspectors wroteBased on record review and staff interview, the facility failed to complete a change in condition (CIC) for Resident #22's development of a pressure ulcer on the right heel. This was a random opportunity for discovery. Resident Identifier: #22. Facility Census: 65. Findings Include: a) Resident #22 On 03/31/25 at 2:30 PM, a progress note was reviewed. The progress note dated 03/31/25 at 1:16 PM stated, Resident has a blister to her right heel. NP (Nurse Practitioner) in facility this morning and visited resident. New order for Sure Prep to right heel BID (twice daily). POA (Power of Attorney) notified and in agreement with order. (Typed as written.) Upon further review, no change in condition was found for Resident #22. On 04/01/25 at 2:00 PM, an interview was held with the Director of Nursing (DON). [...]

Inspectors wroteBased on observation, record review, and staff interview, the facility failed to implement or develop comprehensive, person-centered care plans for four (4) of 22 residents. Resident #22's care plan was not implemented regarding a dietary restriction, documenting meal intakes, and for the risk of limited engagement. Resident #31's care plan was not implemented for monitoring of medication side effects and behaviors, pain assessments,and anticoagulation monitoring. The facility failed to develop a care plan for Resident #57 and #59 to include all diagnoses. Resident Identifiers: #22, #31, #57, #59, #25. and #51. Facility Census: 65.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure care plans were revised for Residents #42 fall, #22 dependent for meals, #57 independent for mobility, #4 full code, #23 give fluids when NPO, and #28 hospice when not ordered. These failed practices affected more than a limited number of residents. Resident identifiers: #42, #22, #57, #4, #23, and #28. Facility census: 65.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure physician orders were followed. medications were administered timely, behaviors, and pain were monitored. This had the potential to affect more than a limited number of residents. Resident identifiers: #31, #22, #59, #57, #25, #51 and facility late mdications, #28, #49, #37, #23, #36, #8, #7, $41, #50, #9, #41, #50, #20, #63, #42, #58, #61, #23, #10, #15, #17, #267, and #268. Facility census: 65.

Inspectors wroteBased on record review and staff interview, the facility failed to have sufficient staffing for the B hall on 03/29/25 and 03/30/25. This failure has the potential to affect more than a limited number of residents. Facility Census: 65. Findings Include: a) B hall residents On 04/03/25 at 11:30 AM, the daily staff postings were reviewed for 03/29/25 and 03/30/25. The review found only two (2) nurses scheduled for both dates; one (1) on the red hall and one (1) on the blue hall. The red hall has 26 beds and the blue hall had a census of 42 residents. No other nurse was scheduled on the blue hall during day shift. The nurse schedule provided had noted a need for day shift on 03/29/25 and 03/30/25. The daily nursing hours per patient day were above the minimum; but, multiple medications were late and multiple treatment orders were incomplete. [...]

Inspectors wroteBased on observation, staff interview and record review, the facility failed to ensure daily menus were followed. This was a random opportunity for discovery and had the potential to affect more than a limited number of residents. FACILITY:FACILITY. Facility Census: 65.

Inspectors wroteBased on record review, staff interview, resident interview and observation, the facility failed to prepare and serve food at a safe and appetizing temperature. This failed practice had the potential to affect more than a limited number of residents. FACILITY:FACILITY. Facility Census: 65.

Inspectors wroteBased on observation, staff interview and record review, the facility failed to ensure food was stored properly and food preparation equipment was clean. This failed practice had the potential to affect more than a limited number of residents. FACILITY:FACILITY. Facility Census: 65.

Inspectors wroteBased on record review and staff interview, the facility failed to maintain complete, accurate, and timely medical records. This deficient practice had the potential to affect five (5) of 22 residents reviewed in the long-term care survey sample. Resident Identifiers: #5, #58, #25, #51, and #3. Facility census: 65.

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. These were random opportunities for discovery that had the potential to affect more than a limited number of residents. The facility failed to ensure Enhanced Barrier Precautions (EBP) signage was appropriately placed outside Resident #3's room. The facility failed to follow EBP for Resident #7. The facility also failed to provide resident hand hygiene in the dining room. Resident Identifiers: #3 and #7. Facility census: 65.

Inspectors wroteBased on observation, record review and staff and resident interview, the facility failed to ensure a resident with limited Range of Motion (ROM) was able to reach the call light to call for assistance. This was a random opportunity for discovery and had the potential to affect a limited number of residents. Resident Identifier: #38. Facility Census:

Inspectors wroteBased on observation and record review, the facility failed to provide a home-like environment during the dining experience. This failed practice had the potential to affect more than a limited number of residents. FACILITY:FACILITY. Facility Census: 65.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure documentation that the appropriate information was communicated to the receiving health care institution or provider upon resident transfer. This deficient practice had the potential to affect one (1) of two (2) residents reviewed for the care area of hospitalization. Resident identifier: #66. Facility census: 65.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure an accurate Minimum Data Set (MDS) regarding weight loss. This was true for one (1) of two (2) residents reviewed under the care area of tube feeding. Resident Identifier: #61. Facility Census: 65. Findings Include: a) Resident #61 On 03/31/25 at 4:51 PM, a record review identified the resident was noted with significant weight loss. The resident's weight on 02/05/25 was 176.8 pounds. The resident's weight on 03/07/25 was 167.2 pounds. This is a significant weight loss of -5.43% in 30 days. A review of the MDS significant change dated 03/10/25 section K regarding weight loss was reviewed on 03/31/25 at 7:00 PM. The MDS stated no or unknown for the question K0300 for loss of 5% or more in the last month or loss of 10% or more in 6 months. [...]

Inspectors wroteBased on record review and staff interview, the facility failed to prevent the development of an avoidable pressure ulcer to the right heel for Resident #22. This was true for one (1) of three (3) records reviewed under the care area of pressure ulcers. Resident Identifier: #22. Facility Census: 65.

Inspectors wroteBased on observation, record review, and staff interview, the facility failed to transfer oxygen tanks in a safe manner. This was a random opportunity for discovery. Facility Census: 65. Findings Include: a) Oxygen tanks On 04/03/25 at 12:32 PM, an observation of the Maintenance Director carrying four (4) oxygen tanks, with no carrier used. The Maintanence Director had two (2) oxygen tanks in each hand, as he walked around the building the tanks were clanking together. On 04/03/25 at 12:34 PM, an interview was held with the Maintanence Director. the Maintanence Director stated, I know I'm not supposed to carry them this way .I'm trying to help her (referring to the oxygen delivery person) and she is tired. On 04/03/25 at 12:48 PM, the Corporate RN was notified. The Corporate RN shook her head in agreement and confirmed the oxygen tanks should not be transported without a carrier.

Inspectors wroteBased on record review and staff interview, the facility failed to provide pneumococcal immunizations according to standards of practice. This deficient practice had the potential to affect one (1) of five (5) residents reviewed for the care area of immunizations. Resident identifier: #59. Facility census: 65.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure two (2) allegations of resident-to-resident sexual abuse were reported in a timely fashion and/or to the appropriate state agencies. Resident identifiers: #27 and #23. Facility census: 55. The Office of Health Facility Licensure and Certification (OHFLAC) Long-Term Care Reporting Requirements guidance, dated December 4, 2019, instructs that OHFLAC and Adult Protective Services (APS) should receive an immediate fax report of allegations within two (2) hours.

Inspectors wroteBased on record review and staff interview, the facility failed to develop and implement a comprehensive person -centered care plan for one (1) of three (3) residents reviewed in the complaint survey process. The facility failed to address Resident #24's inappropriate sexual behaviors towards residents. Facility identifier: #24. Facility census: 55.

Inspectors wroteBased on medical record review and staff interview, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice. This deficient practice was true for one (1) out of three (3) residents reviewed during a complaint survey process. Resident identifier: #3. Facility census: 55.

Inspectors wroteBased on medical record review and staff interview, the facility failed to ensure the attending physician documented in the resident's medical record that an identified irregularity had been reviewed and what, if any, action was to be taken to address it. This deficient practice was true for one (1) out of three (3) residents reviewed during a complaint survey process. Resident identifier: #3. Facility census: 55.

Inspectors wroteBased on observation and staff interview the facility failed to ensure the resident environment was clean and sanitary. The dementia care unit dining area was unclean, a vitals machine had a brown splattered substance on the bottom, and there was a smeared brown substance on a hand sanitizer dispenser . This failed practice has the potential to effect all residents currently residing in the dementia care unit. Facility Census: 65 Findings Include: a) A tour of the dementia care unit on 04/01/24 beginning at 12:30 PM found the floor in the dining room to be littered with food debris the walls in the dining room had what appeared to be food splatters on several spots on the walls throughout the dining room. By the sink there was food splatters on the wall and several gnats were noted to be positioned on the wall around the food splatters. [...]

Inspectors wroteBased on observations, record review, resident interviews and staff interviews, the facility failed to implement an ongoing resident centered activities program designed to meet the interest of and support the physical, mental and psychosocial well-being of each resident. This was a random opportunity for discovery. This failed practice had the potential to affect more than a limited number of residents residing in the facility. Resident identifiers: Resident #26, Resident #15, and Resident #32. Facility Census: 65. Findings Include: a) Observations: During several observations throughout the complaint revisit survey on 04/01/24 to 04/02/24, several group activities were not being conducted as scheduled. The monthly activity calendar for the Blue Hall scheduled events were as follows: [...]

Inspectors wroteBased on observations and staff interviews the facility failed to ensure the activities program is directed by a qualified professional. This had a potential to affect all residents residing in the facility. Facility Census: 65 Findings Include: a) Activity Professional During several observations throughout the complaint revisit survey on 04/01/24 to 04/02/24, several group activities were not being conducted as scheduled. The monthly activity calendar for the Blue Hall scheduled events were as follows: -04/01/24 2:00 PM Getting to Know me (3) three residents were in attendance 4:00 PM Meaningful Moments was not conducted -04/02/24 9:30 AM Sensory Group was not conducted 10:30 AM Move and Grove was not conducted The monthly activity calendar for the Red Hall (Memory Unit) was dated for the month of February. [...]

Inspectors wroteBased on observations, water temperature measurement and staff interview the facility failed to ensure the resident environment over which it had control was as free from accident hazards as possible. The water temperature was found to be 119 degrees and the medication and treatment cart were discovered unlocked and unattended on the night of 04/01/24. This failed practice had the potential to affect more than an isolated number of residents. Facility Census: 65. Findings Include: a) Water Temperature An observation on 04/01/24 at 4:00 PM found the hot water in the restroom in the front lobby of the building was too warm to the touch. At 4:45 PM on 04/01/24 a visiting Maintenance Director came to the restroom and obtained the temperature. He stated, This will be in Celsius we will convert it Fahrenheit. The temperature obtained was 48.7 degrees Celsius. [...]

Inspectors wroteBased on policy review, staff interview, and record review, the facility failed to protect the residents right to be free from abuse that resulted in mental anguish for Resident #57, #56, #61, and #62. Resident #64 was touching female residents in the breast and vaginal area. The staff felt it was not a big deal if the female residents were not in distress. All sixteen (16) female residents on the dementia unit had the potential to be affected. The facilities lack of action to investigate the sexual abuse allegations placed Residents #57, #56, #61, and #62 at continued risk of sexual abuse for over six (6) months prior to Surveyor intervention. Resident identifiers: #64, #57, #56, #61, #62, #42, #43, #44, #45, #48, #49, #50, #51, #52, #58, #66. Facility census: 64. The facility was notified of the Immediate Jeopardy (IJ) at 5:26 PM on 02/13/24. [...]

Inspectors wroteBased on staff interview and record review, the facility failed to implement their written Abuse Prohibition policy as it related to identifying investigating and reporting allegations of sexual abuse. The facility also failed to follow procedures to investigate any such allegations and prevent future sexual abuse from happening. The facilities lack of action to identify, investigate, and report the sexual abuse allegations placed sixteen (16) female residents residing on the dementia unit at continued risk of sexual abuse for over six (6) months prior to surveyor intervention. Review of facility records found that there were 16 other female residents on the locked memory care unit where Resident #64 resided and were potential victims of his behavior. Resident identifiers: #64, #57, #56, #61, #62, #42, #43, #44, #45, #48, #49, #50, #51, #52, #58, #66. Facility census: 64. [...]

Inspectors wroteBased on policy review, record review and staff interview, the facility failed to ensure that alleged violations involving resident sexual abuse were reported, not later than 2 hours of the events / allegations being brought to the facility's attention, to appropriate state agencies as required. Resident #64 was touching female residents in the breast and vaginal area. The staff felt it was not a big deal if the female residents were not in distress. All sixteen (16) female residents on the dementia unit had the potential to be affected. The facilities lack of action to investigate and report the sexual abuse allegations placed the residents on the dementia unit at risk for serious injury or death. The abuse continued over six (6) months prior to surveyor intervention. These were random opportunities for discovery during a complaint survey. Resident identifiers: [...]

Inspectors wroteBased on record review and staff interview, the facility failed to have evidence of thorough investigations and prevention of further abuse while investigations were in progress. The facility was aware of sexual abuse by a male resident toward female residents. They did not conduct investigations when the abuse occurred. They did work to protect female residents from further sexual abuse after multiple occurrences of sexual abuse were observed. For the one (1) unusual occurrence that was reported there was no five (5) day follow up that contained an appropriate corrective actions. Resident #64 was touching female residents in the breast and vaginal area. The staff felt it was not a big deal if the female residents were not in distress. All sixteen (16) female residents on the dementia unit had the potential to be affected. [...]

Inspectors wroteBased on staff interview and record review, the facility administration failed to ensure the facility was administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Administration including the facility administrator and director of nursing (DON) was aware of resident to resident sexual abuse going on in the facility and failed to take appropriate action(s) to protect vulnerable residents. This was a random opportunity for discovery throughout the complaint survey process. The lack of action on the part of the administration created a problem for all seventeen (17) female residents living on the dementia unit. Resident identifiers: 64, #57, #56, #61, #62, #42, #43, #44, #45, #48, #49, #50, #51, #52, #58, #66. Facility census: 64.

Inspectors wroteBased on medical record review and staff interview the facility failed to maintain the resident's highest practicable level of physical, mental, and psychosocial well-being and the ability to prevent or minimize adverse consequences related to medication therapy to the extent possible. The facility failed to act upon the pharmacist medication regimen review reports for comments and recommendations identified for three (3) of three (3) residents reviewed during the complaint survey. Resident identifiers: Resident #50, Resident #66, and Resident #67. Census: 64.

Inspectors wroteBased on observation, medical record review and staff interview, the facility failed to develop and implement a baseline care plan within 48 hours of admission for resident #41 that included the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. This was true for one (1) of three (3) residents reviewed during a complaint survey. Resident identifier: #41. Facility Census 64. a) Resident #41 During a medical record review on 02/14/24 at 10:28 AM, Resident #41 was identified to have a BIMS of 10 and lacked capacity. The baseline care plan, dated 02/02/24, reviewed for Resident #41 identified only one (1) focus that was incomplete, one (1) incomplete goal, and outlined only two (2) interventions for the incomplete focus. - FOCUS: Resident/Patient requires assistance/is dependent for mobility related to: _____. [...]

Inspectors wroteBased on record review and staff interview, the facility failed to ensure two (2) residents received treatment and care in accordance with professional standards of practice. The facility failed to ensure neurological checks were completed for Resident #66 and Resident #67. This failed practice was true for two (2) of three (3) residents reviewed in the complaint care survey process. Resident identifier: #66, #67. Facility Census: 64.

Inspectors wroteBased on observation, record review, and staff interviews the facility failed to ensure they maintained medical records that were complete, accurately documented, readily accessible and systematically organized in the resident's medical record. This was true for one (1) of three (3) residents reviewed for falls during the complaint survey. Resident identifier: #50. Facility Census: 64. a) Resident #50 During a medical record review for Resident #50 on 02/13/24 at 9:56 AM a fall was identified to have happened on 09/02/23 and documented as incident #737 on the fall list that was provided by the facility. [...]

Inspectors wroteBased on staff interview, resident council meeting, and record review the facility failed to provide residents a confidential way to file a grievance. This failed practice has the potential to affect more than an isolated number of residents currently residing in the facility. Facility census: 60. Findings Included: a) Grievances On 04/05/23 at 10:23 AM, during a Resident Council meeting it was revealed there was no confidential way for the residents and/or family members to file a grievance without involving a staff member. On 04/05/23 at 1:45 PM, an observation throughout the facility found no grievance forms available throughout the facility. During an interview on 04/11/23 at 8:56 AM, with the Social Work Director #44 stated the Residents must come to a staff member to file the grievance on the computer. [...]

Inspectors wroteBased on record review and staff interview the facility failed to provide Notice of Discharge to the Office of the State Long Term Care (LTC) Ombudsman during a discharge / transfer or the Resident Representative. This was true for three (3) of three (3) Hospitalizations reviewed. Resident Identifier #60, #51 and # 45. Facility Census 60. Findings Included: a) Resident #60 A medical record review on 09/13/22 at 1:27 PM, revealed resident #60 was discharged to the hospital on [DATE]. Subsequent review of Resident #60's medical record showed it did not contain documentation the Notice of Transfer or Discharge was provided to the Resident Representative, or the Ombudsman of the discharges on 03/31/23. [...]

Inspectors wroteBased on medical record review and staff interview, the facility failed to provide evidence the resident and/or the resident's representative was provided a written Bed Hold Notice for a hospital transfer. This was true for three (3) of three (3) residents reviewed for hospitalizations during the Long-Term Care Survey Process. Resident identifiers: #51, #45, and #60. Facility census: 60.

Inspectors wroteBased on observation, medical record review and staff interview, the facility failed to implement comprehensive person-centered care plans for residents with wounds. In addition, the facility failed to include in the care plan the side effects of psychotropic medications which staff should watch for. This was found for one (1) of five (5) residents reviewed for unnecessary medications, one (1) of two (2) reviewed for pressure ulcers and one (1) of one (1) reviewed for wounds. Resident identifiers: #23, #17 and #43. Facility census: 60.

Inspectors wroteBased on medical record review and staff interview, the facility failed to ensure residents receive treatment and care in accordance with professional standards of practice. Resident #38's antibiotics were not given as ordered, Resident #17's wound changes were not documented, Vancomycin trough levels were not drawn correctly causing a resident to miss his antibiotic and a resident was allowed to self administer a medication without a physician's order.

Inspectors wroteBased on record review and staff interview the facility failed to ensure Nurse Aides (NA) were able to demonstrate competencies on an annual basis. This was true for four (4) of five (5) nurse aides reviewed for staffing during the Long-Term Survey Process (LTCSP). Staff Identifiers: Nurse Aide (NA) #50,#35, #42, and #52. Facility census: 60.

Inspectors wroteBased on record review and staff interview the facility failed to complete yearly performance evaluation for all Nurse Aides (NA). This was true for five (5) of five (5) nurse aides reviewed for staffing during the Long-Term Survey Process (LTCSP). Employee Identifiers: Nurse Aide (NA) #50, #35, #42, #2, amd NA #52. Facility census: 60.

Inspectors wroteThe facility failed to ensure the daily nurse staff posting was completed accurately for three (3) days throughout the long-term care survey process. This was a random opportunity for discovery and has the potential to affect all residents currently residing in the facility. Facility census: #60.

Inspectors wroteBased on observation, record review and staff interview, the facility failed to ensure prescribed medications were available to be administered as ordered and staff failed to document the administration of controlled substances in the narcotic drug count book at the time of disposition. This is true for one (1) of five (5) residents and one (1) of two (2) nurses observed during medication administration. Resident identifiers: #15, #18, and #37. Facility census: 60.

Inspectors wroteBased on record review, and staff interview, the facility failed to ensure the physician responded to monthly drug regimen reviews. This was true for four (4) of five (5) reviewed for unnecessary medications. Resident identifier #1, #51, #43 and #36. Facility census: 60.

Inspectors wroteBased on medical record review and staff interview, the facility failed to monitor residents for side effects of psychotropic medications. This is true for three (3) of five (5) residents reviewed for unnecessary medications. Resident identifiers: #43, #36, #51. Facility census: 60.

Inspectors wroteBased on observation and staff interview, the facility failed to provide food services in accordance with professional standards. The facility failed to ensure food was labeled and dated, domed lids were visibly stained / whitened with what the Food Service Director identified as lime / calcium buildup, a ceiling vent was covered in dust, and various repairs were needed. This practice had the potential to affect more than a limited number of residents. Facility census: 60.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure the Medical Director attended quarterly Quality Assurance and Performance Improvement Committee Meetings (QAPI). This has the potential to affect more than a limited number of residents currently residing in the facility. Facility census: 60.

Inspectors wroteBased on observation, staff interview and policy review, the facility failed to establish and maintain an effective infection prevention and control program designed to prevent the development and transmission of communicable diseases and infections. Staff failed to perform adequate hand hygiene and used their thumb nail to open pill blisters during medication pass. Gloves were not changed timely during wound care. Bed pans were not covered and labeled. A food cart was in disrepair and a resident consumed the remainder of another resident's lunch. This is true for one (1) of two (2) nurses observed during medication administration, one (1) of one (1) observed for wound care and one (1) of three (3) food carts. The remainder were random opportunities for discovery. Resident identifier: #18, #15, #35, #23, and #11. Facility census: 60.

Inspectors wroteBased on observation and staff interview, the facility failed to provide care to residents in a manner that promoted the right to a dignified existence and failed to protect a residents privacy during care. These were random opportunities for discovery. Resident identifier: #43 and #23. Facility census: 60.

Inspectors wroteBased on record review and staff interview, the facility failed to report incidents resulting in serious bodily injury in a timely manner to the appropriate state agencies. This was true for one (1) of three (3) residents reviewed for falls and one (1) of six (6) residents reviewed for accidents during the Long-Term Care Survey Process. Resident identifiers: #51 and #11. Facility census: 60.

Inspectors wroteBased on medical record review and staff interview, the facility failed to complete an accurate comprehensive assessment for one (1) of two (2) residents reviewed for pressure ulcers. The comprehensive assessment does not identify Resident #23's pressure ulcer. This is true for one (1) of two (2) residents reviewed for pressure ulcers. Resident identifier: #23. Facility census: 60.

Inspectors wroteBased on medical record review and staff interview, the facility staff failed to accurately complete the significant change comprehensive assessment for a resident with a pressure ulcer. This is true for one (1) of two (2) reviewed for pressure ulcers. Resident identifiers: 23. Facility census: 60.

Inspectors wroteBased on medical record review and staff interview, the facility failed to update Resident #55's care plan to reflect a change in nutritional status. This is true for one (1) of six (6) residents reviewed for the care area of nutrition. Resident identifier: #55. Facility census: 60.

Inspectors wroteBased on record review, and staff interview the facility failed to assess pressure ulcers weekly to promote the healing of pressure areas. This was true for two (2) of two (2) residents reviewed for pressure areas. Resident identifiers #46 and #23. Facility census 60. Findings Included: a) Resident #46 A medical record review for Resident #46 revealed the following physician orders: -- Apply HYDRA Guard two times a day and as needed to sacrum to maintain skin integrity every day and night shift for to maintain skin integrity. -- Wash coccyx/buttocks with wound wash, pat dry. Apply foam dressing. Change every other day and as needed as soiled every night shift every two 2 day(s) for wound healing. -- Apply skin prep to bilateral heels and ensure that heels are offloaded. Monitor skin for any changes to skin integrity. [...]

Inspectors wroteBased on observation, record review, and staff interview, the facility failed to ensure each resident was afforded the amount of supervision required to prevent accidents during the lunch time hour. This was true for one (1) of three (3) residents reviewed for falls in the Long-Term Care Survey process. Resident identifier: #42. Facility census: 60. a) Resident #42 Review of the facility matrix, on 04/03/23 at 10:43 AM, revealed Resident #43 had a history of falls with injury. Review of the physician orders, on 04/03/23 at 10:44 AM, found the following order, Nonskid footwear for resident safety as resident allows which was given on 04/19/21. Review of Resident #42's care plan, on 04/03/23 at 10:45 AM, found the following focus area: [Resident's First Name] is at risk for falls: cognitive loss, lack of safety awareness, hx [history] of falls with injury. [...]

Inspectors wroteBased on record review and staff interview, the facility failed to maintain a complete and accurate medical record for one (1) of 24 sampled residents during the Long-Term Care Survey Process. Specifically, the facility failed to accurately accept verbal consent on a Physician Orders for Scope of Treatment (POST) form by using only one (1) witness to the consent. Resident identifiers: #43. Facility census: 60. Findings Included: a) Resident #43 A medical record review, completed on 04/03/23 at 1:52 PM, revealed the following details: -There was a Physician Orders for Scope of Treatment (POST) form on file for Resident #43. - Liscensed Practical Nurse (LPN) #46 had accepted verbal consent from Resident #43's Health Care Surrogate (HCS). The verbal consent was accepted on 11/22/22. LPN #46 was the only witness to the verbal consent. [...]