Surry Community Health Center by Harborview

Inspectors wroteBased on record review and staff interviews, the facility failed to obtain consent and inform the resident or resident representative in advance of the risks and benefits of psychotropic medications prior to initiation for 1 of 5 residents reviewed for unnecessary medications (Resident #32).

Inspectors wroteBased on record reviews and staff and Nurse Practitioner (NP) interviews, the facility failed to ensure an as needed (PRN) psychotropic medication, lorazepam (medication used to relieve anxiety), had a stop date of 14 days for 1 or 5 residents reviewed for unnecessary medications (Resident #7).

Inspectors wrote2. Resident #7 was admitted to the facility on [DATE] with diagnoses that included major depressive disorder with major neurocognitive disorder due to Alzheimer's Disease. Review of Resident #7's medical record revealed an order dated 03/17/25 for quetiapine 50 milligrams (mg) by mouth twice a day for major depressive disorder with major neurocognitive disorder due to Alzheimer's Disease. Review of Resident #7's Medication Administration Record for 03/2025 indicated the Resident received 50 mg quetiapine by mouth twice a day beginning 03/17/25. Review of Resident #7's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the Antipsychotic Medication Review section indicated the Resident had not received antipsychotic medication since readmission/reentry or since the last assessment. [...]

Inspectors wroteBased on observations, record reviews resident and staff interviews, the facility failed to secure an oxygen cylinder stored in Resident #11's room for 1 of 4 residents reviewed.

Inspectors wroteBased on observations, record reviews and staff interviews, the facility failed to have a medication error rate of less than 5% as evidenced by 2 medication errors out of 31 opportunities, resulting in a medication error rate of 6.45% for 2 of 6 residents observed during the medication administration (Resident #52 and Resident #49).

Inspectors wroteBased on record review and Resident, Resident Representative (RR) and staff interviews the facility failed to implement grievance policy and procedures when a resident (Resident #21) reported on 11/30/23 the facility was running out of her Methadone. The Director of Nursing (DON) was assigned the grievance and on 12/01/23 confirmed Resident #21 had Methadone in the medication cart, and it had been documented as administered. The DON did not interview the resident or determine if there had been any supply issues with Resident #21's Methadone. Due to the lack of investigation this problem continued. Resident #21 reported she experienced terrible/awful pain of greater than ten on a scale of 1 to 10. [...]

Inspectors wroteBased on record review and family, Pharmacist, Medical Director (MD), Physician Assistant (PA), former staff, and current staff interviews the facility failed to protect a resident (Resident #21) from misappropriation of controlled substances by facility staff. Resident #21 reported starting the end of November 2023 she was told by Medication Aide (MA) #3 the facility had run out of her Methadone (analgesic opioid agonist), or MA #3 would tell her that she would bring her pain medication and never return during the night shift (7:00 pm to 7:00 am). Review of Resident #21's Medication Administration Record (MAR) for 11/2023 through 02/14/2024 revealed Resident #21's Methadone was signed out as administered by Medication Aide (MA) #3 every night shift she was assigned to the resident. [...]

Inspectors wroteBased on record review and staff interviews the facility failed to implement their abuse, neglect, and exploitation policy in the areas of protection, reporting, and investigating allegations of abusive actions perpetrated by staff toward residents. On 3/10/24 Medication Aide (MA) #1 and Nurse Aide (NA) #2 placed Resident #98 and Resident #305 in involuntary seclusion and on 3/12/24 Nurse Aide (NA) #1 utilized a physical restraint for Resident #15 that was not required to treat the resident's medical symptoms. Following the incidents, MA #1 and NA #1 were allowed to continue working direct care resident assignments. Additionally, the facility failed to investigate the allegations and to report the allegations to the state agency, law enforcement, and Adult Protective Services. [...]

Inspectors wroteBased on observation, record review and resident, resident representative, Pharmacy, Medical Director (MD), Physician Assistant (PA), and staff interviews, the facility failed to address a resident's pain (Resident #21) after repeated reports to staff that she had not received her pain medications during the night shift (7:00 AM to 7:00 PM). Resident #21 reported starting the end of November 2023 she was told by Medication Aide (MA) #3 the facility had run out of her Methadone (analgesic opioid agonist), or MA #3 would tell her that she would bring her pain medication and never return during the night shift. Resident #21 informed the PA on 12/12/23 that her pain medications were not being given to her. On 1/05/24 Resident #21 was seen by the PA and reported increased pain primarily at night. [...]

Inspectors wroteBased on record review and Resident, Pharmacist and staff interviews the facility failed to have systems in place for accurately receiving and reconciling controlled medications from the pharmacy. On 10/23/23 a possible drug diversion by Nurse #5 was reported to administration by Nurse #4. An effective investigation was not conducted which put other residents at risk for loss or diversion of controlled medications. In addition, a discrepancy was identified between the pharmacy dispensary reports and the controlled medication sign-out sheets for Resident #21's Methadone received by Medication Aide (MA) #3 on 10/13/23 and 1/16/24. The deficient practice was identified for 1 of 1 resident (Resident #21) reviewed for pharmacy services and due to the lack of effective systems there was the high likelihood of further diversion or loss of residents controlled medications. [...]

Inspectors wroteBased on observations, staff interviews, and record review, the facility staff failed to disinfect a shared blood glucose meter (glucometer) after use and before placing the glucometer back in the medication cart. Furthermore, the facility failed to disinfect a shared glucometer between residents with an approved disinfectant wipe for 3 out of 4 residents whose blood glucose levels were checked (Resident #60, Resident #54, and Resident #47). This occurred while there was a resident with known bloodborne pathogens in the facility. Three different staff were involved in the deficient practice (Nurse #1, Medication Aide #4 and Nurse #7). Shared glucometers can be contaminated with blood and must be cleaned and disinfected after each use with an approved product and procedure. [...]

Inspectors wroteBased on observation, record review, video review, physician, physician assistant and staff interviews the facility failed to protect Resident #98 and Resident #305 from involuntary seclusion when Medication Aide #1 and Nurse Aide (NA) #2 placed the residents in an activity/dining room in the evening with the doors closed, dim lighting, and no supervision due to the residents' yelling/screaming behaviors. The residents were unable to exit the room without assistance. Residents #98 and #305 were diagnosed with dementia and were at risk for falls. The reasonable person concept was applied for this deficient practice in that a reasonable person would have experienced feelings of fear and isolation from being confined to a room with no ability to exit. This deficient practice affected 2 of 2 residents reviewed for involuntary seclusion (Resident #98 and Resident #305). [...]

Inspectors wroteBased on record review and staff interview the facility failed to protect a resident (Resident #15) from unauthorized physical restraint when the Activities Director witnessed Nurse Aide (NA) #1 administer a COVID test to Resident #15, while Resident #15 was flailing her arms, resisting, and saying that she did not want a COVID test. NA #1 failed to identify a medical necessity that warranted restraining a resident. The reasonable person concept was applied for this deficient practice in that a reasonable person would experience feelings such as fear, pain, and dehumanization (deprivation of human qualities such as compassion). The deficient practice was revealed for 1of 3 residents (Resident #15) reviewed for the right to be free from physical restraints. [...]

Inspectors wroteBased on record reviews, observations, resident, and staff interviews, the facility failed to protect residents' dignity when residents were left soiled in feces and saturated in urine for 2 of 2 residents reviewed for dignity issues (Resident #4 and Resident #305). When they were not provided incontinent care Resident #4 reported feeling unworthy of being looked at, sanitary rights being ignored, uncomfortable, and nasty; Resident #305 reported feeling cold, wet, and uncomfortable. 1.) Resident #4 was admitted to the facility on [DATE] with diagnoses including muscle weakness, neuromuscular dysfunction of the bladder, and the need for assistance with personal care. The Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed Resident #4 was cognitively intact. [...]

Inspectors wroteBased on record review and staff interviews the facility's Quality Assessment and Assurance (QAA) committee failed to maintain implemented procedures and monitor interventions the committee had put into place following the recertification survey and complaint investigation on 12/01/2022. The failure included five deficiencies that were originally cited in the areas of Free from Abuse and Neglect (F600), Developing/Implementing Abuse/Neglect Policies (F607), Accuracy of Assessments (F641), Nutrition/Hydration Status Maintenance (F692), Sufficient Nurse Staffing (F725), Pharmacy Services and Procedures (F755), and Significant Medication Errors (F760) that were subsequently recited on the current recertification and complaint investigation on 3/27/2024. [...]

Inspectors wroteBased on observations, record review, resident and staff interviews the facility failed to provide baths and showers, and incontinence care for residents requiring or dependent on staff assistance with activities of daily living (ADL). This was for 3 of 8 residents reviewed for ADLs (Residents #59, #305 and #4).

Inspectors wroteBased on record review, observations, resident and staff interviews, the facility failed to provide sufficient nursing staff to honor a resident's preference for showers for 2 of 4 residents (Resident #59 and Resident #256) and to provide baths, showers, and incontinence care to dependent residents for 3 of 8 (Resident #4, Resident #59, and Resident #305) residents reviewed for sufficient nursing staff.

Inspectors wroteBased on resident, staff interviews, observations and record review, the facility failed to honor resident's preference for showers. This was for 2 (Resident #59 and Resident #256) of 4 residents reviewed for choices.

Inspectors wroteBased on observations, record review, Medical Director, resident, and staff interviews, the facility failed to ensure a resident's urinary catheter collection bag was drained for 2 of 2 residents reviewed for catheter care (Resident #4 and Resident #52).

Inspectors wroteBased on staff interviews, Medical Director interview, and record review, the facility failed to prevent a significant medication error when Medication Aide #1 and Medication Aide #4 did not administer medications for 1 of 1 resident (Resident #98) reviewed for significant medication errors.

Inspectors wroteBased on observations and staff interviews, carts containing medications were left unlocked and unattended for 2 of 4 carts (A and C Hall medication carts) observed for medication storage.

Inspectors wroteBased on observations and staff interviews, the facility failed to update the posted nurse staffing information on each shift for 2 of 5 days during the onsite recertification survey.

Inspectors wroteBased on record review and staff interviews, the facility failed to accurately complete the discharge Minimum Data Set (MDS) assessment for 1 of 1 resident reviewed for hospitalization (Resident #103).

Inspectors wroteBased on record review, staff and Medical Director interviews, the facility neglected to implement a physician order for intravenous fluids for 1 of 3 residents reviewed for neglect. (Resident #255).

Inspectors wroteBased on record review, staff and Medical Director interviews, the facility failed to implement a physician order for intravenous fluids (Resident #255). The deficient practice was for 1 of 3 sampled residents for review of hydration.

Inspectors wroteBased on record review, staff and Medical Director interviews, the facility failed to maintain accurate medical records related to intravenous fluids for 1 of 3 residents reviewed for hydration (Resident #255).

Inspectors wroteBased on record review, staff, Consultant Pharmacist, Pharmacy Director of Quality, and Medical Director interviews the facility failed to have an effective system in place to ensure staff did not have to borrow controlled substance medications from 3 of 3 residents (Resident #13, Resident #42, and Resident #69) to give to other residents whose medications were not available in the facility on 3 of 4 hallways (200, 300, and 400 hall) and failed to administer a physician ordered medication for 1 of 1 resident reviewed for psychotropic medications (Resident #21).

Inspectors wroteBased on record reviews and staff, Resident, and Physician interviews, the facility failed to prevent a significant medication error when they failed to obtain and administer a sleeping medication as ordered by the Physician for 1 of 1 resident reviewed for medications. A result Resident #21 missed 4 doses of the sleeping medication.

Inspectors wroteBased on record review, staff interviews and family interview the facility failed to ensure that a resident was free from neglect when it failed to provide the care after requested for 1 of 1 sampled resident (Resident #64) who required extensive assistance and had an episode of vomiting and incontinence. The reasonable person concept was applied to this deficiency. Individuals would expect to receive the care needed and would be upset wearing a shirt soiled with vomit and wearing a soiled brief after requesting assistance.

Inspectors wroteBased on record review, staff interviews and family interview the facility failed to implement their abuse and neglect policy in the area of reporting. Nurse #3 failed to report an allegation of neglect to facility administration after the allegation was reported directly to her, therefore a report to the state was not done. This occurred for 1 of 1 sampled resident (Resident #64).

Inspectors wroteBased on record review and staff interviews, the facility failed to accurately code an annual Minimum Data Set assessment for the presence of a level 2 Preadmission Screening and Resident Review (PASRR) for 1 of 2 residents reviewed for PASRR. (Resident #53)

Inspectors wroteBased on observations, record review, and staff interviews the facility failed to carry out and implement nutritional interventions recommended by the Registered Dietician for a resident with significant weight loss following a hospitalization for 1 of 6 residents reviewed for nutrition (Resident #55).

Inspectors wroteBased on record review, resident interviews, staff interview and family interviews the facility failed to provide sufficient nurse staffing to provide care for residents dependent on staff for assistance. This occurred for 2 of 2 sampled residents (Resident #64 and Resident #31).