The Foley Center At Chestnut Ridge
The Foley Center at Chestnut Ridge in Blowing Rock, NC — inspection on July 3, 2024.
Found 10 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
Additional review of the facility's investigation into the incident revealed Nurse Aide #10 did not
An interview with the Administrator on 06/28/24 at 1:28 PM revealed she was the facility's abuse coordinator and that she remembered the incident and stated it was her understanding that Nurse Aide #11 observed Nurse Aide #10 raise her hand in the face of Resident #41.
The Administrator reported Nurse Aide #10 was terminated and followed up by stating she expected her staff to treat all residents in the facility with respect and dignity, even if the resident was being difficult.
She indicated Nurse Aide #10 should have removed herself from the situation and returned at a later time if Resident #41 was having a difficult moment instead of becoming confrontational.
345045 07/03/2024
The Foley Center at Chestnut Ridge 621 Chestnut Ridge Parkway Blowing Rock, NC 28605
jeopardy to resident health or Licensed Practical Nurses (LPN) and certified nursing assistants (full time, part time, and prn safety including agency) on the need to notify the provider for any acute change in condition to include: Any symptom, sign or apparent discomfort that is: acute or sudden in onset, and is a marked change (i.e.,
including any change in condition where the resident has difficulty breathing, low oxygen saturations, new onset cough, and congestion with decreased appetite.
The DON will ensure that all licensed nurses, RNs, LPNs, and CNAs (full time, part time, and prn including agency) who do not complete the in-service training by [DATE] will not be allowed to work until the training is completed.
This in-service was incorporated into the new employee facility and agency orientation for all licensed nurses and certified nursing assistants (full time, part time, and prn including agency) by the Director of Nursing.
Alleged date of IJ removal [DATE] A validation of immediate jeopardy removal was conducted on [DATE].
The initial audit of residents was reviewed, and no issues were noted.
Staff interviews across all departments were able to verbalize that they had received education on notification of change it condition, examples of change in condition, who to notify of a change in resident condition, etc.
The staff were able to verbalize examples of a change in condition and the appropriate steps to take in notification, including the hall nurse, Director of Nursing, Administrator, and medical provider.
The immediate jeopardy removal date of [DATE] was validated.
345045 07/03/2024
The Foley Center at Chestnut Ridge 621 Chestnut Ridge Parkway Blowing Rock, NC 28605
(full time, part time, and prn including agency) by the Director of Nurses.
jeopardy to resident health or Administrator will be responsible for ensuring the removal plan is implemented. safety Alleged date of IJ removal [DATE]
A validation of immediate jeopardy removal was conducted on [DATE].
The initial audit of residents was reviewed, and no issues were noted.
Staff interviews across all departments were able to verbalize that they had received education regarding abuse and neglect.
The staff were able to verbalize examples of neglect, such as not assessing a resident with a change in condition, not notifying a provider of a change in condition, etc.
The staff were able to verbalize what to do if they suspected a resident was being abused or neglected, which included letting the hall nurse know, and following the chain of command if no action was taken.
The immediate jeopardy removal date of [DATE] was validated.
345045 07/03/2024
The Foley Center at Chestnut Ridge 621 Chestnut Ridge Parkway Blowing Rock, NC 28605
During a follow up interview with the Administrator on 07/02/24 at 3:00 PM she was informed the SW revealed during interview that she had not interviewed Resident #26 when he returned from the hospital.
The Administrator revealed she was not aware of this information.
345045 07/03/2024
The Foley Center at Chestnut Ridge 621 Chestnut Ridge Parkway Blowing Rock, NC 28605
Director of Nursing met with all direct care nurses who were working to initiate an assessment of
jeopardy to resident health or condition to include: Any symptom, sign or apparent discomfort that is: acute or sudden in onset, and safety is a marked change (i.e., more severe) in relation to usual symptoms and signs, or unrelieved by measures already prescribed including any change in condition where the resident has difficulty
where emergent care needs can't be met at the facility.
The audit was completed on: [DATE].
The audit identified that 2 of 79 residents had an acute change in condition to include: Any symptom, sign or apparent discomfort that is: acute or sudden in onset, and is a marked change (i.e., more severe) in relation to usual symptoms and signs, or unrelieved by measures already prescribed including any change in condition where the resident has difficulty breathing, low oxygen saturations, new onset cough, and congestion with decreased appetite and where emergent care needs can't be met at the facility. On [DATE], correction action was completed to include notification of the provider of the resident change in condition and orders, transfer to ER, X ray, etc. No residents required transfer to an acute care hospital.
Specify the actions the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or reoccurring and when the action will be completed: On [DATE] the Director of Nursing began in servicing all licensed nurses, Registered Nurses (RN) and Licensed Practical Nurses (LPN) and certified nursing assistants (full time, part time, and prn including agency) on assessment of any acute change in condition including how to respond to change in condition, how to assess a change in condition, when to activate Emergency Medical Services, what to do when a family makes a request to address a change in condition, and the importance of shift to shift report for continuity of care.
The DON will ensure that all licensed nurses, RN's, LPN's, and CNA's (full time, part time, and prn including agency) who do not complete the in-service training by [DATE] will not be allowed to work until the training is completed.
This in-service was incorporated into the new employee facility and agency orientation for all licensed nurses and certified nursing assistants (full time, part time, and prn including agency) by the Director of Nursing.
Alleged date of IJ removal [DATE] A validation of immediate jeopardy removal was conducted on [DATE].
The initial audit of residents was reviewed, and no issues were noted.
Staff interviews across all departments were able to verbalize that they had received education on notification of change in condition, examples of change in condition, who to notify of a change in resident condition, etc.
Non-nursing staff were able to verbalize examples of a change in condition and the appropriate steps to take in notification, including the hall nurse, Director of Nursing, Administrator, and medical provider.
Nursing staff were able to verbalize steps to be taken when a resident was observed with a change in condition which included a thorough head to toe assessment, complete set of vital signs, assessment and vital sign documentation, and notification of a provider/initiation of Emergency Medical Services (EMS).
The immediate jeopardy removal date of [DATE] was validated.
345045 07/03/2024
The Foley Center at Chestnut Ridge 621 Chestnut Ridge Parkway Blowing Rock, NC 28605
communication sheet in the medical provider book to obtain a new order for pain medication.
Nurse
#10 stated she had administered acetaminophen to Resident #279, but that Resident #279 continued
knee. Resident #279 was unavailable for an interview.
An interview was conducted on [DATE] at 12:27 pm with Nurse Aide (NA) #3. NA #3 reported she was assigned Resident #279 on [DATE] during dayshift (7:00 am to 7:00 pm). NA #3 stated she was not able to recall Resident #279.
An attempt to interview NA #4, that was assigned Resident #279 on [DATE] during night shift (7:00 pm to 7:00 am) was unsuccessful.
An interview was conducted on [DATE] at 12:09 pm with Nurse #3.
Nurse #3 reported she worked on [DATE] on dayshift (7:00 am to 7:00 pm) and was assigned Resident #279.
Nurse #3 stated she remembered Resident #279 had a knee replacement surgery but was unable to recall Resident #279 complaining of pain.
An interview was conducted on [DATE] at 11:25 am with the Nurse Practitioner (NP).
The NP stated she had seen Resident #279 following a knee replacement.
The NP stated she had issues with pain following her surgery.
The NP stated she was aware the on-call provider had refused to order pain medication for Resident #279 during night shift on [DATE] and reported she felt like the on-call provider should have given a one time order for pain medication to get the resident through the night until a facility provider could evaluate Resident #279 the next day.
The NP stated she had noticed on-call providers were hesitant to prescribe pain medications and would often refer the staff to the regular facility providers.
The NP stated she had written an order for Resident #279's oxycodone on [DATE].
A review of a physician's order dated [DATE] at 6:00 pm revealed an order for Resident #279 to be administered oxycodone 10 mg every six hours as needed for pain for 7 days.
A review of the February 2024 MAR revealed documentation that Resident #279 received oxycodone 10 mg at on [DATE] 6:00 pm (pain 0 out of 10) from Nurse #3.
An interview was conducted on [DATE] at 12:37 with Resident #279's Representative (RR).
The RR stated Resident #279 was admitted to the facility following knee replacement surgery.
The RR stated shortly after Resident #279 had issues getting pain medications and staff continued to tell her there were no orders for pain medication.
The RR stated Resident #279 reported she was in pretty bad pain at times.
An interview was conducted on [DATE] at 12:18 pm with the Interim Director of Nursing (DON).
The Interim DON stated she was aware of Resident #279 requesting pain medication on [DATE].
The Interim DON reported Nurse #10 had contacted on-call for a one-time pain medication order, and the on-call provider instructed Nurse #10 to have the regular facility provider order pain medication.
The Interim DON reported this was not typical of the on-call providers and stated she had no explanation for why the provider had not ordered any pain medication.
345045 07/03/2024
The Foley Center at Chestnut Ridge 621 Chestnut Ridge Parkway Blowing Rock, NC 28605
back up.
Nurse #8 stated he called the emergency pharmacy, and they delivered the medication
The Interim DON stated when a resident was running low on a medication, the Nurse should reorder the medication through their Electronic Health Record (EHR).
The Interim DON stated if a resident was out of medication, the Nurse should pull the medication from the emergency backup.
The Interim DON was unsure if Humulin N was kept in back up and stated facility staff should have ordered additional insulin when Resident #52 was observed to be low on insulin.
345045 07/03/2024
The Foley Center at Chestnut Ridge 621 Chestnut Ridge Parkway Blowing Rock, NC 28605
stopped by Resident #286 when she asked, what did you say my name was? Nurse #5 replied {name
stated, no I am {name of Resident #286}.
Nurse #5 removed the cup from Resident #286 and left the
Nurse #5 administered Resident #286's correct medications.
An interview was conducted on 6/27/2024 at 10:33 am with Nurse #5.
Nurse #5 reported she worked as an agency nurse in the facility.
Nurse #5 stated residents should be verified by their name and date of birth prior to administering medications.
Nurse #5 stated she was going to ask Resident #286 her name and date of birth and reported Resident #286 had intervened before should was able to.
Nurse #5 stated she should have verified the resident's name and date of birth prior to handing her the cup of medication.
An interview was conducted on 6/27/2024 at 10:37 with the Interim Director of Nursing (DON).
The Interim DON reported prior to administering medications, the Nurse should verify the right resident, right medication, right dose, right route, right date, and right time.
The Interim DON stated Nurse #5 was an agency nurse and had just started working at the facility.
The Interim DON stated Nurse #5 should have known to verify the rights of medication administration prior to attempting to give Resident #286 her medication.
An interview was conducted on 6/27/2024 at 1:02 pm with the NP.
The NP stated several things could have happened if Resident #286 had received apixaban without a diagnosis of atrial fibrillation (irregular heart rate).
She could have had bleeding.
The NP stated, you should know the possible adverse effects of receiving the wrong medications and refused to answer further questions.
The NP stated the encounter was not a medication error because Resident #286 had not received the medication.
An interview was conducted on 6/27/2024 at 4:21 pm with the MD.
The MD stated medications should be given to the resident that they are ordered for.
The MD was made aware of the observations on the medication pass with Resident #286.
The facility failed to notify a provider when Resident #278 was noted by Medication Aide #1 to have difficulty breathing, had an oxygen saturation of the high 70's/low 80's, and was asking for help. On [DATE], Upon being made aware of allegation of neglect, Administrator completed and submitted initial allegation report to Department of Health and Human Services. On [DATE], all current residents were assessed for change in condition to ensure anyone requiring change in condition received necessary care & services.
On [DATE], the Director of Nursing identified residents that were potentially impacted by this practice by completing head to toe body audits and assessed residents for any acute distress or verbal/nonverbal indicators of neglect with a BIMS 12 or less on all current residents.
The results included: all current residents with BIMS 12 (impaired cognition) or less had no areas of concern identified related to abuse/neglect. On [DATE], all current residents with a BIMS of 13 or above were interviewed by the Administrator and were asked if they had any concerns related to abuse/neglect and if they had any care concerns.
The results included: All current resident with BIMS 13 (intact cognition) or higher denied any allegations of abuse/neglect occurred and identified.
Additionally, on [DATE], the Director of Nursing met with all direct care nurses who were working to initiate an assessment of 100% of current residents.
This audit consisted of review of any residents with any acute change in condition to ensure the provider was notified of the change in condition.
The change in condition included: Any symptom, sign or apparent discomfort that is: acute or sudden in onset, and is a marked change (i.e., more severe) in relation to usual symptoms and signs, or unrelieved by measures already prescribed including any change in condition where the resident has difficulty breathing, low oxygen saturations, and new onset cough, congestion with decreased appetite.
This audit was completed on: [DATE].
The audit identified that 2 of 79 residents had an acute change in condition to include: Any symptom, sign or apparent discomfort that is: acute or sudden in onset, and is a marked change (i.e., more severe) in relation to usual symptoms and signs, or unrelieved by measures already prescribed including any change in condition where the resident has difficulty breathing, low oxygen saturations, new onset cough, and congestion with decreased appetite. On [DATE], a corrective action was completed for 2 of 79 residents identified as having a change in condition when the provider was notified of the change in condition and orders for the change in condition were carried out by the direct care staff.
345045
Form Approved OMB
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.
Building 345045 B.
Wing 07/03/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
The Foley Center at Chestnut Ridge 621 Chestnut Ridge Parkway Blowing Rock, NC 28605
F-F684: Based on record review, and staff, Resident Representative (RR), Social Worker (SW), Nurse Practitioner (NP), and Medical Director (MD) interviews Based on record review, and staff, Resident
jeopardy to resident health or facility failed to complete and document on-going thorough assessments for an acute change in condition safety and failed to respond effectively to a medical emergency. On [DATE] at 7:00 pm, Resident #278's Representative requested a chest x-ray, when Nurse #1 observed Resident #278 had a cough, congestion,
breaking up mucous/congestion every 12 hours and nebulizer breathing treatments four times a day were ordered for 7 days for a cough. On [DATE] at 7:00 am, Medication Aide (MA) #1 was told by the off going nurse, Nurse #2, that Resident #278 was not doing well. MA #1 checked Resident #278's oxygen saturation and noted it was in the high 70's/low 80's (normal oxygen saturation is 92 to 100%) and got the Director of Nursing (DON).
The DON advised MA #1 to place Resident #278 on oxygen and continue to monitor oxygen saturation levels. MA #1 continued to report breathing issues and concern about Resident #278 struggling to breathe to the DON throughout the day until Resident #278 was removed from the facility by the RR at 4:47 pm.
The RR took Resident #278 to the Emergency Department where Resident #278 was diagnosed with Influenza A (the flu) Influenzal Bronchitis (inflammation of the airway), had an elevated white blood cell count (which indicated infection), and was given intravenous fluids, steroids (used to decrease inflammation), a breathing treatment, and was admitted to the hospital. Resident #278 was later diagnosed with acute hypoxemic respiratory failure and was placed on comfort measures on [DATE], received inpatient hospice services in the hospital and expired on [DATE].
The certificate of death revealed Resident #278's immediate cause of death was acute hypoxemic respiratory failure, Influenza A, and bacterial pneumonia.
The deficient practice was identified for 1 of 3 residents (Resident #278) reviewed for change in condition.
Frequently Asked Questions
More Reports
Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.