Based on record review and resident interviews, the facility failed to ensure residents had the right to make choices about aspects of their life in the facility that are significant to the resident, including the right to participate in social, religious, and community activities that do not interfere with the rights of other residents in the facility. This was true for two (2) of five (5) residents reviewed for the category of choices, during the long-term care survey. Resident Identifiers: #25 and #40. Facility Census: 58. Findings Included: a) Resident #25 During an interview on 08/06/24 at 11:05 AM, Resident #25 revealed she would like to have three showers a week, but the facility only schedules her for showers on Tuesdays and Saturdays. She stated that she had mentioned her preference to the Nursing Assistants (NAs) on more than one occasion, but her requests had been ignored. Record review revealed a shower schedule for the facility's East Wing with Resident #25 scheduled for showers on Tuesdays and Saturdays in the AM. In an interview with NA #42 on 08/07/24 at 12:06 PM regarding showers, she emphasized the difficulty of getting the residents showered, highlighting the constraint of having only one shower room on each wing. LPN #30, on 08/07/24 at 12:33 PM, stated that she had informed Clinical Operations Specialist #6 that Resident #25 requested three showers per week. On 08/08/24 at 2:58 PM, Resident #25 approached this surveyor near the office, and Clinical Operations Specialist #6 was within hearing range. Resident #25 asked, Am I going to get my three showers from now on? The resident was reassured that the facility had been notified of her request. b) Resident #40 In an interview with Resident #40 on 08/06/24 at 3:19 PM, she disclosed that she is Catholic. She mentioned that she wakes up around 4:30 AM every morning to watch church services on TV. She also stated that she says her rosary, and would like assistance getting out of bed and being cleaned by 7:00 AM. However, she mentioned that her requests had been ignored by the Nursing Assistant (NA). Additionally, she mentioned that a woman representing the State had visited her a few weeks ago, to whom she had also expressed her request, but nothing had come of it. Record review revealed a nursing note dated 8/6/2024 at 12:56 PM which stated: Resident is alert & oriented person place time intermittently confused forgetful On 08/06/24 at 04:11 PM, during an interview with LPN #60, she mentioned that Resident #40 is often confused, but can still respond to questions. The LPN also noted that the staff were uncertain about the resident's needs due to her frequent changes of mind.

. Based on interview, record review and policy review the facility failed to make prompt efforts to resolve a grievance and to keep the resident notified of progress toward resolution. This was true for one (1) of three (3) grievances reviewed during the Long-Term Care Survey Process (LTCSP). Resident identifier: #55. Facility census: #58. Findings Include: a) Policy Review Record review of the facility's policy titled, Grievance, revision dated 09/14/22, showed: -Upon receipt of an oral, written or anonymous grievance submitted by a Resident, the grievance official will take immediate action to prevent further potential violations of any residents' rights while alleged violation is being investigated, if indicated. -The Grievance Committee / Grievance official shall complete an investigation of the resident's grievance. This may include a review of facility processes, programs and policies, as well as interviews with staff, residents, and visitors, as indicated. And any other review deemed necessary by the Grievance Committee. -The facility will keep evidence of the resolution of all grievances for a period of three (3) years from the date the grievance decision is issued. b) Resident Council On 08/08/24 at 12:00 PM during an interview with Resident Council, they stated the facility did not respond to grievances or help with resolution. Continued interview revealed Resident #55 stating she had complained about her roommates Husband coming late at night and stays most of the night. She continued to say nothing was ever done. Subsequent interview with Resident Council members stating Resident #12 and her husband is loud during his visit and keep them awake. They stated they complain to the nurses at night, and no one ever says anything to them. During an interview with the Social Worker on 08/08/24 at 12:50 PM, she stated Resident #55 did come to her with a grievance about leaving the facility because she did not like having a semiprivate room. She continued to say Resident #55 told her at time, her roommate's husband comes in late at night and is in her room. The Social Worker stated she thought Resident #55 just wanted to move back to the community. She continued to say, she did not file a grievance about Resident #12's husband late visitation and being in the resident #55's room late at night.

. Based on medical record review and staff interview, the facility failed to accurately complete a Minimum Data Set (MDS) assessment for one (1) of 19 residents reviewed during the Long-Term Care Survey process. The MDS for Resident #36 did not accurately reflect the resident had bilateral hearing amplifiers. Resident identifier: Resident #36. Facility Census: 58. Findings included: a) Resident #36 During an interview, on 08/06/24 at 1:15 PM, Resident #36 reported, she was hard of hearing and was dependent on bilateral hearing amplifiers to hear better. Resident #36 stated, the Social Worker had helped her purchase the hearing amplifiers. The Social Worker reported the resident had her bilateral hearing amplifiers since 05/16/24. A review of Resident #36's Medicare - 5 Day MDS, with an Assessment Reference Date (ARD) of 06/23/24, revealed Section B titled Hearing, Speech, and Vision, answered Question B0300 titled Hearing Aid as: No. During an interview on 08/08/24 at 11:12 AM, MDS LPN #57 acknowledged the MDS with ARD date of 06/23/24 had incorrectly coded NO to Question B0300 Hearing aid or other hearing appliance used? She stated the MDS would need modified to reflect the correct answer.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure that the resident's Pre-admission Screening (PAS) reflected pre-admission diagnoses for one (1) of one (1) residents reviewed for the category of PASRR (Pre-admission Screening and Record Review), during the Long-Term Care Survey process. Resident identifier: #58. Facility census: 58. Findings included: a) Resident #58 A record review, completed on 08/06/24 at 12:53 PM, revealed Resident #58 had been admitted to the facility on [DATE] with an admitting diagnosis of Major Depressive Disorder. The admitting Pre-admission Screening and Resident Review (PASARR), dated 05/08/24, did not identify Resident #58 had a major depressive disorder on Section III, Question 30 of the PASRR. This PASRR indicated no Level II was required. A continued record review also revealed a there was never a new PAS completed to reveal resident's major depressive disorder diagnosis in order to address whether or not specialized services were needed. During an interview on 08/07/24 at 11:30 AM, the Social Worker acknowledged the admitting PAS failed to identify resident's major depressive disorder diagnosis. The Social Worker noted the facility had recently identified the need to review new resident admission PASRRs to be sure they were accurate and she had been working on monitoring those. The Social Worker then stated she would complete a new PASRR for Resident #58 to reflect his major depressive disorder diagnosis.

Based on observation and interview, the facility failed to identify and implement measures to reduce hazards and risks, and to ensure that the resident environment remained free of accident hazards. This failed practice had the potential to affect more than a limited number of residents who resided at the facility. This was a random opportunity for discovery. Facility census:58. Findings Included: a) On 08/06/24 at 1:24 PM, it was observed that two bathrooms in close proximity to the physical therapy room, and conference room/lounge, were unlocked and accessible to both staff and residents at any time. Upon further inspection, it was discovered that these bathrooms were not equipped with nurse call devices or emergency pull alarms. During an interview with Administrator #72 on 08/06/24 at 1:39 PM, he stated that Those bathrooms are not for residents. When asked what prevented residents from using those bathrooms, he could not provide a reason. However, he mentioned that if residents did use the bathrooms, they were equipped with grab bars for safety. He also mentioned that these bathrooms had passed multiple surveys without any questions raised by surveyors about their use.

Based on interview and record review the facility failed to provide services to provide appropriate toileting schedule for one (1) of one (1) resident reviewed for the bowel and bladder care area during the long term care survey. Resident identifier #32. Facility census: 58. Findings include: a) Resident #32 During an interview 08/06/24 at 12:53 PM with Resident #32's sister, she stated, the staff don't take her to the bathroom when she needs to go. She continued to say her sister has accidents because they make her wait. A Medical record review found a physician order dated 9/6/22: Toilet upon rise, before meals and after meals at bedtime (HS) as needed if voiced. A continued review of Activities of Daily Living (ADL's) Toileting documentation showed Resident #32 was only toileted two (2) times a day. During an Interview on 08/08/24 at 11:00 AM, Minimum Data Set Coordinator #57 verified, the documentation of toileting did not follow the active physicians order.

Based on interview and review of documents, facility failed to adequately assess and control resident's pain. This failed practice had the potential to cause harm to one (1) of two (2) residents reviewed for pain. Resident #13. Facility Census: 58. Findings included: a) Resident #13 During an interview with Resident #13 on 08/06/24 11:32 AM, Resident #13 stated that she had fractured her right ankle and previously a cast on her leg. She stated that the cast had been removed on 08/02/24 and a cam walker boot had been applied. Resident was seated in a wheelchair and stated that she was in pain. She rated her pain at a level of ten (10) on a scale of ten (10). LPN #60 stated that she was aware and administered Acetaminophen 650 MG as prescribed. When this surveyor performed a follow-up interview with the resident at 12:55 PM, the resident was in bed, and rated her pain as five (5) on a scale of ten (10). During an interview with LPN #60 she stated, she always rates her pain high. Document review revealed a physicians note dated 6/24/2024 at 3:03 PM which stated: I certify that all information contained in Resident's medical record is a true and accurate reflection of his / her care. A review of the care plan revealed a note that stated: Resident is at increased risk for pain r/t fractured (R) ankle, DM. Report to Nurse any change in usual activity attendance patterns or refusal to attend activities related to s/sx or c/o pain or discomfort. Date Initiated: 06/28/2024 Further review revealed a non-specific physicians order on 07/13/24 at 11:00 AM for Acetaminophen 8 Hour Oral Tablet Extended Release 650 MG, which stated: Give 650 mg by mouth every 8 hours as needed for temp over 100 or pain During an interview with the Clinical Operations Specialist #6, she stated that Resident #13's pain was managed by her Orthopedic Surgeon, and that her next appointment was scheduled for 09/16/24. Upon being asked about resident's current level of pain, and why the physician had not been notified of the resident's pain, and no order for pain relief had been obtained, she stated that she would contact the physician immediately. Record review revealed resident's rating of her pain on the following days: 07/13/24 - 4 07/15/24 - 5 07/17/24 - 5 07/24/24 - 4 07/25/24 - 2 07/26/24 - 7 07/27/24 - 7 08/01/24 - 6 08/06/24 - 10 08/07/24 - 5 On 08/08/24 the Clinical Operations Specialist #6 notified this surveyor that the physician had been contacted and an order, that would address the resident's pain, would be entered into point click care.

Based on review of facility documentation and staff interview, the facility failed to have the required members attend the Quality Assessment and Assurance (QAA) meetings at least quarterly. The facility failed to ensure the Medical Director or designee attended the QAA meetings at least on a quarterly basis. This practice had the potential to affect more than a limited number of residents. Facility census: 58. Findings included: a) Quarterly QAA Meetings During an interview on 08/08/24 at 2:20 PM, the Director of Nursing and Administrator reported the the facility had QAA Meetings on a quarterly basis. Sign in sheets for QAA meetings were reviewed from August 2023 through August 2024. The sign in sheets for the meetings showed no attendance, by signature, of the Medical Director or designee for the quarter for January 2024 through March 2024. The DON reviewed for the minutes for the 01/24/24 QAA meeting and failed to find any evidence the Medical Director was present.

b) [NAME] wing shower room Inspection of the [NAME] wing shower room on 08/06/24 02:10 PM revealed a black substance between the tiles of the shower room walls. In addition, the air conditioning vent grills in the ceiling were coated with a thick, furry layer, of lint and debris. During an interview with the Environmental Services Supervisor #53 on 08/06/24 at 2:28 PM, she stated they power wash the walls, but confirmed that the shower room walls, and air conditioning vents, were dirty and needed to be cleaned. . Based on observation and staff interview, the facility failed to provide a safe, sanitary, and homelike environment. This was a random opportunity for discovery. Room identifier: east and west shower rooms. Facility census: 58. Findings include: a) East Shower Room During an interview with Resident #1 on 08/06/24 at 12:46 PM she stated the shower room had mold on the floor and up the walls. She continued to say she did not like to put her feet down because they do not clean the shower room very well. An observation, on 08/06/23 1:33 PM, of the east shower found a black substance on the floor and up the walls, and a thick layer of lent and debris on the ceiling vents. During an interview on 08/06/24 at 2:15 PM the Environmental Services Supervisor confirmed the shower room floor, walls, and vents needed cleaned. She stated, It's hard to keep up on because of the moisture in the room, so they power wash the black substance off the floors and walls once a month. b) [NAME] wing shower room Inspection of the [NAME] wing shower room on 08/06/24 at 2:10 PM revealed a black substance between the tiles of the shower room walls. In addition, the air conditioning vent grills in the ceiling were coated with a thick, furry layer, of lint and debris. During an interview with the Environmental Services Supervisor #53 on 08/06/24 at 2:28 PM, she stated they power wash the walls, but confirmed the shower room walls, and air conditioning vents, were dirty and needed to be cleaned.

Based on medical record review and staff interview, the facility failed to provide care and services in accordance with acceptable standards of practice. The facility failed to ensure the physician was notified when Resident #56's blood sugar levels were above 400. This affected one (1) of five (5) residents reviewed for unnecessary medications during the long-term care survey process. Additionally, the facility failed to have matching treatment orders when comparing the Physician Orders for Scope of Treatment (POST) form and written physician orders on the chart. This was true for one (1) of 19 residents reviewed in the Long-Term Care Survey Process. Resident identifiers: #56 and #3. Facility census: 58. Findings included: a) Resident #56 During a resident representative interview on 08/06/24 at 12:01 PM, it was discovered Resident #56 occasionally had high blood sugar levels. A record review, completed on 08/07/24 at 1:59 PM, revealed the following physician order: NovoLOG FlexPen Subcutaneous Solution Pen-injector 100 UNIT/ML. Inject subcutaneously before meals and at bedtime for Type II Diabetes Mellitus. Hold for blood glucose less than 150. Call MD (doctor) if BS (blood sugar) is above 400. Review of the April 2024, May 2024, June 2024 and July 2024 Medication Administration Records (MARs) indicated Resident #56's blood sugar level was over 400 the following nine (9) times without notification to his attending physician: -04/26/24 at 9:00 PM, Blood Sugar 412 -05/05/24 at 4:00 PM, Blood Sugar 438 -05/05/24 at 9:00 PM, Blood Sugar 529 -05/07/24 at 4:00 PM, Blood Sugar 421 -05/08/24 at 4:00 PM, Blood Sugar 456 -05/09/24 at 9:00 PM, Blood Sugar 479 -05/12/24 at 4:00 PM, Blood Sugar 462 -05/14/24 at 9:00 PM, Blood Sugar 409 -07/12/24 at 9:00 PM, Blood Sugar 447 During an interview on 08/07/24 at 4:00 PM, the Director of Nursing (DON) stated the facility was unable to locate evidence the physician was notified of the above-mentioned blood sugar levels. b) Resident #3 A record review, completed on 08/06/24 at 11:01 AM, revealed the following discrepancy: -The code status listed on the profile page of the electronic medical record stated: Full Code - Limited Additional Interventions-12/10/18 -The Physician Orders for Scope of Treatment (POST) form, signed 03/21/24, stated: FULL Code / FULL Treatment During an interview on 08/07/24 at 12:00 PM, the Director of Nursing (DON) reported the facility had failed to change Resident #3's code status to Full Code / Full Treatment following the 03/21/24 updated POST form being signed.

Based on review of the staff schedules for Registered Nurse (RN) coverage and staff interview, the facility failed to ensure RN coverage eight (8) consecutive hours a day, seven (7) days a week. This had the potential to affect all residents at the facility. Facility census: 58. a) RN Coverage A review of the staffing schedules for RN coverage, completed on 08/08/24 at 12:30 PM, revealed ten (10) occasions when RN coverage did not occur eight (8) consecutive hours a day: 01/13/24 - RN Coverage was 7.00 hours 01/14/24 - RN Coverage was 7.00 hours 02/03/24 - RN Coverage was 6.00 hours 02/04/24 - RN Coverage was 6.00 hours 02/11/24 - RN Coverage was 6.00 hours 02/25/24 - RN Coverage was 0.00 hours 03/09/24 - RN Coverage was 7.00 hours 03/23/24 - RN Coverage was 6.25 hours 03/30/24 - RN Coverage was 6.75 hours 03/31/24 - RN Coverage was 7.00 hours During an interview on 08/08/24 at 2:50 PM, the Administrator reported the facility was unable to produce evidence of RN coverage for eight (8) consecutive hours on the above-mentioned dates.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview the facility failed to have a clean sanitized mobile utility food cart and debris under the kitchen prep tables, the stove and [NAME]. This had the potential to affect all residents that get their nutrition from the kitchen. Facility census. 58. Findings included: a) Kitchen tour During Initial tour on 08/06/24 at 9:44 AM found: 1- One (1) mobile utility cart with the toaster, having old food and other debris on all three (3) shelves. 2-old food and debris under prep tables, the stove and [NAME]. An Interview with the Dietary Manager during initial tour verified all issues noted. She stated that she was unaware of the issues, and she would fix the issues.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on Resident Council Interview, observation, resident interview, staff interview, record review and documentation review the facility neglected to have a system in place for Residents to notify staff when outside on the patio. Resident identifier: #7. Facility census: 56. Findings included: a) Non-Functioning Doorbell/Call System During an interview on 09/13/22 at 2:00 PM, Resident Council identified a concern related to re-entry back into the facility from the patio area. Resident Council disclosed that the doorbell does not work, and most Residents cannot physically open the door to go back into the facility. Resident Council stated that Residents had to wave to alert the staff to get back inside the facility from the patio. An observation on 09/13/22 at 2:20 PM showed Resident #7 sat outside alone. An observation on 09/13/22 at 2:20 PM of the patio door doorbell revealed no sound when pushed. The doorbell located beside the patio door was pushed by two (2) Surveyors multiple times over a 15-minute interval with no sound after doorbell button was pushed. The patio door was noted to be unlocked and needed to be pulled to be opened. During an interview on 09/13/22 at 2:35 PM, Activity Aide #48 confirmed doorbell did not ring when pushed. During an interview on 09/13/22 at 2:38 PM, Dietary Manager (DM) stated the doorbell was not actively working but it worked last week. During an interview on 09/13/22 at 2:40 PM, Director of Nursing (DON) stated the doorbell does not work and was not in use but there was a fob that alerts staff on their phones when Residents wanted to come in from the patio. During an interview on 09/13/22 at 2:45 PM, Receptionist #2 stated there was a doorbell for Residents to push when wanting to come inside from the patio. Receptionist #2 was asked if doorbell was heard ringing today and Receptionist stated, No I wasn't listening for it. During an interview on 09/13/22 at 2:50 PM Licensed Practical Nurse (LPN) #82 stated some Residents use their personal phones to call the nurses desk and ask to come in, some Residents push the doorbell and other Residents pass off one (1) fob to one another to alert staff while outside. Surveyors requested to see the fob and no fob was available to show the surveyor team when requested. A review of Resident #7's medical record showed an admission date of 12/27/22 with a diagnosis of hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, Muscle wasting and atrophy, not elsewhere classified and muscle weakness. Resident #7 had an annual minimal data set (MDS) dated [DATE] that showed Resident #7 had a brief interview for mental status (BIMS) of 15. The annual MDS dated [DATE] showed Resident #7's functional status as followed: Bed Mobility: Extensive Assistance with a two (2) person assist Transfer: Extensive Assistance with a two (2) person assist Walk in room: Activity did not occur Walk in corridor: Activity did not occur Locomotion on unit: Extensive Assistance with a two (2) person assist Locomotion off unit: Extensive Assistance with a one (1) person assist Dressing: Extensive Assistance with a two (2) person assist Toilet use: Extensive Assistance with a two (2) person assist Personal Hygiene: Extensive Assistance with a two (2) person assist The care plan stated a focus of ADL self-care performance deficit due to history of stroke with left side weakness. The goal was to have decreased risk of complications of stroke. Interventions included transfer with Hoyer lift and two (2) person-assist and out of bed daily in wheelchair. During an interview on 09/13/22 around 4:00 PM LPN #82 brought in the fob that was requested to be viewed by Surveyors at 2:50 PM. LPN #82 displayed how the push button fob was to be pushed and how it alerted staff cell phones. LPN #82 had to push the fob button four (4) times to get the phone to alert and stated, the fob worked fine when testing it before showing it to Surveyors. During an interview on 09/03/22 at 5:00 PM, [NAME] President of Operations (VPO) discussed the fob purpose was only a form of a call light only. VPO stated that the doorbell was used to alert staff when Residents wanted to enter the facility from the patio. .

. Based on observation, staff interview, and operation policy the facility failed to report alleged violation related to, neglect, or abuse, and report the results of all investigation to the proper authorities within prescribe time frames. This was a random opportunity for discovery. Resident identifier: #1. Facility census: 56. Record review of the facility's policy titled, Abuse, Neglect, Exploitation & Misappropriation of Resident Property, showed: -It is the facility's policy to investigate all allegations involving Abuse, Neglect, Exploitation & Misappropriation of Resident Property, including injuries of unknown source, in accordance with this policy. -Facility staff should immediately report all such allegations to the Administrator and to [NAME] Virginia Office of Health Facility Licensing and Certification (OHFLAC) in accordance with the procedures in this policy. -If Abuse or serious Bodily Injury is Alleged. If the event that caused the allegation involves an allegation of Abuse or serious bodily injury, it should be reported to OHFLAC immediately, but not later than two (2) hours after the allegation is made. Findings include: a) Resident #1 An observation on 09/13/22 at 4:15 PM in the dining room, found Resident #1's family member attempting to force food in her mouth. Food was on resident #1's mouth and face. Resident #1's family member was being verbally aggressive. Resident #1 family member was stating in a harsh tone You ordered this food. I don't know why you won't eat it. You are being ridicules.'' Continued observation revealed, the Dietary Manager (DM) asking Resident #1's family member, not to feed her at this time. She responded, she ordered it, and she won't even eat it. During an interview 09/13/22 at 4:19 PM, the DM stated that he was going to get a nurse. Subsequent observation revealed Resident #1's family member continuing to talk to her in harsh tones, stating I can't believe you do this; you have to eat this. This Surveyor notified the Director of Nursing (Don) 09/13/22 at 4:20 pm of the situation. The DON came into the dining room and cleaned the food off Resident #1s face. Resident #1's family member stated, she needs to eat her food. The DON left the dining room after cleaning Resident #1's face. Continued observation at 4:25 PM revealed, the DM returned and ask Resident #1s family member to move over to another table with her husband who also resides in the facility. She responded, I should have moved earlier, I was getting frustrated with her. During an interview on 9/14/22 at 2:12 PM DON, confirmed he did not report or investigate the allegation of verbal abuse. The DON verified that he should have investigated and reported the incident per policy. .

. Based on observation, staff interview, and operation policy the facility failed to take actions to investigate an alleged violation related to, verbal abuse. This was a random opportunity for discovery. Resident identifier #1. Facility Census 56. Record review of the facility's policy titled, Abuse, Neglect, Exploitation & Misappropriation of Resident Property, showed: -It is the facility's policy to investigate all allegations involving Abuse, Neglect, Exploitation & Misappropriation of Resident Property, including injuries of unknown source, in accordance with this policy. -Facility staff should immediately report all such allegations to the Administrator and to [NAME] Virginia Office of Health Facility Licensing and Certification (OHFLAC) in accordance with the procedures in this policy. -If Abuse or serious Bodily Injury is Alleged. If the event that caused the allegation involves an allegation of Abuse or serious bodily injury, it should be reported to OHFLAC immediately, but not later than two (2) hours after the allegation is made. Findings include: a) Resident #1 An observation on 09/13/22 at 4:15 PM in the dining room, found Resident #1's family member attempting to force food in her mouth. Food was on resident #1's mouth and face. Resident #1's family member was being verbally aggressive. Resident #1 family member was stating in a harsh tone You ordered this food. I don't know why you won't eat it. You are being ridicules.'' Continued observation revealed, the Dietary Manager (DM) asking Resident #1's family member, not to feed her at this time. She responded, she ordered it, and she won't even eat it. During an interview 09/13/22 at 4:19 PM, the DM stated that he was going to get a nurse. Subsequent observation revealed Resident #1's family member continuing to talk to her in harsh tones, stating I can't believe you do this; you have to eat this. This Surveyor notified the Director of Nursing (Don) 09/13/22 at 4:20 pm of the situation. The DON came into the dining room and cleaned the food off Resident #1s face. Resident #1's family member stated, she needs to eat her food. The DON left the dining room after cleaning her face. Continued observation at 4:25 PM revealed, the DM returned to the dining room and ask Resident #1's family member to move over to another table with her husband who also resides in the facility. She responded, I should have moved earlier, I was getting frustrated with her. During an interview on 9/14/22 at 2:12 PM DON, confirmed he did not report or investigate the allegation of verbal abuse. The DON verified that he should have investigated and reported the incident per policy. .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based 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 two (2) of three (3) Hospitalizations reviewed. Resident Identifier #40 and #54. Facility Census 56. Findings Included: a) Resident #40 Record review on 09/13/22 at 1:27 PM, revealed resident #40 was discharged to the hospital on [DATE] and 09/02/22. Subsequent review of the resident #40's medical record showed it did not contain documentation that the Notice of Transfer or Discharge was provided to the Resident Representative, or the Ombudsman of the discharges on 08/28/22 or 09/02/22. b) Resident #54 Record review on 09/13/22 at 1:27 PM, revealed resident #54 was discharged to the hospital on [DATE]. Subsequent review of the resident #54's medical record showed it did not contain documentation that the Notice of Transfer or Discharge was provided to the Resident Representative, or the Ombudsman of the discharges on 07/23/22. On 09/14/22 at 8:35 AM during an interview the Director of Nursing (DON) verified, the Ombudsmen was not notified of the discharges for Resident #40's on 08/28/22 or 09/02/22 and Resident #54 on 07/23/22. He stated that the facility does not notify the representative of the office of the Long -Term Care Ombudsman for hospital discharges. On 09/14/22 at 08:50 AM the Social Worker (SW) stated that she sends a copy of a resident list that all names and where they were transferred/discharged to, is marked out with black sharpie, so the names, dates and location are not legible prior to faxing. The SW states that she writes a blanket statement, the residents cease to breath, transferred home or other facility, or request to leave. The SW stated that she crosses out all names on the form prior to faxing and writes a blanket statement because that's how the facility did it when she started. .

. Based on observation, medical record review and staff interview, the facility failed to implement a care plan. Resident #50's foot brace was not applied when up in her wheel chair. This was a random opportunity for discovery. Resident identifier: #50. Facility census: 56. Findings include: a) Resident (R) #50 Observations on 09/12/22 at 3:00 PM and on 09/13/22 at 10:00 AM, found R# 50 in her wheel chair without a right foot brace. Review of the medical record on 09/13/22 revealed R #50 had a stroke affecting her right dominant side. The care plan updated on 08/18/22 states Brace to right foot when up in w/c (wheel chair). During an interview on 09/13/22 at 1:30 PM, Licensed Practical Nurse (LPN) #7 and LPN #82 confirmed R #50's care plan includes an intervention to place the right foot brace on when she is up in her wheel chair. LPN #82 acknowledged R# 50 has not been wearing her foot brace. .

. Based on observation, medical record review, and staff interview the facility failed to ensure residents received treatment and care in accordance with professional standards of practice. Physician orders were not followed for the application of a foot brace when up in a wheel chair. This was a random opportunity for discovery. Resident identifier: #50. Facility census: 56. Findings include: a) Resident (R) #50 Observations on 09/12/22 at 3:00 PM and on 09/13/22 at 10:00 AM, found R #50 up her wheel chair without a right foot brace. Review of the medical record on 09/13/22 revealed R #50 had a stroke affecting her right dominant side. A physician order written 08/04/22 states Brace to right foot while up in chair. During an interview on 09/13/22 at 1:30 PM, Licensed Practical Nurse (LPN) #82 reported R #50 has not been wearing her foot brace. LPN #7 confirmed R #50's physician orders include directions to place a right foot brace when she is up in her wheel chair and acknowledged the medical record lacks information indicating R #50's refusal to wear the brace. .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review and staff interview, the facility failed to ensure a resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing. Weekly pressure ulcer assessments were not completed. This is true for one of three reviewed for pressure ulcers. Resident identifier: R #106. Facility census: 56. Findings include: a) Resident (R) #106 Review of the medical record on 09/13/22 revealed R #106 was readmitted to the facility on [DATE]. The wound nurse's initial visit / assessment dated [DATE] states R #106 was admitted to the facility with two pressure ulcers. The left heel had an unstageable 3.1 centimeter (CM) long by 2.9 cm wide pressure ulcer with a black eschar wound bed. The left second toe had an unstageable 0.4 cm long by 0.3 cm wide pressure ulcer with a black eschar wound bed. The physician history and physical dated 09/01/22 identifies a stage 2 pressure ulcer to the left heel and chronic redness to the right heel. **The medical record lacks any other measurements or assessments of R #106's pressure ulcers. During an interview on 09/13/22 at 2:00 PM, Licensed Practical Nurse (LPN) #82 reported wound measurements and assessments are completed weekly by the visiting wound clinic staff. The Director of Nursing (DON) acknowledged R #106 was readmitted to the facility on [DATE] with two unstageable pressure ulcers on her left heel and left second toe during an interview on 09/13/22 at 3:00 PM. When asked about weekly wound assessments and measurements he stated the wound nurse was sick and staff should have been tracking the measurements. **No additional pressure ulcer measurements or assessments were presented to the survey team prior to exit. .

. Based on observation, record review and staff interview the facility failed to store oxygen tubing in the appropriate bag when not in use and ensure there was a physician order to administer oxygen to a resident. This was a random opportunity for discovery. The failed practice had the potential to affect a limited number of residents. Resident identifier: #10. Facility census: 56. Findings included: a) Resident #10 An observation on 09/12/22 at 4:57 PM showed Resident #10 laid in bed with nasal cannula in place and oxygen being administered at four (4) liters per minute. An observation on 09/13/22 at 10:21 AM showed Resident #10 was not in room and the oxygen nasal cannula tubing was stored on top of concentrator and not in the storage bag that was present. Review of Resident #10's medical record showed there was no current physician order for oxygen administration. An observation on 09/13/22 at 12:03 PM, showed Resident # 10 was sitting in wheelchair with oxygen being administered via nasal cannula with wheelchair oxygen canister. The bedside oxygen concentrator was also beside bed with nasal cannula and tubing stored on top of the concentrator and not in the protective bag. During an interview on 09/13/22 12:05 PM, Licenses Practical Nurse (LPN) #82 stated the nasal cannula that laid across the bedside concentrator should have been stored in the appropriate bag. LPN #82 confirmed there was no current physician order for oxygen. .

. Based on policy review, record review and staff interview The facility failed to develop and implement policies and procedures for the monthly drug regimen review that include, but are not limited to, time frames for the different steps in the process and steps the pharmacist must take when he or she identifies an irregularity that requires urgent action to protect the resident. In addition, pharmacy recommendations were kept in the Director of Nursing's (DON) office and not forwarded to the physician for a timely response. This is true for one of five reviewed for unnecessary medications, but has the potential to affect all residents. Resident identifier: #51. Facility census: 56. Findings include: a) Facility policy The undated facility policy titled Village Long Term Care Pharmacy Services Policy and Procedures for Documentation and Communication of Consulting Pharmacist Recommendations states pharmacist recommendations regarding residents' drug therapy are communicated to those with authority and/or responsibility to implement the recommendations, and respond to in an appropriate and timely fashion. The timing of these recommendations should enable a response prior to the next drug regiment review. **The policy lacks specific time frames for the different steps in the process and steps the pharmacist must take when he or she identifies an irregularity that requires urgent action The policy was reviewed with the DON and Registered Nurse Supervisor #147 on 09/14/22 at 8:20 AM. The staff agreed there were no specific time frames for the different steps in the review process. b) Resident (R) #51 Review of the medical record on 09/14/22, revealed the pharmacist recommended a gradual dose reduction for Remeron (antidepressant) during a monthly drug regimen review on 08/12/22. The medical record was silent for the pharmacist's note to the physician with his recommendation to decrease the Remeron and any indication the physician accepted or declined this recommendation. On 09/14/22 at 7:35 AM, the Director of Medical Records confirmed the recommendation was not on the resident #51's chart and reported they are kept in the DON's office. On 09/14/22 at 7:40 AM, the Director of Medical Records retrieved R #51's recommendation from the DON's office and presented it to the physician to review before giving it to the surveyor. The physician was presented with the recommendation and agreed to the dose reduction 33 days after the pharmacist's recommendation was written. .

. Based on observation, and staff interview, the facility failed to ensure a resident's personal privacy and confidentiality of his or her personal and medical records information. This was a random opportunity for discovery and was true for Resident #42 Census: 56 Findings included: A review of Policy, Medical Records- Documentation , dated 02/2021, showed, under paragraph 2, the facility would comply with all measures stipulated by the federal and state regulations within each discipline in order to protect the confidentiality, dignity, and rights of the resident as well as the integrity of their medical record. An observation on 05/24/21 at 12:47 PM, of the [NAME] medication cart located at the main nurse's station, revealed an electronic record for Resident #42 was visible to anyone passing by the main nurse's station. The Medication administration record (MAR) for Resident #42 was on display with no staff present at the medication cart. LPN #46 was interviewed, after returning to [NAME] hall Medication cart, on 05/24/21 at 12:48 PM, and verified the screen had been left open for a while when LPN #42 had gone to check on something out of sight of the medication cart. LPN #42 stated further, she did not realize she was going to be gone that long and the MAR should have been closed out to prevent Resident #42's confidential medical information from being viewed by anyone walking by the area. .

. Based on observation, record review, and staff interview, the facility failed ensure the resident's environment was free of accident hazards of which they had control. The facility failed to properly secure medications, leaving medication in resident rooms on the back of the toilet, on the television stand, and on the dresser. These were random opportunities for discovery. Resident Identifiers: #13 and #16. Facility Census: 56 Findings included: a) Resident #13 On 05/24/21 at 12:17 PM, LPN #48 verified the following medications were on the back of the toilet in Resident #13's room: -Yellow ointment in a clear 30 ml medicine cup. There was no writing on the medicine cup to identify the substance. -Powder in a clear 30 ml medicine cup. There was no writing on the medicine cup to identify the substance. -One (1) container of hemorrhoidal pads with 50% witch hazel with the wording: Keep out of reach of children. LPN #48 retrieved all three (3) medications from the back of the toilet and took them to the Nurse's Station to identify the substances. -Resident #13 had an order for hemorrhoid ointment. LPN #48 reported that was the yellow ointment in the first medicine cup. -LPN #48 did not find an order for the powder found in the second medicine cup, but she identified it as [anti] Monkey Butt powder. -Resident #13 had an order for hemorrhoidal pads to be kept at resident's bedside. LPN #48 noted resident had been assessed for self-administration of the hemorrhoidal pads, but that the medication should not have been left unattended in the bathroom and accessible to others. During an interview on 05/25/21 at 11:10 AM, the Director of Nursing stated the medications should have never been kept on the back of the toilet in Resident #13's room. b) Resident #16 An observation on 05/24/21 at 01:23 PM found, a thick, pink tinted cream in a 30 ml medication cup, and a thick white liquid in a 30ml medication cup at Resident #16's bed side, unsecured and unattended and allowing access to these medication by residents, unauthorized staff, or visitors. During an interview on 05/24/21 at 01:28 PM, Licensed Practical Nurse (LPN) #48 verified, the cream and white liquid should not be left out in the room. LPN #48 removed the 30ml cups at this time. A medical record review revealed, Resident #16 did not have physician's order for medication self-administration. .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure twelve (12) of twenty-one (21) residents reviewed during the long-term care survey process had a Physician Orders for Scope of Treatment (POST) form completed correctly per directions specified by the [NAME] Virginia Center for End-of-Life Care in conjunction with the [NAME] Virginia Health Care Decisions Act (16-30-1). Resident identifiers: #13, #15, #43, #20, #29, #32, #34, #41, #17, #38, #152, and #153. Facility census: 56. Findings included: a) Resident #13 A medical record review, completed on [DATE] at 2:55 PM, found a POST form on Resident #13's medical chart. The POST form indicated Resident #13 chose to receive cardiopulmonary resuscitation. (CPR) and wanted to receive full interventions. Section C of the POST form entitled Medically Administered Fluids and Nutrition was left blank. No directive was given regarding Resident #13's expressed wishes regarding either receiving or not receiving IV fluids as well as either receiving or not receiving tube feedings. In 2002 the POST form was incorporated into the [NAME] Virginia Health Care Decisions Act, which was enacted to ensure that a patient's right to self-determination in healthcare decisions be communicated and protected (16-30-2). On [DATE] at 2:18 PM, the Director of Nursing (DON) confirmed there was no way to know what Resident #13's treatment wishes were regarding medically administered fluids and nutrition. The DON acknowledged the POST form was not completed in its entirety, did not adequately reflect Resident #13's treatment preferences, and the form should be updated. b) Resident #15 A medical record review, completed on [DATE] at 3:54 PM, found a POST form on Resident #15's medical chart. The POST form indicated Resident #15 chose to receive cardiopulmonary resuscitation. (CPR) and wanted to receive full interventions. Section C of the POST form entitled Medically Administered Fluids and Nutrition was left blank. No directive was given regarding Resident #15's expressed wishes regarding either receiving or not receiving IV fluids as well as either receiving or not receiving tube feedings. On [DATE] at 2:18 PM, the Director of Nursing (DON) confirmed there was no way to know what Resident #15's treatment wishes were regarding medically administered fluids and nutrition. The DON acknowledged the POST form was not completed in its entirety, did not adequately reflect Resident #15's treatment preferences, and the form should be updated. c) Resident #43 A medical record review, completed on [DATE] at 2:43 PM, found a POST form on Resident #43's medical chart. The POST form indicated Resident #43 chose to receive cardiopulmonary resuscitation. (CPR) and wanted to receive full interventions. Section C of the POST form entitled Medically Administered Fluids and Nutrition was left blank. No directive was given regarding Resident #43's expressed wishes regarding either receiving or not receiving IV fluids as well as either receiving or not receiving tube feedings. On [DATE] at 2:18 PM, the Director of Nursing (DON) confirmed there was no way to know what Resident #43's treatment wishes were regarding medically administered fluids and nutrition. The DON acknowledged the POST form was not completed in its entirety, did not adequately reflect Resident #43's treatment preferences, and the form should be updated. d.) Resident # 20 A record review for Resident #20, showed an advance directive (POST) form indicating additional interventions were desired by the resident. A review of Section C of the POST form was blank and did not contain additional information regarding fluids and nutrition. An interview, on [DATE] at 02:21 PM, with the Director of Nursing (DON), verified Section C was incomplete and all sections of the form were required to be completed. e) Resident #29 A record review on [DATE], revealed section C-(medical administered fluids and nutrition), was not completed on Resident #29's POST form. During an interview on [DATE] at 02:21 PM, the DON verified Resident #29's POST form was not complete, and all sections of the POST should be completed. f) Resident #32 A record review on [DATE], revealed section C- (medical administered fluids and nutrition) and Section E (Patient /Resident Preferences as a guide for this form), was not completed on Resident #32's POST form. During an interview on [DATE] at 02:21 PM, the DON verified Resident #32's POST form was not complete, and all sections of the POST should be completed. g) Resident #34 A record review on [DATE], revealed section C-(medical administered fluids and nutrition), was not completed on Resident #34's POST form. During an interview on [DATE] at 02:21 PM, the DON verified Resident #34's POST form was not complete, and all sections of the POST should be completed. h) Resident #41 A record review on [DATE], revealed section C-(medical administered fluids and nutrition), was not completed on Resident #41's POST form. During an interview on [DATE] at 02:21 PM, the DON verified Resident #41's POST form was not complete, and all sections of the POST should be completed. i) Resident #153 A review of Resident #153's medical record, on [DATE] at 3:42 PM, revealed sections C and D of the POST form were incomplete. There was also a green dot located on the spine of the hard copy medical record. The POST form also indicated Resident #153 wanted to be a DNR. An interview with Director of Nursing (DON), on [DATE] at 2:21 PM, confirmed sections C and D of the POST form were incomplete and all sections of the form were required to be completed. An interview with Medical Records Coordinator (MRC) #12, on [DATE] at 9:00 AM, revealed green dots on the medical records indicated a resident is a full code and a red dot indicated a resident was a Do Not Resuscitate (DNR). MRC #12 confirmed Resident #153 was a DNR and that the green dot on the medical record was incorrect and should have been red. j) Resident #152 A review of Resident #152's medical record, on [DATE] at 3:43 PM, revealed section C of the POST form was incomplete. An interview with Director of Nursing (DON), on [DATE] at 2:21 PM, confirmed section C of the POST form was incomplete and all sections of the form were required to be completed. k) Resident #17 A review of Resident #17's medical record, on [DATE] at 3:44 PM, revealed section C of the POST form was incomplete. An interview with Director of Nursing (DON), on [DATE] at 2:21 PM, confirmed section C of the POST form was incomplete and all sections of the form were required to be completed. l) Resident #38 A review of Resident #38's medical record, on [DATE] at 3:44 PM, revealed sections B and C of the POST form were incomplete. An interview with Director of Nursing (DON), on [DATE] at 2:21 PM, confirmed sections B and C of the POST form were incomplete and all sections of the form were required to be completed .

. Based on observation, resident interview, staff interview, and record review, the facility failed to provide care and services in accordance with professional standards. This was true for three (3) of the twenty-one (21) residents reviewed during the long-term care survey process. An order for weekly weights was not followed for Resident #27. An order for bilateral half side rails to be padded at all times was not followed for Resident #47. Additionally, Resident #47 had an active order for hospice services, multiple facility staff identified Resident #47 as receiving active hospice services, but Resident #47 had received notification from the hospice agency resident's last day of hospice was 05/05/21. Additionally, the facility failed to identify bruising on Resident #153. Resident identifiers: #27, #47, and #153. Facility census: 56. Findings included: a) Resident #27 An electronic health record review, completed on 05/24/21 at 3:33 PM, revealed an active order, dated 03/21/20, for Resident #27 to be weighed weekly. -There was no weight recorded for Resident #27 the week of 03/21/21 - 03/27/21 -There was no weight recorded for Resident #27 the week of 03/28/21 - 04/03/21 -Resident #27 weighed 128.0 lbs. on 04/09/21 -Resident #27 weighed 128.0 lbs. on 04/16/21 -Resident #27 weighed 127.0 lbs. on 04/24/21 -Resident #27 weighed 123.0 lbs. on 04/30/21 -There was no weight recorded for Resident #27 the week of 05/02/21 - 05/08/21 -Resident #27 weighed 121.0 lbs. on 05/10/21 -There was no weight recorded for Resident #27 the week of 05/16/21 - 05/22/21 On 05/26/21 at 9:09 AM, LPN #48 reported resident weights are completed by restorative aides and kept in each resident's electronic medical record. When questioned, LPN #48 reported she believed there may also be a written log of weights that the restorative aides keep for their records. During an interview with Restorative Aide #68 on 05/26/21 at 9:23 AM, it was confirmed that the weights listed in Resident #27's electronic medical record were the only ones listed on the paper copies kept on file. Restorative Aide #68 reported if Restorative Aides are pulled to work the floor, sometimes resident weights may not get done. The Director of Nursing acknowledged, during an interview on 05/26/21 at 11:03 AM, the facility had failed to follow Resident #27's order for weekly weights. b-1) Resident #47 Active Order for Padded Bilateral Half Side Rails On 05/25/21 at 9:30 AM, an electronic health record review was completed and revealed an active order for Resident #47 to have bilateral half side rails to be padded at all times due to resident hitting hands on them at times. Observation, on 05/25/21 at 10:45 AM, revealed there was no padding on Resident #47's half side rails. During an interview on 05/25/21 at 1:15 PM, LPN #48 verified there was no padding on Resident #47's half side rails. LPN #48 acknowledged that the resident had moved rooms, but resident has been in this room for quite a while. LPN #47 stated, The padding should be present. B-2) Resident #47 - Active Order for Hospice Despite Hospice Being Discontinued On 05/25/21 at 10:50 AM, an electronic health record review was completed. There was an active order, dated 01/22/21, for Resident #47 to receive hospice care. Resident #47's care plan, dated 05/11/21, stated: [Resident #47's First Name] is under Hospice Palliative Care. The care plan went on to outline the following interventions: -Hospice services as ordered, review hospice intervention as part of care plan. -Hospice CNA to visit resident 1-2 times per week and prn and to provide nursing facility with a copy of schedule 2 to 3 days prior. -Hospice RN to visit resident 1-2 times per week and prn, social worker prn, volunteer prn, and clergy prn. -Hospice staff and nursing facility staff will establish and communicate upon a coordinated plan of care. -Invite Hospice staff to attend Care Conference. -On-going communication and collaboration with hospice staff for coordination of care. During a resident representative interview on 05/25/21 PM 12:00 PM, the family member stated even though the family had been very pleased with the services provided by hospice, Resident #47 is no longer an active hospice patient. Resident #47's family member reported that family had received notification from the hospice agency that resident's last day of hospice was 05/05/21. On 05/25/21 at 12:25 PM, LPN #48 and the Director of Nursing (DON) verbally reported Resident #47 was currently receiving hospice services and hospice documentation could be found under the hospice tab on resident's chart. Surveyor was unable to find any hospice documentation from the month of May on resident's chart. Upon Surveyor request on 05/25/21 at 3:00 PM, Resident #47's family member shared a copy the hospice's detailed explanation of non-coverage dated 05/03/21 which documented the hospice agency had reviewed Resident #47's case and decided that Medicare coverage of resident's current hospice services should end. The facts used to make this decision were noted to be: Pt. (patient) 138 lbs. upon readmission in January 2021. Last weight from April 2021 is 152 lbs. Patient is stable with no decline noted. The Notice of Medicare Non-Coverage reflected hospice services would end on 05/05/21. On 05/26/21 at 11:20 AM, the DON was asked to produce a list of residents on the east wing currently receiving hospice services. Resident #47 was included in the list produced by the DON. Surveyor questioned if the DON was 100% certain, as family reported they had received written notice from the hospice agency that 05/05/21 was Resident #47's last day of hospice. The DON stated the hospice agency had recently cut several residents, but she did not believe Resident #47 was one of them. The DON was unable to find any documentation in the month of May reflecting that hospice had been in the building and seen Resident #47. The DON then led Surveyor to the MDS Coordinators office to confirm if the active order for hospice was correct. The MDS Coordinator reported the order was correct and Resident #47 was actively receiving hospice services. The MDS Coordinator had no knowledge the hospice agency provided the resident's family with written notification ending hospice services as of 05/05/21. The DON acknowledged the hospice agency had notified the family in writing of Resident #47's last day of hospice being 05/05/21 and stated the facility would contact the hospice agency to clarify if Resident #47 had indeed been cut from services. No further information was provided prior to exit. c) Resident #153 An observation, on 05/24/21 at 2:00 PM, revealed Resident #153 had a large brown bruise on the back of the upper right arm just above the elbow. The bruise appeared to have a puffy area in the center part of the bruise that resembled a knot. An immediate interview with Resident #153, on 05/24/21 at 2:00 PM, revealed no previous falls and no abuse. Resident #153 was unaware of how the bruise got on the upper right arm area. A record review, on 05/25/21 at 10:00 AM, revealed Resident #153 had no falls noted and no bruising noted to the upper right arm area indicated on the skin evaluation conducted on 05/11/21. A record review of the Treatment Administration Record (TAR) revealed a physician order that stated, Weekly head to toe body inspection in morning on Sundays every day shift every Sunday for routine skin. The TAR indicated since admission date of 05/11/21 two (2) skins assessments were completed on 05/16/21 and 05/23/21. The assessment on 05/23/21 revealed no skin problems. A review of the May 2021 Fall Log, Incident/Accidents Report and Reportables, on 05/25/21 at 3:30 PM, were reviewed and revealed no involvement of Resident #153 in any of the facility documentation. An interview with Resident #153, on 05/26/21 at 8:16 AM, revealed no one in the facility abused her and no falls have occurred. Resident #153 stated, I don't know how I got the bruise on my arm. An observation, on 05/26/21 at 8:17 AM, revealed a large faded greenish/brown bruise on the back of the upper right arm just above the elbow. The bruise appeared to continue to have a puffy area in the center part of the bruise that resembled a knot. An interview with Licensed Practical Nurse (LPN) #44, on 05/26/21 at 9:15 AM, revealed LPN #44 had not worked with Resident #153 in a long time. LPN #44 stated the bruising could be from insulin shots in the right arm or those times when Resident #153 was combative maybe hitting her arm on the bed rails when flailing about. An interview with Licensed Practical Nurse (LPN) #48, on 05/26/21 at 9:20 AM, stated when a Resident is found with new bruising staff are to talk with a resident to find out what happened, write an incident report and then contact the Family, Doctor and the Director of Nursing. An interview with Medical Records Coordinator (MRC) #11 on 05/26/21 at 9:40 AM revealed there were no available incident reports for Resident #153. An interview with Director of Nursing (DON), on 05/26/21 at 10:30 AM, verified the bruising on Resident #153's upper right arm and stated an incident report should have been completed with such a visible bruise as seen on Resident #153's arm. An interview with Nursing Supervisor (NS) #8, on 05/26/21 at 11:00AM, revealed measurements of the bruise on Resident # 153's right upper arm was seven and a half centimeters (7.5 cm) long and seven and half centimeters (7.5 cm) wide. NS #8 confirmed the bruise had not been identified by the facility so no incident report or reportable had been completed. .

. Based on observation, staff interview and facility documentation review the facility failed to provide food services in accordance with professional standards. The facility failed to discard expired food and did not date items in the storage areas. The facility failed to complete the refrigeration temperature log for the coolers and freezer areas. The practice had the potential to effect more than a limited number of residents. Facility census: 56. Findings included: a) Expired food An observation during the initial kitchen tour, on 05/24/21 at 11:40 AM, revealed a quart sized Dairy Pure Low fat cultured Buttermilk with an expired date of 05/06/21 stored in the walk in cooler. An interview with Culinary Team Leader (CTL) #58, on 11/24/21 at 11:45 AM confirmed the Buttermilk was expired and should have been discarded. b) Undated food An observation during the initial kitchen tour, on 05/24/21 at 11:45 AM, revealed a 15 ounce pork flavored gravy mix bag, in the dry storage area, that was not in the originally dated box and had no date written on the bag. An additional observation, on 05/24/21 at 11:46 AM, revealed a 20 ounce bag of Vanilla Mousse Mix, in the dry storage area, that was not in the originally dated box and had no date written on the bag. An observation in the freezer area, on 05/24/21 at 11:49 AM, revealed an opened bag of Lamb Weston frozen hash browns that were not in the original dated box and no date written on the bag. An interview with Culinary Team Leader (CTL) #58, on 11/24/21 at 11:50 AM confirmed there we no dates on the pork gravy mix, vanilla mousse mix or the frozen hashbrowns. CTL #58 stated, the kitchen had been having problems with not dating food items which had been addressed in the Quality Assurance and Performance Improvement (QAPI) meetings. CLT #58 confirmed, when food is taken out of the original box the items should be dated. c) Temperature Log A review of the May 2021 Refrigeration Temperature Log, on 11/24/21 at 11:55 AM, revealed the documentation was incomplete. The following dates did not have temperatures checked and logged for the coolers and freezer areas. The following dates on the temperature log that were incomplete included: 05/07/21 05/08/21 05/11/21 05/12/21 05/13/21 05/14/21 05/15/21 05/21/21 05/22/21 An interview with Culinary Team Leader (CTL) #58 , on 11/24/21 at 11:55 AM, confirmed the Refrigeration Temperature Log was incomplete. CTL #58 stated, the kitchen had been having problems with recording temperatures which had also been a QAPI matter. CTL #58 confirmed the temperature log was missing temperatures for a total of nine (9) days during the month of May 2021. .

. Based on observation, policy review, and staff interview, the facility failed to establish and maintain an infection prevention program to help prevent the development and transmission of communicable diseases and infections in regard to laundry services, Personal Protective Equipment (PPE), and Respiratory Care. This failed practice had the potential to affect more than a limited number of residents. Facility Census: 56. Findings Included: a) Personal Protective Equipment (PPE) An observation on 05/24/21 at 01:51 PM, found Nursing Assistant (NA) #66 walking up the east hall carrying two (2) dirty / saturated adult incontinence diapers without being secured in a plastic bag or wearing gloves. NA #66 took the incontinence products to the soiled utility room. An Interview on 05/24/21 with NA #66 confirmed that the adult incontinence products should have been placed in a bag prior to taking them out on the East hall. NA #66 also stated that she should have been wearing gloves. b) Laundry Services An observation on 05/25/21 at 10:05 AM of the laundry room, found no separation between the clean and soiled areas failing to maintain a functional and safe laundry area to avoid contamination. The laundry was in progress in both areas, with clean laundry being exposed on the table being folded in the soiled area. An exhaust fan was in the area of the soiled laundry but, was not working at this time. An interview on 05/25/21 at 10:15 AM with the Laundry Supervisor and Maintenance Assistance #38 verified the exhaust fan was not working and the air was not flowing from the clean laundry area to the soiled laundry area and it should be working. An Interview with the Maintenance Supervisor and VP of Operations on 05/25/21 at 10:26 AM verified, the laundry folding table would be moved out of the soiled laundry area and the exhaust fan would be fixed or replaced. c) Resident #21 An observation on 05/24/21 at 01:10 PM found, Resident #21's nasal cannula (N/C-an oxygen delivery device) from an oxygen concentrator and tubing were laying on the bed side stand without being placed in a protective bag. A second observation on 05/25/21 at 11:19 AM the N/C was not in a protective respiratory supply bag and laying on top of the oxygen concentrator. An interview on 05/25/21 at 11:40 PM with LPN # 46 confirmed that Resident #21's N/C and tubing should be placed in a protective bag when not in use. LPN #46 removed the respiratory supplies, at this time. d) Resident #34 An observation on 05/24/21 at 02:24 PM found, Resident #34's nasal cannula (an oxygen delivery device) and tubing from an oxygen concentrator was laying on the floor and nebulizer machine (a breathing machine that lets you inhale medicated vapors), mask and tubing laying in on the nightstand without being placed in a protective bag. A second observation on 05/25/21 at 11:26 AM found, Resident #34's nasal cannula and tubing from an oxygen concentrator was laying on the top of the concentrator and nebulizer machine mask and tubing laying in on the nightstand without being placed in a respiratory supply protective bag. On 05/25/21 at 11:36 AM an interview with LPN #46 verified that Resident #34's N/C and nebulizer machine mask should be placed in a protective bag when not in use. LPN #46 removed the respiratory supplies, at this time. On 05/26/21 at 10:45 PM, all Infection control findings were discussed with the Clinical Operations Manager. No further information was provided prior to the end of the survey on 05/26/21 at 01:30 PM. .