**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure advanced directives were implemented for Resident #133. This was true for one (1) of three (3) residents reviewed during the survey. This will be cited as past non-compliance because the facility identified what had happened and took immediate steps to correct the failure to ensure it does not reoccur. All components of the plan of correction were completed prior to this survey beginning. This did occur, and was substantiated by the facility as occurring. Resident #133 had completed a Physician Order for Scope of Treatment (POST) form, indicating her wishes to be a full code therefore this will be cited as past non-compliance. Facility census: 32. Resident identifiers: Resident #133. Findings included: a) Facility On [DATE] at 02:25 PM, a record review was completed for Resident #133 which revealed the following progress notes, (typed as written): [DATE] 22:00 Health Status Note Note Text: Resident resting in bed with O2 (oxygen) in place at 2L/nc; HOB elevated 30 degrees; she told CNA that she was having some trouble breathing, and felt nauseated; CNA alerted this nurse, and placed pulse ox on; this nurse checked resident at 22:15 and found her not breathing, no pulse, pupils fixed and nonreactive, extremities cold to touch, torso rigid; color yellow, pale; sternal rub, shaking resident, calling her name were ineffective; monitored VS x 5 min with no signs of life; NOC and Administrator notified; call to family who requested to come in to see resident; call to Provider at 2300 who gave order to not attempt CPR and pronounce resident deceased . [DATE] 23:20 COMMUNICATION Note Text: Call to family to let them know of resident passing; (granddaughter) very upset and gave phone to husband; family requesting to come in to see resident; stated they would be here in 30-45 min; family arrived at MN; this nurse relayed sequence of events and interventions by staff; (granddaughter) voiced understanding; family expressed wishes for [NAME] Funeral Home and wants to wait until they arrive; family boxed up some personal items (pictures, glasses, hearing aids, jewelry), and stated they would probably donate some items to this facility; awaiting Funeral Home arrival. Further review of Resident #133's medical record revealed Resident #133 had completed a POST which indicated her wishes for Cardiopulmonary Resuscitation (CPR), including mechanical ventilation, defibrillation and cardioversion with full treatments and a time limited trail of 14 days of medically assisted nutrition but no surgically placed tubes. In addition, Resident #133's physician's orders and care plans were reviewed which revealed the following: Physician's order: Full Code- Full interventions. Medically assisted nitration for a limited trail of 14 days but no surgically placed tubes. Active [DATE] Care plan: Focus: West Virginia (WV) Advanced Directives: full code, full treatments. Provide medically assisted nutrition time limited trail of 14 days but no surgically placed tubes. Goal: Wishes will be honored through next review. Interventions: Full Code. Review advanced directives with resident/family yearly and as needed. On [DATE] at 03:15 PM, a review of the facility reportable incident (FRI) was completed. The review of this FRI, dated [DATE], revealed that Resident #133 was observed to be nonresponsive upon staff entering Resident #133's room. Resident #133 was noted to be cold to touch, rigid, with yellow pale skin tone. Resident #133 was noted to have a full code status in the medical record. Resident #133's physician was notified of Resident #133's status including above findings and the order was given to not begin CPR due to signs of death. The investigation started immediately on [DATE]. A statement was obtained from all staff on duty the night of [DATE] which included the following statements: b) Nurse Aide (NA) #46 NA #46 stated that at 10:00 PM, NA #46 went to change Resident #133. Resident #133 voiced having trouble breathing. NA #46 states she elevated the position of Resident #133's head of bed, Resident #133 voiced being nauseous. NA #46 states she went and told RN #53 what Resident #133 had voiced. NA #46 stated that she got the vital pole and put the pulse oximetry on Resident #133 noting an oxygen saturation of 94%. NA #46 told Resident #133 she was going to leave the pulse oximetry on Resident #133 for a few minutes and come back to check on her. NA #46 reports at 10:15 PM, when NA #46 re-entered Resident #133's room that RN #53 was in there at this time with Resident #133's medications. NA #46 stated that she told RN #53 was not breathing and voiced that Resident #133's skin color appeared to be yellowish-pale color. NA #46 states RN #53 began sternal rubs and Resident #133 was cold to touch. NA #46 states she continued to check for a pulse with no pulse found. c) RN #53 RN #53 stated that on [DATE] around 10:00 PM, Resident #133 had been resting in bed with oxygen in place at two (2) liters per minute via nasal cannula with the head of bed elevated to 30 degrees. RN #53 stated Resident #133 had expressed to NA #46 that she was having some trouble breathing and felt nauseated. RN # 53 stated NA #46 alerted her and that NA #46 had placed the pulse oximeter on Resident #133 RN #53 stated that she checked Resident #133 at 10:15 PM and found Resident #133 not breathing, no pulse, pupils fixed and non-reactive, extremities cold to touch, torso rigid, color yellow and pale. RN # 53 stated she began sternal rubs, shaking Resident #133, calling Resident #133's name, which was ineffective. RN #53 stated Resident #133's vital signs were monitored for five (5) minutes with no signs of life. RN #53 stated she attempted to call the nurse on call and administrator with no answer initially. RN #53 stated she called Resident #133's family who requested to come in and see Resident #133. RN #53 also stated she made a call to Resident #133's physician, who gave orders to not attempt CPR and pronounced Resident #133 deceased . On [DATE] the Administrator had an additional conversation with RN #53, in which RN #53 stated that when asked why she did not initiate CPR, RN #53 stated that she didn't know why. RN #53 further stated that she was in the mode of pronouncing death and not thinking about CPR. RN #53 stated that was why she was observing for five (5) minutes for signs of life. RN #53 stated because of her assessment, she thought that Resident #133 was gone. When the Administrator asked RN #53 if she thought those observations represented irreversible signs of death, RN #53 stated yes she did. RN #53 stated that she was just trying to do the right thing. On [DATE] the five (5) day follow up investigation was submitted which stated RN #53 was suspended pending investigation and later terminated as a result of the investigation with the allegation having been substantiated. On [DATE] at approximately 9:30 AM, the Administrator provided a copy of the facility plan of action which indicated the following: On [DATE] all staff on duty to be educated on Full Code Protocol and Responding to resident change in condition which was followed by 100% compliance with education of all staff. On [DATE] all staff were re-educated on Full Code Protocol, Responding to resident change in condition, visual aid for clinical algorithm for unresponsive resident and irreversible signs of death with 100% compliance with education of all staff. In addition, a post test of education is scheduled within one (1) month and six (6) months. This education was added to the orientation process for all newly hired employees also. Two (2) ADHOC (impromptu) Quality Assurance and Performance Improvement meetings were conducted to evaluate the occurrence and review actions, a root cause analysis was performed with the above action plans developed. On [DATE] at approximately 10:00 AM, a review of the staff education was completed in addition to the QAPI meetings. All staff signatures were obtained and were verified via the staff roster. On [DATE] at approximately 10:30 AM, an interview was conducted with the facility Administrator who confirmed the incident which involved Resident #133 did happen as reported.

Based on observation and staff interview, the facility failed to maintain adequate, appetizing temperatures for breakfast foods served in resident rooms. This was a random opportunity for discovery in the Long Term Care Survey process. Resident identifiers: Resident #09, Resident #26. Facility census: 32. Findings included: a) Facility On 09/24/24 at 2:00 PM, a resident council meeting was held. During the meeting, Resident #26 stated Breakfast delivered to our rooms are cold. It just doesn't taste right. At that time, Resident #9 stated, Yes, sometimes our breakfast is cold when they bring it. I don't say anything about it though. They bring me something else if I ask them too. On 09/25/24 at 7:20 AM, an observation was made of breakfast trays being delivered resident rooms. The last tray was taken from the food cart at 7:36 AM and the temperature of the food being served was taken. The following are the temperatures obtained by Dietary Staff #12: Scrambled eggs: 103.5 degrees Fahrenheit (F) Pancakes: 93.8 degrees F Oatmeal: 143 degrees F At that time, Dietary Staff #12 acknowledged the scrambled eggs and pancakes were not within the recommended temperature range of 120 degrees at point of service.

. Based on record review and staff interview, the facility failed to ensure all required members of the Quality Assurance and Performance Improvement Committee (QAPI) attend a quarterly meeting as required. Facility Census: 62. Findings Included: a) On 09/25/14 at 11:57 AM record review indicates the facility Quality Assurance Committee meets every second (2nd) Tuesday of each month. The following individuals are listed as individuals that attend: Medical Director Consultant Pharmacists Director of Nursing (DON) Administrator Social Service Director Therapy Director Activities Director Dietary Manager Minimum Data Set (MDS) Nurse Nursing House Supervisor (Infection Preventionist) IP Nursing Unit Manager Business Office Manager Human Resources Director Review of the QAPI meeting sign in sheets for four (4) quarters starting in September 2023, the following information was obtained: March, April, May 2024 - All required members were not present at any meeting this quarter. March, there was no IP present April, there was no Medical Director or IP present May, there was no IP or Administrator present June, July, August 2024 - All required members were not present at any meeting this quarter. June, there was no IP, no DON and no Medical Director present. July, there was no IP, no DON and no Medical Director present. August, there was no IP present. On 09/25/24 at 1:33 PM the Director of Nursing and the Administrator confirmed there were missing required personnel for two (2) of the four (4) quarterly meetings.

. Based on record review and staff interview, the facility failed to ensure a safe and effective transition of care for one (1) of two (2) residents reviewed for the care area of hospitalization during the long term care survey process. There was no documentation the following information was sent with Resident #24 when transferred to the hospital: the reason for the transfer, contact information of the practioner responsible for care, resident representative contact information, advance directive information, diagnosis, medications (including when last received) comprehensive care plan goals, any treatment or devices, most recent labs, other diagnostic tests, and recent immunizations, recent vital signs, etc. Resident identifier: #25. Facility census: 32. Findings included: a) Resident #25 Record review found the following nursing note: 10/23/2022 11:10 Health Status Note Note Text: Resident not at baseline this am. responsive to verbal stimuli will not answer staff question fixed gaze. weak grasps, pupil's small resident would not open eyes enough to see reaction. Resident lethargic Respiration labored and shallow VS (vital signs) bp (blood pressure) 164/80, temp 99.7, hr 68, O2 97%, Resp (respirations) 26. Doctor in new order for resident to be sent to ED (emergency department) for evaluation. POA (power of attorney) agreeable with order. On 12/06/22 at 10:15 AM, the Clinical Nurse Consultant (CNC) said the facility nurse is to complete an E-interact transfer form to send with the resident when transferred to the hospital. The CNC confirmed she was unable to find any evidence the form was completed; therefore, there was no evidence of what information, if any, was communicated to the hospital at the time of transfer. .

. Based on record review and staff interview, the facility failed to provide a copy of the bed-hold policy to two (2) of two (2) residents and or the responsible party when the residents were admitted to the hospital. This was true for two (2) of two (2) residents reviewed for the care area of hospitalization during the long term care survey process. Resident identifiers: #25 and #35. Facility census: 32. Findings included: a) Resident #25 Record review found the following nursing note: 10/23/2022 11:10 Health Status Note Note Text: Resident not at baseline this am. responsive to verbal stimuli will not answer staff question fixed gaze. weak grasps, pupil's small resident would not open eyes enough to see reaction. Resident lethargic Respiration labored and shallow VS (vital signs) bp (blood pressure) 164/80, temp 99.7, hr 68, O2 97%, Resp (respirations) 26. Doctor in new order for resident to be sent to ED (emergency department) for evaluation. POA (power of attorney) agreeable with order. On 12/06/22 at 1:49 PM, the Clinical Nurse Consultant (CNC) #13 verified she was unable to find evidence a copy of the bed hold policy was sent with the resident or responsible party at the time of transfer or within 24 hours of the emergency transfer. b) Resident #35 Record review found the resident was transferred to the hospital on 9/21/2022 at 9:55 AM, Change of Condition Note Text: Resident coughed up dark red sputum. Is having increase SOB O2 89% @3l via NC (nasal cannula.) adventitious lung sounds noted throughout lung fields with diminished sounds in left lower lobe. Doctor notified and order resident to be sent to ED for evaluation. POA (power of attorney) notified and agreeable with transfer. On 12/06/22 at 2:50 PM, the Clinical Nurse Consultant (CNC) #13 and the Social worker (SW) verified they were unable to find evidence a copy of the bed hold policy was sent with the resident or responsible party at the time of transfer or within 24 hours of the emergency transfer. .

. Based on observation, medical record review, resident interview and staff interview, the facility failed to accurately complete a Minimum Data Set (MDS) assessments for two (2) of thirteen (13) residents reviewed during the Long-Term Care Survey (LTCSP). The MDS's for Resident #20 did not accurately reflect the use of hearing aides and Resident #34 MDS did not accurately reflect the prognosis of end of life of less than six (6) months. Resident identifier: #20 and #34. Facility Census: 32 Findings Included: a) Resident #20 During an interview on 12/05/22 at 2:40 PM Resident # 20 stated I have a hearing aid in one ear and the other hearing aid is broken. During an observation on 12/05/22 at 2:40 PM Resident # 20 had a hearing aid in the right ear only. Review of the quarterly MDS's on 12/06/22 with Assessment Reference Dates (ARD) of 09/02/22 discovered the following: Section B, titled Hearing, Speech and Vision, Section B0300 Hearing Aid was coded as: zero (0) for no hearing aid. During an interview on 12/06/22 at 10:22 AM, the Social Worker (SW) #30 stated I did not know Resident # 20 had a broken hearing aid. During an interview on 12/06/22 at 10:36 AM, the SW stated I spoke to Resident #20's representative. They keep one at home in case this one breaks. They will not bring it; they are afraid it will get misplaced. I know no one had mentioned broken hearing aides. During an interview on 12/06/22 at 10:55 AM the MDS Register Nurse (RN) #20 acknowledged the quarterly MDS with ARD of 09/02/22 Section B hearing aid was coded incorrectly. b) Resident #34 Review of the quarterly MDSs on 12/06/22 with (ARD) of 10/20/22 discovered the following: Section J, titled Health Conditions, Section J1400 Prognosis was coded as: zero (0) for life expectancy of less than 6 months. During a review on 12/06/22 Resident # 20's medical record revealed a physician note dated 09/27/22 stated .typed as written He has palliative care. Cancer pain. During a review on 12/06/22, Resident # 20's medical record revealed a Social Services note dated 1019/22: He has a Dx of Ca to his liver, abdomen and colon. He is prescribed Tylenol PRN and Oxycodone Q6hrs for pain. Lately his pain has increased. He continues to feed himself and is still able to propel himself up the hallway to activities or around the block. Resident's name is pleasant and cooperative with staff. No changes in POST (DNR with selective treatments) Hospice was offered but denied this review. Family realizes that the time will come that Hospice may be needed. .

. Based on observation, medical record review, resident interview and staff interview the facility failed to develop and implement a comprehensive person-centered care plan with communication devices such as hearing aid. This is true for one (1) of thirteen (13) resident care plans reviewed during the Long-Term Care Survey (LTCSP). Resident # 20. Facility Census: 32 Findings Included: a) Resident #20 During an interview on 12/05/22 at 2:40 PM Resident # 20 stated I have a hearing aid in one ear and the other hearing aid is broken. During an observation on 12/05/22 at 2:40 PM Resident # 20 had a hearing aid in the right ear only. Further review of the medical record revealed Resident # 20 care plan with an initiation date of 08/11/22. The care plan contained the following: Focus: Communication deficit related to difficulty being understood Goal: Basic needs will be met through review date. Inventions: -ask questions requiring yes or no -observe for non-verbal communication -use short phrases when communicating with resident. Allow ample response time. There was no evidence of a hearing aid intervention in Resident # 20's care plan. During an interview on 12/06/22 at 10:55 AM the Minimum Data Set (MDS) Registered Nurse (RN) #20 acknowledged the care plan with an initiated date of 08/11/22 was incorrect and did not reflect a hearing aid intervention. .

. Based on medical record review, resident interview and staff interview the facility failed to ensure the residents had the right to participate and must be given the opportunity to participate in development, review and revision of his/her care plan. This was true for one (1) of thirteen (13) reviewed for care plans during the Long-Term Care Survey Process. Resident Identifiers: Resident #30. Facility Census: 32. Findings Included: a) Resident #30 During an interview on 12/05/22 at 12:03 PM, Resident # 30 stated I am not invited and have never attended a care planning meeting. During a review on 12/06/22, Resident # 30 medical record revealed a Care plan note dated 10/26/2022 Typed as written Resident #30's name was discussed in care plan meeting today. R/P (responsible party) was invited but did not attend. During an interview on 12/06/22 at 9:11 AM the Social Worker stated I send a letter to the representatives inviting them to the care plan meeting. If the Resident does not have capacity we still invite the resident to the meetings or go to their rooms. Her sister attends the meetings by phone. Resident #30 has attended some of her care plans meetings. During an interview on 12/06/22 at 9:16 AM, the SW stated my progress note did not reflect she was invited or attended the care plan meeting on 10/26/22. .

. Based on observation, record review, and staff interview, the facility failed to ensure the oxygen concentrator was set on the physician ordered flow rate. Resident #5. Facility census: 32. Findings included: a) Resident #5 Observation on 12/05/22 at 12:33 PM, found the oxygen concentrator flow rate was set at 3 liters per minute. Licensed Practical Nurse (LPN) #21 confirmed the physician's order directed the flow rate to be set at 2 liters per minute. LPN #21 said she would correct the problem. Review of the medical record found an order, dated 12/28/21, Oxygen at 2L (liters) via nasal cannula. On 12/06/22 at 2:01 PM, the Clinical Nurse Consultant (CNC) #13 was advised of the above observation. No further information was provided. .

. Based on record review and staff interview, the facility failed to ensure the physician addressed each recommendation made by the pharmacist for a gradual dose reduction (GDR) for medications for two (2) of five (5) residents reviewed for unnecessary medications during the long - term care survey. Resident identifiers: #8 and #19. Facility census: 32. Findings Included: a) Resident #8 On 12/06/22 at 09:54 AM, based on documentation, a Gradual Dose Reduction (GDR) recommendation was completed by Pharmacist on 08/08/22 for multiple antipsychotic medications. The GDR listed two medications, olanzapine 2.5mg qhs and quetiapine 12.5mg qhs. The Physician signed the GDR form on 08/29/22 agreeing with the recommendation, discontinuing only the olanzapine. The physician failed to provide any clinical contraindications for the quetiapine to be continued at current level. On 12/06/22 at 11:54 AM, the Clinical Nurse Consultant #13 acknowledged the physician failed to address the pharmacist recommendation for a GDR for quetiapine. On 12/07/22 at 9:43 AM, Director Of Nursing (DON) #1 reviewed the pharmacists recommendations. The DON confirmed not all medications were addressed, and said she would work with pharmacist and physician to assure all medications are addressed going forward. b) Resident #19 Record review on 12/06/22 at 8:53 AM, found a Gradual Dose Reduction (GDR) recommendation was completed by the pharmacist on 09/14/22 for multiple antipsychotic medications. The GDR listed three (3) separate medications, Aripiprazole 5mg daily, Lorazepam 0.5mg / 1 mg daily and Sertraline 50mg daily. The physician signed the GDR form on 09/27/22 agreeing with the recommendation, decreasing Lorazepam to 0.5mg two times per day. The Physician ordered that Ativan be decreased to 0.5mg BID. The physician failed to provide the clinical rational for continuing Sertraline at the current levels. On 12/06/22 at 11:54 AM, the Clinical Nurse Consultant #13 reviewed the recommendations of the pharmacist and acknowledged not all the recommendations were addressed. On 12/07/22 at 9:43 AM, Director Of Nursing (DON) #1 confirmed not all recommendations were addressed. The DON said she would work with pharmacist and physician to assure all medications are addressed going forward. .

. Based on record review and staff interview, the facility failed to ensure two (2) of five (5) residents receiving psychotropic medications received a gradual dose reduction (GDR) or had documentation by the physician a GDR was clinically contraindicated. Resident identifiers, #8, #19. Facility census 32. Findings included: a) Resident #8 On 12/06/22 at 09:54 AM, based on documentation, a Gradual Dose Reduction (GDR) recommendation was completed by Pharmacist on 08/08/22 for multiple antipsychotic medications. The GDR listed two medications, olanzapine 2.5mg qhs and quetiapine 12.5mg qhs. The Physician signed the GDR form on 08/29/22 agreeing with the recommendation, discontinuing only the olanzapine. The physician failed to provide any clinical contraindications for the quetiapine to be continued at current level. Resident #8 continued to receive quetiapine from 08/29/22 until present with no documentation the medication continued to be required. On 12/06/22 at 11:54 AM, the Clinical Nurse Consultant #13 acknowledged the physician failed to address the pharmacist recommendation for a GDR for quetiapine. On 12/07/22 at 9:43 AM, Director Of Nursing (DON) #1 reviewed the pharmacists recommendations. The DON confirmed the physician failed to address all medications recommended by the pharmacist for a GDR. She said she would work with pharmacist and physician to assure all medications are addressed going forward. b) Resident #19 Record review on 12/06/22 at 8:53 AM, found a Gradual Dose Reduction (GDR) recommendation was completed by the pharmacist on 09/14/22 for multiple antipsychotic medications. The GDR listed three (3) separate medications, Aripiprazole 5mg daily, Lorazepam 0.5mg / 1 mg daily and Sertraline 50mg daily. The physician signed the GDR form on 09/27/22 agreeing with the recommendation, decreasing Lorazepam to 0.5mg two times per day. The Physician ordered that Ativan be decreased to 0.5mg BID. The physician failed to provide the clinical rational for continuing Sertraline at the current levels. Resident #19 continued to receive Sertraline from 09/27/22 until present. On 12/06/22 at 11:54 AM, the Clinical Nurse Consultant #13 reviewed the recommendations of the pharmacist and acknowledged not all the recommendations were addressed. On 12/07/22 at 9:43 AM, Director Of Nursing (DON) #1 confirmed not all recommendations made by the pharmacist were addressed. The DON said she would work with pharmacist and physician to assure all medications are addressed going forward. .

. b) Resident #27 During a medical record review on 12/05/22 at 3:04 PM, Resident # 27's Physician Orders for Scope of Treatment (POST) form was reviewed. On the POST form section E, Signature: Patient or Patient Representative signature date was her date of birth not the date of signature. During a interview on 12/06/22 10:26 AM the Social Worker acknowledged on Resident # 27's POST form, Resident signature date was her date of birth not the date it was signed. Based on observation and staff interview, the facility failed to ensure the resident's medical record was accurate and complete. Resident #25's dental assessments were incorrect. Resident #27's post form did not have the correct date. Resident identifiers: #25 and #27. Facility census: 32. Findings included: a) Resident #25 Observation of the resident on 12/05/22 at 11:43 AM, found the resident had several likely broken and decayed teeth. The most recent full Minimum Data Set (MDS) a significant change MDS, with an assessment reference date (ARD) of 06/17/22 found the MDS coded the resident as having obvious broken or decayed teeth. On 12/06/22 at 8:35 AM, the Clinical Nurse Consultant (CNC) #13 reviewed the last three (3) dental status assessments in the resident's medical record, dated 09/05/22, 10/25/22 and 11/15/22, and agreed the assessments did not indicate the resident had any dental issues. .

. Based on observation and staff interview the facility failed to ensure residents were treated with dignity and respect. The facility failed to protect the rights of a resident by posting signs of personal care in a residents room. This was a random opportunities for discovery. Resident identifier: #23. Facility census: 30. Findings included: a) Resident #23 An observation on 08/16/21 at 11:00 AM, revealed a sign posted on the wall beside Resident #23's bed that stated, STOP, no blood pressure in the right arm. An interview with the Director of Nursing (DON), on 08/17/21 at 1:30 PM, revealed no evidence as to why the sign would be posted on the wall. The DON confirmed understanding on how the sign would be a dignity issue. .

. Based on observation and staff interview, the facility failed to ensure drugs and biological's used in the facility were stored and labeled in accordance with current accepted professional practices. Medications observed in one (1) of two (2) medication carts did not contain medications with a packaging label from an approved source in accordance with Professional pharmaceutical standards of labeling. This was true in a random observation during medication administration for Resident #20. Facility census: 30. Findings included: a.) Policy and Procedure review A review of the facility policy, Labeling of Medication Containers, revision date of April 2019, noted all medications maintained in the facility are properly labeled in accordance with current state and federal guidelines and regulations and under Item 2, it was noted any medication packaging or containers that are inadequately or improperly labeled are returned to the issuing pharmacy. A review of the policy for Storage of Medications, revision date of November 2020, noted Item 2. Drugs and biological's are stored in packaging , containers or other dispensing systems in which they are received and only the issuing pharmacy is authorized to transfer medications between containers. Under item 4 of this policy it was noted: Drug containers that have missing , incomplete, improper or incorrect labels are returned to the pharmacy for proper labeling before storing. b.) Medication Administration Observation During a medication pass observation on 08/17/21 at 08:43 AM, Registered Nurse #38 (RN #38) was preparing the medication pass for Resident #20's medication. RN #38 was preparing to administer Nexium ER 40 mg for the morning pass. The bottle the medication was labeled with a piece of white tape with the name of the medication written with a pen. An interview with the Director of Nursing (DON), on 08/17/21 at 09:28 AM, verified the medication container was not labeled properly and the container did not have an approved label from the pharmacy. .

. Based on observation and interview the facility failed to make a reasonable effort to provide food that was appetizing to Residents based on needs and preferences. The facility failed to honor a dislike preference of a Resident. This was a random opportunity for discovery. Resident identifier #15. Facility census: 30. Findings included: a) Preferences An observation during the follow-up kitchen tour, on 08/17/21 at 12:30 PM, revealed a tray card on a tray that stated, dislikes broccoli with a plate that contained broccoli. An immediate interview with Dietary Staff (DS) #44, on 08/17/21 at 12:30 PM, confirmed the tray was ready to be served. DS #44 confirmed broccoli was on the plate and the tray card located beside the plate stated, dislikes broccoli. An interview with DS #76, on 08/17/21 at 12:30 PM, stated, sorry didn't pay attention to that. .

. Based on observation, resident interview, staff interview and a test tray temperature check the facility failed to provide residents with palatable and appetizing food and drink. The facility failed to provide a Resident with food that was within acceptable temperatures. The failed practice had the potential to effect more than an unlimited number of residents. Resident identifier # 80. Facility census: 30. Findings included: a) Food Temperature Two (2) confidential interviews on initial tour, on 08/16/21 at 11:00 AM, revealed concerns about food being cold and not very good. An observation of the breakfast tray pass, on 08/17/21 07:30 AM, revealed the following time line: 7:30 AM- Tray pass began 7:35 AM- Drinks and hydration began to be passed 8:08 AM- Last food tray remained in the tray cart 8:16 AM- Last food tray removed from the tray cart to be served by Nurse Aide (NA) #68 and was entering Resident #80's room. An interview with Nurse Aide (NA) #68, on 08/17/21 at 8:16 AM, revealed, Resident # 80 was in need of assistance with feeding so NA #68 was taking the tray in to assist Resident #80 in eating breakfast. Surveyor intervention stopped the tray and asked for the tray to be used as a test tray for food temperatures. NA #68 provided the tray as a test tray for food. A test tray temperature check on 08/17/21 at 8:24 AM with the Dietary Manager (DM) and facility thermometer revealed the following food temps of the last tray off the food cart: - Eggs - 88 degrees - Sausage- 87 degrees - Milk- 56 degrees - Orange Juice- 57 degrees An immediate interview with the DM, on 08/17/21 at 8:24 AM, confirmed the food temperatures on the last tray off the food cart, was not at acceptable temperatures. .

. d) Resident #8 A record review, on 08/16/21 at 1:15 PM, revealed a capacity form dated 02/23/21 that indicated Resident #8 had capacity. An additional document, the Physician Order Scope of Treatment, (POST) form dated 03/19/21 was not signed by Resident #8. An interview with the Social Worker, on 08/17/21 at 11:40 AM, confirmed capacity of Resident #8 and revealed the normal scope of practice was to have Residents with capacity sign their own POST forms. Based on record review and staff interview, the facility failed to ensure resident's Advance Directives were formulated with the resident in accordance with State Law for four (4) of fifteen (15) residents reviewed. The Physician Orders for Scope of Treatment (POST) forms were not signed by the physician, not completed by residents having capacity, signed by other individuals when the resident had capacity, and signed by individuals when no legal document was in place giving them permission to do so. Resident identifiers: Residents #20, #15, #4 and #8. Census: 30 Findings included: a.) Resident #20 A record review for Resident #20 showed a [NAME] Virginia Physician Orders for Scope of Treatment (POST) form signed by a Power of Attorney for Health Care on 06/16/21. A review of the Physician's determination of Capacity statement for Resident #20 noted the resident demonstrated capacity to make decisions on 06/18/21, and there was no evidence the resident was incapacitated and unable to formulate a decision when the POST was completed on 06/16/21. An interview, on 08/17/21 at 01:11 PM, with the Social Service Director verified there was no evidence Resident #20 could not have formulated and signed the POST form and that was a mistake on her part. b.) Resident #4 A record review for Resident #4 showed a POST form signed by the physician and dated on 11/17/20, but the form failed to include the Residents signature and date. The POST form also failed to include a date of when the Social worker prepared the form. Further review, noted Resident #4 had a Physician's Determination of Capacity showing Resident #4 had capacity to make medical decisions dated 11/05/20, but showed no evidence confirming Resident #4 was involved in the decision. An interview on 08/17/21, at 01:11 PM, with the Social Services Director verified the resident should have been involved with the decision making process. The Social Services Director confirmed there was no signature of the resident on the POST form and the form should have been signed by Resident #4. c.) Resident #15 A record review for Resident #15 showed a POST form signed, but not dated, by an individual, other than the resident. Further record review showed no legal decision making document noted in the chart permitting that person to make decisions for Resident #15. Additionally, the POST form was not signed by the physician but there was a date of 12/18/20 beside where the mandatory physician signature should have been documented. A review of the Physician's Determination of Capacity, dated 12/22/20, confirmed Resident #15 had the capacity to make medical decisions. An interview on 08/17/21, at 01:11 PM, with the Social Services Director verified the resident should have been involved with the decision making process and confirmed there was no signature of the resident on the POST form. It was also verified by the Social Service Director, at this time, there was no document in the medical record or in the building, noting the individual signing the POST form was to be legally involved in the medical decision making process, in the event Resident #15 was unable to make medical decisions. .

. Based on review of facility documentation and staff interview, the facility failed to ensure residents were informed when changes were made to their services rendered by the facility and provided written notification when the facility initiated the discharge from Medicare Part A Services when benefit days were not exhausted. This was true for two (2) of three (3) sampled residents reviewed for Skilled Nursing Facility (SNF) Beneficiary Protection Notification. Resident identifiers: Resident #4 and Resident #8. Census: 30 a.) Resident #4 A review of facility documentation for Resident #4 noted there resident was discharged from Medicare Part A when benefit days were not exhausted on 02/19/21. There was no evidence notification was made by providing form CMS-10055 to the resident to notify them on the change in services. Resident #4 resided in the facility at the time of the survey. b.) Resident #8 A review of facility documentation for Resident #4 noted the resident was discharged from Medicare Part A when benefit days were not exhausted on 06/23/21, There was no evidence, the facility provided form CMS-10055 to the resident to notify them of the changes in services. Resident #8 resided in the facility at the time of the survey. c.) Staff Interview An interview, on 08/18/21 at 10:03 AM, with the Business Office Manager, verified she was unaware of doing cut letters and was not doing them. It was confirmed at the time of the interview , Resident #4 and Resident #8 did not receive the notice, CMS-10055, and the form should have been provided to both of the residents. .

. Based on the Resident Council meeting and staff interviews the facility failed to give residents the right to voice grievances to the facility and provide a prompt effort to resolve the grievance. The facility failed to provide a written response to the Resident Council's voiced grievance. The failed practice had the potential to affect more than unlimited number of residents. Facility census: 30. Findings included: a) Facility Policy A policy review titled Grievances/Complaint, Filing with a revised April 2017 was conducted on 08/18/21 at 10:19 AM. The policy stated, Residents and their representatives have the right to file grievances, either orally or in writing to the facility staff or to the agency designated to hear grievances. The resident or person filing the grievance and or complaint in behalf of the resident, will be informed of the findings of the investigation or actions that will be taken to correct the identified problems. b) Resident Council Meeting A Resident Counsel meeting, on 08/17/21 at 2:00 PM, revealed the members were informed by Administration that the pop machine had to be moved from the hallway into the dayroom/activity room. The members revealed the issue was when the pop machine's cooling feature ran most members could not hear the bingo numbers being called during bingo or hear the sermon during church services. The members stated an oral grievance was addressed with the Corporate Administrator (CA) but it was felt the pop machine grievance was ignored and seemed the CA really didn't listen to them. The Resident Council agreed the pop machine noise interfered with the ability to hear and understand that caused a barrier to activities held in the facility. The members agreed that the Resident use of the pop machine was non existent as the pop resident's drink came from the kitchen so the pop machine is mainly for the staff anyway. The members confirmed no one ever responded to the Resident Council on how to solve the pop machine noise interference with activities. It was noted during the Resident Council meeting, members asked Surveyor to unplug the pop machine so they could hear in the meeting. It was observed most members struggled to understand the Surveyor during the meeting because of the pop machine noise; however, when the cooling feature of the pop machine was not running there were more participation with the members. An interview with Activities Director (AD) #72, on 08/17/21 at 3:15 PM, revealed acknowledgement of the pop machine noise grievance. AD #72 stated, that had been an issue for the past two (2) or three (3) weeks since the pop machine was moved into the dayroom/activities room. An interview with Administrator, on 08/17/21 at 3:17 PM, confirmed the Resident Council voiced a grievance about the pop machine to the Corporate Administrator (CA) . The Administrator stated the CA chose to leave it there for now. .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . b) Resident #21 A record review, on 08/17/21 at 7:45 AM, revealed a Quarterly Minimal Data Set (MDS) with an (ARD) of 07/17/21, that stated No wandering behaviors. Further record review, on 08/17/21 at 7:50 AM, revealed multiple Behavior and At Risk notes related to Resident #21's behavior. The notes were as followed: A Behavior Note dated 7/10/2021 (Name of resident) came out to desk screaming there was a man sleeping in her room in the other bed. Found (name of resident) asleep in the other bed. Resident was removed from the room, was found to be soiled with urine. Resident was cleaned up, and placed back in his own bed. Resident became angry, and tried retaliating when removing from the other room , but soon settled when he was given clean dry clothes. An interview with Minimum Data Set (MDS) Coordinator, on 08/18/21 at 8:38 AM, confirmed the Quarterly MDS dated for 07/17/21 stated no wandering behavior when Resident #21 does have some wandering behavior. c) Resident #22 A record review, on 08/17/21 at 3:20 AM, revealed an Admission/Medicare -five (5) Day MDS dated [DATE] that stated Anticoagulants received seven (7) days. Further record review, on 08/17/21 at 3:25 PM, revealed no physician orders for anticoagulants and no anticoagulants on the Medication Administration Record (MAR) were given to Resident #22 during the month of July 2021. An interview with MDS Coordinator, on 08/17/21 at 3:40 PM, confirmed no anticoagulant was given to Resident #22 during the seven (7) day look back. MDS Coordinator confirmed no orders were present during the month of July 2021. MDS Coordinator stated, I don't know why I marked anticoagulant especially when I try to be meticulous about the MDS. Based on record review and staff interview, the facility failed to ensure assessments accurately reflected the resident's status for three (3) of fifteen (15) residents reviewed. The Minimum Data Set (MDS) was not accurately coded for Resident #18, Resident #21 and Resident #22. Census: 30 Findings included: a.) Resident #18 A review of the MDS with an assessment reference date (ARD) of 07/10/21, under Section N, item E, noted Resident #18 had received anticoagulant therapy during the last seven (7) days of the assessment date. Section N shows the assessment is to be based on medications by pharmalogical classification. A review of the physicians orders failed to show Resident #18 had received an anticoagulant medication during this assessment period. An interview, on 08/17/21 at 03:55 PM , with the MDS Coordinator, verified Resident #18 had not received an anticoagulant medication and it had been coded as such on the MDS under Section N, Item E. Further in the interview, the MDS Coordinator revealed she had been incorrectly marking medications in the anticoagulant category that were not pharmacologically classified as anticoagulant agents and now realized the error. .

. Based on record review, observation and staff interview the facility failed to identify and provide needed care and services to residents in accordance with professional standards of practice. The facility failed to ensure a physicians order was clarified when treatment was not available. This was true for three (3) of three (3) residents who had therapeutic dietary orders for super donuts. Resident identifiers: #9, #15 and #22. Facility census: 30. Findings included: a) Resident #9 An interview with the Dietary Manager (DM), on 08/18/21 at 11:10 AM, revealed the three (3) Residents who were to receive super donuts with meals. DM stated the three (3) Residents had not received the super donuts for a few weeks because the facility has not been able to get any from the vendor and the food truck still had still not arrived for the present week. A record review on, 08/18/21 at 11:20 AM, revealed a physician order dated for 08/04/21 that stated, Slurry super doughnut with meals for weight loss. Further record review on, 08/18/21 at 11:25 AM, revealed an At Risk Note dated for 08/12/21. The At Risk Note stated, (Resident Name) is being reviewed by the IDT in the weekly at risk meeting. (Resident Name) is being discussed for falls/weight loss/behaviors, and decreased intakes interventions are in place including non skid strips, helmet, special shoes ect. (Resident Name)'s weight is 100.0 lbs which is stable previous weights but continues to slowly loose weight. Resident was readmitted after a brief stay in the hospital and was down 12 lbs when she returned. Resident is on glucerna TID, and super doughnuts with meals. Continued record review, on 08/18/21 at 11:30 AM, revealed no evidence was available to conclude the facility notified the physician to clarify the physician order for the super donut shortage. An interview with the director of Nursing (DON), on 08/18/21 at 11:38 AM , revealed staff have been trained to inform the doctor and to put order on hold if treatment was not available. b) Resident #15 An interview with Resident #15, on 08/17/21 at 8:06 AM, revealed, I did not get my super donut for breakfast. On observation, on 08/17/21 at 8:06 AM, revealed no super donut was present on Resident #15's tray. The absence of the super donut on the tray was confirmed by Registered Nurse (RN) #38. An additional interview with Resident #15, on 08/17/21 at 9:00, revealed the super donut was not received even after RN #38 requested it. A record review, on 08/17/21 at 10:15 AM, revealed a physician order dated 08/04/21 that stated, Super doughnut with meals for weight loss An interview with Resident #15, on 08/17/21 at 1:00 PM, revealed no super donut was received on lunch tray. An observation, on 08/17/21 at 1:00 PM, revealed Resident #15 did have a donut on lunch tray. An interview with the Dietary Manager (DM), on 08/18/21 at 11:10 AM, revealed the three (3) Residents who were to receive super donuts with meals. DM stated the three (3) Residents had not received the super donuts for a few weeks because the facility has not been able to get any from the vendor and the food truck still had still not arrived for the present week. A record review, on 08/18/21 at 11:30 AM, revealed no documentation was available that the facility notified the physician to clarify the physician order for the super donut shortage. An interview with the director of Nursing (DON), on 08/18/21 at 11:38 AM , revealed staff have been trained to inform doctor and to put order on hold if treatment was not available. c) Resident #22 An interview with the Dietary Manager (DM), on 08/18/21 at 11:10 AM, revealed the three (3) Residents who were to receive super donuts with meals. DM stated the three (3) Residents had not received the super donuts for a few weeks because the facility has not been able to get any from the vendor and the food truck still had still not arrived for the present week. A record review on, 08/18/21 at 11:15 AM, revealed a physician order dated for 08/06/21 that stated, Slurry super doughnut with meals, mix with milk for weight loss. Continued record review, on 08/18/21 at 11:30 AM, revealed no documentation was available that the facility notified the physician to clarify the physician order for the super donut shortage. An interview with the director of Nursing (DON), on 08/18/21 at 11:38 AM , revealed staff have been trained to inform doctor and to put order on hold if treatment was not available. .

. Based on observation, facility documentation, and staff interview the facility failed to store, prepare and distribute food in accordance with professional standards for food safety. The facility failed to label and date food items and monitor the temperatures daily of the refrigerators, freezer and dish washer. This had the potential to affect an unlimited number of residents. Facility census: 30. Findings included: a) Initial Kitchen Tour An observation during the initial kitchen tour, on 08/16/21 at 10:10 AM, revealed the dry storage area. The dry storage area revealed the following issues: - (2) 16 ounce unopened packages of marshmallows had an expiration date of 05/10/21. - A big plastic bin filled with multiple 1.9 ounces of crystal light packets not dated and with no expiration date. - A big plastic bin filled with individual jelly packets not dated and with no expiration dates, An interview with the Dietary Manager (DM), on 08/16/21 at 10:15 AM, confirmed the bags of marshmallows were expired. DM stated, the bin of jelly and crystal light packages should have either had the bin labeled or the items should not be taken out of original box with expirations dates on them. An observation during the initial kitchen tour, on 08/16/21 at 10:20 AM, revealed an opened box filled with garlic bread stored on the floor of the freezer. An immediate interview with DM, on 08/16/21 at 10:20 AM, confirmed, No, the box of garlic bread should not be on the floor of the freezer it should be on the cart or on a shelf. Review of facility documents, on 08/16/21 at 10:25 AM, revealed the refrigerator/freezer temperature log and the dish machine/sanitation log. Both logs revealed missing dates in which temperature checks were not conducted. The dates and times were as followed: Temp Log Fridge and Freezer: No temps were taken on the refrigerator or the freezer on 08/06/21 No day shift temps were taken for refrigerator or freezer on 08/07/21 No day shift temps were taken for refrigerator or freezer on 08/09/21 No evening shift temps were taken for refrigerator or freezer on 08/12/21 No day shift temps were taken for refrigerator or freezer on 08/15/21 Dish Machine Temp/Sanitation Log: No temps taken for dish machine on 08/06/21 No temps taken for breakfast or lunch times on 08/07/21 No temps taken for breakfast or lunch times on 08/09/21 No temps taken for dinner time on 08/12/21 No temps taken for breakfast or lunch times on 08/15/21 A policy review, on 08/18/21 at 10:36 AM, Food receiving and storage with revised date of July 2014 stated refrigerators must have working thermometers and be monitored for temperatures according to state specific guidelines. An interview with DM, on 08/16/21 at 10:25 AM, confirmed the logs were not completed and stated that temperature logs are expected to be completed daily. b) Nourishment Area An observation on 08/17/21 at 9:03 AM, revealed a two (2) quart container filled with eight (8) individual strawberry jelly and 35 individual blackberry jelly packets. The container revealed no label or date of expiration of contents. An interview with the Director of Nursing (DON), on 08/17/21 11:00 AM, confirmed no expiration date or label for the jelly was available. .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** c.) Dietary Observations 1. Dry Storage An observation during the initial tour kitchen tour, on 8/16/21 at 10:10 AM, revealed a blue surgical mask that laid on the shelf with stored food items in the dry storage area. An interview with the Dietary Manager (DM), on 08/16/21 at 10:10 AM, revealed the DM was unaware if the mask was used or not. DM stated, masks should not be stored on dry storage shelves. 2. Tray Cart An observation during breakfast tray pass, on 08/17/21 at 8:08 AM, revealed Director of Nursing (DON) placed a used food tray in the tray cart above Resident # 80's tray that was unused and not offered to Resident #80 at that time. An observation during breakfast tray pass, on 08/17/21 at 8:16 AM, revealed Nurse Aide (NA) #68 taking Resident # 80's tray out of the tray cart and was entering room. An immediate interview with NA #68, on 08/17/21 at 8:16 AM, revealed, Resident #80 was in need of assistance with feeding so NA #68 was taking the tray in to assist Resident #80 in eating breakfast. NA #68 stated that regular protocol and practice was to not place any used food trays in the food tray cart before all unused or unserved trays were out. NA #68 stated she did not realize the tray above Resident #80's tray was used. NA #68 looked into the cart again and verified the tray was used and should not have been placed in the cart with Resident #80's clean and unused tray. 3. Food Service An observation on 08/17/21 at 12:10 PM, revealed Dietary Staff (DS) #76 was preparing lunch plates by placing food on Resident's plates with surgical mask worn under his nose. An immediate interview with DS #76, on 08/17/21 at 12:10 PM, revealed the mask continued to drop below his nose when he talked. DS #76 stated, the mask should be worn covering his nose at all times. Based on random observations, and interview, the facility failed to establish and maintain an effective infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. The facility failed to prevent contamination when donning and doffing of Personal Protective Equipment (PPE) when caring for residents in Transmission Based Precautions (TBP), failed to ensure linens were stored properly, failed to maintain infection control standards when serving meals and failed to provide a separation to prevent airflow from cross- contamination of linens. This practice had the potential to effect more than a limited number of residents. Census: 30 Findings included: a.) Laundry Observation A review of the policy and procedure Departmental (Environmental Services)- Laundry and Linen, Revision date of January 2014, notes all soiled linen must be placed directly into a covered laundry hamper which can contain the moisture. During the Laundry area observation on 08/18/21 at 08:09 AM , it was revealed the door closed between the soiled and clean areas of the laundry. However, air could be felt flowing through the closed door seal. The airflow noted to be flowing from the soiled area of the laundry to the clean side was verified by Laundry Staff #46 (LS #46) . On 08/18/21 at 08:15 AM, an interview with the Plant Manager confirmed even though the door was closed , the door did not seal to prevent the airflow from the soiled to the clean area. Further observation of the laundry area revealed a bin of soiled linens with the lid ajar and the bin overflowing with linens. During an interview on 08/18/21 at 08:15 AM, with LS #46, it was confirmed the lid was ajar from the linen bin with linens over flowing and the linens were soiled. The Plant Manager at this time verified this was not correct storage of soiled linens and the lid should cover the linens. b.) Donning and doffing During a random observation on 08/17/21 at 08:00 AM, RN #38 was observed preparing to enter room [ROOM NUMBER] which had a sign indicating Enhanced Droplet Precautions were necessary to enter the room. RN #38 donned a gown, only securing the gown at the neck which allowed the gown to expose the back of the uniform of R #38 and was covering the front and arms only when RN #38 entered room [ROOM NUMBER]. An interview with RN #38 on 08/17/21 at 08:10 AM verified the employee was trained to tie the gown at the neck and waist to cover the body but stated she was rushing and did not do it. An additional observation of RN #38 doffing the PPE when leaving room [ROOM NUMBER], revealed RN #38 removed the mask worn in the isolation room and placed it in a plastic bag. RN #38 then placed the clean mask on without washing hands after removing the soiled mask. An interview 08/17/21 at 09:38 AM with the DON, revealed it was stated it is the practice to secure the gown at the neck and waist and a paper bag should be used that is breathable to store PPE when not in use. At this time, the DON verified staff should wash hands when removing the soiled mask before replacing the clean mask A review of the Centers for Disease Control (CDC) guidance for Donning and Doffing , provided by the Director of Nursing and interview on 08/18/21 at 11:40 AM reemphasized staff had been instructed to secure gowns at the neck and waist. .