Does FAIRMONT REHABILITATION AND HEALTHCARE CENTER LLC have any serious inspection findings?

Yes, FAIRMONT REHABILITATION AND HEALTHCARE CENTER LLC has 2 Immediate Jeopardy citations on record, which represent the most serious type of deficiency. The facility has 70 total deficiencies from recent inspections.

What are the staffing levels at FAIRMONT REHABILITATION AND HEALTHCARE CENTER LLC?

FAIRMONT REHABILITATION AND HEALTHCARE CENTER LLC has a one-star staffing rating from CMS with 0.31 RN hours per resident per day. This rating is based on registered nurse (RN), licensed practical nurse (LPN), and nurse aide staffing hours.

FAIRMONT REHABILITATION AND HEALTHCARE CENTER LLC

Name: FAIRMONT REHABILITATION AND HEALTHCARE CENTER LLC
Address: 130 KAUFMAN DRIVE, FAIRMONT, WV, 26554, US
Telephone: (304) 363-5633
Rating: 1.0

130 KAUFMAN DRIVE, FAIRMONT, WV 26554 · (304) 363-5633

For profit - Corporation 120 Beds GUARDIAN ELDER CARE Data: November 2025 2 Immediate Jeopardy citations

Trust Grade

1/100

#96 of 122 in WV

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Last Inspection: May 2023

Over 2 years since last inspection. Current conditions may differ from available data.

Overview

Fairmont Rehabilitation and Healthcare Center LLC has received a Trust Grade of F, which indicates significant concerns about the facility's care and operations. It ranks #96 out of 122 nursing homes in West Virginia, placing it in the bottom half, and is the lowest-ranked facility in Marion County. The facility's trend is improving; it went from 25 issues in 2023 to 5 in 2025, suggesting some progress. Staffing is a weakness as it has a low rating of 1 out of 5 stars and a turnover rate of 50%, which is average but may indicate instability. While there have been no fines recorded, there are critical concerns, including incidents of resident-to-resident sexual abuse that went unaddressed, and failures in infection control practices that could expose residents to diseases. Families should weigh these serious weaknesses against the slight improvements seen in recent inspections.

Trust Score: F
In West Virginia: #96/122
Safety Record: High Risk
Inspections: Getting Better
Staff Stability: 50% turnover. Above average. Higher turnover means staff may not know residents' routines.
Penalties: No fines on record. Clean compliance history, better than most West Virginia facilities.
Skilled Nurses: Each resident gets only 18 minutes of Registered Nurse (RN) attention daily — below average for West Virginia. Fewer RN minutes means fewer trained eyes watching for problems.
Violations: 70 deficiencies on record. Higher than average. Multiple issues found across inspections.

★☆☆☆☆

1.0

Overall Rating

★☆☆☆☆

1.0

Staff Levels

★☆☆☆☆

1.0

Care Quality

★☆☆☆☆

1.0

Inspection Score

↔

Stable

2023: 25 issues

2025: 5 issues

The Good

Full Sprinkler Coverage · Fire safety systems throughout facility
No fines on record

Facility shows strength in fire safety.

The Bad

1-Star Overall Rating

Below West Virginia average (2.7)

Significant quality concerns identified by CMS

Staff Turnover: 50%

Near West Virginia avg (46%)

Higher turnover may affect care consistency

Chain: GUARDIAN ELDER CARE

Part of a multi-facility chain

Ask about local staffing decisions and management

The Ugly 70 deficiencies on record

2 life-threatening

Aug 2025 4 deficiencies 2 IJ (2 affecting multiple)

CRITICAL (K) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Immediate Jeopardy (IJ) - the most serious Medicare violation

Free from Abuse/Neglect (Tag F0600)

Someone could have died · This affected multiple residents

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of policies, records, resident interviews, and staff interviews, the facility failed to protect the residents' right to be free from abuse, resulting in mental anguish for Resident #47, #34, and #83. Specifically, Resident #73 was reportedly touching female residents in the breast and vaginal area. This situation indicates that an unlimited number of female residents had the potential to be affected. The facility's lack of action to identify this unwelcome sexual contact and prevent its recurrence placed Residents #47, #34, and #83 at continued risk of sexual abuse prior to Surveyor intervention. Using the reasonable person concept, the facility's failure to protect the residents' right to be free from sexual abuse/resident-to-resident sexual aggression more than likely resulted in mental anguish and psychosocial harm for Residents #47, #34, and #83. Resident identifiers: #47, #34, and #83. Facility census: 103.Findings included:a) Policy ReviewThe facility's Abuse, Neglect, Exploitation and Misappropriation Prevention Program policy, with a revision date of 2021, stated that residents have the right to be from abuse which included sexual or physical abuse. It also mentioned a facility-wide commitment and resource allocation to protect residents from abuse by anyone, noting that it could be from other residents. Nowhere in the policy was there a definition of sexual abuse. However, the policy did direct that all possible incidents of abuse were to be identified and investigated. Additionally, the facility was to establish and implement a QAPI review and analysis of reports, allegations, or finding of abuse. It is important to note that at no point throughout the survey process did the facility report that they had self-identified Resident #73, who had capacity until mid-June 2025, as an individual who touched women without capacity in an unwanted sexual way. The facility's Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating policy, with a revision date of September 2022, stated that all reports of resident abuse are reported and thoroughly investigated by facility management. Findings of all investigations were documented and reported. This policy goes on to state: -If resident abuse is suspected, the suspicion must be reported immediately to the Administrator.-The allegation is immediately reported to the appropriate state agencies, the state long-term care Ombudsman, and the resident's legal representative. -Upon receiving any allegation of abuse, the Administrator is responsible for determining what actions (if any) are needed for the protection of residents. -All allegations are to be thoroughly investigated. -The individual conducting the investigation at a minimum will review the resident's medical record to determine if the resident's physical and cognitive status at the time of the incident. Observe the alleged victim, including his or her interactions with staff and other residents. Interview the person reporting the incident. Interview any witnesses to the incident. Interview staff members (on all shifts) who have had contact with the resident during the period of the alleged incident. Interview the resident's roommate, family members, and visitors. Document the investigation completely and thoroughly. -Upon conclusion of the investigation, the investigator records the findings of the investigation on approved documentation forms.-Within five (5) business days of the incident, the Administrator will provide a follow-up investigation report which will describe the results of the investigation, and indicate any corrective actions taken if the allegation was verified. -The resident and/or representative are notified of the outcome immediately upon conclusion of the investigation. Review of the Long-Term Care Nursing Home Program Reporting Requirements guidance from the Office of Health Facility Licensure & Certification (OHFLAC) office describes sexual abuse as non-consensual sexual contact of any type with a resident.b) First Inappropriate Resident-to-Resident IncidentOn 01/26/24 at 5:30 PM, it was reported that Resident #73 and Resident #47 were unsupervised in the activity room. A staff member walked into the room and Resident #73 jumped and moved his hands from under Resident #47's shirt. At that time, Resident #73 had capacity and was believed to be cognitively intact. Resident #47 lacked capacity and had a BIMS of 09, indicating moderate cognitive impairment.The facility reported this incident to the appropriate state agencies as an unusual occurrence noting that the residents had reportedly touched each other. The facility intervention was to move Resident #47 to the opposite side of the building, body audits were performed, and safety checks initiated. There were no written statements from either resident.However, during an interview on 08/07/26 at 10:49 AM, Resident #47 reported she recalled the incident in question. She stated that [Resident #73's First Name] was the man that hurt her and repeatedly said that the facility does not believe her. Resident #47 described being in the activity room, Resident #73 pulling down his pants, taking her hand and making her touch his private parts. Resident stated, He put his hand in my shirt and touched my boob. She said she reported this to the facility. She also expressed fear of Resident #73.Resident #73 was not care planned for inappropriate physical sexual behavior related to unknown etiology until 03/04/24. The goal at that time was, Will only engage in sexual activity with consenting partners, No where in the electronic medical record was there documentation as to what the inappropriate sexual behavior was and who it involved. During an interview on 08/06/25 at 1:44 PM, the Director of Social Services stated that she could not report with 100% certainty but that to the best of her recollection the initial care plan for inappropriate sexual behavior may have involved Resident #104 who had since passed away. The Director of Social Services stated that the two (2) residents dated each other. Further record review revealed that around the 03/04/24 timeframe, Resident #104 had a BIMS score of 10, indicating moderate cognitive impairment. Resident #104 did not have capacity. The alleged relationship between the aforementioned residents was not care-planned. c) Second Inappropriate Resident-to-Resident IncidentA record review revealed that on 09/06/24 at 2:54 PM, there was a physician order for 15-minute safety checks for 72 hours. The facility was unable to provide documentation that the checks were done every 15 minutes as ordered. When initially asked the reason for the 15-minute checks, the Administrator could not produce an immediate answer. Later the Administrator produced a 09/06/24 reportable where Resident #47 had reported an allegation of sexual abuse involving Resident #73. It was noted that Resident #47 was crying and expressing fear. Resident #47 stated that Resident #73 touched her breast and down there. A written statement from LPN #200 read, On 09/06/24 this nurse went to the dining room area to give the resident (Resident #47) her medications. The resident reported to this nurse that [Resident #73's First and Last Name] touched her breast inappropriately on 09/05/24 while she was sitting in the dining room area watching her tablet.The facility's Five-Day Follow-Up did not verify the allegation. However, the facility looked into the date of 08/14/24 when Resident #47 was restricted to her room for COVID isolation. There was no mention of the 09/05/24 incident that was reported by resident and documented in a written statement by LPN #200. As she was sharing a copy of the reportable on 08/06/25 at 2:50 PM, the Administrator stated she was not familiar with the incident but had found the paperwork explaining what had happened. A physician determination of capacity, dated 05/21/24, reflected that Resident #73 did have capacity at the time of the incident. A quarterly MDS, with an assessment reference date of 09/22/24, reflected that Resident #47 had a BIMS score of 11, indicating moderate cognitive impairment. d) Documented Inappropriate Sexual Behavior - Resident #73Record review revealed documentation, on the October 2024 MAR, indicating some form of inappropriate sexual behavior on 10/09/24 and 10/20/24. The Administrator was asked, on 08/06/25 at approximately 4:00 PM, if the facility could provide documentation as to what those events were. On 08/07/25 at 8:45 AM, the Administrator reported she was unable to provide documentation and I'm not sure what those were from.Subsequent review of the paperwork provided by the facility revealed a 10/09/24 Nursing Note which read, Resident was sitting in the main hallway by the windows with his genitals hanging out and the front of his pants were shocked [soaked]. Asked him to put it away and he did.Record review revealed Resident #73 was not care planned for such behavior. e) Third Inappropriate Resident-to-Resident IncidentA 06/14/25 Nursing Note documented, Housekeeper found resident [#73] with his hands down a female resident's [#34] top fondling her breasts.A quarterly MDS, with an assessment reference date of 06/11/25, reflected that Resident #73 had a BIMS score of 14, indicating that he was cognitively intact. A physician of capacity, dated 05/14/25, reflected that resident had capacity.A quarterly MDS, with an assessment reference date of 06/2725, reflected that Resident #34 had a BIMS score of 00, indicating severe cognitive impairment. Resident #34 did not have capacity.A 06/16/25 note from the Physician Assistant stated, There was an episode over the weekend where he [Resident #73] inappropriately touched another resident [Resident #34]. His mood and behaviors have progressively worsened over time.The facility reportable noted that an investigation was conducted, the Residents were separated, and law enforcement was called. In the facility's Five-Day Follow-Up, the incident was verified that Resident #73 did inappropriately touch Resident #34. A 06/17/25 note from the Physician Assistant stated, Psych 360 has been consulted for his mood disorder.During a telephone interview on 08/06/25 at 2:41 PM, Floor Care Employee #81 reported he had walked around the corner and saw Resident #73 with his hands down Resident #34's top fondling her breasts. Resident #73 saw the floor care employee and immediately drew back his hand and moved his wheelchair away from her. The floor care employee stated he then reported what he witnessed to LPN #90. When asked if he had received any training / directive on paying close attention to Resident #73 when he was around women, the housekeeper replied he had not. When asked how he knew he should report what he witnessed he replied jokingly: First of all, I am not dumb. But it was also mentioned a long time ago like when I first started about what to report and to who. He then added that he knew Resident #73 had done something similar to Resident #83 in July.During an interview on 08/06/25 at 3:30 PM, LPN #90 stated she recalled the above-mentioned incident between Resident #73 and Resident #34. He seems to go towards women who are defenseless. LPN #90 reported she was also aware of the incident later that involved Resident #73 and Resident #83. She stated, I'm surprised she [Resident #83] didn't haul off and hit him. I don't know. Maybe she liked it.f) Fourth Inappropriate Resident-to-Resident IncidentOn 06/22/25, a Nursing Note documented, Resident [#73] attempted to put his hands down a female resident's shirt, residents were placed in different areas away from each other. There was no documentation to reveal the identity of the female resident involved in this incident. Additionally, there was no evidence that this incident was documented as a possible allegation of sexual abuse.g) Fifth Inappropriate Resident-to-Resident Incident Record review revealed that on 07/14/25 at 1:17 PM, the Activities Director reported that she witnessed Resident #73 hands inside of Resident #83 dress touching her breasts. A quarterly MDS assessment, with an assessment reference date of 05/22/25, reflected that resident had a BIMS score of 03, indicating severely impaired cognition. Although Resident #73's physician determination of capacity in mid-June 2025 had taken resident's capacity away, it is important to note at the time of the incident Resident had a BIMS of 14, which is indicative of a resident being cognitively intact. On 07/14/25 at 2:57 PM, there was a physician order given for 15-minute checks for 72 hours on Resident #73. The facility was unable to provide documentation that the checks were done every 15 minutes as ordered. In the facility's Five-Day Follow-Up report, under the corrective actions taken section, it read Residents normal behavior reported, and no corrective action needed. During an interview on 08/06/25 at 3:53 PM, the Activities Director reported she came around the corner and questioned, Hey, what are you doing? She went on to say Resident #73 yanked his hand back and immediately propelled himself into the dining room. She stated Resident #83 was just sitting there with a shocked look on her face. The Activities Director added, He knows what he is doing. She reported she began employment on 06/03/25 and was told by a nurse aide within days of working in the building that staff try to keep Resident #73 and Resident #83 separated. When asked if she felt any female residents tried to seek Resident #73 out she replied, Those ladies do not have the mental capacity to seek him out. They just like sitting in the hallway looking out the windows to nature watch and feel the sun on their faces. Aides take them there because it's closer to the dining room and to activities.During an interview on 08/06/25 at 1:44 PM, the Director of Social services reported that she had never done any training with staff members regarding Resident #73 [NAME] inappropriate sexually aggressive behaviors and how to intervene, and that to her knowledge no one had ever addressed it with staff. She indicated that staff just knew to separate the residents. There was nothing mentioned about staff knowing that they would need to report such instances. Additionally, the Director of Social Services reported that she had not interviewed the residents involved in the resident-to-resident incidents, had not interviewed other staff members, and had not interviewed other residents to determine if they had experienced anything similar or witnessed any other resident being inappropriately touched by Resident #73. The facility was unable to produce evidence that a referral had been made to Pscyh 360 for Resident #73 as per the physician order on 06/17/25. h) Witnessed Inappropriate Sexual BehaviorDuring an interview on 08/07/25 at 9:24 PM, Activity Assistant #136 reported the two times in the month of June 2025 she had witnessed resident's genitals exposed while he was in the hallway. The first instance was reported to the nurse on duty on the 400 Hall where residents resided. The second instance was reported to the Director of Nursing. There was no documentation to reflect this behavior in the resident's medical record nor is it a behavior that is part of his care plan. Using the reasonable person concept, one can conclude that having a random male place their hands inside of a woman's top to fondle her breast or taking the woman's hand and forcing her to touch his penis would result in serious psychosocial harm; therefore, the severity of this recipient's psychosocial harm from such abuse can be determined to be serious, rising to the immediate jeopardy level. The facility was notified of the Immediate Jeopardy (IJ) at 2:15 PM on 08/07/25. The facility submitted their plan of correction (POC) at 5:11 PM on 08/07/25. The State Agency (SA) approved the facility's POC at 6:30 PM on 08/07/25. The IJ began on 01/26/24 the date of the first incident between Resident #73 and female Resident #47. The IJ was abated at 7:40 PM on 08/07/25.The facility's approved abatement POC consisted of the following:1. Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice. Resident #47, #34 and #83 were all affected by this deficient practice.a. Education to all employee on mandated reporting Abuse, protection of resident duringinvestigation and identifying sexual abuse for capacity to consent.b. Education to Admin, Don, SSD and IDT team on investigation and reportingc. Assailant is one on one supervision when out of bedd. Referral sent to SNF facilities for relocation of assailant. With POAs verbal permission.e. Appointments have been requested for emergency mental anguish and psychosocial harm evaluations for resident #47, #34 and #83.f. Started safety interviews on 8/6/25 with female residents. Nonverbal residents will beobserved for change in mood and sudden change in behavior and emotional state.g. Update policy on abuse.h. Updated Care Plans on identified residents.2. Address how the facility will identify other residents have the potential to be affected by the same deficient practice.a. All female residents have the potential to be affected by this deficient practice.b. Interviews are being conducted on all female residents for indication of abuse.c. No others were identified at this time.3. Address what measures will be put into place or systemic change made to ensure that the deficient practice will not reoccur.a. Education to all employee on mandated reporting Abuse, protection of resident during investigation and identifying sexual abuse for capacity to consent.b. Education to Admin, Don, SSD and IDT team on investigation and reporting.c. Update policy on abuse.-All staff education for abuse/ incident management started on 8/7/25 and prior to next scheduled shift, new hires will be trained upon hire and annual thereafter. -DON/designee will educate staff and IDT on behavior documentation and implementing person-centered interventions beginning on 08/7/2024.-Any resident displaying adverse behaviors that may lead to sexual misconduct with other residents will have interventions put in place, such as 15-minute behavior monitoring or 1-on-1 supervision, to prevent sexual misconduct with other residents. If a resident-to-resident sexual misconduct occurs, immediate interventions will be put in place to ensure the safety of both residents. NHA or designee will ensure the Medical Director is notified, the resident's family or responsible party is notified, and appropriate authorities are notified, i.e. police, ombudsman, DHHR occurrence reporting system. Administration will complete full investigation to include the abuse packet.4. Indicate how the facility plans to monitor its performance to make sure that solutions are sustained. The facility must develop a plan for ensuring that correction is achieved and sustained. This plan must be implemented and the corrective action evaluation for its effectiveness. The plan of correction must be integrated into the quality assurance system. The correction date will be the latest completion day on your accepted plan of correction.NHA or designee will review 24-hour report for sexual abuse and/or behavioral concerns during the daily clinical meeting Monday - Friday. Monday's review will include Friday, Saturday, and Sunday 24-hour reports as well. An audit form with a list of residents with potential sexual abuse and/or behavior concerns will be discussed in the daily clinical meeting with the IDT for tracking, trending and re-evaluation of interventions and effectiveness of resident care plan. Changes will be made according to the results of the documentation. This plan of correction will be monitored at the monthly Quality Assurance meeting for three months or until substantial compliance has been met.5. Include dates when the corrective action will be completed. Corrective action is completed 8/07/25.

CRITICAL (K) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Immediate Jeopardy (IJ) - the most serious Medicare violation

Investigate Abuse (Tag F0610)

Someone could have died · This affected multiple residents

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, record review, resident interview, and staff interview, the facility failed to protect the residents' right to be free from abuse that resulted in mental anguish for Residents #47, #34, and #83. Resident #73 was reportedly touching female residents in the breast and vaginal area. An unlimited about of female residents had the potential to be affected. The facility's failure to thoroughly investigate, correct, and prevent inappropriate sexual contact placed Residents #47, #34, and #83 at continued risk of sexual abuse prior to Surveyor intervention. This cread an immediate jeopardy situation. Facility census: 103.Findings included:a) Policy ReviewThe facility's Abuse, Neglect, Exploitation and Misappropriation Prevention Program policy, with a revision date of 2021, stated that residents had the right to be from abuse which included sexual or physical abuse. It also mentioned a facility-wide commitment and resource allocation to protect residents from abuse by anyone, noting that it could be from other residents. Nowhere in the policy was there a definition of sexual abuse. However, the policy did direct that all possible incidents of abuse were to be identified and investigated. Additionally, the facility was to establish and implement a QAPI review and analysis of reports, allegations, or finding of abuse. It is important to note that at no point throughout the survey process did the facility report that they had self-identified Resident #73, who had capacity until mid-June 2025, as an individual who touched women without capacity in an unwanted sexual way. The facility's Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating policy, with a revision date of September 2022, stated that all reports of resident abuse are reported and thoroughly investigated by facility management. Findings of all investigations were documented and reported. This policy goes on to state: -If resident abuse is suspected, the suspicion must be reported immediately to the Administrator.-The allegation is immediately reported to the appropriate state agencies, the state long-term care Ombudsman, and the resident's legal representative. -Upon receiving any allegation of abuse, the Administrator is responsible for determining what actions (if any) are needed for the protection of residents. -All allegations are to be thoroughly investigated. -The individual conducting the investigation at a minimum will review the resident's medical record to determine if the resident's physical and cognitive status at the time of the incident. Observe the alleged victim, including his or her interactions with staff and other residents. Interview the person reporting the incident. Interview any witnesses to the incident. Interview staff members (on all shifts) who have had contact with the resident during the period of the alleged incident. Interview the resident's roommate, family members, and visitors. Document the investigation completely and thoroughly. -Upon conclusion of the investigation, the investigator records the findings of the investigation on approved documentation forms.-Within five (5) business days of the incident, the Administrator will provide a follow-up investigation report which will describe the results of the investigation, and indicate any corrective actions taken if the allegation was verified. -The resident and/or representative are notified of the outcome immediately upon conclusion of the investigation. Review of the Long-Term Care Nursing Home Program Reporting Requirements guidance from the Office of Health Facility Licensure & Certification (OHFLAC) office describes sexual abuse as non-consensual sexual contact of any type with a resident.b) First Inappropriate Resident-to-Resident IncidentOn 01/26/24 at 5:30 PM, it was reported that Resident #73 and Resident #47 were unsupervised in the activity room. A staff member walked into the room and Resident #73 jumped and moved his hands from under Resident #47's shirt. At that time, Resident #73 had capacity and was believed to be cognitively intact. Resident #47 lacked capacity and had a BIMS of 09, indicating moderate cognitive impairment. The facility reported this incident to the appropriate state agencies as an unusual occurrence noting that the residents had reportedly touched each other. The facility intervention was to move Resident #47 to the opposite side of the building, body audits were performed, and safety checks initiated. There were no written statements from either resident.However, during an interview on 08/07/26 at 10:49 AM, Resident #47 reported she recalled the incident in question. She stated that [Resident #73's First Name] was the man that hurt her and repeatedly said that the facility does not believe her. Resident #47 described being in the activity room, Resident #73 pulling down his pants, taking her hand and making her touch his private parts. Resident stated, He put his hand in my shirt and touched my boob. She said she reported this to the facility. She also expressed fear of Resident #73.Resident #73 was not care planned for inappropriate physical sexual behavior related to unknown etiology until 03/04/24. The goal at that time was, Will only engage in sexual activity with consenting partners, No where in the electronic medical record was there documentation as to what the inappropriate sexual behavior was and who it involved. During an interview on 08/06/25 at 1:44 PM, the Director of Social Services stated that she could not report with 100% certainty but that to the best of her recollection the initial care plan for inappropriate sexual behavior may have involved Resident #104 who had since passed away. The Director of Social Services stated that the two (2) residents dated each other. Further record review revealed that around the 03/04/24 timeframe, Resident #104 had a BIMS score of 10, indicating moderate cognitive impairment. Resident #104 did not have capacity. The alleged relationship between the aforementioned residents was not care-planned. c) Second Inappropriate Resident-to-Resident IncidentA record review revealed that on 09/06/24 at 2:54 PM, there was a physician order for 15-minute safety checks for 72 hours. The facility was unable to provide documentation that the checks were done every 15 minutes as ordered. When initially asked the reason for the 15-minute checks, the Administrator could not produce an immediate answer. Later the Administrator produced a 09/06/24 reportable where Resident #47 had reported an allegation of sexual abuse involving Resident #73. It was noted that Resident #47 was crying and expressing fear. Resident #47 stated that Resident #73 touched her breast and down there. A written statement from LPN #200 read, On 09/06/24 this nurse went to the dining room area to give the resident (Resident #47) her medications. The resident reported to this nurse that [Resident #73's First and Last Name] touched her breast inappropriately on 09/05/24 while she was sitting in the dining room area watching her tablet.The facility's Five-Day Follow-Up did not verify the allegation. However, the facility looked into the date of 08/14/24 when Resident #47 was restricted to her room for COVID isolation. There was no mention of the 09/05/24 incident that was reported by resident and documented in a written statement by LPN #200. As she was sharing a copy of the reportable on 08/06/25 at 2:50 PM, the Administrator stated she was not familiar with the incident but had found the paperwork explaining what had happened. A physician determination of capacity, dated 05/21/24, reflected that Resident #73 did have capacity at the time of the incident. A quarterly MDS, with an assessment reference date of 09/22/24, reflected that Resident #47 had a BIMS score of 11, indicating moderate cognitive impairment. d) Documented Inappropriate Sexual Behavior - Resident #73Record review revealed documentation, on the October 2024 MAR, indicating some form of inappropriate sexual behavior on 10/09/24 and 10/20/24. The Administrator was asked, on 08/06/25 at approximately 4:00 PM, if the facility could provide documentation as to what those events were. On 08/07/25 at 8:45 AM, the Administrator reported she was unable to provide documentation and I'm not sure what those were from.Subsequent review of the paperwork provided by the facility revealed a 10/09/24 Nursing Note which read, Resident was sitting in the main hallway by the windows with his genitals hanging out and the front of his pants were shocked [soaked]. Asked him to put it away and he did.Record review revealed Resident #73 was not care planned for such behavior. e) Third Inappropriate Resident-to-Resident IncidentA 06/14/25 Nursing Note documented, Housekeeper found resident [#73] with his hands down a female resident's [#34] top fondling her breasts.A quarterly MDS, with an assessment reference date of 06/11/25, reflected that Resident #73 had a BIMS score of 14, indicating that he was cognitively intact. A physician of capacity, dated 05/14/25, reflected that resident had capacity.A quarterly MDS, with an assessment reference date of 06/2725, reflected that Resident #34 had a BIMS score of 00, indicating severe cognitive impairment. Resident #34 did not have capacity. A 06/16/25 note from the Physician Assistant stated, There was an episode over the weekend where he [Resident #73] inappropriately touched another resident [Resident #34]. His mood and behaviors have progressively worsened over time. The facility reportable noted that an investigation was conducted, the Residents were separated, and law enforcement was called. In the facility's Five-Day Follow-Up, the incident was verified that Resident #73 did inappropriately touch Resident #34. A 06/17/25 note from the Physician Assistant stated, Psych 360 has been consulted for his mood disorder.During a telephone interview on 08/06/25 at 2:41 PM, Floor Care Employee #81 reported he had walked around the corner and saw Resident #73 with his hands down Resident #34's top fondling her breasts. Resident #73 saw the floor care employee and immediately drew back his hand and moved his wheelchair away from her. The floor care employee stated he then reported what he witnessed to LPN #90. When asked if he had received any training / directive on paying close attention to Resident #73 when he was around women, the housekeeper replied he had not. When asked how he knew he should report what he witnessed he replied jokingly: First of all, I am not dumb. But it was also mentioned a long time ago like when I first started about what to report and to who. He then added that he knew Resident #73 had done something similar to Resident #83 in July.During an interview on 08/06/25 at 3:30 PM, LPN #90 stated she recalled the above-mentioned incident between Resident #73 and Resident #34. He seems to go towards women who are defenseless. LPN #90 reported she was also aware of the incident later that involved Resident #73 and Resident #83. She stated, I'm surprised she [Resident #83] didn't haul off and hit him. I don't know. Maybe she liked it.f) Fourth Inappropriate Resident-to-Resident IncidentOn 06/22/25, a Nursing Note documented, Resident [#73] attempted to put his hands down a female resident's shirt, residents were placed in different areas away from each other. There was no documentation to reveal the identity of the female resident involved in this incident. Additionally, there was no evidence that this incident was documented as a possible allegation of sexual abuse.g) Fifth Inappropriate Resident-to-Resident Incident Record review revealed that on 07/14/25 at 1:17 PM, the Activities Director reported that she witnessed Resident #73 hands inside of Resident #83 dress touching her breasts. A quarterly MDS assessment, with an assessment reference date of 05/22/25, reflected that resident had a BIMS score of 03, indicating severely impaired cognition. Although Resident #73's physician determination of capacity in mid-June 2025 had taken resident's capacity away, it is important to note at the time of the incident Resident had a BIMS of 14, which is indicative of a resident being cognitively intact. On 07/14/25 at 2:57 PM, there was a physician order given for 15-minute checks for 72 hours on Resident #73. The facility was unable to provide documentation that the checks were done every 15 minutes as ordered. In the facility's Five-Day Follow-Up report, under the corrective actions taken section, it read Residents normal behavior reported, and no corrective action needed. During an interview on 08/06/25 at 3:53 PM, the Activities Director reported she came around the corner and questioned, Hey, what are you doing? She went on to say Resident #73 yanked his hand back and immediately propelled himself into the dining room. She stated Resident #83 was just sitting there with a shocked look on her face. The Activities Director added, He knows what he is doing. She reported she began employment on 06/03/25 and was told by a nurse aide within days of working in the building that staff try to keep Resident #73 and Resident #83 separated. When asked if she felt any female residents tried to seek Resident #73 out she replied, Those ladies do not have the mental capacity to seek him out. They just like sitting in the hallway looking out the windows to nature watch and feel the sun on their faces. Aides take them there because it's closer to the dining room and to activities.During an interview on 08/06/25 at 1:44 PM, the Director of Social services reported that she had never done any training with staff members regarding Resident #73 [NAME] inappropriate sexually aggressive behaviors and how to intervene, and that to her knowledge no one had ever addressed it with staff. She indicated that staff just knew to separate the residents. There was nothing mentioned about staff knowing that they would need to report such instances. Additionally, the Director of Social Services reported that she had not interviewed the residents involved in the resident-to-resident incidents, had not interviewed other staff members, and had not interviewed other residents to determine if they had experienced anything similar or witnessed any other resident being inappropriately touched by Resident #73. The facility was unable to produce evidence that a referral had been made to Pscyh 360 for Resident #73 as per the physician order on 06/17/25. h) Witnessed Inappropriate Sexual BehaviorDuring an interview on 08/07/25 at 9:24 PM, Activity Assistant #136 reported the two times in the month of June 2025 she had witnessed resident's genitals exposed while he was in the hallway. The first instance was reported to the nurse on duty on the 400 Hall where residents resided. The second instance was reported to the Director of Nursing. There was no documentation to reflect this behavior in the resident's medical record nor is it a behavior that is part of his care plan. The facility's failure to thoroughly investigate, correct, and prevent inappropriate sexual contact. The facility's failure placed residents at risk for sexual abuse and serious psychosocial harm. The severity of the psychosocial harm from such abuse can be determined to be serious, rising to the immediate jeopardy level. The facility was notified of the Immediate Jeopardy (IJ) at 2:15 PM on 08/07/25. The facility submitted their plan of correction (POC) at 5:11 PM on 08/07/25. The State Agency (SA) approved the facility's POC at 6:30 PM on 08/07/25. The IJ began on 01/26/24 the date of the first incident between Resident #73 and female Resident #47. The IJ was abated at 7:40 PM on 08/07/25.The facility's approved abatement POC consisted of the following:1. Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice. #47, #34 and #83 were all affected by this deficient practice.a. Education to all employee on mandated reporting Abuse, protection of resident during investigation and identifying sexual abuse for capacity to consent.b. Education to Admin, Don, SSD and IDT team on investigation and reportingc. Assailant is one on one supervision when out of bedd. Referral sent to SNF facilities for relocation of assailant. With POAs verbal permission.e. Appointments have been requested for emergency mental anguish and psychosocial harm evaluations for resident #47, #34 and #83.f. Started safety interviews on 8/6/25 with female residents. Nonverbal residents will be observed for change in mood and sudden change in behavior and emotional state.g. Update policy on abuse.h. Updated Care Plans on identified residents. 2. Address how the facility will identify other residents have the potential to be affected by the same deficient practice.a. All female residents have the potential to be affected by this deficient practice.b. Interviews are being conducted on all female residents for indication of abuse.c. No others were identified at this time. 3. Address what measures will be put into place or systemic change made to ensure that the deficient practice will not reoccur.a. Education to all employee on mandated reporting Abuse, protection of resident during investigation and identifying sexual abuse for capacity to consent.b. Education to Admin, Don, SSD and IDT team on investigation and reporting.c. Update policy on abuse.-All staff education for abuse/ incident management started on 8/7/25 and prior to next scheduled shift, new hires will be trained upon hire and annual thereafter. -DON/designee will educate staff and IDT on behavior documentation and implementing person-centered interventions beginning on 08/7/2024.-Any resident displaying adverse behaviors that may lead to sexual misconduct with other residents will have interventions put in place, such as 15-minute behavior monitoring or 1-on-1 supervision, to prevent sexual misconduct with other residents. If a resident-to-resident sexual misconduct occurs, immediate interventions will be put in place to ensure the safety of both residents. NHA or designee will ensure the Medical Director is notified, the resident's family or responsible party is notified, and appropriate authorities are notified, i.e. police, ombudsman, DHHR occurrence reporting system. Administration will complete full investigation to include the abuse packet.4. Indicate how the facility plans to monitor its performance to make sure that solutions are sustained. The facility must develop a plan for ensuring that correction is achieved and sustained. This plan must be implemented and the corrective action evaluation for its effectiveness. The plan of correction must be integrated into the quality assurance system. The correction date will be the latest completion day on your accepted plan of correction.NHA or designee will review 24-hour report for sexual abuse and/or behavioral concerns during the daily clinical meeting Monday - Friday. Monday's review will include Friday, Saturday, and Sunday 24-hour reports as well. An audit form with a list of residents with potential sexual abuse and/or behavior concerns will be discussed in the daily clinical meeting with the IDT for tracking, trending and re-evaluation of interventions and effectiveness of resident care plan. Changes will be made according to the results of the documentation. This plan of correction will be monitored at the monthly Quality Assurance meeting for three months or until substantial compliance has been met.5. Include dates when the corrective action will be completed. Corrective action is completed 8/07/25.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Notification of Changes (Tag F0580)

Could have caused harm · This affected 1 resident

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Based on facility record review, medical record review, and interview, the facility failed to ensure a resident's Medical Power of Attorney (MPOA) was notified immediately concerning an allegation of abuse and to keep the MPOA updated on the findings. This practice affected two (2) of four (4) residents reviewed. Resident identifiers: #34. Facility census: 103.Findings include: R a) Resident #34On June 14, 2025, a sexual abuse allegation was reported involving Resident #73, who had his hand down Resident #34's shirt. An investigation was conducted, and the residents were separated. Law enforcement, the MPOA, the Director of Nursing (DON), and the Administrator (ADM) were all notified. A quarterly MDS assessment on 06/27/25, showed Resident #34 with a BIMS score of 00, indicating severe cognitive impairment and lack of capacity. The 5-Day report verified the incident, confirming that Resident #73 inappropriately touched Resident #34. During an interview on 08/07/25, at 12:20 PM, Resident #34's responsible party stated she was initially made aware of a possible incident on June 14, 2025, but was later informed by the facility that it did not happen.

CONCERN (E) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Abuse Prevention Policies (Tag F0607)

Could have caused harm · This affected multiple residents

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Based on staff interviews, electronic medical record, facility record review and Operation Policy the facility failed to implement their written policy for thoroughly investigating allegations of sexual abuse. This was true of one (3) of three (3) residents reviewed for sexual abuse. Resident identifiers: #34, #83 and #47. Facility census: 103.A review of the facility's Abuse, Neglect, Exploitation and Misappropriation Prevention Program policy, with a revision date of 2021, revealed that residents had the right to be from abuse which included sexual or physical abuse. It also mentioned a facility-wide commitment and resource allocation to protect residents from abuse by anyone, noting that it could be from other residents. Nowhere in the policy was there a definition of sexual abuse. However, the policy did direct that all possible incidents of abuse were to be identified and investigated. Additionally, the facility was to establish and implement a QAPI review and analysis of reports, allegations, or finding of abuse. The facility's Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating policy, with a revision date of September 2022, stated that all reports of resident abuse were to be reported and thoroughly investigated by facility management. Findings of all investigations were to be documented and reported. This policy went on to state:If resident abuse is suspected, the suspicion must be reported immediately to the Administrator. The allegation is immediately reported to the appropriate state agencies, the state long- term care Ombudsman, and the resident's legal representative. Upon receiving any allegation of abuse, the Administrator is responsible for determining what actions (if any) are needed for the protection of residents. All allegations are to be thoroughly investigated. The individual conducting the investigation at a minimum will review the resident's medical record to determine if the resident's physical and cognitive status at the time of the incident. Observe the alleged victim, including his or her interactions with staff and otherresidents. Interview the person reporting the incident. Interview any witnesses to the incident. Interview staff members (on all shifts) who have had contact with the resident during the period of the alleged incident. Interview the resident's roommate, family members, and visitors. Document the investigation completely and thoroughly. Upon conclusion of the investigation, the investigator records the findings of the investigation on approved documentation forms. Within five (5) business days of the incident, the Administrator will provide a follow-up investigation report which will describe the results of the investigation, and indicate any corrective actions taken if the allegation was verified. The resident and/or representative are notified of the outcome immediately upon conclusion of the investigation. Resident #73 On 06/22/25, a Nursing Note documented, Resident [#73] attempted to put his hands down a female resident's shirt, residents were placed in different areas away from each other. There is no evidence that this incident was documented as a possible allegation of sexual abuse. Resident #67On 01/26/24 at 5:30 PM, it was reported that Resident #73 and Resident #67 were unsupervised in the activity room. A staff member walked into the room and Resident #73 jumped and moved his hands from under Resident #67's shirt. At that time, Resident #73 had capacity and was believed to be cognitively intact. Resident #67 lacked capacity and had a BIMS of 09, indicating moderate cognitive impairment. The facility reported this incident to the appropriate state agencies as an unusual occurrence noting that the residents had reportedly touched each other. The facility intervention was to move Resident #67 to the opposite side of the building, body audits were performed, and safety checks initiated. There were no written statements from either resident.A reportable review dated 09/06/24 revealed Resident #67 had reported an allegation of sexual abuse involving Resident #73. It was noted that Resident #67 was crying and expressing fear. Resident #67 stated that Resident #73 touched her breast and down there. A written statement from LPN #200 read, On 09/06/24 this nurse went to the dining room area to give the resident (Resident #67) her medications. The resident reported to this nurse that [Resident #73's First and Last Name] touched her breast inappropriately on 09/05/24 while she was sitting in the dining room area watching her tablet.The facility's Five-Day Follow-Up did not verify the allegation. However, the facility investigated the date of 08/14/24 when Resident #67 was restricted to her room for COVID isolation. There was no mention of the 09/05/24 incident that was reported by Resident #67 and documented in a written statement by LPN #200. Resident #34A review of a reportable found a sexual abuse allegation on 06/14/25 where Resident #73 had his hand down Resident #34's shirt. A review of the quarterly MDS, with an assessment reference date of 06/27/25, reflected that Resident #34 had a BIMS score of 00, indicating severe cognitive impairment. Resident #34 did not have capacity. A review of the 5 Day report revealed the incident was verified Resident #73. Resident #73 did inappropriately touch Resident #34. Resident #83A review of a reportable found a sexual abuse allegation on 07/14/25. The reportable stated that Resident #73 inappropriately touched Resident #83. On 07/14/25 at 1:17 PM, the Activities Director reported that she witnessed Resident #73's hands inside of Resident #83's dress touching her breasts. A quarterly MDS assessment, with an assessment reference date of 05/22/25, reflected that the resident had a BIMS score of 03, indicating severely impaired cognition.In the facility's Five-Day Follow-Up report, under the corrective actions taken section, it read Residents normal behavior reported, and no corrective action needed. During an interview on 08/06/25 at 1:44 PM, the Director of Social services reported that she had never done any training with staff members regarding Resident #73's inappropriate sexually aggressive behaviors and how to intervene. Resident #73 said that to her knowledge no one had ever addressed it with staff. She indicated that staff just knew to separate the residents. There was nothing mentioned about staff knowing that they would need to report such instances. She also reported that she had never obtained staff statements or residents statements about abuse and interviews were not conducted on all female residents for possible sexual abuse.

Aug 2025 1 deficiency

CONCERN (E) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

ADL Care (Tag F0677)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to provide dependent residents with the assistance needed for showers and personal hygiene. This was true for three (3) of four (4) residents sampled. Resident Identifiers: #24, #72 and #76. Facility Census: 106. Findings Includea) Resident #24During an interview on 07/29/2025 at 10:39 AM, Resident #76 stated that she was scheduled for showers on Tuesday and Friday. The resident explained that the availability of showers depended on staffing levels. She further stated that she was admitted on [DATE] and her first shower occurred on 07/15/25. Record review on 07/29/25 at approximately 10:45 AM revealed that Resident #24 had received a shower on 07/15/25 and 07/19/25. The record also revealed that Resident #24 refused showers on 07/22/25 and 07/25/25. Resident denies refusing showers. She stated, I'll take anything that I can get. b) Resident #72 During an interview with Resident #72 on 07/29/25 at approximately 12:06 PM, the resident stated that she was admitted on [DATE]. Resident #72 stated that she had received a bed bath on 07/14/25. Record review on 07/29/25 at 11:30 AM revealed that Resident #72 received the following:bed bath 07/14/25shower 07/16/25bed bath 07/23/25Resident #72 went on to state that she would be lucky if she could get two baths a week. c) Resident #76 On 07/29/25 at approximately 1:13 PM, Resident #76 stated that she was scheduled for two (2) showers a week. She said that she could request showers, but it depended on who was working. If the staff didn't feel like showering her, she would get a bed bath instead. Resident #76 denied refusing a shower or a bed bath. 07/29/25 2:00 PM record review revealed the following:Refused to shower at 8:45 PM on 07/01/25Shower at 8:44 PM on 07/04/25Shower at 8:33 PM on 07/08/25Bed bath at 9:34 PM on 07/11/25Refused a shower at 10:05 PM on 07/15/25Bed bath at 7:31 PM on 07/25/25. Records reveal that Resident #76 did not receive a bed bath or shower for a period of nine (9) days, between 07/15/25 and 07/25/25 During an interview with the Administrator on 07/30/25 at approximately 10:55 AM, the Administrator provided shower logs and stated that they were accurate. During an interview on 07/29/25 at approximately 3:45 PM, with Nursing Assistants (NAs) #34, #53, and #107, they stated that there were times when, in the evenings, it was difficult to get all the residents on the schedule.

Sept 2023 3 deficiencies

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Comprehensive Care Plan (Tag F0656)

Could have caused harm · This affected 1 resident

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Based on record review and staff interview, the facility failed to implement the care plans for three (3) of six (6) residents who were care planned for the potential for falls. Facility census: 109. Findings include: At 10:30 AM on 09/11/23, a tour of the 200 hallway with the Housekeeping Supervisor (HS) #52 found three (3) residents on the 200 hallway who's call systems were in the floor and not within reach of the Residents who were in their beds. These three (3) Resident's were care planned for being at risk of falls. Each Resident had an intervention to have call bells within reach. a) Resident's #85 Review of the Residents electronic medical record found a care plan focus: At risk for falls due to poor safety awareness/cognitive deficits, revised on 03/08/23 The goal associated with the focus is: Minimize risk for injury related to falls, revised 03/14/23. Interventions included: Call bell in reach, initiated 03/08/23 b) Resident #9 Review of the electronic medical record found a care plan focus: At risk for falls due to myasthenia gravis, labile personality secondary to paranoid schizophrenia, date initiated, 11/19/20 The goal associated with the focus: Minimize risk for injury related to falls, imitated on 11/19/20 Interventions included: Call bell in reach, initiated on 11/24/20 c) Resident #10 Review of the electronic medical record found a care plan focus: At risk for falls due to history of falls, impaired balance/poor coordination, medication side effects, unsteady gait, date initiated 09/14/22 The goal associated with the focus: Minimize risk for injury related to falls, initiated 09/14/22 Interventions included: Call bell in reach At 5:10 PM on 09/13/23 the above findings were discussed with the Director of Nursing. No further information was provided.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0919 (Tag F0919)

Could have caused harm · This affected 1 resident

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Based on observation and staff interview, the facility failed to ensure the call system was accessible to residents while in their bed. This was a random opportunity for discovery. Facility census: 109. Findings include: At 10:30 AM on 09/11/23, a tour of the 200 hallway with the housekeeping supervisor (HS) #52 found six (6) residents on 200 hallway who's call systems were in the floor and not within reach of the Residents who were in their beds. HS #52 confirmed the following residents did not have access to the call light system: #10, #9, #85, #77, #70 and #75. At 5:10 PM on 09/13/23 the above findings were discussed with the Director of Nursing.

CONCERN (E) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Staffing Information (Tag F0732)

Could have caused harm · This affected multiple residents

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Based on observation and staff interview, the facility failed to ensure the nurse staffing information was posted in the facility accessible to residents and visitors. This has the potential to affect more than a minimal number of residents. Facility census: 109. Findings include: a) Nurse staffing Observation of the nurse staffing folder at the front hallway with the admissions director (AD) #25 at 10:20 AM on 09/11/23, found there was no information regarding the nurse staff on duty for 09/11/23. At 5:10 PM on 09/11/23, the Director of Nursing (DON) said she had been made aware the staff posting was not completed for 09/11/23.

Jul 2023 5 deficiencies

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Assessment Accuracy (Tag F0641)

Could have caused harm · This affected 1 resident

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. Based on medical record review and staff interview, the facility failed to complete an accurate Minimum Data Set (MDS) in the area of skin conditions for Resident #80, and #6. This failed practice affected a limited number of residents. Resident identifiers: #80 and #6. Facility census: 110. Findings included: a) Resident #80 Review of Resident #80's medical records showed the resident had an unstageable pressure ulcer/injury of the sacral region secondary to slough. This pressure ulcer was in-house acquired on 01/29/23 as documented from the Nurse Practitioner (NP). A review of the MDS with an Assessment Reference Date (ARD) of 05/05/23, under Section S - Skin conditions was blank. An interview with the Director of Nursing (DON), on 07/20/23 at 1:15 PM, verified the MDS with ARD of 05/05/23 was inaccurate in the area of pressure ulcers. b) Resident #6 A review of Resident #6's medical records showed the resident had an unstageable pressure ulcer/injury of the sacral region secondary to slough and eschar. A review of the MDS with an ARD of 05/17/23, under Section S - Skin conditions was blank. An interview, with the DON, on 07/20/23 at 1:15 PM verified the MDS with ARD of 05/17/23 was inaccurate in the area of pressure ulcers.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

ADL Care (Tag F0677)

Could have caused harm · This affected 1 resident

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. Based on medical record review and staff interview, the facility failed to ensure a resident who was unable to carry out activities of daily living (ADL) received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. The facility failed to shower residents as per their schedule. Resident identifiers: #17 and #31. Facility census: 110. Findings included: a) Resident #17 Review of Resident #17's medical records found the resident was scheduled to have a shower twice weekly on Tuesdays and Fridays on day shift. A review of Resident #17's ADL records found: June 2023- was given a shower on three (3) occasion out of nine (9) opportunities. July 2023- was given a shower on two (2) occasions out of five (5) opportunities. b) Resident #31 A review of Resident #31's medical records found the resident was scheduled to have a shower three (3) times weekly on Mondays, Wednesday, and Fridays on day shift. A review of Resident #31's ADL records found: June and July 2023- All baths given were coded as (3) bed baths. No showers were documented. An interview was held with the Director of Nursing (DON) on 07/20/23 at 11:30 AM. During this interview she reviewed the ADL sheets for Resident #17 and Resident #31 and she confirmed the record did not reflect why the residents did not receive their scheduled showers.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Quality of Care (Tag F0684)

Could have caused harm · This affected 1 resident

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. Based on medical record review and staff interview, the facility failed to assess pressure ulcers when first identified to ensure the resident's receive appropriate care and treatment. This failed practice affected a limited number of residents. Resident identifiers: #80, #6, and #107. Facility census :110. Findings included: a) Resident #80 Review of Resident #80's medical records found the resident was assessed with a Stage II (2) pressure ulcer/injury on the left buttocks The ulcer was initially identified as facility acquired on 01/29/23. The wound measured 2.0 centimeters (cm) in length and 2.0 in width and wound bed is 100% covered with slough. National Pressure Ulcer Advisory Panel's (NPUAP) list the following stages: Stage 2 Pressure Ulcer: Partial-thickness skin loss with exposed dermis Partial-thickness loss of skin with exposed dermis, presenting as a shallow open ulcer. The wound bed is viable, pink, or red, moist, and may also present as an intact or open/ruptured blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present. This stage should not be used to describe moisture associated skin damage including incontinence associated dermatitis, intertriginous dermatitis (inflammation of skin folds), medical adhesive related skin injury, or traumatic wounds (skin tears, burns, abrasions). Unstageable Pressure Ulcer: Obscured full-thickness skin and tissue loss. Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because the wound bed is obscured by slough or eschar. Stable eschar (i.e., dry, adherent, intact without erythema or fluctuance) should only be removed after careful clinical consideration and consultation with the resident's physician, or nurse practitioner, physician assistant, or clinical nurse specialist if allowable under state licensure laws. If the slough or eschar is removed, a Stage 3 or Stage 4 pressure ulcer will be revealed. If the anatomical depth of the tissue damage involved can be determined, then the reclassified stage should be assigned. The pressure ulcer does not have to be completely debrided or free of all slough or eschar for reclassification of stage to occur. An interview with the Director of Nursing (DON) on 07/20/23 at 11:45 AM. She confirmed the resident's initial assessment's staging was incorrect. She confirmed the wound on the left buttocks should have been staged as an unstageable wound. b) Resident #6 Review of Resident #6's medical records found the resident was assessed with an unstageable pressure ulcer/injury on the left heel. This wound was initially identified as facility acquired on 02/17/23. It measured 0.8 centimeters (cm) in length and 0.8 cm in width and unable to measure depth due to 100% covered with a black/brown crust. National Pressure Ulcer Advisory Panel's (NPUAP) list the following stages: Unstageable Pressure Ulcer: Obscured full-thickness skin and tissue loss. Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because the wound bed is obscured by slough or eschar. Stable eschar (i.e., dry, adherent, intact without erythema or fluctuance) should only be removed after careful clinical consideration and consultation with the resident's physician, or nurse practitioner, physician assistant, or clinical nurse specialist if allowable under state licensure laws. If the slough or eschar is removed, a Stage 3 or Stage 4 pressure ulcer will be revealed. If the anatomical depth of the tissue damage involved can be determined, then the reclassified stage should be assigned. The pressure ulcer does not have to be completely debrided or free of all slough or eschar for reclassification of stage to occur. Deep Tissue Pressure Injury (DTPI): Persistent non-blanchable deep red, maroon, or purple discoloration. Intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration due to damage of underlying soft tissue. This area may be preceded by tissue that is painful, firm, mushy, boggy, warmer, or cooler as compared to adjacent tissue. These changes often precede skin color changes and discoloration may appear differently in darkly pigmented skin. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. The wound may evolve rapidly to reveal the actual extent of tissue injury or may resolve without tissue loss. If necrotic tissue, subcutaneous tissue, granulation tissue, fascia, muscle, or other underlying structures are visible, this indicates a full thickness pressure ulcer. Once a deep tissue injury opens to an ulcer, reclassify the ulcer into the appropriate stage. Do not use DTPI to describe vascular, traumatic, neuropathic, or dermatologic conditions. An interview with the DON on 07/20/23 at 1:00 PM, the DON confirmed the resident's initial assessment's staging was incorrect. She confirmed the wound on the left heel stage should have been staged as a deep tissue injury (DTI) wound. c) Resident #107 Review of Resident #107's medical records found the resident was assessed with a Stage III (3) pressure ulcer/injury on the right calf area secondary to an immobilizing device for treatment of right leg fracture. This wound was initially identified as facility acquired on 04/12/23. It measured 2.5 centimeters (cm) in length and 0.8 cm in width and unable to measure depth due to 75% of wound bed was covered by slough. National Pressure Ulcer Advisory Panel's (NPUAP) list the follow: Stage 3 Pressure Ulcer: Full-thickness skin loss. Full-thickness loss of skin, in which subcutaneous fat may be visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible but does not obscure the depth of tissue loss. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. If slough or eschar obscures the wound bed, it is an Unstageable PU/PI. An Interview, with the DON on 07/20/23 at 10:45 AM confirmed the resident's initial assessment's staging was incorrect. She confirmed the wound on the right calf should have been staged as an unstageable wound.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Medical Records (Tag F0842)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and policy review, the facility failed to ensure resident weights were accurate and failed to have a physician order for pressure ulcers. Resident identifiers: #103 and #89. These failed practices affected a limited number of residents. Facility census: 110. Findings included: a) Resident #103 Resident #103 A review of the medical record revealed the following weights: 07/17/23 157.2 Lbs. 07/05/23 194.3 Lbs. 06/28/23 163.0 Lbs. 06/27/23 159.5 Lbs. 06/21/23 163.2 Lbs. 06/15/23 166.2 Lbs. 06/14/23 168.8 Lbs. The physician ordered a Controlled Carbohydrate diet, Pureed texture, and Nectar consistency . A supplement of Suplena in the afternoon four (4) ounces daily was ordered on 07/04/23. Medical diagnoses included Dementia, hypertension (high blood pressure), Diabetes Mellitus, difficulty swallowing, behaviors, chronic kidney disease Stage 4 (severe) and Parkinson's Disease. The following Nutrition notes were found in the electronic medical record: 07/17/23 16:40 (4:40 PM) *Nutrition Note Note Text: RD (Registered Dietician) Weight Review: (Resident age and gender). Diet Order-Controlled Carbohydrate (CCHO) Diet, Pureed Texture, Nectar Consistency; Nosey Cup with all meals. Supplement Order-Suplena 4 oz in afternoon. Intakes x past week: Meals-3 refused,2 at 0-25%,4 at 26-50%,3 at 51-75%,9 at 76-100%; Suplena-100%;Avg documented fluid-2049 ml with range of 1840-2300 ml. Additional fluids may be taken throughout the day. Weight on 07/05/23-194.3# (BMI 27.1),+31.3# (19.2%) since 06/28/23, +25.5#(15.1%) since admission [DATE]. Per Physician Assistant (PA) note 07/11/23, no lower extremity edema noted. No decubs noted. Fingersticks since 06/16/23 ranged from 86-354. Meal intakes have slightly improved since last RD review on 07/03/23 and has good supplement intakes. RD spoke with nursing on obtaining another weight. Will continue to monitor for changes via facility staff. 07/03/2023 13:43 (1:43 PM) *Nutrition Note Note Text: Intakes x past week: Meals- 2 refused, 6 at 0-25%, 3 at 26-50%, 5 at 51-75%, 5 at 76-100%; Bedtime snack accepted six (6) evenings with 1 no; Avg documented fluid-2030 ml with range of 1340-2640 ml. Additional fluids may be taken throughout the day. Weight on 06/28/23-163# (BMI 22.7), -5.8#(3.4%) since admission 6/14/23. No edema or pressure injuries noted. Fingersticks since 06/14/23 ranged from 86-360. Abnormal labs on 06/23/23: HGB 10.9; HCT 34; RBC 3.68;CO2 20; BUN 38; Creatinine 2.86; GFR 23; Albumin 3.1. Per PA note 06/26/23, noted resident was pocketing food. Recommend Suplena 4 oz qd r/t inconsistent meal intakes. Will continue to monitor for changes via facility staff. On 07/19/23 observed Resident #103 eating lunch meal. The resident fed himself potatoes and bread. Nursing Aide (NA) # stated Resident #103 ate 100% breakfast and usually ate less at lunch and then ate all of dinner meal. Review of meal intake for this week revealed at times refused to eat. He does take a supplement. A review of the facility Weight Management Guide with no date found if there was a five (5) pound difference in the residents weight the resident is to be reweighed. An interview with the Nursing Home Administrator (NHA) on 07/20/23 at 10:20 AM verified Resident #103 should have been reweighed when there was a 31.3-pound gain on 07/05/23 and a 37.1-pound loss on 07/17/23. b) Resident # 89 A review of Resident #89's medical records found a physician order to read, Cleanse with wound cleanser, air dry, pack wound with lightly fluffed 1/4 Dakin's-soaked gauze, cover with border gauze daily and as needed for wound care. No site of wound found. An interview with the Director of Nursing (DON) on 07/19/23 at 2:30 PM the DON confirmed the order was incomplete due to no wound site was listed. She wrote a new order immediately, which noted the wound was on the sacrum.

CONCERN (E) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Food Safety (Tag F0812)

Could have caused harm · This affected multiple residents

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. Based on observation of the lunch meal on 07/17/23 and staff interview, the facility failed to distribute and serve food in accordance with professional standards for food service safety. The trays taken to the units failed to have covering on the corn bread and brownie. Both were outside of the tray cover and open to air. Facility census: 110. Findings included: During observation of the lunch meal on 07/17/23 found the trays prepared to be distributed on the units with the corn bread and brownie uncovered and outside of the tray cover. An interview with the Certified Dietary Manager (CDM) on 07/17/23 at 1:00 PM when asked why the corn bread and brownie were sent out to the units uncovered. The CDM stated that she thought it was enough to put them in the carts. The CDM agreed the corn bread and brownie left uncovered exposed the food to contamination.

May 2023 17 deficiencies

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0551 (Tag F0551)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review and staff interview, the facility failed to provide Resident #38's Health Care Surrogate (HCS) the opportunity to participate in a conversation with the Physician Assistant to discuss treatment risks and benefits and to choose the options he would prefer. This was true for one (1) of 27 residents reviewed in the Long-Term Care Survey Process. Resident identifier: #38. Facility census: 105. Findings included: a) Resident #38 Record review, completed on [DATE] at 2:23 PM, identified the following: --Resident #38 lacked capacity to make medical decisions --A Health Care Surrogate (HCS) form was on file and designated Resident #38's son as the legal decision maker. --A Physician Orders for Scope of Treatment (POST) was on file and indicated Resident #38 was to receive CPR [Cardiopulmonary resuscitation], selective treatments, and no artificial means of nutrition. The Certified Physician Assistant had discussed the POST form with Resident's spouse and had accepted verbal consent from the spouse. During an interview with the Social Worker and Administrator, on [DATE] at 3:30 PM, both agreed deferring to Resident #38's spouse for decisions made when implementing the POST form had been in error. They also agreed the error had not afforded the Health Care Surrogate the opportunity participate in a conversation with the Physician Assistant to discuss treatment risks and benefits and to choose the options he would prefer. .

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Report Alleged Abuse (Tag F0609)

Could have caused harm · This affected 1 resident

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. Based on record reviews, and staff interviews, the facility failed to ensure allegations of serious bodily injuries were reported immediately, but not later than 2 hours after the allegations were made to the administrator of the facility and other officials (including the State Survey Agency and Adult Protective Services, in accordance with State law). The failed practice of reporting was discovered for three (3) of four (4) residents reviewed for falls with major injuries during the Long-Term Care Survey Process. Resident identifiers: #49, #59, and #38. Facility census: 105. Findings included: a) Resident #49 A medical record review on 05/10/23 for Resident #49, revealed on 01/24/23 resident had a fall, which resulted in a major injury. Resident suffered a right distal femoral fracture. The record did not indicate the serious bodily injury had been reported to any of the required State entities. An interview with the Nursing Home Administrator on 05/10/23 at 1:05 PM, confirmed they were unable to locate any Abuse and Neglect reporting made to the State Survey Agency or Adult Protective Services for the serious bodily injury for Resident #49. b) Resident #59 A medical record review on 05/10/23 for Resident #59, revealed on 01/26/23, resident had a fall, which resulted in a major injury. Resident suffered a right upper arm fracture. The medical record did not indicate the serious bodily injury had been reported to any of the required State entities. An interview with the Nursing Home Administrator on 05/10/23 at 1:05 PM, confirmed they were unable to locate any Abuse and Neglect reporting made to the State Survey Agency or Adult Protective Services for the serious bodily injury for Resident #49. c) Resident #38 A record review, completed on 05/09/23 at 5:45 PM, revealed the following details: --Resident #38 had experienced a fall on 02/28/23. --On 02/28/23 at 11:30 AM, Licensed Practical Nurse (LPN) #134 documented, Resident #38's Medical Power of Attorney (MPOA) was notified a shoulder x-ray was being ordered. --On 02/28/23 at 6:32 PM LPN #134 documented the right shoulder x-ray results were back and revealed a distal clavicle fracture. Review of the facility reportable log, completed on 05/10/23 at 9:00 AM, revealed this serious bodily injury was not reported to the appropriate state agencies within the two (2) hour window. During an interview, on 05/10/23 at 11:30 AM, the Administrator acknowledged the error in not reporting the serious bodily injury in a timely fashion. .

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0625 (Tag F0625)

Could have caused harm · This affected 1 resident

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. Based on record review and staff interview, the facility failed to provide the bed hold policy during two (2) transfers to an acute care facility. This was true for one (1) of two (2) residents reviewed under the care area of hospitalization. Resident Identifier: #94. Facility Census: 105. Findings Included: a1) Resident #94 On 05/08/23 at 1:36 PM, a record review was completed for Resident #94. The review found the resident had been transferred to an acute care facility on 04/05/23 due to nausea and vomiting with a diagnosis of aspiration pneumonia. Upon reviewing the transfer paperwork, the review found no bed hold policy had been given to the resident. On 05/09/23 at 2:19 PM, the Administrator stated we couldn't find the bed hold paperwork. No further information was obtained during the long-term care survey. a2) Resident #94 On 05/08/23 at 2:00 PM, a record review was completed for Resident #94. The review found the resident had been transferred to an acute care facility on 04/20/23 due to an elevated heart rate and low oxygen saturation with a diagnosis of aspiration pneumonia, esophageal stricture with large mass and suspected carcinoma. Upon reviewing the transfer paperwork, the review found no bed hold policy had been given to the resident. On 05/09/23 at 2:19 PM, the Administrator stated, we couldn't find the bed hold paperwork. No further information was obtained during the long-term care survey. .

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Assessment Accuracy (Tag F0641)

Could have caused harm · This affected 1 resident

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. Based on record review and staff interview, the facility failed to have an accurate Minimum Data Set (MDS) for Resident #51 regarding an active diagnoses. This was true for one (1) of 27 residents reviewed during the long-term survey process. Resident Identifier: #51. Facility Census: 105. Findings Included: a) Resident #51 On 05/08/23 at 2:06 PM, a record review was completed for Resident #51. The record review found the resident had a fall with a major injury resulting in a right femur fracture. The MDS with an assessment reference date (ARD) of 03/22/23 modification of a significant change did not list the right femur fracture as a diagnosis. On 05/10/23 at 3:00 PM, the Administrator stated, the diagnosis has been corrected on the MDS. No further information was obtained during the long-term survey process. .

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Comprehensive Care Plan (Tag F0656)

Could have caused harm · This affected 1 resident

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. Based on observation, record review and staff interview, the facility failed to implement the care plan for one (1) of 27 residents reviewed in the long-term care survey sample. Resident identifier: #102. Facility census: 105. Findings included: a) Resident #102 Review of Resident #102's comprehensive care plan showed the following focus written on 04/14/23, Has/At risk for respiratory impairment related to trach [tracheostomy], respiratory failure, pulmonary emboli, pneumonia. An intervention was added on 04/17/23 for Additional same size/type trach #6 and obturator at bedside at all times. Ambu bag, suction canister and catheters in room at all times. On 05/09/23 at 1:30 PM, Registered Nurse (RN) #22 was asked to locate the emergency equipment in Resident #102's room. RN #22 could not locate an Ambu bag in Resident #102's room. An Ambu bag is a device that provides ventilation for a resident with a tracheostomy who is not breathing or not breathing adequately. RN #22 stated there was an Ambu bag on the emergency cart, but she would obtain one specifically for Resident #102's room to comply with the resident's comprehensive care plan. .

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0657 (Tag F0657)

Could have caused harm · This affected 1 resident

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. Based on medical record review and staff interview the facility failed to revise a person-centered, comprehensive care plan, to include changes in respiratory care. This was true for one (1) of 27 residents' care plans reviewed during the Long-Term Care Survey Process. Resident identifier: #19. Facility census: 105. Findings included: a) Resident #19 A medical record review on 05/09/23 revealed orders for oxygen to be received at two (2) liters per minute (lpm) via a nasal cannula, with a start date of 12/13/22. The current care plan had not been revised and indicated Resident #19 was receiving oxygen at four (4) lpm as needed since 12/01/21. An interview with the Nursing Home Administrator (NHA) on 05/10/23 at 12:31 PM, confirmed Resident #19 was now receiving two (2) lpm of oxygen via nasal cannula and the care plan had not been revised. .

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Quality of Care (Tag F0684)

Could have caused harm · This affected 1 resident

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. Based on record review and staff interview, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice. The facility failed to ensure a physician order for pain medication was correctly followed for Resident #37. This failed practice was true for one (1) of one (1) residents reviewed for pain. Additionally, the facility to ensure a medication patch was dated and signed when applied to Resident #27. Resident identifiers: #37 and #27. Facility census: 105. Findings included: a) Resident #37 A medical record review, completed on 05/09/23 at 11:27 AM, revealed the following physician order, dated 02/28/23 at 1:00 PM, HYDROcodone-Acetaminophen Oral Tablet 5-325 MG. Give 2 tablets by mouth every 4 hours as needed for pain 5-10. Review of the March 2023, April 2023, and May 2023 Medication Administration Records (MARs) revealed the following dates and times the medication was not given in accordance with the physician's order: --03/06/23 at 5:17 PM the medication was given with a pain level of 0. --03/07/23 at 10:37 AM the medication was given with a pain level of 0. --03/12/23 at 5:10 PM the medication was given with a pain level of 0. --03/28/23 at 9:41 AM the medication was given with a pain level of 1. --04/07/23 at 4:41 PM the medication was given with a pain level of 4. --04/13/23 at 1:03 AM the medication was given with a pain level of 4. --04/18/23 at 4:18 PM the medication was given with a pain level of 4. --05/01/23 at 4:11 PM the medication was given with a pain level of 2. --05/03/23 at 6:12 AM the medication was given with a pain level of 0. --05/05/23 at 2:14 PM the medication was given with a pain level of 1. --05/06/23 at 5:45 AM the medication was given with a pain level of 3. --05/08/23 at 5:25 AM the medication was given with a pain level of 3. During an interview on 05/09/23 at 2:50 PM, the Interim Director of Nursing (DON) acknowledged nurses did not follow the physician's order correctly and had administered medications outside the parameters of the designated pain scale. b) Resident (R) #27 A random observation on 05/08/23 at 12:55 PM, revealed an unlabeled and undated white foam patch on R#27's left upper chest. At 3:22 PM on 05/08/23, the Director of Nursing (DON) reported this was a clear Clonidine patch covered with a foam dressing. The DON verified the patch should be dated and signed when applied weekly. .

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Tube Feeding (Tag F0693)

Could have caused harm · This affected 1 resident

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. Based on observation, record review, and staff interview, the facility failed to ensure eternal feeding care was provided according to professional standards of practice. This was true for one (1) of two (2) residents reviewed under the care area of tube feeding. Resident Identifier: #357. Facility Census: 105. Findings Included: a) Resident #137 Upon the initial interview on 05/08/23 at 11:50 AM, Resident #357's bottle of Glucerna was found not dated upon administration. On 05/08/23 at 11:53 AM, Registered Nurse (RN) #22 confirmed the Glucerna bottle was not dated upon administration. On 05/09/23 at 10:14 AM, the Administrator was notified and confirmed the Glucerna bottle should have been dated upon administration. No further information was obtained during the long-term survey process. .

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Respiratory Care (Tag F0695)

Could have caused harm · This affected 1 resident

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. Based on observations and staff interviews the facility failed to provide respiratory services in accordance with professional standards of practice. This was true for three (3) of four (4) residents reviewed for respiratory care services. Resident #19 and #355, did not have respiratory equipment stored properly and Resident #4's oxygen tubing was not dated. Resident identifiers #19, #355, and #4. Facility census: 105. Findings included: a) Resident #19 During an observation on 05/08/23 at 1:45 PM, it was discovered the mask for the Average Volume Assured Pressure Support (AVAPS) Trilogy machine was not bagged properly after using. Licensed Practical Nurse (LPN) #99 on 05/08/23 at 1:45PM, verified the AVAPS Trilogy mask was not stored properly. b) Resident #355 Upon the initial interview with Resident #355 on 05/08/23 at 1:18 PM, the bilevel positive airway pressure (BIPAP) mask was found laying on the night stand without being stored in a respiratory bag. On 05/08/23 at 1:20 PM, Registered Nurse (RN) #22 confirmed the BIPAP mask was not stored correctly in a respiratory bag. On 05/08/23 at 3:00 PM, the Administrator was notified and confirmed the BIPAP mask should have been stored in a respiratory bag. No further information was obtained during the long-term survey process. c) Resident (R) #4 An observation on 05/08/23 at 11:43 AM, found R#4's oxygen tubing without a date indicating it is changed weekly. On 05/08/23 at 3:10 PM, the Director of Nursing (DON) verified R#4's oxygen tubing was not dated. The DON reported the oxygen tubing is scheduled to be changed every Friday and should be marked with a piece of tape containing the date the tubing was changed. .

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Drug Regimen Review (Tag F0756)

Could have caused harm · This affected 1 resident

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. Based on record review and staff interview the physician and or designee failed to respond to a Medication Regimen Review (MRR). This was discovered for one (1) of five (5) residents reviewed for unnecessary medications during the Long-Term Care Survey Process. Resident identifier: #19. Facility census: 105. Findings included: a) Resident #19 During a medical record review on 05/10/23, it was discovered the MRR completed by the pharmacist on 11/25/22 recommended a pulse be taken before Metoprolol was to be administered. A review of the order on 05/10/23 at 10:33 AM, revealed Metoprolol Tartrate 25 milligrams (mg), give 12.5 mg two (2) times daily for hypertension, had no reference for a pulse to be taken before administering the medication. An interview with the Assistant Director of Nursing (ADON) on 05/10/23 at 10:33 AM, verified the recommendation by the pharmacist on 11/25/22, had no response from the physician and or designee. .

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0810 (Tag F0810)

Could have caused harm · This affected 1 resident

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. Based on observation, record review and staff interview, the facility must provide special eating equipment for residents who need special equipment. This deficient practice was true for one (1) of five (5) residents reviewed for the care area of nutrition. Resident identifier: #2. Facility census: 105. Findings included: a) Resident #2 Review of Resident #2's physicians' orders showed an order written on 02/22/23 for a two-handled cup with flat lid with meals. On 05/10/23 at 7:55 AM, Resident #2 was observed eating breakfast in her room. Her tray had a cup with no handles. Nursing Aide (NA) #27 confirmed Resident #2 was supposed to have a two-handled cup and went to the kitchen to get one for the resident. No further information was provided through the completion of the survey. .

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Accident Prevention (Tag F0689)

Could have caused harm · This affected multiple residents

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. Based on observation, record review and staff interview, the facility failed to ensure the resident environment over which it had control was as free from accident hazards as possible. Resident #31 had medication at her bedside. The medication was not secured and could be accessed by any wandering resident. This was a random opportunity for discovery during the care area of medication administration. Resident identifiers: #31, #51, #155, #40, and #156. Facility census: 105. Findings included: a) Medication pass On 05/09/23 at 8:00 AM, medication administration by Licensed Practical Nurse (LPN) #134 to Resident #31 was observed. Resident #31 had an order for Flonase Suspension (Fluticasone Propionate), one (1) spray in both nostrils every 12 hours as needed for congestion. LPN #134 stated Resident #31 kept the Flonase bottle at her bedside. The Flonase spray was located on the resident's bedside table. LPN #134 administered Flonase spray to the resident and returned the bottle to the top of the resident's bedside table. Upon questioning, LPN #134 stated it was the resident's preference to have Flonase kept at the bedside. LPN #134 stated the resident did not usually self-administer Flonase and preferred to have nurses administer the medication. Flonase nasal spray is used for seasonal allergies. According to the Flonase package insert, available online, Flonase should not be sprayed in the eyes and mouth. According to the National Library of Medicine product information for Flonase, available on-line, the poison control center should be contacted if Flonase was ingested orally. Review of Resident #31's physician's orders showed the resident did not have an order for medication self-administration. On 05/09/23 at 9:01 AM, the Director of Nursing was informed Resident #31 had unsecured medication at her bedside. The Director of Nursing stated she would have the medication removed. On 05/10/23 at 10:23 AM, the Clinical Operations Manager stated the resident had not had an assessment for medication self-administration done but that would be done today. The facility provided a list of residents who wandered. These residents were Residents #51, #155, #40, and #156. No further information was provided through the completion of the survey. .

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0761 (Tag F0761)

Could have caused harm · This affected multiple residents

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. Based on record review and staff interview, the facility failed to ensure medications were kept in proper temperature controls in accordance with the accepted professional standards of practice. This was a random opportunity for discovery and has the potential to affect more than an isolated number of residents. Facility Census: 105. Findings Included: a) Medication Refrigerator On 05/09/23 at 10:25 AM, a tour of the South medication room was completed. During the tour, the medication refrigerator temperature logs were found to be incomplete. The following dates did not have the refrigerator temperatures logged: --03/31/23 AM and PM -- 04/20/23 PM -- 04/21/23 AM and PM -- 04/22/23 AM and PM -- 04/23/23 AM and PM -- 04/24/23 AM and PM -- 04/25/23 AM and PM -- 04/26/23 AM and PM -- 04/27/23 PM -- 04/28/23 AM and PM -- 04/29/23 AM and PM -- 04/30/23 AM and PM -- 05/01/23 AM and PM -- 05/02/23 AM -- 05/03/23 AM -- 05/04/23 AM and PM -- 05/05/23 AM and PM -- 05/06/23 AM -- 05/07/23 AM -- 05/08/23 AM On 05/09/23 at 10:30 AM, Registered Nurse (RN) #22 confirmed the temperature logs for the South medication room refrigerator were incomplete. On 05/09/23 at 2:30 PM, the Administrator was notified and confirmed the temperature logs should be kept up-to-date. .

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Food Safety (Tag F0812)

Could have caused harm · This affected multiple residents

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. Based on observation and staff interview, the facility failed to maintain the kitchen in a safe and sanitary manner in accordance with professional standards of practice. During the kitchen tour it was discovered no temperatures were taken on the coolers or freezers, the threshold and freezer door was damaged. Water pitchers were not stored properly and the rice bin was not dated. This failed practice has the potential to affect more than an isolated number of residents. Facility census: 105. Findings included: a) Kitchen tour During the kitchen tour on 05/08/23 at 11:22 AM, it was discovered the temperatures had not been taken on 05/07/23 on any of the freezers or refrigerators. The floor of the freezer and cooler were heavily soiled and needed to be cleaned. The threshold strip and the front of the metal door to the walk-in freezer were damaged and needed to be repaired. The rice bin in the storage room was not dated and pitchers and lids were stored rim down on a soiled shelf. In an interview with the Dietary Manager on 05/08/23 at 11:25 AM, they verified the temperatures were not completed on 05/07/23. The floors of the cooler and freezer needed to be cleaned. Repairs were needed for the walk-in freezer. She also verified the rice bin had not been dated. She also noted the pitchers and lids were not stored properly. .

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Medical Records (Tag F0842)

Could have caused harm · This affected multiple residents

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. Based on record review and staff interview, the facility failed to ensure complete and accurate medical records. Physician Orders for Scope of Treatment (POST) forms were incomplete for 16 of 27 residents reviewed in the long-term care survey sample. Additionally, one of these residents also had an inaccurate medical diagnosis recorded in the medical record. Resident identifiers: #72, #2, #24, #32, #355, #357, #64, #10, #4, #59, #80, #36, #37, #93, #38, and #305. Facility census: 105. Findings included: a) 2021 POST form guidance The 2021 POST form guidance titled, Using the POST Form: Guidance for Health Care Professionals, 2021 edition, available on-line, stated the following: - Complete all sections in the demographic information section with the patient's information. - If the incapacitated patient's MPOA [medical power of attorney] representative or health care surrogate is unavailable at the time of form completion, this section can be signed by two witnesses for verbal confirmation of agreement from the patient's MPOA representative or health care surrogate. The form should be signed at the earliest available opportunity. - The health care provider completing this form (MD, DO, APRN, or PA) must print their name, sign, and date this section for the form to be legally valid. Failure to print their name or provide a license number may result in the WV e-Directive Registry being unable to verify the provider's information, thus preventing the form from being available through the Registry. Failure to provide a contact number may result in the inability to contact the provider regarding any errors in the form completion that need to be addressed. b) Staff interview On 05/09/23 at 3:08 PM, the Administrator and Social Worker #59 were interviewed by the survey team regarding POST form deficiencies that had been identified during the survey. The Administrator and Social Worker #59 confirmed the POST forms discussed in the following findings were incomplete. c) Resident #72 Review of Resident #72's Physician Orders for Scope of Treatment (POST) form showed that verbal consent was obtained from the resident's Medical Power of Attorney (MPOA) on 04/14/23. The form was completed by the Physician's Assistant. However, a second witness had not been obtained for verbal consent. Additionally, the form had not been signed by the MPOA during a subsequent visit to the facility. Also, the Physician's Assistant did not provide a phone number and license or certification number. d) Resident #2 Review of Resident #2's Physician Orders for Scope of Treatment (POST) form showed that verbal consent was obtained from the resident's Medical Power of Attorney (MPOA) on 09/07/22. The form was completed by the Physician's Assistant. However, a second witness had not been obtained for verbal consent. Additionally, the form had not subsequently been signed by the MPOA. Also, the Physician's Assistant had not provided a phone number and license or certification number. e) Resident #24 Review of Resident #24's Physician Orders for Scope of Treatment (POST) form showed that verbal consent was obtained from the resident's Health Care Surrogate (HCS) on 01/26/23 . The form was completed by the Physician's Assistant. However, a second witness had not been obtained for verbal consent. Additionally, the form had not subsequently been signed by the HCS. Also, the Physician's Assistant did not provide a phone number and license or certification number. f) Resident #32 Review of Resident #32's Physician Orders for Scope of Treatment (POST) form showed that no information other than the resident name was completed in the patient information section of the form. Verbal consent was obtained on 06/22/23. However, the form did not indicate who had given verbal consent. The form was completed by the Physician. A second witness had not been obtained for the verbal consent. Additionally, the form had not subsequently been signed by the resident representative who provided the verbal consent. Also, the Physician did not provide a phone number and license or certification number. g) Resident #355 On 05/08/23 at 1:00 PM, the POST form was reviewed for Resident #355. The review found the POST form was incomplete. The resident's signature was not dated and the back of the form did not list the resident's first and last name. h) Resident #357 On 05/08/23 at 1:05 PM, the POST form was reviewed for Resident #357. The review found the POST form was incomplete. The address, the last four (4) numbers of the social security number, section C, and section D were left blank. The resident's signature and date were missing as well. The physician's telephone number was also left blank. The back of the form did not list the resident's first and last name. i) Resident #64 On 05/08/23 at 1:12 PM, the POST form was reviewed for Resident #64. The review found the POST form was incomplete. Both Section C and Section D were blank. There was no resident signature or date on the form as well. j) Resident #10 On 05/08/23 at 1:20 PM, the POST form was reviewed for Resident #10. The review found the POST form was incomplete and only had one (1) witness signature for the verbal consent obtained from the Medical Power of Attorney (MPOA). The resident's address and last four (4) numbers of the social security number were blank. The physician's signature did not list the telephone number or license number. k) Resident (R) #4 Review of the medical record on 05/08/23 revealed R#4's POST form was incomplete, missing the following items: the last four digits of her social security number and address, a second witness for the verbal consent obtained by the physician's assistant, the phone number and license/certificate number of the physician's assistant, and a follow up confirmation signature by the resident's power of attorney. l) Resident #59 During a medical record review on 05/09/23 for Resident #59, it was discovered the Physician's Order for Scope of Treatment (POST) form had not been completed accurately. There was no second witness for the verbal consent on 02/07/23, and no signature had been obtained from the resident representative. Also the physician and or designee had not provided a phone contact. m) Resident #80 During a medical record review on 05/09/23 for Resident #80, it was discovered the POST form had not been completed accurately. There was no second witness for the verbal consent on 11/09/22, and no signature had been obtained from the resident representative. Also the physician and or designee had not provided a phone contact. n) Resident #36 During a medical record review on 05/09/23 for Resident #36, it was discovered the Physician's Order for Scope of Treatment (POST) form had not been completed accurately. The section for Medically Assisted Nutrition had been left blank and the physician and or designee had not provided a phone contact. o) Resident #37 A record review, completed on 05/08/23 at 3:22 PM, revealed there was a POST form on file for Resident #37. There was no physician contact number listed on the POST. Review of the USING THE POST FORM GUIDANCE FOR HEALTH CARE PROFESSIONALS, 2021 Edition indicates, Failure to provide a contact number may result in the inability to contact the provider regarding any errors in the form completion that need to be addressed. p) Resident #93 A record review, completed on 05/08/23 at 2:30 PM, revealed there was a POST form on file for Resident #93. There was no physician contact number listed on the POST. Review of the USING THE POST FORM GUIDANCE FOR HEALTH CARE PROFESSIONALS, 2021 Edition indicates, Failure to provide a contact number may result in the inability to contact the provider regarding any errors in the form completion that need to be addressed. q) Resident #38 A record review, completed on 05/08/23 at 2:23 PM, revealed there was a POST form on file for Resident #38. The physician assistant had accepted verbal consent but there were not two (2) witnesses. Review of the USING THE POST FORM GUIDANCE FOR HEALTH CARE PROFESSIONALS, 2021 Edition indicates, If the incapacitated patient's MPOA representative or health care surrogate is unavailable at the time of form completion, this section can be signed by two witnesses for verbal confirmation of agreement from the patient's MPOA representative or health care surrogate. r) Resident #305 A record review, completed on 05/08/23 02:33 PM, revealed there was a POST form on file for Resident #305. The physician assistant had accepted verbal consent but there were not two (2) witnesses. Review of the USING THE POST FORM GUIDANCE FOR HEALTH CARE PROFESSIONALS, 2021 Edition indicates, If the incapacitated patient's MPOA representative or health care surrogate is unavailable at the time of form completion, this section can be signed by two witnesses for verbal confirmation of agreement from the patient's MPOA representative or health care surrogate. s) Resident #38 A record review, completed on 05/09/23 at 5:45 PM, revealed the following details: --Resident #38 had experienced a fall on 02/28/23. --On 02/28/23 at 11:30 AM, LPN #134 documented, Resident #38's Medical Power of Attorney (MPOA) was notified a shoulder x-ray was being ordered. --On 02/28/23 at 6:32 PM LPN #134 documented the right shoulder x-ray results were back and revealed a distal clavicle fracture. In addition to the above information, the record also revealed two (2) medical diagnoses for Resident #38 that were dated 03/01/23: --Displaced fracture of the lateral end of the RIGHT clavicle --Displaced fracture of the lateral end of the LEFT clavicle During an interview, on 05/10/23 at 11:32 AM, the Administrator acknowledged the error in listing a LEFT clavicle fracture as a diagnosis. That was an error. .

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0847 (Tag F0847)

Could have caused harm · This affected multiple residents

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. Based on resident interview, family interview, and staff interview, the facility failed to ensure the arbitration agreement was explained to the resident and/or his representative in a form and manner that he or she could understand and decide whether or not to enter into such an agreement. This is true for two (2) of three (3) residents reviewed for the facility task of arbitration during the Long Term Care Survey Process. Resident identifiers: #98 and #205. Facility census: 105. Findings included: a) admission staff interview During an interview on 05/10/23 at 10:47 AM, the Admissions Coordinator (AC)#96 was unable to explain the arbitration agreement. AC #96 stated both parties obtain a lawyer if there is an incident. If resident needs help finding a lawyer, the facility will help. When the surveyor told her this is not the definition of an arbitration agreement, AC #96 stated I am new to this position. The above information was discussed with the Administrator at 11:00 AM on 05/10/23. The facility administrator agreed this was not the definition of arbitration. b) Resident #98 Review of the arbitration agreement on 05/10/23, revealed R#98 signed an arbitration agreement on 04/14/23 which was witnessed by AC #96. During an interview on 5/10/23 at 11:29 AM, R#98 asked the surveyor what an arbitration agreement was. After a brief explanation R#98 reported he does not remember signing an arbitration agreement and stated he does not want one. c) Resident #205 Review of the arbitration agreement on 05/10/23, revealed the arbitration agreement was signed by R#205's daughter/power of attorney (POA) on 05/07/23 and witnessed by AC #96. During a telephone interview on 05/10/23 at 11:20 AM, R#205's POA stated she signed a lot of papers on admission and was unaware an arbitration agreement was included. When informed she had signed the arbitration agreement, the POA asked for an explanation of what an arbitration agreement was. .

CONCERN (F)

Potential for Harm - no one hurt, but risky conditions existed

Infection Control (Tag F0880)

Could have caused harm · This affected most or all residents

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. The facility failed to establish and maintain an infection prevention and control program designed to help prevent the development and transmission of communicable diseases and infections. Five (5) residents eating in their rooms did not have hand hygiene when their lunch trays were served. Proper infection control practices were not followed during medication pass. Additionally, laundry was not processed and transported properly. These were random opportunities for discovery that had the potential to affect all residents residing in the building. Resident identifiers: #69, #83, #74, #48, #2, and #31. Facility census: 105. Findings included: a) Lunch tray distribution On 05/09/23 at 12:35 PM, lunch tray distribution was observed for residents eating in their rooms in the 400 hallway. Prior to the lunch tray service, the surveyor had been observing the residents and did not observe resident hand hygiene being performed. At 12:35 PM PM, Nurse Aide (NA) #200 was observed taking a lunch tray to Resident #69 who was dining in their room. Hand hygiene was not offered to Resident #69. Immediately following, NA #200 was observed taking a lunch tray to Resident #83 who was dining in the their room. Hand hygiene was not offered to Resident #83. At 12:39 PM, NA #27 was observed taking a lunch tray to Resident #74 who was dining in their room. Hand hygiene was not offered to Resident #74. Immediately following, NA #27 was observed taking a lunch tray to Resident #48 who was dining in their room. Hand hygiene was not offered to Resident #48. At 12:40 PM, Licensed Practical Nurse (LPN) #134 was observed taking a lunch tray to Resident #2 who was dining in their room. Hand hygiene was not offered to Resident #134. On 05/09/23 at 12:41 PM, LPN #134 was questioned about resident hand hygiene prior to meals. LPN #134 stated everyone must have forgot to perform resident hand hygiene. On 05/09/23 at 12:42 PM, NA #27 was questioned about resident hand hygiene prior to meals. NA #27 stated he would perform hand hygiene for the rest of the residents for meal pass. On 05/09/23 at 12:44 PM, NA #200 was questioned about resident hand hygiene prior to meals. NA #200 stated she understood hand hygiene should have been performed for residents prior to their meals. No further information was provided through the completion of the survey. b) Medication Administration On 05/09/23 at 8:00 AM, Licensed Practical Nurse (LPN) #134 was observed administering medications to Resident #31. Resident was prescribed a Lotrel capsule. LPN #134 removed the Lotrel tablet from the blister packaging and the tablet fell into the medication cart drawer. LPN #134 removed the Lotrel tablet from the drawer with her bare hands and put it in the medication cup to administer to the resident. After preparing the rest of Resident #31's medications, LPN #134 administered the medications to the resident. Following medication administration, LPN #134 was informed that infection control practices had not been maintained during medication administration when Resident #31's Lotrel tablet was dropped in the medication cart drawer and retrieved with her ungloved hand. LPN #134 stated she understood. No further information was provided prior to the completion of the survey process. c) Linen Cart On 05/08/23 at 12:43 PM, a linen cart containing clean linen was observed with no covering while being transported from the laundry area to the resident units. Laundry Aide #52 stated, I forgot .I'm so sorry .I'm new. On 05/09/23 at 10:15 AM, the Administrator was notified and confirmed the clean linen cart should be covered when transporting the clean linen. d) Laundry On 05/09/23 at 11:40 AM an observation of the laundry room, found laundry worker (LW) #47, placing soiled bed linen into the washing machine with one glove on her right hand and no gown to protect her clothes. Her left hand and front of her shirt touching the top edge of the dirty linen cart. When asked about wearing a gown and two gloves while handling soiled linen to prevent contamination of clean linen, LW#47 stated she only does that during a COVID outbreak. During an interview on 05/09/23 at 11:42 AM, the Director of Nursing (DON) confirmed staff should wear a gown and cloves when handling soiled linen. .

Feb 2022 28 deficiencies

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0558 (Tag F0558)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, staff interview and resident interview, the facility failed to ensure reasonable accommodations of needs for Resident #55 during a room change. Resident #55 was left in the hallway for an extended period of time without a call light and bed linens. This failed practice was a random opportunity for discovery. Resident identifiers: #55. Facility census: 108. Findings included: a) Resident #55 Resident #55 On 02/15/22 at 10:20 PM, Resident #55 was observed to be laying in a hospital bed, in the North side of the building at the end of the 400-hallway facing the exit door with only a hospital gown on that came down to Resident's mid-thigh. The Resident had no blanket or sheet covering him. The Resident's Foley catheter was hanging from the bottom of the bed without a dignity cover with the tubing running parallel between both legs. Resident #55 was not placed in room [ROOM NUMBER] until 11:04 PM. Licensed Practical Nurse (LPN) #4 was asked why the resident was in hallway? LPN #14 said they called and told us [facility staff] to move him because of Covid. LPN #4 was asked where are the nurse aides? LPN #4 said, They are moving people, we need more help more help around here. During an interview on 02/15/22 at 10:25 PM, Resident #55 stated he had been there [400-hallway] for a while and he wasn't sure what they were doing with him. Resident was asked if he was cold, or needed anything, and the Resident stated, Guess they [staff] are busy and will get to me sometime, you can get me a cover if you want. On 02/15/22 at 10:45 AM, Temporary Nurse Aide (TNA) #105 came down hallway 400 and stated, She [LPN #4] won't answer me, I don't even know where he [Resident #55] goes. Who brought him over here [North hall] anyway, he at least needs a sheet over him [Resident #55]. On 02/15/22 at 11:32 PM, LPN #4 was asked if the Resident #55 had access to a call light while the Resident was left out in the hallway awaiting room placement? LPN #4 stated No he did not, he could yell if he needed something. On 02/15/22 at 12:01 AM, LPN #24 verified the Resident left the South Side unit at 9:30 PM and was brought over the North Side of the building. She stated the Resident had all his meds prior to being transferred. Review of Patient #55's medical record showed a progress note dated 02/15/22 written by LPN #24 at 11:34 PM that stated, Resident transferred over to 400 hall. Resident was transferred in own bed. A/O [alert and oriented] to person, place, verbal, and able to make needs known. 400 Hall nurse notified of transfer and narcotics were transferred and verified with nightshift supervisor. .

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0577 (Tag F0577)

Could have caused harm · This affected 1 resident

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. Based on observation and staff interview, the facility failed to display the most recent State inspection survey results in a readily accessible area frequented by residents. It was discovered the State inspection survey was placed in an area not easily accessible to residents. This had the potential to affect more than a limited number of residents. Facility census: 108. Findings included: a) Accessible survey results During an observation on 02/16/22 at 10:50 AM, it was discovered the State inspection was not located in an area easily accessible to residents. An interview with the Nursing Home Administrator on 02/16/22 at 10:50 AM, verified the Survey book was not located in an area easily accessible to residents. .

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Grievances (Tag F0585)

Could have caused harm · This affected 1 resident

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. Based on record review and staff interview, the facility failed to ensure prompt efforts were made to resolve a residents grievance/concern. This was a random opportunity for discovery. Resident identifier: #86. Facility census: 108. Findings included: a) Resident #86 On 02/14/22 at 1:22 PM, the resident said nursing assistant (NA) #76 is very bossy to her. She tells me the room is too hot and she turns off my heat. She only works when, the State comes in. She wants to boss everybody including me. I have been in many disagreements with her. She talks too loud and I tell her, Don't talk so loud to me, I can hear. She said, I have told other people about her, and nothing is done although everyone agrees she's a problem. Due to her position here, she can't be fired. Review of the grievance/concern forms on 02/15/22 at 12:05 PM, found no written verification the resident had voiced any concern regarding NA #76. On 02/15/22 at 12:18 PM, the resident's concerns with NA #76 were communicated to the administrator. On 02/16/22 at 2:25 PM, the administrator said she had not talked to the resident in all the confusion. The administrator said the resident was out to dialysis. The resident goes to dialysis on Monday, Wednesday and Friday at 7:30 AM and returns around noon; therefore, the resident was at the facility all day on 02/15/22 when the concern was reported to the administrator. .

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Abuse Prevention Policies (Tag F0607)

Could have caused harm · This affected 1 resident

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. Based on record review, facility policy, and staff interview, the facility failed to implement their policy and procedure for reporting potential allegations of abuse and or neglect. This was a random opportunity for discovery. Resident identifier: #261. Facility census: 108. Finding included: a) Resident #261 Review of the facility's, Abuse Policy, found The facility ensures that any incidents of substantiated abuse are reported and analyzed and the appropriate correct, remedial or disciplinary action occurs, in accordance with applicable local, state or federal law . On 02/16/22 at 8:39 AM, while reviewing another complaint, a copy of an email was found from a Department of Health and Human Resource (DHHR) worker, emailed to the Director of Nursing (DON) at the facility on 10/05/21 at 7:31 AM, regarding Resident #261. The email is as follows: Good morning (Name of DON.) Here is the intake as received by my office. Please respond and provide any documents to discount these contentions- care plan for falls etc. Reporter states that (name of Resident #261) is in the Fairmont Nursing and Rehab. He has been there a while now and it is reported that he falls a lot. Reporter states that the family is called each time he falls and they say he has been checked out and is fine. This had happened 10 or more times recently but they have never noted him to a fall risk or anything and they are doing nothing to manage his falls. It is reported that he fell the other day again and the call was made that he was okay. Then he ended up a day or so later being sent to (name of local hospital) and then transferred to (name of another hospital) because he had a severe brain bleed and had to have a hole drilled in his skull to release the pressure. Reported states that when the administrator was called about this she laughed it off saying they were going to have to duct tape him to his chair. Reported states that a nurse there had reported that the facility is so understaffed that it is unknown how they manage to stay in business. It is also reported that (Name of Resident's) face looks like he went a round with (Name of a famous boxer.) If is also reported that the room he is in was smelling horrible and hadn't been cleaned in who knows how long. Further investigation found this incident was not reported to the proper State authorities until 10/09/21 at 3:10 PM. This was four (4) days after the facility was made aware of the allegations possible involving abuse and or neglect. The copy of the email indicated the DON responded to the workers email on 10/05/21 at 7:38 AM. The response was, Sure will (name of DHHR worker)! thanks. So we know what happened to him. Obviously the family called you but not us which is fine. Do we report this to the State?? Its not unknown, nor is it abuse??? At 7:45 AM on 10/05/21 the DHHR worker responded with, There isn't any reason to fe-report (typed as written.) We already had an intake on it. Indicating the DHHR office was already aware of the allegation and the DHHR did not need to be notified again. There was nothing to suggest other State agencies did not need to know about the incident. On 02/15/22 at 10:53 AM, the administrator said she wasn't the administrator of record at the time of the complaint. She did confirm the email was sent to the facility four days prior to reporting. The administrator confirmed the facility is required to report allegations of abuse / neglect to the proper State authorities when discovered. .

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Report Alleged Abuse (Tag F0609)

Could have caused harm · This affected 1 resident

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. Based on policy review, record review, and staff interview, the facility failed to ensure all alleged violations involving abuse and neglect were reported immediately, but not later than 2 hours after the allegation is made. This was a random opportunity for discovery. Resident identifier: #261. Facility census: 108. Findings include: a) Resident #261 Review of the facility's, Abuse Policy, found The facility ensures that any incidents of substantiated abuse are reported and analyzed and the appropriate correct, remedial or disciplinary action occurs, in accordance with applicable local, state or federal law . On 02/16/22 at 8:39 AM, while reviewing another complaint, a copy of an email was found from a Department of Health and Human Resource (DHHR) worker, sent to the Director of Nursing (DON) at the facility on 10/05/21 at 7:31 AM, regarding Resident #261. The email is as follows: Good morning (Name of DON.) Here is the intake as received by my office. Please respond and provide any documents to discount these contentions- care plan for falls etc. Reporter states that (name of Resident #261) is in the Fairmont Nursing and Rehab. He has been there a while now and it is reported that he falls a lot. Reporter states that the family is called each time he falls and they say he has been checked out and is fine. This had happened 10 or more times recently but they have never noted him to a fall risk or anything and they are doing nothing to manage his falls. It is reported that he fell the other day again and the call was made that he was okay. Then he ended up a day or so later being sent to (name of local hospital) and then transferred to (name of another hospital) because he had a severe brain bleed and had to have a hole drilled in his skull to release the pressure. Reported states that when the administrator was called about this she laughed it off saying they were going to have to duct tape him to his chair. Reported states that a nurse there had reported that the facility is so understaffed that it is unknown how they manage to stay in business. It is also reported that (Name of Resident's) face looks like he went a round with (Name of a famous boxer.) If is also reported that the room he is in was smelling horrible and hadn't been cleaned in who knows how long. Further investigation found this incident was not reported to the proper State authorities until 10/09/21 at 3:10 PM. This was four (4) days after the facility was made aware of the allegations possible involving abuse and or neglect. The copy of the email indicated the DON responded to the workers email on 10/05/21 at 7:38 AM. The response was, Sure will (name of DHHR worker)! thanks. So we know what happened to him. Obviously the family called you but not us which is fine. Do we report this to the State?? Its not unknown, nor is it abuse??? At 7:45 AM on 10/05/21 the DHHR worker responded with, There isn't any reason to fe-report (typed as written.) We already had an intake on it. Indicating the DHHR office was already aware of the allegation and the DHHR did not need to be notified again. There was nothing to suggest other State agencies did not need to know about the incident. On 02/15/22 at 10:53 AM, the administrator said she wasn't the administrator of record at the time of the complaint. She did confirm the email was sent to the facility four days prior to reporting. The administrator confirmed the facility is required to report allegations of abuse / neglect to the proper State authorities when discovered. .

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

MDS Data Transmission (Tag F0640)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review and staff interview, the facility failed to ensure the timely completion and transmittal of a discharge Minimum Data Set (MDS) Assessment. This was a random opportunity for discovery. Resident identifier: #2. Facility census: 108. Findings included: a) Resident #2 Review of Resident #2's medical record showed the resident was discharged home on [DATE]. Further review of the medical record, showed an Entry MDS assessment with Assessment Reference Date (ARD) 10/05/21, an admission MDS assessment with ARD 10/11/21, and a Five (5) Day Medicare Assessment with ARD 10/11/21. No Discharge MDS was located in the medical record. During an interview on 02/15/22 at 1:37 PM, the MDS Coordinator confirmed Resident #2 did not have a Discharge MDS completed. On 02/15/22 at 2:05 PM, the MDS Coordinator stated she completed a Discharge MDS for Resident #2 today. No further information was provided through the completion of the survey. .

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0657 (Tag F0657)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review and staff interview, the facility failed to ensure the comprehensive care plan was revised when changes occurred or additional information should have been elicited. This had the potential to affect two (2) of 26 residents reviewed in the long-term care survey process. Resident identifiers: #5, #90. Facility census: 108. Findings included: a) Resident #5 On 02/14/22 at 1:39 PM, Resident #5 was observed following staff members and visitors down the hallway, asking them to take her with them. The resident was repeatedly saying, What are we going to do? Review of Resident #5's comprehensive care plan showed the following focus, Repetitive physical movements related to cognitive impairment /dementia. The focus was initiated on 09/10/2018. An intervention initiated on 09/10/2018 was to Illicit [sic] family input for best approaches. During an interview on 02/16/22 at 11:17 AM, the Minimum Data Set (MDS) Coordinator agreed Resident #5's comprehensive care plan had not been revised since 2018 with specific interventions for the resident. No further information was provided through the completion of the survey process. b) Resident #90 Review of the medical record revealed Resident #90 was admitted on [DATE]. Resident #90's comprehensive care plan revealed the following focus initiated on 05/25/19, Episodes of anxiety related to relocation. During an interview on 02/16/22 at 8:57 AM, Resident #90 expressed no complaints related to the facility. During an interview on 02/16/22 at 9:03 AM, the Minimum Data Set (MDS) Coordinator confirmed the resident had been residing in the facility since 05/14/19 and was no longer experiencing anxiety related to relocation to the facility. She stated the care plan would be revised. No further information was provided through the completion of the survey. .

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Accident Prevention (Tag F0689)

Could have caused harm · This affected 1 resident

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. Based on observation, resident interview and staff interview the facility failed ensure the resident environment remains as free of accident hazards as is possible. Medications were left unattended on a bedside table belonging to Resident # 313. This was a random opportunity for discovery. Resident identifier: #313. Facility census 108. Findings included: a) Resident #313 On 02/14/22 at 1:57 PM, an observation revealed medications were left unattended on a bedside table belonging to Resident #313. There was a green paste like substance in a medication cup. Resident #313 said it was Icy Hot. (The manufactures guidelines for Icy Hot note: may cause harm if swallowed, call the poison control center or doctor), Two (2) bottles of eye drops for glaucoma Pilocarpine HCL Solution. (The side effects could chest pain, diarrhea, fast slow or irregular heartbeat, headache, nausea or vomiting, shortness of breath and stomach aches). Dorzolamide (Side effects: bloody nose, burning, crawling, itching, numbness, prickling.) Nasal spray- Oxymetazoline (overdose symptoms may include drowsiness, slow heartbeat, dizziness, fainting.) On 02/14/2022 at 3:15 PM, Licensed Practical Nurse (LPN) #14 verified the medications were on the bedside table in the room of Resident # 313. On 02/14/2022 at 4:10 PM, LPN #14 stated she removed the medications from the room. .

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Incontinence Care (Tag F0690)

Could have caused harm · This affected 1 resident

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. b) Resident #260 On 02/16/22 at 2:23 PM, Observation was made of Resident #260 self-propelling in a wheelchair in the 400-hallway with the Foley catheter drainage bag hanging under the seat of wheelchair dragging on the floor. The Administrator was walking by at the time of surveyor observation and confirmed the Foley catheter drainage bag was inappropriately positioned on the wheelchair in order to prevent infection control issues, and stated, Sorry about that. Based on observation, record review, and staff interview, the facility failed to ensure residents with indwelling urinary catheters receive treatment and care in accordance with professional standards of practice. This failed practice was true for two (2) out of two (2) residents reviewed for catheter care. Resident identifiers: #102 and #260. Facility census: 108. Findings included: a) Resident #102 During the initial tour on 02/14/22 at 12:26 PM, it was noted the collection Foley bag and tubing were lying on the floor under the wheelchair of Resident #102. Licensed Practical Nurse #14 came in room and adjusted the collection bag to the back of the wheelchair. In addition, the Foley collection bag did not have a privacy cover. Observation of catheter care with Nurse Aide #47 on 02/16/22 at 2:30 PM, revealed the following: NA #47 prepared a pan of water, obtained two wash cloths and one towel. NA #47 did not use the folding technique with the washcloth. NA#47 initiated peri care by wiping down the right side of the groin then initiated a downward stoke on the left side of the groin, without changing the washcloth or folding it over to a clean side. NA #47 wiped the Foley tubing without holding the base of the tubing. NA #47 used the towel and dried the groin area. NA #47 did not open the labia folds to cleanse the inner folds of the vagina, before moving on to clean the buttock. There was no anchor device in place to prevent the indwelling Foley catheter from being dislodged and/or pulled on (an anchor device is used to prevent tissue injury.) While emptying the collection bag, NA# 47 did not use a barrier and did not prevent the drainage spigot from touching the side of the urinal that was being used to collect and empty the urine. On 02/16/2022 at 3:00 PM, the Director of Clinical Operations #112 was informed about the observation of the peri care and catheter care. .

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0692 (Tag F0692)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review and staff interview, the facility failed to ensure one (1) of four (4) residents reviewed for the care area of nutrition maintained acceptable parameters of nutritional status. Facility staff incorrectly documented the percentage of food consumed for meals. Resident identifier: #692. Facility census: 108. Findings included: a) Resident #692 Observation on 02/14/22 at 1:39 PM, found the resident was in her room, up in her wheelchair with the noon meal on the bed-side table in front of her wheelchair. The residents' fork was lying on her plate with a small corner (one bite) of lasagna cut off, still on the plate. The residents' tray also contained a vegetable blend, bread, and strawberry shortcake. None of the other items on her plate had been touched. When asked, the resident said she did not want to eat and didn't want anything else because she wouldn't eat it either. I'm just not hungry. The residents' tray was picked up from her room and placed on the dirty food cart. On 02/15/22 at 12:51 PM, Nursing assistant (NA) #63, observed the resident's lunch tray which was inside the dirty food cart after being picked up from the resident's room. NA #63 confirmed the resident's tray was untouched. The resident did not eat anything on her tray. NA #63 said she did not feed the resident, she was merely taking the food cart back to the kitchen. The residents tray consisted of soup beans, coleslaw, cornbread and a vanilla pudding tart with cherry topping. After the observation of the noon meals on 02/14/22 and 02/15/22, the surveyor reviewed the documentation survey report to determine how long the resident had been refusing to eat. The resident was admitted to the facility on [DATE]. Review of the documentation survey report found a nursing assistant recorded the resident as consuming 51% to 75% of the noon meal on 02/14/22 and 51% to 75% on 02/15/22, when observation revealed the resident did not eat either meal. On 02/15/22 at 1:25 PM, the documentation survey report was reviewed with the administrator. At 12:49 PM on 02/15/22 a facility staff member had recorded the resident ate 50% to 75% of the meal. On 02/14/22 at 12:49 PM, a staff member recorded the resident consumed 50% to 75% of the noon meal. The administrator stated the facility has other reports regarding the percentages of meal consumed and she would bring those reports. At the close of the survey no further evidence was provided. .

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0698 (Tag F0698)

Could have caused harm · This affected 1 resident

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. Based on resident interview, record review, and staff interview, the facility failed to ensure one (1) of one (1) resident reviewed for the care area of dialysis was monitored for any possible complications after receiving dialysis treatments at an outpatient certified dialysis facility. Resident #86. Facility census: 108. Findings included: a) Resident #86 During an interview with the resident about dialysis care and treatments on 02/14/22 at 1:26 PM, the resident said facility staff don't always check on her after she returns from dialysis. She stated staff don't take her vital signs when she returns. She said, just like today, I came back and handed my papers to the nurse at the desk and nothing has been done yet. (Resident stated name of Licensed Practical Nurse #38) and said the nurse still hasn't taken my blood pressure, temperature or pulse and I have been back for an hour now. Record review found an order dated 10/17/21 for: Dialysis Days M-W-F (Monday, Wednesday, and Friday) at (Name of dialysis center, telephone number, and address); pickup time 7 am for chair time 740 am for dx (diagnosis) ESRD (end stage renal disease.) On 02/15/22 at 9:00 AM, the Assistant Director of Nursing (ADON) #21 observed the dialysis book with surveyor. She confirmed for the month of February dialysis communications are missing for two (2) of the five (5) days the resident went to dialysis on 02/2/22 and 02/11/22. The ADON said she was not able to find the communication sheets for January 2022. In addition, at 9:00 AM on 02/15/22, the ADON confirmed yesterdays dialysis communication form for 02/14/22 was still not completed. The communication form requires the nurse at the facility to document the residents temperature, pulse, respirations, blood pressure, access site (Bruit/Thrill present- Yes or No), dressing dry/intact (Yes or no) when the resident returns to the facility. The vital signs were still not completed. On 02/15/22 at 2:19 PM, the administrator said staff are still looking for January's communication sheets with dialysis. The dialysis book contained only one communication sheet for January-01/31/22. At the close of the survey, no further information had been provided. .

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0741 (Tag F0741)

Could have caused harm · This affected 1 resident

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. Based on observation, resident interview, staff interview and record review, the facility failed to ensure staff have the basic competencies needed to provide care to a resident with psychosocial disorders. This was true for one (1) of two (2) residents reviewed for choices. Resident identifier: #22. Facility census: 108. Findings included: a) Resident #22 On 02/14/22 at 12:27 PM, the resident was in her room crying. When asked why she was tearful, the resident said, Everything has been taken away from me. The resident was unable to state specifics, she just kept crying and saying when she came here she doesn't have any say into what happens to her. In addition, the resident said a nurse that works here said, I probably don't have long to live anyway. Record review found the resident does have a diagnosis of depression and receives Lexapro Tablet, 10 MG, an antidepressant, daily. Review of the most recent Minimum Data Set (MDS) with an assessment reference date (ARD) of 11/21/21 noted the resident scored 10 on her brief interview for mental status (BIMS). A score of 10 indicates the resident has moderately impaired cognition. Review of the residents medical record found the resident is not diagnosed with Dementia, Alzheimer's Disease, or any mental illness. Review of the resident's care plan found a focus: At risk for changes in mood related to depression. Goal: -Will maintain involvement with ADL performance and social activities -Will accept care and medication as prescribed -Will initiate social interaction with peers Interventions included: -Administer medication per physician orders -Assess for physical/environmental changes that may precipitate change in mood -Attempt psychotropic dose reduction per physician orders -Observe for mental status/mood state changes when new medication is started or with dose changes -Offer choices to enhance sense of control validate feeling of loss. (This intervention was to be carried out by nursing and social services.) A second care plan listed the focus as: At risk for adverse effects related to use of anti-depressant medication. Receives Lexapro per physicians order, revised on 06/22/21. Goals included: Will have medication dose reduction/eliminated as indicated Will show no side effects of medication use Will show improvement in mood/behavior Will show no signs of hallucinations or delusional thinking Increase patients ability to fall asleep or maintain sleep Interventions included: -Administer medications as ordered -Dose reduction attempts as appropriate -Notify physician of decline in ADL ability or mood/behavior related to a dosage change -Obtain lab results as order and notify physician of abnormal values -Provide patient education to risks and benefits of medications as needed -Psychiatrist consult and follow-up as needed -Reduce environmental noise/distractions to facilitate sleep -Report to physician signs of adverse reaction such as decline in mental status, decline in positioning/ambulation ability, lethargy, complaints of dizziness, tremors, etc. On 02/15/22, at 3:00 PM, the resident was again crying in her room. When asked why she was crying, the resident said, Don't worry about it, you can't help me anyway. On 02/15/22 at 3:32 PM, the Director of Nursing (DON) was interviewed. The residents observed behaviors was discussed. The DON was asked if the resident had ever seen a psychiatrist or psychologist? The DON said the resident had not been out for any professional services. The care plan was reviewed with the DON. The DON asked if she had any documentation to substantiate nursing staff or the social worker had offered choices to enhance sense of control, validate feelings of loss as indicated on the care plan as an intervention for the social worker and nursing staff. The DON reviewed the record and found no documentation to support the resident was offered any choices or allowed to validate feeling of loss. On 02/15/22 at 3:33 PM, nursing assistant (NA) #78 said the resident cries frequently. NA #78 said she believed the resident was just frustrated because she can't do for herself anymore. She doesn't want to leave her room, she doesn't go to activities, she won't eat in the dining room. Sometime she says to me, I am sorry you have to help me. NA #78 said when the resident says that, I tell her I get paid to help you and it's all right. On 02/16/22 at 9:07 AM, the administrator was asked asked for verification of the facility tasks listed on the care plan to offer choices to enhance sense of control validate feeling of loss. The administrator was asked, do you know why the resident is crying? What are facility staff doing when the resident is upset and crying? What choices are you offering the resident? Where is documentation staff intervened when the resident is upset? On 02/16/22 at 10:00 AM the resident was crying in her room. When asked if she needed anything she said, just don't worry about me. The residents roommate came out of the bathroom and began stating how she didn't like the resident who she said is, just nasty. At 10:09 AM on 02/16/22, the Minimum Data Set (MDS) coordinator said she was unable to find documentation of interventions offered/provided when the resident is upset. On 02/16/22 at 10:35 AM, the residents licensed practical nurse (LPN) #4 said she didn't know why the resident cries. You go in and she can't tell you what she wants. LPN #4 confirmed the resident frequently cries in her room. At 10:40 AM on 02/16/22, the assistant director of nursing (ADON) said she did not believe the resident had been out for a, psy consult. She said the resident is sometimes tearful. On 02/16/22 at 1:20 PM nursing assistants (NA) #86 and #88 working on the residents hallway were asked what they do when the resident is crying or upset. NA #88 said she was light duty and she didn't know. NA #86 said she just came off of light duty and she didn't really know anything about the resident. On 02/16/22 at 2:00 PM, the activity director (AD) #8 provided a copy of the residents activity participation record for February 2022. The record showed the resident participated in TV/Movies daily. The AD said this activity was the resident watching TV in her room, alone. Under a category entitled socializing it was noted the resident exhibited unusual behavior on 02/01/22, 02/05/22, and 02/07/22. The AD did know what unusual behavior occurred. She said the resident doesn't like to come out of her room for group activities. A one on one activity was provided on 02/01/22, 02/05/22 and 02/07/22. The AD said she would have to check with her staff to determine what the unusual behavior was. No further information was provided by the close of the survey. .

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Safe Environment (Tag F0921)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview the facility failed to provide a safe, clean environment. A broken outlet cover in a resident room with visible wiring showing and large hole in a over-the-bed table were observed . This was a random opportunity for discovery and has the potential to affect a limited number of residents that currently reside at the facility. Resident identifier: #8. Facility census: 89. Findings included: a) wall outlet On 02/14/2022 at 11:45 AM, it was observed in room [ROOM NUMBER] there was a broken outlet cover on the wall between the two beds, without any furniture in front of the outlet. The outlet had visible wires showing and was approximately 12 inches from the floor and easily accessible. This was verified with Nurse Aide #45. b) Resident #8 On 02/14/22 at 1:44 PM, observation revealed a large hole measuring approximately 5 inches by 4 inches on the right corner of the over- the- bed table. This was verified with Nurse Aide #45.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Resident Rights (Tag F0550)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . c) Resident #102 During the initial tour on 02/14/22 at 12:26 PM, Resident #102 had an indwelling Foley catheter bag hanging under her wheelchair. There was no privacy cover on the collection bag. Licensed Practical Nurse #14 witnessed this and stated she would get a nurse aide to put a privacy cover on the collection bag. Based on observation, record review, resident interview, and staff interview, the facility failed to ensure residents' dignity. The residents' indwelling urinary catheter bedside urine collection bags did not have privacy covers for Resident #260, Resident #55, and Resident #102. Additionally, Resident #55 was left in a bed in the hallway without being covered. Resident identifiers: #260, #55, #102. Facility census: 108. Findings included: a) Resident #260 During observation on 02/14/22 at 12:00 PM, Resident #260 was noted to be resting in bed. An indwelling urinary catheter bedside urine collection bag was noted to be hanging on the bedside rail. The catheter collection bag did not have a privacy cover, which allowed the urine to be viewed by anyone walking past the room. During a second observation on 02/14/22 at 4:02 PM, Resident #260's indwelling urinary catheter urine collection bag continued to be uncovered. Licensed Practical Nurse (LPN) #38 stated Resident #260 was admitted to the facility with the catheter collection bag uncovered. LPN #38 stated she would get a privacy cover for Resident #260's indwelling urinary catheter urine collection bag. On 02/16/22 at 2:23 PM, observation was made of Resident #260 self-propelling in a wheelchair in the 400-hallway. The Foley catheter drainage bag was hanging under the seat of wheelchair dragging on the floor without a catheter cover [dignity cover]. The Administrator was walking by at the time of surveyor observation and confirmed the Foley catheter drainage bag was not appropriately maintained. She stated, Sorry about that. No further information was provided through the completion of the survey process. b) Resident #55 On 02/15/22 at 10:20 PM, Resident #55 was observed to be laying in a hospital bed, in the North side of the building at the end of the 400-hallway facing the exit door with only a hospital gown on that came down to Resident's mid-thigh. The Resident had no blanket or sheet covering him. The Resident's Foley catheter was hanging from the bottom of the bed without a dignity cover with the tubing running parallel between both legs. Resident #55 was not placed in room [ROOM NUMBER] until 11:04 PM. Licensed Practical Nurse (LPN) #4 was asked why the resident was in hallway? LPN #14 said they called and told us [facility staff] to move him because of Covid. LPN #4 was asked where are the nurse aides? LPN #4 said, They are moving people, we need more help more help around here. During an interview on 02/15/22 at 10:25 PM, Resident #55 stated he had been there [400-hallway] for a while and he wasn't sure what they were doing with him. Resident was asked if he was cold, or needed anything, and the Resident stated, Guess they [staff] are busy and will get to me sometime, you can get me a cover if you want. On 02/15/22 at 10:45 AM, Temporary Nurse Aide (TNA) #105 came down hallway 400 and stated, She [LPN #4] won't answer me, I don't even know where he [Resident #55] goes. Who brought him over here [North hall] anyway, he at least needs a sheet over him [Resident #55]. On 02/15/22 at 11:32 PM, LPN #4 was asked if the Resident #55 had access to a call light while the Resident was left out in the hallway awaiting room placement? LPN #4 stated No he did not, he could yell if he needed something. On 02/15/22 at 12:01 AM, LPN #24 verified the Resident left the South Side unit at 9:30 PM and was brought over the North Side of the building. She stated the Resident had all his meds prior to being transferred. Review of Patient #55's medical record showed a progress note dated 02/15/22 written by LPN #24 at 11:34 PM that stated, Resident transferred over to 400 hall. Resident was transferred in own bed. A/O [alert and oriented] to person, place, verbal, and able to make needs known. 400 Hall nurse notified of transfer and narcotics were transferred and verified with nightshift supervisor. .

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0578 (Tag F0578)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . c) Resident #106 Review of Resident #106's paper chart [medical record] on [DATE] at 2:50 PM showed it did not contain the required Advanced Directive documentation needed to correspond with the pink sheet of paper in the front of chart that only stated DNR in bold letters, with Resident #106's full name handwritten on the paper. The pink sheet of paper was not signed by any facility personnel or by the Resident. There was no evidence to confirm the Resident had determined a code status. Further review of the resident's electronic medical record at 2:51 PM showed the Resident to be a full code. During an interview on [DATE] at 3:00 PM, the Assistant Director of Nursing (ADON) was asked what documentation staff would refer to in the event the Resident may need lifesaving interventions. The ADON stated they [staff] would probably refer to the paper chart, especially if the resident was being transferred out of the facility. The ADON further stated there should be an orange card [verification of do not resuscitate order card] in the paper chart and verified the paper chart did not contain that documentation. The only advanced directive information in the paper chart was the plain pink sheet of paper that stated DNR. During an interview on [DATE] at 3:29 PM, the Resident stated she is a full code but does not recall being asked by anyone at the facility. b) Resident #44 During a review of the medical record on [DATE] at 2:53 PM, there was an order for Resident # 44 to be a Full code. The order in the electronic chart was verified by Licensed Practical Nurse (LPN) #14 at this time. LPN #14 also verified the paper chart contained a plan piece of pink paper with the name of the resident that said, Do Not Resuscitate (DNR). Also in the chart was an orange card, completed on [DATE] by the resident and physician indicating the resident was a DNR. (A orange card is specific to this State and is for residents to designate DNR orders only.) On [DATE] at 3:00 PM, LPN #14 was asked that if Resident # 44 would happen to stop breathing, would you provide CPR or not? LPN #14 stated she would go by what the order in the chart said. LPN #14 was then shown that if that were the case, she would be going against the wishes of Resident # 44 because she had a DNR card dated [DATE]. On [DATE] at 3:09 PM, Assistant Director of Nursing (ADON) was standing at the nurse's station while the conversation with LPN #14 was occurring. The ADON stated she would correct it. Based on record review and staff interview, the facility failed to ensure three (3) of twenty-six (26) residents advance directives were communicated to staff in a clear and concise manner to allow staff to immediately determine the resident's code status in the event of an emergency. Resident identifiers: #411, #44, and #106. Facility census: 108. Findings included: a) Resident #411 On [DATE] at 3:02 PM, observation with Licensed Practical Nurse (LPN) #38, found two (2) pink sheets of paper in the front of the paper chart; one (1) which said Do not Resuscitate (DNR) and one (1) that said full code. LPN #38 confirmed there was no indication the resident or a resident representative had completed any paperwork to determine if the resident wished to formulate an advance directive or had an existing advance directive. LPN #38 said usually there is an orange card in the chart signed by the physician after discussion with the resident or responsible party. There was no information in the medical record indicating anyone had completed any paperwork regarding the residents choose for code status. Licensed Practical Nurse (LPN) #38 said if she found a resident not breathing, the first thing she would do would be to check the paper chart to determine the resident's code status. She confirmed, after looking and the conflicting code status documentation, she would have to get into the computer to check the physician's order. When ask if she had time to do that during a code, she stated, No, not really. On [DATE] at 10:12 AM, the Social Worker (SW) #36 said the resident is a full code with full interventions. When asked how she was aware of this information, she stated, I talked to her son on the phone and the son said he wanted the resident to be a full code. She stated, I haven't written a note yet about our conversation. The SW #36 said this information is obtained upon admission. (The resident was admitted to the facility on [DATE].) On [DATE] at 10:23 AM, the above issue was reviewed with the Director of Nursing. On [DATE] at 2:18 PM, the above information was discussed with the administrator. No further information was provided by the close of the survey. .

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Safe Environment (Tag F0584)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, resident interview, and staff interview, the facility failed to ensure Residents #106 and #107 had a clean, safe and well maintained bathroom. In addition, Resident #106's bed linens were not clean, and the facility did not have an adequate number of wash clothes for daily use. This failed practice was a random opportunity for discovery and had the potential to affect more than a limited number of residents. Resident identifiers: #106, #107. Facility census: 108. Findings included: a) Resident #106 During an interview on 02/14/22 at 2:22 PM, Resident #106 stated, They [facility staff] need to fix the toilet sprayer, it leaks, and the bathroom floor is always wet that's why we have the towels laying there in front of the toilet. The Resident further stated, And look here [resident pointed to bed sheet] this hasn't been changed in a week. The Resident's bottom bed sheet was visibly soiled with a dark brown dried substance. On 2/14/22 at 2:30 PM, the Assistant Director of Nursing (ADON) verified the wet towels in floor and soiled bed sheet. The ADON stated she will have maintenance look the leak as soon as possible. b) Resident #107 On 02/14/22 at 2:32 PM, observation was made of pile of dirty briefs laying in the corner on the Residents bathroom in a gray bed pan. The Resident stated the briefs have been laying there for a good long time and they [staff] take them off and just sling them over there in the corner. Resident stated the sprayer above the toilet was leaking and causes a mess in the floor and she has had to clean it up in the middle of the night when she goes to bathroom. Resident #107's roommate [Resident #106] stated the dirty briefs have been laying there since she was admitted , and she came to the facility on [DATE]. Resident #107 stated, They are also taking towels and cutting them up to have enough wash clothes. The Resident specified that the facility does not have enough wash clothes for daily use and the staff are cutting up the towels in order to have enough for the Resident's use. On 2/14/22 at 2:33 PM the Assistant Director of Nursing (ADON) verified the wet towels in floor, leaking sprayer and soiled briefs laying in the corner of Resident #107's bathroom. The ADON stated, I will have all this cleaned up immediately. c) Laundry room During a tour of the laundry room on 02/15/2022 at 11:05 AM, Housekeeping #93 was asked how many washcloths were in the building. Housekeeping #93 stated, that there was approximately 60 in the building with a possibility of 120 residents to be in the building at one time. She was not sure how long the facility has been short on washcloths, but stated, It has been awhile. On 02/15/2022 at 12:00 PM, Housekeeping Manager #11 provided an order sheet noting 220 washcloths were ordered on 01/14/2022. The delivery date is 03/31/2022. .

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Comprehensive Care Plan (Tag F0656)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . c) Resident #42 During a medical record review on 02/14/22, it was discovered the comprehensive person-centered care plan was not developed to address the potential for pain. Resident #42 had an order for Norco Tablet 7.5-325 milligrams (mg) give one tablet by mouth four times a day for pain. During an interview on 02/14/22 at 11:30 AM, the Minimum Data Set (MDS) Coordinator verified the care plan was not developed to address the potential for pain for Resident #42. Based on record review, resident review, and staff interview, the facility to develop and implement the comprehensive care plan for three (3) of 26 residents reviewed during the long-term care survey process. The facility failed to develop the comprehensive care plan in the area of anxiety and anti-anxiety medications for Resident #93 and in the area of pain for Resident #42. The facility failed to implement the care plan in the area of non-pressure wound treatments for Resident #410. Resident identifiers: #93, #410, #42. Facility census: 108. Findings included: a) Resident #93 Review of Resident #93's medical records revealed a diagnosis of anxiety disorder. The resident was receiving two (2) medications, Trazodone and Buspar, for anxiety. Review of Resident #93's comprehensive care plan did not show a focus related to anxiety and anti-anxiety medications. During an interview on 02/15/22 at 2:52 PM, Social Worker (SW) #36 confirmed the resident was not care planned for anxiety. SW #36 stated she would develop a care plan focus for the resident regarding anxiety and the use of anti-anxiety medications. No further information was provided through the completion of the survey process. b) Resident #410 On 02/14/22 at 12:39 PM, the resident said he is not getting his treatments on his butt as ordered. The resident explained he was admitted to the facility with the wound on 02/03/22. He said he is just here for therapy and treatment to his wound and then he is getting out of here. The resident explained it is very important to him to get his wound healed, so he won't end up back in the hospital. The doctor didn't order treatments 2 times a day for nothing. If this gets worse, I will be in big trouble. Record review found the resident was admitted to the facility from a local hospital on [DATE]. Review of the physicians' orders found an order for: Cleanse wound to perineum with NSS (normal saline solution.) Apply wet to dry packing. Cover with ABD, secure with paper tape. Change BID (two times a day) every day and evening shift for Perineum wound. Start Date: 02/04/2022. Review of the treatment administration record (TAR) found no treatment was provided on the evening shifts of 02/07/22, 02/08/22, and 02/09/22. On 02/15/22 at 10:28 AM, the Director of Nursing (DON) reviewed the TAR and confirmed there was no indication the treatments were provided on 02/07/22, 02/08/22, and 02/09/22. Review of the care plan found a focus: Surgical wound/site related to debridement of necrotizing fasciitis, date initiated: 02/07/22 The goal associated with the focus is: Surgical wound/site will heal without complications and Surgical wound/site will remain free of signs and symptoms of infection. Interventions included: Administer treatment per physician orders On 02/15/22 at 11:54 AM, Registered Nurse (RN) Minimum Data Set (MDS) coordinator (MDS- RN) #30 looked at treatment administration record (TAR) and care plan and said, Well I guess they didn't do the treatments. On 02/15/22 at 2:17 PM, the above situation was discussed with the administrator. No further information was provided. .

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Quality of Care (Tag F0684)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, medical record review, resident interview, and staff interview the facility failed to ensure residents received treatment and care in accordance with professional standards of practice. Resident (R) #212's antibiotic was not administered for three days. The interdisciplinary team failed to coordinate services for R #49 between the facility and contracted Hospice services and ensure Hospice visitation records were included in the medical record. Physician orders for specialized treatments and lab work were not completed for Residents #55, #410 and #90. This is true for five (5) of 26 sampled residents reviewed during the long term care survey process. Resident identifiers: #212, #49, #55, #410, and #90. Facility census: 108. Findings included: a) Resident (R) #212 During an interview on 02/14/22 at 1:45 PM, R #212 reported she did not receive her antibiotics the first three days in the facility. A review of the medical record on 02/14/22, confirmed R #212 was admitted to the facility from an acute care center on 02/01/22. The Discharge summary dated [DATE] identifies a discharge diagnosis of labial abscess with necrotizing fasciitis. The discharge summary states in the section titled Hospital Course .Continue Tigecycline (antibiotic) 50 mg (milligrams) BID (twice a day) through 2/7 . A review of the physician orders and Medication Administration Record verifies the Tigecycline was not ordered until 02/05/22. The Assistant Director of Nursing (ADON) acknowledged the facility missed the antibiotic order for R #212 and the Tigecycline was not started until 02/05/22. b) Resident (R) #49 Review of the medical record on 02/15/22, revealed Resident #49 has received Hospice services since 09/03/21. The Hospice form titled Nursing Facility Resident Designation of Responsibility states .2. Nursing services scheduled 2 times per week (facility to be notified by hospice of any change in visit schedule) .3. Home Health Aides available to provide bathing/personal care Monday-Friday. Currently scheduled 2 visits per week (facility to be notified by hospice of any schedule change . During an interview on 02/15/22 at 03:38 PM, The Assistant Director of Nursing (ADON) and Licensed Practical Nurse (LPN) #6 acknowledged R #49 is receiving Hospice services. The ADON reviewed the care plan and agreed the care plan states nurses and aides will visit twice a week, but lacks information related to the dates and times of the visits to assist with coordination of care. Both nurses reported they are unaware of when Hospice staff are scheduled to visit. In addition, the ADON reviewed the medical record and confirmed the medical record lacks documentation related to any Hospice visits by nurses or aides since the initiation of Hospice services in September 2021. c) Resident #55 Review of Resident #55's medical record on 02/17/22 at 2:30 PM, showed a progress note dated 2/14/22 written by Registered Nurse (RN) #27 that stated, Orders received to discontinue cath [Foley catheter]. During an interview on 02/17/22 at 2:30 PM, Assistant Director of Nursing (ADON) stated he [Resident #55] really didn't have the diagnosis for the Foley catheter, and it should have been taken out. The ADON verified the Resident still had the Foley catheter in place. During an interview on 02/17/22 at 2:59 PM, RN #27 stated Resident #55 went to a follow up urology appointment and was supposed to have catheter removed and they [staff] had identified it in the morning meeting. RN #27 stated, I put the note in and forgot to put the order in. Sorry, I will put the order in now to get it taken out. d) Resident #410 On 02/14/22 at 12:39 PM, the resident said he is not getting his treatments on his butt as ordered. The resident explained he was admitted with the wound on 02/03/22. He said he is just here for therapy and treatment to his wound and then he is getting out of here. The resident explained it is very important to him to get his wound healed, so he won't end up back in the hospital. The doctor didn't order treatments 2 times a day for nothing. If this gets worse, I will be in big trouble. Record review found the resident was admitted to the facility from a local hospital on [DATE]. Review of the physicians' orders found an order for: Cleanse wound to perineum with NSS (normal saline solution.) Apply wet to dry packing. Cover with ABD, secure with paper tape. Change BID (two times a day) every day and evening shift for Perineum wound. Start Date: 02/04/2022. Review of the treatment administration record (TAR) found no treatment was provided on the evening shifts of 02/07/22, 02/08/22, and 02/09/22. On 02/15/22 at 10:28 AM, the Director of Nursing (DON) reviewed the TAR and confirmed there was no indication the treatments were provided on 02/07/22, 02/08/22, and 02/09/22. On 02/15/22 at 2:17 PM, the above situation was discussed with the administrator. No further information was provided. e) Resident #90 Review of Resident #90's medical records showed an order written on 05/19/21 for uric acid laboratory testing every six (6) months in May and November. No uric acid results for November 2021 could be located in the Resident #90's medical records. During an interview on 02/16/22 at 1:34 PM, the administrator confirmed Resident #90's uric acid testing was not performed in November 2021. She stated uric acid testing would be performed now. No further information was provided through the completion of the survey. .

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0725 (Tag F0725)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on staff interview, resident interview, and observation, the facility failed to have sufficient nursing staff to ensure call lights were answered timely and room changes were completed in a timely manner. This failed practice had the potential to affect more than a limited number of residents and was a random opportunity for discovery. Resident identifiers: #107, #55, #212, #69. Facility census: 108. Findings included: a) Resident #107 During an interview on 02/14/22 at 12.25 PM Resident # 107 stated the nighttime staff has smart mouths and they have a hard time answering bells, its worse at night, especially on the weekends. The Resident stated, I help my roommate to the rest room because they won't. Then they get hateful with me and tell me to get out of bathroom and leave. b) Resident #55 On 02/15/22 at 10:20 PM, Resident #55 was observed to be laying in a hospital bed, in the North side of the building at the end of the 400-hallway facing the exit door. The hospital gown only came down to the Resident's mid-thigh. The Resident had no blanket or sheet covering him. The Resident's Foley catheter was hanging from the bottom of the bed without a dignity cover. The catheter tubing was running parallel between both legs. The Resident did not have a call light or access to call light. Resident #55 was placed in room [ROOM NUMBER] at 11:04 PM. Licensed Practical Nurse (LPN) #4 was asked why the resident was in hallway? LPN #4 said they called and told us [facility staff] to move him because of Covid. LPN #4 was asked where are all the Nurse Aides (NA) to help get the Resident moved and answer call lights? LPN #4 replied, They are moving people, we need more help more help around here. LPN #4 stated, That room needs cleaned before he can go in there. During an interview on 02/15/22 at 10:25 PM, Resident #55 stated he had been there [400-hallway] for a while and he wasn't sure what they were doing with him. Resident was asked by Surveyor if he was cold, or needed anything? The resident stated, Guess they [staff] are busy and will get to me some time, you can get me a cover if you want. On 02/15/22 at 10:45 AM, Temporary Nurse Aide (TNA) #105 came down hallway 400 and stated, She [LPN #4] won't answer me, I don't even know where he [Resident #55] goes. Who brought him over here [North Hall] anyway, he at least needs a sheet over him [Resident #55]? TNA #105 stated she didn't even know the Residents name, but he had been there since she came back from lunch break around 9:30 PM. On 02/15/22 at 11:32 PM, LPN #4 was asked if the Resident #55 had access to a call light while the Resident was left out in the hallway awaiting room placement? LPN #4 stated, No he did not, he could yell if he needed something. On 02/15/22 at 12:01 AM, LPN #24 verified the Resident left the South Side unit at 9:30 PM and was brought over the North side of the building. She stated the Resident had all his meds prior to being transferred. The Resident had been in the left in the 400-hallway unattended from 9:30 PM until 11:04 PM. Review of Patient #55's medical record showed a progress note dated 02/15/22 written by LPN #24 at 11:34 PM that stated, Resident transferred over to 400 hall. Resident was transferred in own bed. A/O [alert and oriented] to person, place, verbal, and able to make needs known. 400 Hall nurse notified of transfer and narcotics were transferred and verified with nightshift supervisor. c) Resident #212 On 02/15/22 at 10:35 PM, the call light was observed to be alarming for Resident #212. At 10:50 PM the Resident stated she needed help getting untangled from the wires and cords [wound vac device and Foley catheter.] She stated she could go to bathroom herself but was afraid of pulling something out. Resident #212 stated they must be [staff] really busy tonight. The call light for Resident #212 was answered and turned off by the 11-7 shift TNA #96 at 11:06 PM. Observation found the evening shift staff clocked out and left the building without answering the call light. No facility staff were observed in the presence of the room for the 31 minutes the call light was alarming. d) Resident #69 On 02/15/22 at 10:35 PM, the call light was going off for Resident # 69. At 10:52 PM, Resident #69 stated, They [staff] take a while but will come along eventually if not I just wet myself. I know that's not a good answer but The call light for Resident #69 was answered and turned off by the 11-7 shift TNA #96 at 11:09 PM. Observation revealed the evening shift clocked and went home without answering the call light. No facility staff were observed in the presence of the room for the 34 minutes the call light was alarming. .

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0726 (Tag F0726)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, and staff interview the facility failed to ensure staff possessed the appropriate competencies and skills sets to provide nursing and related services at a professional standard of care. Medications were not administered as scheduled. This was a random opportunity for discovery and had the potential to affect more than a limited number of staff. Resident identifiers: #76, #8, #44, and #83. Facility census 108. Findings included: a) Resident #76 Resident #76 was located behind the double zipper wall in the COVID-19 unit. A review of the facility, Medication Admin Audit Report dated 02/13/22 revealed the following medications were administrated five hours late by Licensed Practical Nurse #2. The scheduled time was for 9:00 AM and was administration time was 2:00 PM: *Risperdal, give 1 tablet two times a day for anxiety, paranoid schizophrenia. *Carvedilol, give 1 tablet two times a day for Congestive heart failure. *Eliquis, give 1 tablet two times a day for atrial flutter (an irregular heartbeat that can cause a stoke) *Diazepam, give 1 tablet two times a day for anxiety b) Resident #8 A review of the facility, Medication Admin Audit Report dated 02/13/22 revealed Resident #8 was ordered to receive Metoprolol TAR one tablet two times a day for hypertension, scheduled to be given at 8:00 AM. The medication was administered at 2:02 PM on 02/13/22 by Licensed Practical Nurse #2. c) Resident #44 A review of the facility, Medication Admin Audit Report dated 02/13/22 found the following: Resident #44 was ordered to receive Doxycycline Hyclate, give one tablet two times a day for [NAME] (abbreviation unknown) for infection of the left femur and Metoprolol Tartrate, give two times a day for hypertension. Both medications were scheduled for 8:00 AM and both were received by the resident at 1:33 PM. This was five (5) hours and 33 minutes late on 02/13/2022, by Licensed Practical Nurse #2. On 02/14/22 Resident #44 was ordered to receive Doxycycline Hyclate, give one tablet two times a day for [NAME] (abbreviation unknown) infection of the left femur and Metoprolol Tartrate, give two times a day for hypertension. The medication was scheduled for 8:00 AM and received at 10:05 AM. This was two (2) hours and five minutes late, given by Licensed Practical Nurse #14. d) Resident #83 On 02/15/2022 at 10:55 PM Licensed Practical Nurse (LPN) #4 was standing at a medication cart with a list of Residents that where to receive a medication on her laptop. Nine (9) of 16 residents on the 400 halls where in the red (to indicate late to be administrated.) LPN#4 was asked why was there are so many residents with late medications? LPN #4 said, Because I'm slow. A review of the facility, Medication Admin Audit Report dated 02/15/22 found the following: Resident #83 was scheduled to receive Humalog Solution (used to control the glucose in the blood, high levels of sugar in the blood can cause heart disease, stroke, kidney disease and vision problems) on 02/15/22 at 10:00 PM. The resident did not receive this medication until 02/16/2022 at 1:01 AM. This was three (3) hours late. This medication was given by LPN #4. A review of the facility, Medication Admin Audit Report dated 02/15/2022 found Resident #83 was scheduled to receive Carvedilol for hypertension to be given two times a day at 9:00 PM. Resident #83 received the medication at 11:53 PM, which was two hours and 53 minutes late given by LPN #4. .

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Pharmacy Services (Tag F0755)

Could have caused harm · This affected multiple residents

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. Based on observation, staff interview, and medical record review, the facility failed to provide routine and prescribed pharmaceuticals for residents during the daily medication administration and failed to maintain complete and accurate narcotic records. This was found for two (2) of five (5) residents reviewed during medication pass but has the potential to affect all residents. Resident identifiers: #39 and #95. Facility census: 108. Findings include: a) Resident (R) #39 During an observation of medication administration on 02/15/22 at 8:10 AM, Registered Nurse (RN) #27 and Licensed Practical Nurse (LPN) #6 were unable to find a multi-dose vial of Calcium Carbonate - Vitamin D 500-200 milligrams (mg) per unit to match the physician's order. LPN #6 stated the facility does not normally carry the dose ordered and RN #27 reported she would hold the medication until she could clarify the order. A follow up interview with RN #27 at 12:00 PM on 02/15/22 confirmed the physician was contacted and the order was changed to match the facility stock. A review of the medical record on 02/16/22, confirmed the medication was changed to Calcium Carbonate - Vitamin D 600-400 mg per unit and the drug was now available and given to R #39 on 02/16/22 at 9:00 AM. b) Resident (R) #95 During an observation of medication pass on 02/15/22 at 8:30 AM, RN #27 held R #95's daily Sertraline Hydrochloride (HCL) (an antidepressant) 25 mg dose because the medication card contained the incorrect dose of Sertraline HCL 50 mg. RN #27 reported the wrong available dose to the Assistant Director of Nursing (ADON) and stated she would contact the pharmacy to correct the medication punch card. RN #27 confirmed the pharmacy was contacted and the medication corrected during a follow up interview on 02/15/22 at 12:00 PM. c) Narcotic counts During an observation of shift count on 2/15/22 at 8:12 AM, between LPN #4 and RN #27, staff identified a discrepancy on the controlled medication utilization record (CMUR) for R #212's Gabapentin 800 milligrams (mg). There were 24 pills in the punch card and the CMUR form indicated the count was 25. LPN #4 acknowledged she had previously counted the narcotics at 9:00 PM on 02/14/22 and did not identify a missing pill. Staff immediately notified the ADON, who found a missing notation for 02/13/22 at 9:00 PM. The ADON immediately began educating all nursing staff on timely and accurate documentation of all controlled substances on the CMUR. .

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Food Safety (Tag F0812)

Could have caused harm · This affected multiple residents

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. Based on observation and staff interview, the facility failed to maintain the kitchen in a safe and sanitary manner in accordance with professional standards of practice. The initial kitchen tour found a dirty drip pan, food debris on the floor of the walk-in cooler and freezer, and missing floor tiles along the wall in the dish room. The flour in the flour bin was not dated after opening. These failed practices had the potential to affect a limited number of residents receiving nourishment from the kitchen. Facility census: 108. Findings included: a) Kitchen tour During a kitchen tour on 02/14/22 at 11:30 AM, it was discovered the stove drip pan was dirty and the walk-in cooler/freezer had food debris on the floors. There were missing floor tiles along the wall in the dish room and the flour in the flour bin was not dated after opening. An interview with the Dietary Manager (DM) on 02/14/22 at 11:40 AM, verified the floors of the walk-in cooler and freezer were dirty and needed to be cleaned. In addition, the DM also agreed the drip pan needed to be cleaned, the missing floor tiles did not allow for proper cleaning, and the flour in the bin was not dated after opening. .

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

QAPI Program (Tag F0867)

Could have caused harm · This affected multiple residents

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. Based on staff interview and policy review, the facility failed to ensure the Quality Assessment and Assurance (QAA) committee had a system for monitoring departmental performance data routinely in order to identify deviations in performance and adverse events. The facility failed to identify quality deficiencies of which they should been aware of, related to antibiotic stewardship. This had the potential to affect all resident who resident at the facility. Facility census: 108. Findings included: Quality Assurance and Performance Improvement Plan Review of the facility's Quality Assurance and Performance Improvement Plan found the following: Elements of the QAPI design and scope include: Clinical care - monitoring and evaluating performance and opportunities for improvement in areas such as Quality Measure performance, incidents/accidents, infection control and antibiotic stewardship, metric analysis. etc . Antibiotic Stewardship Facility Policy, Antibiotic Stewardship revision date: 12/2016. *Orientation, training and education of staff will emphasize the importance of antibiotic stewardship and will include how inappropriate use of antibiotics affects individual residents and the overall community. *Appropriate indications for use of antibiotics include: -Minimum criteria met for clinical definition of active infection or suspected sepsis -Pathogen susceptibility, based on culture and sensitivity, to antimicrobial. -The staff and practitioner will document the criteria that support the suspicion in the resident's clinical record. a) Resident #317 During an interview on 02/15/2022 at 12:02 PM, the Infection Preventionist (IP) #26 was asked to provide the line listing for the Antibiotic Stewardship. IP #26 confirmed Resident #317 received the antibiotic, Keflex on 08/07/2021 for 10 days for a diagnosis of urinary tract infection (UTI) with a catheter. No urinalysis (UA) was obtained to confirm the resident had a UTI and required an antibiotic. IP#26 said the physician did not order one. b) Resident # 38 On 08/20/2021, Resident #38 received Keflex for seven (7) days for a UTI and no UA was completed. Under the tab on the line listing asking, If ABT (antibiotic) used, is the minimum criteria met? This was marked NO, yet the antibiotic was given. c) Resident #49 On 08/25/2021 Resident #49 received Keflex for seven (7) days for an UTI and no UA was obtained. Under the tab if ABT used, minimum criteria met? This was marked NO, yet the antibiotic was given. d) Resident #314 On 08/29/2021 Resident # 314 was given Keflex for seven (7) days for a UTI with a catheter and no UA was obtained . Under the tab if ABT used, minimum criteria met? This was marked NO, yet the antibiotic was given. e) Resident # 45 On 07/19/2021 Resident #45 was given Bactrim DS for three days for a UTI, no UA was obtained to confirm the resident had a UTI and required an antibiotic. Under the tab if ABT used, minimum criteria met? This was marked NO, yet the antibiotic was given. On 10/21/2021 Resident #45 was given Bactrim for 10 days for a UTI. No UA was obtained to confirm the resident had a UTI and required an antibiotic. Under the tab if ABT used, minimum criteria met? This was marked NO, yet the antibiotic was given. f) Resident #27 On 07/20/2021 Resident #45 was given Bactrim DS for three (3) days for a UTI, no UA was obtained to confirm the resident had a UTI and required an antibiotic. Under the tab if ABT used, minimum criteria met? This was marked NO, yet the antibiotic was given. g) Resident #315 On 10/29/2021 Resident #315 was given Cipro for six (6) days for a UTI, no UA was obtained to confirm the resident had a UTI and required an antibiotic. Under the tab if ABT used, minimum criteria met? This was marked NO, yet the antibiotic was given. On 02/15/2021 at 2:00 PM, IP #26 was interviewed and asked about residents being given antibiotics for UTI's, but not having a UA obtained to confirm the resident had a UTI and required an antibiotic. In addition, without a UA how did the facility determine if the symptoms were from a UTI or another infection / illness? IP #26 stated the facility physician does not want to do urinalysis on everyone. IP #26 went on to say that he assumed the facility physician was just treating them for a UTI because they must have had symptoms or had, been off in some way. IP #26 was asked if he used any type of a tool to ensure the residents met the criteria to receive an antibiotic? IP #26 said he uses the McGeer's criteria for antibiotic surveillance. IP #26 was asked if those assessments using the McGreer's criteria could be provided. At the time of exit, IP #26 still had not provided any evidence the McGreers criteria was used. h) Interviews On 02/16/22 at 3:02 PM, the administrator confirmed the QAA committee should be reviewing infections and the use of antibiotics. The administrator said the committee was unaware antibiotics were being prescribed without laboratory confirmation of an infection. This should have been an opportunity for all of us. On 02/16/22 at 3:23 PM, the Infection Preventionist (IP) #26 said he provides a report on the number of infections residents have acquired during QAA meetings but he doesn't report on anything concerning laboratory testing. .

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Infection Control (Tag F0880)

Could have caused harm · This affected multiple residents

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. d) Resident #102 Observation on 02/14/22 at 12:26 PM, revealed Resident #102's indwelling Foley catheter collection bag was touching the floor. Licensed Practical Nurse (LPN) #14 was in room and re-adjusted the collection bag off the floor. Observation of catheter care with Nurse Aide # 47 on 02/16/22 at 2:30 PM, while emptying the collection bag found NA# 47 did not use a barrier and she did not prevent the drainage spigot from touching the side of the urinal that was being used to collect and empty the urine. Based on medical record review and staff interview, the facility failed to establish and maintain an infection prevention and control program designed to help prevent the development and transmission of communicable diseases and infections. Appropriate hand hygiene was not performed during medication administration. Additionally, proper infection control practices were not followed when emptying a urine collection bag. Resident identifiers: #102, #52, #46, #39, #95. Facility census: 108. Findings included: a) Residents #52 and #46 On 02/15/22 at 8:26 AM, medication administration by Licensed Practical Nurse (LPN) #37 was observed. LPN #37 administered medications to Resident #52. LPN #37 prepared the medications at the medication cart in the hallway and carried the medications into the resident's room for the resident to take. After leaving Resident #52's room, LPN #37 then prepared Resident #46's medications at the medication cart in the hallway and carried the medications into the resident's room for the resident to take. LPN #37 did not perform hand hygiene between medication administration for these two (2) residents. LPN #37 was instructed that hand hygiene had not performed between medication administration for Resident #52 and #46. LPN #37 had no comment regarding the matter. LPN #37 was asked if hand sanitizer was available, and a bottle of hand sanitizer was in the LPN's pocket. No further information was provided through the completion of the survey. b) Handwashing observation During observations of medication administration on 02/15/22 at 8:10 AM, Registered Nurse (RN) #27 administered medications to Resident (R) #39 and then washed her hands in the resident's bathroom for a count of four. RN #27 returned to the med cart checked off her medications using the computer mouse and then began preparing R #93's medications. After administering R #93's medications at the bedside, RN #27 returned to the medication cart, checked off the medications with the computer mouse and moved her ink pen before cleaning her hands with the hand sanitizer. RN #27 was interviewed on 02/15/22 at the end of medication administration observation. She reported the facility policy states she should wash her hands for 30 seconds or after singing the Happy Birthday song. RN #27 agreed she did not wash her hands adequately and acknowledged she should wash and or sanitize her hands immediately after leaving the bedside, prior to touching the medication cart. c) Handwashing Policy The facility Handwashing/Hand Hygiene policy revised August 2019, states under section 7 Use an alcohol based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: .b. Before and after direct contact with the residents; c. Before preparing or handling medications; . The section titled Washing Hands states under number 2. Rub hands together vigorously for at least 15 seconds, . .

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Antibiotic Stewardship (Tag F0881)

Could have caused harm · This affected multiple residents

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. Based on policy, record review, and staff interview the facility failed to implement an antibiotic stewardship program that includes antibiotic use protocols and a system to monitor antibiotic use for seven (7) of seven (7) residents reviewed. Seven (7) residents received antibiotics in absence of the appropriate screening criteria need to determine the effectiveness of antibiotic therapy. Resident identifiers: #317, #38, #49, #314, #45, #315, and #27. Facility Census 108. Findings included: Facility Policy, Antibiotic Stewardship revision date: 12/2016. *Orientation, training and education of staff will emphasize the importance of antibiotic stewardship and will include how inappropriate use of antibiotics affects individual residents and the overall community. *Appropriate indications for use of antibiotics include: -Minimum criteria met for clinical definition of active infection or suspected sepsis -Pathogen susceptibility, based on culture and sensitivity, to antimicrobial. -The staff and practitioner will document the criteria that support the suspicion in the resident's clinical record. a) Resident #317 During an interview on 02/15/2022 at 12:02 PM, the Infection Preventionist (IP) #26 was asked to provide the line listing for the Antibiotic Stewardship. IP #26 confirmed Resident #317 received the antibiotic, Keflex on 08/07/2021 for 10 days for a diagnosis of urinary tract infection (UTI) with a catheter. No urinalysis (UA) was obtained to confirm the resident had a UTI and required an antibiotic. IP#26 said the physician did not order one. b) Resident # 38 On 08/20/2021, Resident #38 received Keflex for seven (7) days for a UTI and no UA was completed. Under the tab on the line listing asking, If ABT (antibiotic) used, is the minimum criteria met? This was marked NO, yet the antibiotic was given. c) Resident #49 On 08/25/2021 Resident #49 received Keflex for seven (7) days for an UTI and no UA was obtained. Under the tab if ABT used, minimum criteria met? This was marked NO, yet the antibiotic was given. d) Resident #314 On 08/29/2021 Resident # 314 was given Keflex for seven (7) days for a UTI with a catheter and no UA was obtained . Under the tab if ABT used, minimum criteria met? This was marked NO, yet the antibiotic was given. e) Resident # 45 On 07/19/2021 Resident #45 was given Bactrim DS for three days for a UTI, no UA was obtained to confirm the resident had a UTI and required an antibiotic. Under the tab if ABT used, minimum criteria met? This was marked NO, yet the antibiotic was given. On 10/21/2021 Resident #45 was given Bactrim for 10 days for a UTI. No UA was obtained to confirm the resident had a UTI and required an antibiotic. Under the tab if ABT used, minimum criteria met? This was marked NO, yet the antibiotic was given. f) Resident #27 On 07/20/2021 Resident #45 was given Bactrim DS for three (3) days for a UTI, no UA was obtained to confirm the resident had a UTI and required an antibiotic. Under the tab if ABT used, minimum criteria met? This was marked NO, yet the antibiotic was given. g) Resident #315 On 10/29/2021 Resident #315 was given Cipro for six (6) days for a UTI, no UA was obtained to confirm the resident had a UTI and required an antibiotic. Under the tab if ABT used, minimum criteria met? This was marked NO, yet the antibiotic was given. On 02/15/2021 at 2:00 PM, IP #26 was interviewed and asked about residents being given antibiotics for UTI's, but not having a UA obtained to confirm the resident had a UTI and required an antibiotic. In addition, without a UA how did the facility determine if the symptoms were from a UTI or another infection / illness? IP #26 stated the facility physician does not want to do urinalysis on everyone. IP #26 went on to say that he assumed the facility physician was just treating them for a UTI because they must have had symptoms or had, been off in some way. IP #26 was asked if he used any type of a tool to ensure the residents met the criteria to receive an antibiotic? IP #26 said he uses the McGeer's criteria for antibiotic surveillance. IP #26 was asked if those assessments using the McGreer's criteria could be provided. At the time of exit, IP #26 still had not provided any evidence the McGreers criteria was used. .

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0882 (Tag F0882)

Could have caused harm · This affected multiple residents

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. Based on staff interview and record review the facility failed to designate an infection preventionist who has completed specialized training in infection prevention and control. This failed practice had the potential to affect more than a limited number of residents that currently reside in the facility. Facility census 108. Finding included: During an interview on 02/14/2022 at 12:05 PM, Infection Preventionist (IP) #26 stated he completed the training from the Center for Medicare and Medicaid Services (CMS) models. IP #26 was asked for proof of certification of completion. IP #26 was asked to provide the certificate of training multiple times: On 02/15/22 at 9:30 AM. On 02/15/22 at 3:22 PM. On 02/16/22 at 4:10 PM. At the conclusion of the survey IP #26 had not provided a Certificate. On 02/16/22 at 3:33 PM, the Administrator was aware IP #26 needed to provide a copy of his infection prevention certificate. .

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0883 (Tag F0883)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review and staff interview the facility failed to vaccinate eligible residents with the influenza and/or the pneumococcal vaccine(s), for five (5) of five (5) residents reviewed. This failed practice had the potential to affect more than a limited number of residents. Resident identifiers: #102, #3, #313, #8 and #24. Facility census: 108 Findings included: a) Policy Review Record review of the facility's policy titled, Influenza Vaccine, revised October of 2019, showed that between October 1st and March 31st each year, the influenza vaccine shall be offered to residents. b) Resident #102 Review of Resident #102's medical record showed it did not contain documentation to show the Resident was offered the required vaccinations for pneumonia and/or influenza. Resident #102 was admitted to the facility on [DATE]. During an interview at 11:00 AM on 02/15/2022, the Infection Preventionist (IP) was asked for the documentation regarding the pneumonia and/or influenza vaccine. On 02/15/22 at 1:53 PM, IP stated the Director of Nursing (DON) was looking into that. At the close of the survey, no documentation was provided to indicate Resident #102 was offered the opportunity to receive the influenza and pneumococcal vaccines. c) Resident # 3 Review of Resident #3's medical record showed a signed a consent on 09/30/21 indicating the choice for Pneumococcal polysaccharide vaccine 23 (PPSV23) to be given. No documentation was provided to indicate the PPSV23 was administered. No documentation was available to show the Prevnar 13 (PVR13) or influenza vaccine was offered or given. Resident #3 was admitted on [DATE]. d) Resident #313 Record review showed Resident was admitted to the facility on [DATE]. No documentation was provided by the IP to show the PPSV23 was offered or administered. e) Resident #8 Review of Resident #8's medical record showed it did not contain documentation to show the Resident received the required vaccinations for pneumonia and/or influenza. Resident #8 was admitted to the facility on [DATE]. The IP was asked if the resident was offered the PVR13 vaccine? The IP provided documentation from the Director of Nursing which stated the PVR13 was never received and the facility staff called and left a message with an unknown date. At the close of the survey, no documentation was provided to indicate Resident #102 was offered the opportunity to receive the influenza and pneumococcal vaccines. f) Resident #24 Record review showed Resident #24 was admitted on [DATE]. No documentation was provided to indicate the Resident received the influenza vaccine in 2021 or the PPSV23 vaccine. .

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0885 (Tag F0885)

Could have caused harm · This affected multiple residents

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. Based on record review and staff interview the facility failed to inform residents, their representatives, and families by 5:00 PM the next calendar day following the occurrence of each a single confirmed infection of COVID-19. This failed practice had the potential to affect more than a limited number of residents that currently reside at the facility. Facility census 108. Findings included: During an interview on 02/14/22 at 12:05 PM, the Infection Preventionist (IP) #26 when asked how the residents/responsible parties was notified about the new positive cases of COVID-19? The most recent outbreak began on 01/04/22 with the most recent positive case occurring on 02/13/22. IP #26 said the social worker handled that and he was not sure how the notification was completed. On 02/15/22 at 11:30 AM, Social Worker (SW) #36 said she calls the families to let them know if their family member test positive for COVID-19. SW #36 confirmed other residents/families were not notified of each new positive case. SW #36 said that if she talked to a family member, she would write a note about it in the chart. During an interview with Administrator on 02/16/22 at 3:33 PM, she confirmed that the facility notifies only the residents and/or families of the residents that have tested positive for COVID-19. For example, there were three (3) Staff members and three (3) residents who tested positive for COVID-19 on 02/10/22. Only the family members of the 3 residents testing positive for COVID-19 were notified. There was no other evidence of notification for all other residents/responsible parties of the new cases. .

Feb 2020 12 deficiencies

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Resident Rights (Tag F0550)

Could have caused harm · This affected 1 resident

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. Based on observation and interview, the facility failed to ensure a resident received respect and dignity regarding staff entering a resident's room without asking or receiving permission to enter. The staff's unannounced testing of the room's light switch, both startled and upset the resident. This was a random opportunity of discovery. This practice had the potential to affect more than a limited number of residents. Resident identifier: #52. Facility census 112. Findings included: a) Resident #52 Random observations during the initial interview with Resident (R#52), on 02/10/20 at 01:37 PM, revealed maintenance staff (M#16) without knocking or asking permission flipped on and off the room's light switch startling and upsetting the resident. The resident was lying in his bed, on a rainy cloudy day, with his room light off. This surveyor asked the resident at the beginning of the interview if he would like his light on, and R#52 replied he would not, the light bothered his eyes. During the interview in the semi dark room, suddenly the room light came on and went off. R#52 was startled and became extremely anxious and disturbed, and clutching at his blanket shrieked, What was that?. This Surveyor replied, I'm not sure but I will try to find out. This Surveyor went over to the door and observed a man (M#16) in the hallway and asked him if he had just been in the resident's room. The man replied, Yeah, I was just checking lights., he then turned and walked on up the hall. This surveyor went back to the resident to calm the resident down and finish the interview. It took several moments to calm the resident and reassure him that everything was okay before the interview could continue. An interview with M#16, on 02/10/20 at 02:34 PM, revealed M#16 was checking lights in different rooms. When asked why he did not knock on R#52's door and ask permission to go in or explain to the resident what he was doing. M#16 said, I was just checking lights I didn't go in the room. I stood in the hall and reached my hand in the room and flipped the light switch on and off. This surveyor explained how upset the resident had become and the room is the resident's home. This surveyor asked, If you are going to do anything in someone's home or a resident's room, do you think you might need to knock and ask permission before doing it?. M#16 agreed and replied, I will next time. On 02/13/20 at 10:00 AM, the Administrator confirmed staff are to knock before entering a resident's room and should explain what they are doing. The Administrator said her expectation is that all staff would knock and ask permission before entering a resident's room or before doing any maintenance. That staff should respect the resident. .

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0561 (Tag F0561)

Could have caused harm · This affected 1 resident

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. Based on resident interview, staff interview, and record review, the facility failed to honor Resident #65 choices regarding an aspect of his life in the facility which was significant to the resident. The resident was not afforded the opportunity to receive the frequency of showers according to his preferences and choice. This was true for 1 of 1 resident reviewed for the care area of choices. This practice had the potential to affect more than a limited number of residents. Resident identifier: #65. Facility census 112. Findings included: a) Resident #65 Initial interview with Resident (R#65), on 02/11/20 at 08:32 AM, revealed the resident wanted showers 3 times a week not 2 times a week. R#65 said he came to the facility right after Christmas after having his leg amputated below his knee and the first week, he got 3 showers but after that only 2 showers a week. When asked if he ever told anyone he wanted showers 3 times a week, R#65 replied, I sure have, several of them. I just got done again this morning raising heck with them over it. They might do it this time, I hope. Review of care plan, on 02/11/20 at 03:14 PM, reveled a Focus concerning activities of daily living (ADL). The focus read ADL Selfcare deficit related to physical limitations . The 3rd goal read Will receive assistance necessary to meet ADL needs One intervention read Assist of 1-2 with ADL's. Review of the admission minimum data set (MDS) with an assessment reference date (ARD) MDS ARD 12/31/19, on 02/11/20 at 03:24 PM, revealed the resident has clear speech, makes himself understood and understands. The resident's Brief Interview for Mental Status (BIMS) score was fifteen (15) indicating the resident is cognitively intact. When R#65 was asked How important is it to you to choose between a tub bath, shower, bed bath, or sponge bath?' R#65 responded Very Important. Coding indicated the resident was not steady and was only able to stabilize with staff assistance when moving from seated to standing position. The MDS also showed for R#65 limited assist was needed with transfers with 2-person physical assist. Resident has impairment in one lower extremities. Some diagnoses include not limited to right below the knee amputation (RBKA), Osteomyelitis, Diabetes, Obesity, Hypertension, Neuropathy, Chronic Kidney Disease Stage 3, Unsteadiness on Feet, and Other Lack of Coordination. On 02/12/20 at 03:01 PM, an interview with Assistant Director of Nursing (ADON#1) revealed she does the shower schedules and was just now changing the shower schedule for R#65. She said she had just gotten a note concerning the matter. ADON#1 said she was just notified this week when she found a note on her desk about him wanting 3 showers. ADON#1 said she is going to add Saturday to his schedule so he can have 3 showers a week. When asked were the note came from and why the resident had to wait till now, before his choice of the number of showers he wanted was honored, ADON#1 said she didn't know but was going to find out and get back to this surveyor. On 02/12/20 at 03:12 PM, ADON#1 brought this surveyor the updated shower schedule and said, We want him to be involved in his care plan. He was pleased when I told him we are adding Saturday. He said he could manage with that, and it was almost like having a shower every other day. ADON#1 said she did not know why it took so long to get him the scheduled showers he wanted. ADON#1 stated the Activity Directory (AD#19) would have done the initial admission assessment concerning showers. An interview with AD#19, on 02/12/20 at 03:59 PM, revealed she was familiar with the resident because she had worked with him in the past at another facility. AD#19 said the resident has changed since the amputation, at the other facility he would at times refuse showers. AD#19 said R#65 told her the leg amputation had changed him, and that he wants to do better and take care of himself. AD#19 said R#65 told her he wanted showers to stay clean. AD#19 said when I completed Section F of the admission MDS the resident had said showers were very important to him so that is how I coded it. When asked why the resident only was scheduled 2 showers, AD#19 said she did not know, the ADON schedules the number of showers. .

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Assessment Accuracy (Tag F0641)

Could have caused harm · This affected 1 resident

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. Based on record review and staff interview the facility failed to ensure a resident received an accurate assessment. The facility failed to accurately complete the Minimum Data Set (MDS) assessment at discharge. The failed practice affected one (1) of six (6) closed records reviewed. Resident identifier: #108. Facility census 112. Findings included: a) Resident #108 A closed record review, on 02/11/20 at 11:27 AM, revealed Resident #108 was discharged home with spouse on 12/25/19. Further record review of the MDS, on 02/11/20 at 11:30 AM, revealed Resident #108 was discharged to Acute Hospital. An interview with Assistant Coordinator (AC) #5, on 02/11/20 at 11:50 AM, confirmed Resident #108 was discharged home. AC #5 stated the MDS was marked wronged and will be modified to show correct discharge location. .

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0657 (Tag F0657)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . b) Resident #106 Review of Resident #106's medical records revealed she had been admitted to the facility on [DATE] for therapy following a femur fracture. A comprehensive care plan focus related to discharge planning was initiated on 10/14/19. The goal was Discharge to most appropriate level of care. The only intervention was Discharge to most appropriate level of care. Further assessments documented in the progress noted revealed Resident #106 had been living with her boyfriend. She had a diagnosis of liver cancer and was under hospice care at home prior to her admission to the facility. A home evaluation was conducted on 01/24/20 to verify a discharge to her home was safe and appropriate. Resident #106's discharge care planning was not revised to include this information. On 01/31/20, Resident #106 was discharged to home with her boyfriend. Hospice services were continued upon discharge. During an interview on 02/12/20, the Director of Nursing was informed Resident #106's comprehensive care plan was not updated regarding discharge planning. She had no further information regarding the matter. No further information was provided through the completion of the survey. Based on record review and interview, the facility failed to ensure Resident #103 was allowed to participate in the development of the resident's care plan, making decisions about his or her care and to ensure residents have the right to refuse treatment. Additionally, the facility failed to revise Resident #106 care plan in the area of discharge planning. Resident identifiers: #103 and #106. Facility census: 112. Findings included: a) Resident #103 Interview with Resident #103 was conducted on 02/11/20 at 10:00 am, during this interview it was conveyed the resident had concerns over her care. These concerns included she felt the staff did not listen to her concerning her allergy to tomato paste, in which she was currently experiencing a rash on her face and her lips were red and swollen. She further stated the staff says I am non-complaint with care and diet, but I know what I want. She further stated, If I live till September, I will be [AGE] years old and I have been taking care of myself for a long time. Review of Resident #103 medical records found a Physician Determination of Capacity, which stated the resident demonstrates the capacity to make medical decisions; signed and dated by the attending physician. Review of Resident #103's five (5) day, Minimum Data Set (MDS) with the Assessment Reference Date (ARD) of 01/08/20, found the resident Brief Interview Mental status (BIMS) was 14. This score indicates the resident is cognitively intact. Additional review of the residents medical records showed the resident had seen a dermatologist on 06/27/19 for a rash and swollen, red and cracked lips. She further stated, this is what tomato paste does to me, but they don't seem to believe me. Review of Resident #103's comprehensive care plan found the following: Focus/Problem: Resistive and noncompliant with treatment/care (i.e. supplements, medication orders/ fingerstick, treatment related to she believes that the treatments are not needed. Goals: Will accept medication, treatment and/or procedures, will comply with care routine/medical regimen, and will verbalize understanding of risks related to refusal/noncompliance. Interventions: If resisting care, leave and return later and provide non-care related conversation proactively before attempting activities of daily living. Interview with the Director of Nursing (DON) and Nursing Home Administrator (NHA) on 02/12/20 at 11:15 am, during this interview they were informed of the resident's concerns with her care and allergy to tomato paste. Her capacity statement and care plan was reviewed. They both confirmed the resident should be allowed to accept and refuse care and participate in her care plan. They both agreed this was not noncompliance but her right to refuse and/or accept care as she desires. .

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Accident Prevention (Tag F0689)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on resident interview, staff interview, and record review, the facility failed to ensure Resident #65's environment over which the facility had control of was as free from accident hazards as possible and had adequate supervision to prevent accidents. This was true for 1 of 5 resident reviewed for the care area of accidents. This practice had the potential to affect more than a limited number of residents. Resident identifier: #65. Facility census 112. Findings included: a) Resident #65 Initial interview with Resident (R#65), on 02/11/20 at 08:29 AM, revealed the resident had a recent right below the knee amputation (RBKA). R#65 stated he had fallen in the shower room about 2 weeks ago, when a nurse aid was trying to transfer him to the scales to be weighed. Review of records showed resident was admitted to the facility on [DATE], after having a RBK amputation on 12/21/19. R#65 fell on [DATE] and the resident's weight was recorded as 338.7 Lbs. on 01/23/20. On 02/11/20 at 02:07 PM an interview with Nurse Aid (NA#44) revealed care is provided to R#65 according to the [NAME]. NA#44 and this surveyor's review of the [NAME] revealed the [NAME] directed 1-2 assist with ADLs (activities of daily living). NA#44 was asked, How do you know when 1 NA or 2 NAs are needed to assist R#65? NA#44 replied,We ask him how he is feeling that day, then we go by how he says he is feeling. NA said, If he says he is feeling strong today and thinks he can do it, then there is only one assist. If he says he is not feeling good or says he is tired, I will get a second NA to help me. This surveyor asked NA#44 to describe how R#65 is weighed in the shower room? NA#44 replied, I wheel him in the shower room and point his wheelchair toward the scales. He stands up and pivots around so he can be weighed. This surveyor asked if R#65 could safely be weighed with the assist of 1 NA or did he need 2 NAs. NA#44 said it depends on how he is feeling. This surveyor asked when he fell on [DATE] in the shower room when you were the only one assisting him to the scales to be weighed, how did he say he was feeling? NA#44 replied, He said he was fine and could do it. Oh, I see what you are saying. Review of care plan, on 02/11/20 at 03:14 PM, revealed a Focus concerning activities of daily living (ADL). The focus read ADL Selfcare deficit related to physical limitations . The 3rd goal read Will receive assistance necessary to meet ADL needs One intervention read Assist of 1-2 with ADL's. Another focus was At risk for falls due to impaired balance/poor coordination recent BKA. A goal was to minimize risk for falls. Review of the admission minimum data set (MDS) with an assessment reference date (ARD) MDS ARD 12/31/19, on 02/11/20 at 03:24 PM, revealed the resident has clear speech, makes himself understood and understands. The resident's Brief Interview for Mental Status (BIMS) score was fifteen (15) indicating the resident is cognitively intact. The MDS also showed R#65 needs limited assist with transfers with 2-person physical assist. Moving from seated to standing position is coded Not Steady, only able to stabilize with staff assistance. Resident has impairment in one lower extremities. Some diagnoses include but are not limited to; right below the knee amputation (RBKA), Diabetes, Obesity, Hypertension, Neuropathy, Unsteadiness on Feet, and Other Lack of Coordination. An interview with Register Nurse (RN#5), on 02/13/20 at 09:08 AM, who is responsible for care plan development, revealed the MDS guides the development of the care plan. After review of R#65's admission MDS with RN#5, RN#5 confirmed the MDS documented 2-person physical assist, and that was what the assessment indicated. .

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0806 (Tag F0806)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on interview and record review, the facility failed to ensure Resident #103 received food to accommodates allergies and/or intolerance to tomato paste. Resident identifier: #103. Facility census: 112. Findings included: a) Resident #103 Interview with Resident #103 was conducted on 02/11/20 at 10:00 am, during this interview it was conveyed the resident had concerns over her care. These concerns included she felt the staff did not listen to her concerning her allergy to tomato paste, in which she was currently experiencing a rash on her face and her lips were red and swollen. She further stated the staff says I am non-complaint with care and diet, but I know what I want. She further stated, If I live till September, I will be [AGE] years old and I have been taking care of myself for a long time. Review of Resident #103 medical records found a Physician Determination of Capacity, which stated the resident demonstrates the capacity to make medical decisions; signed and dated by the attending physician. Review of Resident #103's five (5) day, Minimum Data Set (MDS) with the Assessment Reference Date (ARD) of 01/08/20, found the resident Brief Interview Mental status (BIMS) was 14. This score indicates the resident is cognitively intact. Additional review of the residents medical records showed the resident had seen a dermatologist on 06/27/19 for a rash and swollen, red and cracked lips. She further stated, this is what tomato paste does to me, but they don't seem to believe me. Interview with the Director of Nursing (DON) and Nursing Home Administrator (NHA) on 02/12/20 at 11:15 am, during this interview they were informed of the resident's concerns with her care and allergy to tomato paste. Allergies were reviewed, it was found the medical record contained the allergy to tomato paste had been added on 01/30/20. Review of Resident #103's dietary card found no food allergies listed. The card did contain dislikes which included lettuce, creamed corn, red sauce, lunch meat and white bread. They both agreed it did not list her allergy to tomato paste. They immediately corrected the allergy. .

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Garbage Disposal (Tag F0814)

Could have caused harm · This affected 1 resident

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. Based on observation and staff interview, the facility failed to dispose of garbage and refuse properly. This practice had the potential to affect more than an isolate number of residents. Facility census: 112. Findings included: a) Facility outdoor refuse containers Observation on 02/11/20 at 2:50 PM revealed the facility had two (2) large metal refuse containers behind the building. Debris was scattered on the ground beside the dumpsters, including eight (8) plastic gloves, a plastic medicine cup, and other debris that could not be identified. One dumpster had sliding doors on both sides that had not been closed, leaving the dumpster open to the environment on both sides. This dumpster contained several plastic bags of trash. During an interview on 02/11/20 at 2:55 PM, the facility administrator was informed of the situation. She declined to inspect the dumpster with this surveyor. She stated she would have the debris picked up and the doors closed on the dumpster. On on 02/11/20 at 4:30 PM, the facility administrator stated the debris had been cleaned from around the dumpsters and the doors to the dumpster had been closed. She stated staff had been educated on the matter. .

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Medical Records (Tag F0842)

Could have caused harm · This affected 1 resident

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. Based on record review and staff interview, the facility failed to ensure medical records were complete and accurate. This was true for two (2) of 26 residents reviewed in the long-term care survey sample. Resident identifiers: #11 and #77. Facility census: 112. a) Resident #50 Review of Resident #50's computerized physician orders revealed an order written on 06/06/19 for the resident to be a full code pursuant to the resident's wishes. This means the resident wished to have resuscitation performed in the event of a cardiopulmonary arrest. Each resident's notebook chart located in the rack at the nurses' desk was noted to have a pink piece of paper in the front of the chart which stated either Full Code or DNR [Do Not Resuscitate]. Review of Resident 50's chart located in the rack at the nurse's desk revealed a pink piece of paper in the front of the chart which stated, DNR or Do Not Resuscitate. During an interview on 02/11/20, the Director of Nursing (DON) was informed Resident #50 had an order for full code but the code notification page in her chart indicated she was not to be resuscitated in the event of a cardiopulmonary arrest. The DON stated she would look into the matter. On 02/11/20 at 4:15 PM, the facility administrator stated Resident #50 should have a full code notification page in her chart instead of the DNR page. She stated the physical chart of each resident in the facility was being reviewed to verify each cardiopulmonary resuscitation order matched the notification in the chart. No further information was provided through the completion of the survey. b) Resident #77 Review of Resident #77's medical records revealed an order written on 12/11/19 for Juven (a nutritional supplement) two (2) times a day for wound healing. The order did not specify the amount of Juven to be given. On 02/11/20 at 3:58 PM, the Director of Nursing was informed Resident #77's Juven order did not include the amount to be given. She had no further information regarding the matter. On 02/11/20 at 4:23 PM, the facility administrator stated Resident #77's Juven order had been revised to include the amount to be given. .

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Infection Control (Tag F0880)

Could have caused harm · This affected 1 resident

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. Based on observation and staff interview, the facility failed to establish and maintain an infection prevention and control program designed to help prevent the development and transmission of communicable diseases and infections. A barrier was not used between the resident's bedside table and the inhaler medications for one (1) of four (4) residents observed during the facility task of medication administration. Resident identifier: #54. Facility census: 112. Findings included: a) Resident #54 On 02/11/20 at 9:23 AM, medication administration to Resident #54 by Licensed Practical Nurse (LPN) #13 was observed. Resident #54 was ordered Ventolin and Incruse inhalers. LPN #13 removed the inhalers from their boxes in the medication cart and placed them on the top of the medication cart while she continued to prepare the resident's oral medications. LPN #13 entered Resident #54's room with the medications. She placed the inhalers on the resident's bedside table while she gave the resident her oral medications. LPN #13 did not use a barrier between the inhalers and the bedside table. LPN #13 then administered the inhalers. Upon leaving the resident's room, LPN #13 placed the inhalers back on top of the medication cart before returning them to their boxes in the medication cart. LPN #13 was informed she did not use a barrier between the resident's inhalers and bedside table to prevent the potential transmission of communicable organisms from the bedside table to the medication cart and to other residents. LPN #13 had no additional information regarding the matter. The facility's Director of Nursing was informed of the above findings on 02/11/20 at 8:47 AM, and no further information related to the deficient practice was provided by the end of the survey. .

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0883 (Tag F0883)

Could have caused harm · This affected 1 resident

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. Based on record review and interview, the facility failed to provide information/education regarding the benefits and risks of immunization and appropriately screen Resident #19 prior to administering the flu vaccine. This was true for one (1) of five (5) sampled residents reviewed for influenza and pneumococcal immunizations. This practice had the potential to affect more than a limited number of residents. Resident identifier: #19. Facility census 112. Findings included: a) Resident #19 Review of records on 02/11/20 at 11:35 AM revealed the Influenza Vaccination- Informed Consent/Declination form for Resident (R#19) was not filled out. The consent was signed but the screening questions were left blank. The resident consent section included: - I hereby give the facility permission to administer an influenza vaccination. To the best of my knowledge, I have not received an influenza vaccination. This was not marked but left blank. - Does resident have an allergy to eggs? Yes No This was not marked Yes or No, but left blank. - I have received education on the benefits of the vaccine (VIS). This was not marked but left blank. Review of R#19 medical records did not reveal any evidence the resident was provided education on the benefits or possible side effects, screened prior to receiving the vaccine, or any acknowledgment of permission to receive the vaccine. The facility was unable to provide any evidence concerning these issues. According to the Centers for Medicare and Medicaid Services (CMS) each resident should be informed about the benefits and risks of immunizations; and have the opportunity to receive the influenza vaccine unless medically contraindicated, refused or was already immunized. Ensure documentation in the resident's medical record of the information/education provided regarding the benefits and risks of immunization and the administration or the refusal of or medical contraindications to the vaccine(s). Screening determines if the vaccine is contraindicated for the individual resident. R#19 received the vaccine, however there is no evidence the resident was screened to determine if the vaccine was counter-indicated or gave permission or received education concerning the vaccine. .

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Comprehensive Care Plan (Tag F0656)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review and interview, the facility failed to develop and/or implement a comprehensive care plan related to nutrition, activities of daily living (ADLs) for transfer assistance required and accidents. Resident identifiers: #102, #38, #156, #66, #34, #65 and #207. Facility census: 112. Findings included: a) Resident #102 a.1.) Nutrition Review of Resident #102's medical records showed she was originally admitted to the facility on [DATE]. Review of comprehensive care plan found it was not person-specific in the care area of nutrition and her likes/dislikes and needs to prevent weight loss. The nutritional care plan which read: Nutritional focus/ problem: Weight loss. At risk for self-feeding related to (R/T) extrapyramidal symptoms (EPS). (initiated on 08/15/19 and revised 01/30/20). Goals: 1. Will consume appropriate amounts of food and fluids to maintain nutritional status. (initiated 08/15/19. Revised on 09/09/19). 2. Will not experience a significant change in weight through next review. (Initiated on 01/30/20). 3. Will tolerate diet and textures/consistency. (initiated on 01/30/20). Interventions: 1 on 1 feed all meals.( Initiated 02/06/20), Juven for wound healing (initiated on 12/31/19), Magic with all meals (initiated on 11/22/19), Med pass 2 ounces three times daily (initiated on 08/22/19), No added salt diet, mechanical soft, ground texture. thin/regular consistency (initiated on 11/27/19), Plate guard with all meals (initiated on 02/10/20), and weights as ordered (initiated on 12/31/19). Nutritional assessment/ progress notes completed by the certified dietary manager (CDM)/ Certified Food Protection Professional (CFPP) and the Registered Dietician (RD) on the following dates: --08/15/19 at 11:06 am Nutritional problem(s)/Focus- Inadequate oral intake . -- 10/23/19 at 11:27 am . Nutritional problem(s)/Focus- Inadequate oral intake, inadequate protein intake, underweight, and unintended weight loss (down 27.6 pounds/21.4% loss) -- 11/25/19 at 1:13 pm Nutritional problem(s)/Focus- Inadequate oral intake, underweight, and unintended weight loss (down 18.3 pounds/14.2% loss), and chewing difficulty Interview with the RD on 02/12/20 at 3:15 pm, found the nutritional focus/goals for Resident #102 were not accurately included in the comprehensive care plan. 1.b.) Skin Integrity: Review of the comprehensive care plan found a skin integrity care plan which read: Focus/Problem: left mastectomy. (Initiated on 10/17/19) Goal: Will decrease/minimize skin breakdown risks. (initiated on 08/23/19 and revised on 09/09/19. Intervention: No needlesticks or blood pressure in right arm. (Initiated on 01/03/20) Review of the blood pressures recorded in the electronic chart found the blood pressure was taken in the left arm on the following dates: 01/07/20, 01/08/20, 01/10/20, 01/11/20, 01/12/20 x 2, 01/16/20, 01/17/20, 01/20/20, 01/24/20, and 02/04/20. An interview was conducted with the Director of Nursing (DON) and the Nursing Home Administrator (NHA) on 02/13/20 at 10:30 AM related to the Resident # 102's care plan which was not person-centered and they confirmed the intervention for skin integrity for no blood pressures in the left arm was not implemented. No further information was provided prior to exit. b) Resident #38 Review of Resident #38's medical records found the resident was originally admitted to the facility on [DATE]. Resident was in an acute care facility from 12/08/19 through 12/11/19 for the treatment of congestive heart failure. Nutritional assessments completed: --11/08/19 at 12:38 pm - Resident is edentulous. Full code status. Has an unstageable pressure ulcer on right outer foot, three (3) venous/vascular wounds on left and right lower legs. Problem: prealbumin (protein) level low and needs extra protein for wound healing. On daily weights. -- 12/12/19 at 11:07 am- Nutritional problem/ focus: unintended weight loss. Resident 12/12/19 weight down 9 pounds or 4.8%, down 15.8 pounds or 18.1% loss since 11/07/19. Review of comprehensive care plan found it was not person-specific in the care area of nutrition and his actual weight loss. Focus/Problem: Weight loss potential. Poor appetite. Goals: 1. Will consume appropriate amounts of food and fluids to maintain nutritional status. (initiated 11/08/19. Revised on 11/21/19). Interventions: 1800 fluid restriction. (initiated 11/08/19), Foam handle on all utensils during meals (initiated 11/14/19), Kennedy cup for all meals (initiated 11/14/19), No added salt, mechanical soft, ground meats (initiated 01/10/20, Suplena 4 ounces twice daily (initiated 01/27/20, and daily weights (initiated 11/11/19). Interview with the RD on 02/12/20 at 3:15 pm, found the nutritional focus/goals for Resident #38 were not accurately included in the comprehensive care plan. An interview was conducted with the Director of Nursing (DON) and the Nursing Home Administrator (NHA) on 02/13/20 at 10:30 AM related to Resident #38s care plan was not person-centered and the care plan did not address the resident's actual weight loss. No further information was provided prior to exit. c) Resident #156 Review of Resident #156's medical records found the resident was admitted to the facility on 02/05/20. Nutritional assessments completed: --02/10/20 at 5:59 pm - Resident is obese. Diet order exceeds/meets nutritional needs. Recommend liquid protein 30 milliliters (ml) daily related to unhealed pressure ulcer on right heel. Review of comprehensive care plan found it was not person-specific in the care area of nutrition. Focus/Problem: Nutritional care plan ( initiated 02/06/20) Goals: 1. Will consume appropriate amounts of food and fluids to maintain nutritional status. (initiated 02/06/20). Interventions: No added salt, regular diet. (initiated 02/06/20). Interview with the RD on 02/12/20 at 3:15 pm, found the nutritional focus/goals for Resident #156 were not accurately included in the comprehensive care plan. An interview was conducted with the Director of Nursing (DON) and the Nursing Home Administrator (NHA) on 02/13/20 at 10:30 AM related to Resident #156s care plan. No further information was provided prior to exit. d) Resident #66 Review of Resident #66's medical records found the resident was originally admitted to the facility on 09/25/19. Was in an acute care facility from 11/17/19 through 11/22/19 (readmission). Nutritional assessments completed: -- 09/26/19 at 11:56 am - Resident is a Full code status. Has an unstageable pressure ulcer on right ankle and a pressure ulcer on sacral area. Morbid Obese. Has chewing problem due to lost upper partial lost at the hospital. No edema. Problem: Morbid obese and needs extra protein for wound healing. -- 11/25/19 at 2:57 pm- Nutritional problem/ focus: .Has an unstageable pressure ulcer on right ankle and a pressure ulcer on sacral area. Morbid Obese. Has chewing problem due to lost upper partial lost at the hospital. No edema. Problem: Morbid obese and needs extra protein for wound healing. Review of comprehensive care plan for Resident #66, found it was not person-specific in the care area of nutrition. Focus/Problem: Weight loss. (initiated 09/26/19) Goals: 1. Will consume appropriate amounts of food and fluids to maintain nutritional status. (initiated 09/26/19. Revised on 10/11/19). Interventions: Diagnostics as ordered (initiated 10/15/19), Glucerna 3 ounces (oz) twice daily (initiated 12/03/19, Night snack daily (initiated 09/26/19), Juven as ordered for wound healing (initiated on 02/04/20), Liquid protein 30 cc daily for wound healing (initiated on 10/15/19, and regular diet (initiated on 01/28/20). Interview with the RD on 02/12/20 at 3:15 pm, found the nutritional focus/goals for Resident #66 were not accurately included in the comprehensive care plan. An interview was conducted with the Director of Nursing (DON) and the Nursing Home Administrator (NHA) on 02/13/20 at 10:30 AM related to Resident #66s care plan was not person-centered. No further information was provided prior to exit. e) Resident #34 Review of Resident #34's medical records found the resident was originally admitted to the facility on 10/25/19. Was in an acute care facility from 11/26/19 through 12/06/19 (readmission). Nutritional assessments completed: -- 11/05/19 at 12:41 pm - Has an Stage 2 pressure ulcer on right buttocks. Resident weight on 10/25/19 was 286.6 pounds and on 11/05/19 271.6 pounds. 5% weight loss due to fluid removal. Paracentesis weekly. Problem: Overweight/ Obesity. -- 11/25/19 at 2:17 pm- Nutritional problem/ focus: .Overweight/ Obesity. No pressure ulcers. -- 12/06/19 at 9:30 am--- 11/05/19 at 12:41 pm - Has an Stage 2 pressure ulcer on right buttocks. Resident weight loss 15 % since admission on [DATE] due to fluid removal. Paracentesis weekly. Problem: Overweight/ Obesity. Review of comprehensive care plan for Resident #34, found it was not person-specific in the care area of nutrition. Focus/Problem: Planned weight loss due to paracentesis and diuretic use (initiated 11/05/19) Goals: 1. Will consume appropriate amounts of food and fluids to maintain nutritional status. (initiated 11/05/19. Revised on 11/20/19). Interventions: Controlled carbohydrate diet no nuts or skin of seeds (initiated 11/05/19), Glucerna 3 ounces (oz) twice daily (initiated 1/28/20, and Ensure clear 120 cc daily (initiated on 01/28/20. Interview with the RD on 02/12/20 at 3:15 pm, found the nutritional focus/goals for Resident #34's were not accurately included in the comprehensive care plan. An interview was conducted with the Director of Nursing (DON) and the Nursing Home Administrator (NHA) on 02/13/20 at 10:30 AM related to Resident #34s care plan was not person-centered. No further information was provided prior to exit. f) Resident (R#65) The facility failed to develop a care plan addressing the number of Nurse Aides needed to safely provide ADL (activities of daily living) care, particularly with transfers for R#65. During the initial interview with the resident, on 02/11/20 at 08:29 AM, revealed the resident had a recent right below the knee amputation (RBKA). R#65 stated he had fallen in the shower room about 2 weeks ago, when a nurse aid was trying to transfer him to the scales to be weighed by herself. Review of records showed resident was admitted to the facility on [DATE], after having an amputation RBK on 12/21/19. On 01/23/20 the resident recorded weighed was 338.7 Lbs. (pounds). On 02/11/20 at 02:07 PM an interview with Nurse Aid (NA#44), revealed care is provided to R#65 according to the [NAME]. NA#44 was with the resident when he fell while trying to transfer to the scales to be weighed. Review of the [NAME] with NA#44 revealed the [NAME] directed care as Assist of 1-2 with ADLs (activities of daily living). This surveyor asked NA#44, How do you know when 1 NA or 2 NAs are needed to assist R#65? NA#44 replied,We ask him how he is feeling that day, then we go by how he says he is feeling. NA said, If he says he is feeling strong today and thinks he can do it, then there is only one assist. If he says he is not feeling good or says he is tired, I will get a second NA to help me. This surveyor asked NA#44 to describe how R#65 is weighed in the shower room? NA#44 replied, I wheel him in the shower room and point his wheelchair toward the scales. He stands up and pivots around so he can be weighed. This surveyor asked if R#65 could safely be weighed with the assist of 1 or did he need 2. NA#44 said it depends on how he is feeling. This surveyor asked when he fell on [DATE] in the shower room when you were the only one assisting him to the scales to be weighed, how did he say he was feeling? NA#44 replied, He said he was fine and could do it. Oh, I see what you are saying Review of care plan, on 02/11/20 at 03:14 PM, revealed a Focus concerning activities of daily living (ADL). The focus read ADL Selfcare deficit related to physical limitations . The 3rd goal read Will receive assistance necessary to meet ADL needs One intervention read Assist of 1-2 with ADL's. Another focus was At risk for falls due to impaired balance/poor coordination recent BKA. A goal was to minimize risk for falls. Review of the admission minimum data set (MDS) with an assessment reference date (ARD) MDS ARD 12/31/19, on 02/11/20 at 03:24 PM, revealed the resident needs limited assist with transfers with 2-person physical assist. Moving from seated to standing position is coded Not Steady, only able to stabilize with staff assistance. Resident has impairment in one lower extremities. Some diagnoses include but are not limited to; right below the knee amputation (RBKA), Diabetes, Obesity, Hypertension, Neuropathy, Unsteadiness on Feet, and Other Lack of Coordination. An interview with Register Nurse (RN#5), on 02/13/20 at 09:08 AM, who is responsible for care plan development, revealed the MDS guides the development of the care plan. After review of R#65's admission MDS with RN#5, RN#5 confirmed the MDS documented 2-person physical assist, and the care plan should have reflected 2 NA not 1-2 NA. g) Resident (R#207) Review of records, on 02/13/20 at 10:23 AM, revealed resident has a history of falls. Review of the quarterly minimum data set (MDS) with an assessment reference date (ARD) 11/30/19 revealed the resident has clear speech, makes herself understood and understands. The resident's Brief Interview for Mental Status (BIMS) score was three (3) indicating cognitively the resident is severely impaired. Some diagnoses include but are not limited to; Alzheimer's, Dementia, Congestive Heart Failure ., Also noted was resident had two or more falls since admission or prior assessment. On 02/13/20 at 08:14 AM review of care plan revealed a focus area regarding 'at risk for falls'. One of the interventions simple said neuro-checks. There was no other guidance or direction given to nursing as to when neuro-checks should be done, how often neuro-checks should be done, or for how long. An interview with Register Nurse (RN#5), on 02/13/20 at 09:08 AM, who is responsible for care plan development, confirmed the care plan should have been developed with more instruction in the care plan intervention concerning neuro-checks. RN#5 said instructions on how to do neuro-checks when a resident has an unwitnessed fall or fall with a head injury are written on the neuro-check flow sheet and the instructions are per facility policy. RN#5 agreed when the care plan was developed the instructions should have been included in the intervention or at least a reference as per neuro-check flow sheet instructions or per facility policy. .

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Quality of Care (Tag F0684)

Could have caused harm · This affected multiple residents

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. f) Resident #95 Review of Resident #95's medical records revealed the following progress note written on 10/3/2019 at 11:39 AM, Resident had a seizure which caused her to slide out of her chair, resulting in an abrasion to her mid back. Abrasion is superficial, measuring 7cm x 2cm. Area cleansed w/NSS [with normal saline solution] and left open to air. At the time of the seizure res [resident] was sitting in bedside chair, overhead light was on, res was wearing gripper socks, the floor was dry and the call bell was within the res' reach. [Physician's name} consulted, added Keppra to res' medications. RN [registered nurse], spouse [spouse's name] informed. A fall incident report documented the fall as occurring on 10/03/19 at 7:40 AM. A neurological check flowsheet recorded vital signs, level of consciousness, and motor function for 10/03/19 at 7:40 AM. On 10/3/2019 at 3:40 PM, a post-event note was documented. The note documented vital signs from 07/03/19. Post-event notes were also documented on 10/03/19 at 11:40 PM, 10/4/19 at 7:40 AM, 10/04/19 at 3:40 PM, 10/04/19 at 11:40 PM, 10/5/19 at 7:40 AM, 10/05/19 at 3:40 PM, 10/05/19 at 11:40 PM, and 10/06/19 at 7:40 AM. These notes also documented vital signs from 07/03/19. The neurological check flowsheet continued to record vital signs, level of consciousness, and motor function on 10/03/19 at 7:55 AM, 10/03/19 at 8:10 AM, 10/03/19 at 8:25 AM, 10/3/19 at 9:25, 10/03/19 at 10:25 AM, 10/03/19 at 2:25 PM, 10/03/19 at 6:25 PM, 10/03/19 at 10:30 PM, and 10/04/19 at 2:30 AM. During an interview on 02/12/20 at 4:11 PM, the facility administrator confirmed Resident #106's post-event notes dated 10/03/19 through 10/05/19 recorded vital signs from 07/03/19. Vital signs were documented on the neurological check flowsheet through 10/04/19 at 2:30 AM. However, current vital signs were not recorded after that time. The facility administrator stated she believed vital signs were assessed at the time of the post-event notes but were not recorded because the nurses did not click the button to indicate new vital signs. The administrator stated she would provide education to staff regarding this matter. No further information was provided through the completion of the survey. Based on medical record review and staff interview, the facility failed to ensure each resident receives quality of care for all treatment and care provided based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices. Resident identifiers: #102, #101 and #95. Facility Census: 112. Findings included: a) Resident #102 Medical record review for Resident #102, found an order for Acetaminophen (Tylenol) 325 milligrams (mg); give two (2) tablets to equal 650 mg every four (4) hours as needed (prn) for pain level of 1-5 and Tramadol 50 mg every eight (8) hours prn for pain level 6-10, effective 08/14/19. Review of the Medication Administration Record (MAR) for November, December 2019 and January and February 2020 found; --11/01/19 at 4:57 pm.- Tramadol was given for pain level of 4. --11/07/19 at 11:22 am- Tramadol was given for pain level of 3. --12/06/19 at 5:14 pm- Tylenol was given for pain level of 8. --12/12/19 at 4:16 pm- Tylenol was given for pain level of 8. --12/17/19 at 1:12 pm- Tylenol was given for pain level of 6. --12/24/19 at 4:53 pm- Tylenol was given for pain level of 8. --12/26/19 at 4:35 pm- Tylenol was given for pain level of 8. --01/01/20 at 6:26 pm- Tylenol was given for pain level of 7. --01/14/20 at 5:59 pm- Tylenol was given for pain level of 7. --01/19/20 at 5:52 pm- Tylenol was given for pain level of 6. --01/22/20 at 6:08 pm- Tylenol was given for pain level of 9. --01/23/20 at 5:40 pm- Tylenol was given for pain level of 8. --01/27/20 at 1:10 am- Tylenol was given for pain level of 6. --01/28/20 at 5:20 pm- Tylenol was given for pain level of 8. Additionally, an order for no blood pressure or needlesticks in the left arm due to history of a left mastectomy, effective 08/14/19. Review of the blood pressures in the computerized records for Resident #102, found on the following days the blood pressure was taken in the left arm: 08/15/19, 08/16/19, 08/20/19, 08/21/19, 08/23/19, 08/24/19, 08/25/19, 08/26/19, 08/27/19, 09/13/19, 10/04/19, 10/05/19, 10/06/19, 10/19/19, 10/20/19, 10/23/19, 10/25/19, 11/05/19, 11/06/19, 11/08/19, 11/11/19, 11/12/19, 11/21/19, 11/25/19, 11/26/19, 11/27/19, 11/30/19, 12/01/19, 12/02/19, 12/04/19, 12/06/19, 12/09/19, 12/10/19, 12/13/19, 12/15/19, 12/16/19, 12/29/19, 01/01/20, 01/02/20, 01/07/20, 01/08/20, 01/10/20, 01/11/20, 01/12/19, 01/16/20, 01/17/20, 01/20/20, 01/24/19, and 02/04/20. Interview with the Director of Nursing (DON) and the Nursing Home Administrator (NHA) on 02/13/20 at 10:00 am, found after review of Resident #102 medical records that the physician orders for Tramadol, Tylenol and no blood pressures in the left arm were not followed as per the physician orders. No further information provided. b) Resident # 101 Review of Resident #101's medical records found the resident experienced a fall on 01/04/20 at 7:15 am. The incident report read: Resident found lying on the floor beside her bed on her back, gripper socks on feet. Range of motion (ROM) adequate, complains of right knee pain . Resident's description of the fall was she stood up to go to bathroom and clean herself up. Her knees gave out and she fell to the floor. She said, she hit her head on the floor. Neurological checks initiated. Review of the neurological checks found the motor functions of extremities were blank for the checks done on 01/04/20 at 7:15 am, 7:30 am, 7:45 am, 8:00 am, 9:00 am, 10:00 am and 2:00 pm then resident was transferred to the hospital for treatment of a displaced fracture of lower epiphysis (separation) of the right femur. An interview was conducted with the Director of Nursing (DON) and the Nursing Home Administrator (NHA) on 02/12/20 at 2:30 PM related to the Resident # 101's fall on 01/04/20 and her neurological checks. They confirmed the neurological checks were incomplete. No further information was provided prior to exit. .

Understanding Severity Codes (click to expand)

Life-Threatening (Immediate Jeopardy)

J - Isolated K - Pattern L - Widespread

Actual Harm

G - Isolated H - Pattern I - Widespread

Potential for Harm

D - Isolated E - Pattern F - Widespread

No Harm (Minor)

A - Isolated B - Pattern C - Widespread

Questions to Ask on Your Visit

"What changes have you made since the serious inspection findings?"
"What safeguards are in place to prevent abuse and neglect?"
"Can I speak with families of current residents?"
"What's your RN coverage like on weekends and overnight?"

Our Honest Assessment

Strengths

• No fines on record. Clean compliance history, better than most West Virginia facilities.

Concerns

• Multiple safety concerns identified: Federal abuse finding, 2 life-threatening violation(s). Review inspection reports carefully.
• 70 deficiencies on record, including 2 critical (life-threatening) violations. These warrant careful review before choosing this facility.
• Grade F (1/100). Below average facility with significant concerns.

Bottom line: This facility has a substantiated abuse finding. Extreme caution advised. Explore alternatives.

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About This Facility

What is Fairmont Rehabilitation And Healthcare Center Llc's CMS Rating?

CMS assigns FAIRMONT REHABILITATION AND HEALTHCARE CENTER LLC an overall rating of 1 out of 5 stars, which is considered much below average nationally. Within West Virginia, this rating places the facility higher than 0% of the state's 100 nursing homes. A rating at this level reflects concerns identified through health inspections, staffing assessments, or quality measures that families should carefully consider.

How is Fairmont Rehabilitation And Healthcare Center Llc Staffed?

CMS rates FAIRMONT REHABILITATION AND HEALTHCARE CENTER LLC's staffing level at 1 out of 5 stars, which is much below average compared to other nursing homes. Staff turnover is 50%, compared to the West Virginia average of 46%. RN turnover specifically is 69%, which is notably high. RNs provide skilled clinical oversight, so turnover in this role can affect medical care quality.

What Have Inspectors Found at Fairmont Rehabilitation And Healthcare Center Llc?

State health inspectors documented 70 deficiencies at FAIRMONT REHABILITATION AND HEALTHCARE CENTER LLC during 2020 to 2025. These included: 2 Immediate Jeopardy (the most serious level, indicating potential for serious harm or death) and 68 with potential for harm. Immediate Jeopardy findings are rare and represent the most serious regulatory concerns. They require immediate corrective action.

Who Owns and Operates Fairmont Rehabilitation And Healthcare Center Llc?

FAIRMONT REHABILITATION AND HEALTHCARE CENTER LLC is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility is operated by GUARDIAN ELDER CARE, a chain that manages multiple nursing homes. With 120 certified beds and approximately 100 residents (about 83% occupancy), it is a mid-sized facility located in FAIRMONT, West Virginia.

How Does Fairmont Rehabilitation And Healthcare Center Llc Compare to Other West Virginia Nursing Homes?

Compared to the 100 nursing homes in West Virginia, FAIRMONT REHABILITATION AND HEALTHCARE CENTER LLC's overall rating (1 stars) is below the state average of 2.7, staff turnover (50%) is near the state average of 46%, and health inspection rating (1 stars) is much below the national benchmark.

What Should Families Ask When Visiting Fairmont Rehabilitation And Healthcare Center Llc?

Based on this facility's data, families visiting should ask: "What changes have been made since the serious inspection findings, and how are you preventing similar issues?" "What safeguards and monitoring systems are in place to protect residents from abuse or neglect?" "Can you walk me through typical staffing levels on day, evening, and night shifts?" "Can I visit during a mealtime to observe dining assistance and food quality?" These questions are particularly relevant given the facility's Immediate Jeopardy citations, the substantiated abuse finding on record, and the below-average staffing rating.

Is Fairmont Rehabilitation And Healthcare Center Llc Safe?

Based on CMS inspection data, FAIRMONT REHABILITATION AND HEALTHCARE CENTER LLC has documented safety concerns. The facility has 1 substantiated abuse finding (meaning confirmed case of resident harm by staff or other residents). Inspectors have issued 2 Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death). The facility has a 1-star overall rating and ranks #100 of 100 nursing homes in West Virginia. Families considering this facility should ask detailed questions about what corrective actions have been taken since these incidents.

Do Nurses at Fairmont Rehabilitation And Healthcare Center Llc Stick Around?

FAIRMONT REHABILITATION AND HEALTHCARE CENTER LLC has a staff turnover rate of 50%, which is about average for West Virginia nursing homes (state average: 46%). Moderate turnover is common in nursing homes, but families should still ask about staff tenure and how the facility maintains care continuity when employees leave.

Was Fairmont Rehabilitation And Healthcare Center Llc Ever Fined?

FAIRMONT REHABILITATION AND HEALTHCARE CENTER LLC has no federal fines on record. CMS issues fines when nursing homes fail to meet care standards or don't correct problems found during inspections. The absence of fines suggests the facility has either maintained compliance or corrected any issues before penalties were assessed. This is a positive indicator, though families should still review recent inspection reports for the full picture.

Is Fairmont Rehabilitation And Healthcare Center Llc on Any Federal Watch List?

FAIRMONT REHABILITATION AND HEALTHCARE CENTER LLC is not on any federal watch list. The most significant is the Special Focus Facility (SFF) program, which identifies the bottom 1% of nursing homes nationally based on persistent, serious quality problems. Not being on this list means the facility has avoided the pattern of deficiencies that triggers enhanced federal oversight. This is a positive indicator, though families should still review the facility's inspection history directly.

Facility Details

Beds: 120
Avg. Residents: 100
Occupancy: 83.8%
Ownership: For profit - Corporation
Chain: GUARDIAN ELDER CARE
Medicare: Yes
Medicaid: Yes
Sprinklers: Yes

Trust Score Breakdown

Base Score: 50
1-Star Rating: +0
2 Immediate Jeopardy citations: -24
70 Deficiencies: -10
Abuse Finding: -15
Final Score: 1/100

Nearby Alternatives

FAIRMONT MEDICAL CENTER 5-star ST. BARBARA'S MEMORIAL NURSING... 4-star Majestic Care of Manchin 4-star

View all in FAIRMONT →

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Data: CMS Medicare Care Compare

Updated: November 2025

Facility ID: 515189