**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to issue the required Notification of Medicare Non-Coverage (NOMNC) in a timely fashion for one (1) of three (3) residents reviewed for beneficiary protection notification. This failure had the potential to place the resident at risk of not being informed of her rights prior to the end of Medicare Part A covered services. Resident identifier: #146. Facility census: 47. Findings included: a) Resident #146 On 10/29/24 at 12:00 PM, a review was completed regarding the beneficiary protection notification liability notice(s) given for Resident #146. Resident #146 was discharged to home following his last covered day of Medicare Part A services. Resident #146's last covered day of Part A Services was on 06/06/24. The facility failed to produce evidence that the required Notification of Medicare Non-Coverage (NOMNC) was issued. The Form Instructions for the Notice of Medicare Non-Coverage (NOMNC) CMS-10123 state: The NOMNC must be delivered at least two calendar days before Medicare covered services end . The instructions also state: A NOMNC must be delivered even if the beneficiary agrees with the termination of services. During an interview on 10/29/24 at 12:45 PM, Occupational Therapist #31 reported that Resident #146 had been admitted to the facility with an altered mental state and had demonstrated overall weakness. She recalled that it was the resident's desire to be able to return to home/community living when his skilled care days ended. Occupational Therapist #31 reported that the resident was discharged home on [DATE] once he had plateaued (meet a particular level of functioning and then stayed the same). During an electronic medical record review, completed on 10/29/24 at 8:30 PM, review of Resident#146's care plan revealed that resident had a desire to be discharged to the home following his skilled care/strength-building placement. Review of the resident's physical therapy, occupational therapy, and speech therapy discharge summaries revealed that the resident had met the therapeutic goals that had been established for him for to return to home/community living. During an interview on 10/30/24 at 8:35 AM, the Business Office Manager #60 confirmed a NOMNC was not issued prior to Resident #146's last covered day of Medicare Part A skilled services and subsequent discharge to home

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure a written Notice of Transfer / Discharge was provided to the resident and the long-term care Ombudsman for one (1) of two (2) residents reviewed for hospitalizations during the long-term care survey process. This had the potential to affect all residents being transferred or discharged . Resident identifier: #27. Facility census: 47. Findings included: a) Resident #27 A medical record review was completed on 10/3024 at 12:04 PM. The record review revealed Resident #27 was transferred to the hospital on [DATE]. The record did not reflect the resident/resident's representative was provided with a written Notice of Transfer/Discharge indicating the reason for transfer, the effective date of transfer, the location to which the resident was being transferred, and a statement of the resident's appeal rights. There was also nothing in the electronic medical record to indicate the long-term care Ombudsman had been notified. During an interview on 10/01/24 at 2:55 PM, the Administrator reported the facility could produce no evidence that resident/resident's representative was provided a Notice of Transfer/Discharge or that the long-term care Ombudsman was notified of the transfer.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to provide evidence that a resident/resident's representative was provided with a written Bed Hold notice for an acute hospital transfer. This was true for two (2) out of two (2) residents reviewed under the hospitalization pathway in the annual Long-Term Care Survey Process. Resident identifiers: #27, and #16. Facility census: 47. Findings included: a) Resident #27 A medical record review was completed on 10/3024 at 12:04 PM. The record review revealed Resident #27 was transferred to the hospital on [DATE]. There was no evidence in the electronic medical record that the facility had provided Resident #27 or his representative with a written Bed Hold notice. During an interview, on 10/01/24 at 2:55 PM, the Administrator reported the facility could not produce evidence that a Bed Hold notice had been issued for Resident #27's hospitalization on 05/17/24. b) Resident #16 Record review, on 10/30/22 at 9:27 AM, revealed Resident #16 was discharged to a local hospital on [DATE]. Continued review of Resident #16's medical record showed it did not contain documentation that the resident or the resident's representative received a copy of the bed hold policy at the time of transfer. In addition, there was no documentation in the medical record of contacting the resident/resident representative regarding the bed hold policy. In an interview with the Director of Nursing on 10/30/24 at 12:12 PM, the she confirmed that there was no documentation regarding staff notif0ying the resident/resident representative of the bed hold policy for the hospital transfer on 10/2/24.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to complete a new Pre-admission Screening and Resident Review (PASARR) for residents with newly evident or a possible serious mental disorder. This was true for two (2) out of two (2) residents reviewed under the category of PASARR, during the Long-Term Care Survey Process. Resident identifiers: #6 and #28. Facility census: 47. Findings included: a) Resident #6 A record review, completed on 10/29/24 at 1:50 PM, revealed Resident #6 had been admitted to the facility on [DATE]. Review of resident's diagnoses revealed a Major Depression diagnosis with an effective/active date of 11/01/23. There was only one (1) PASARR, dated 11/02/2022, on file. Section III MI/MR Assessment Question #30 had NONE selected regarding any pertinent diagnosis. Additionally, Section V Supplemental Questions #40 had NONE selected regarding any major mental illness (MI) or suspected MI. There was no evidence that a new PASARR had been done when the Major Depression diagnosis was given. During an interview, on 10/29/24 at 2:15 PM, the Social Worker reported there was not a new PASARR on file that addressed Resident #6's Major Depression diagnosis. b) Resident #28 A record review, completed on 10/29/24 at 2:00 PM, revealed Resident #28 had been admitted to the facility on [DATE]. Review of resident's diagnoses revealed a Bipolar Disorder diagnosis with an effective/active date of 09/26/24. There was an initial PASARR, dated 03/26/24 on file. Section III MI/MR Assessment Question #30 had NONE selected regarding any pertinent diagnosis. Additionally, Section V Supplemental Questions #40 had NONE selected regarding any major mental illness (MI) or suspected MI. There was a second PASARR, dated 07/16/24 on file. Section III MI/MR Assessment Question #30 had DX (diagnosis) of Depression and PTSD selected regarding any pertinent diagnosis. Additionally, Section V Supplemental Questions #40 had DX (diagnosis) of Depression and PTSD selected regarding any major mental illness (MI) or suspected MI. There was no evidence that a new PASARR had been done which captured resident's Bipolar Disorder diagnosis. During an interview, on 10/29/24 at 2:20 PM, the Social Worker reported there was not a new PASARR on file that addressed Resident #28's Bipolar Disorder diagnosis.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to develop and implement a comprehensive person-centered care plan for one (1) of 24 residents reviewed in the Long-Term Care Survey process. The facility failed to address Resident #145's preferred bedtime preference. Facility identifier: #145. Facility census: 47. Findings included: a.) Resident #47 A record review, completed on 10/29/24 at 7:40 PM, revealed that Resident #145 was admitted to the facility on [DATE] A review of the Recreation Comprehensive Assessment completed for resident, dated 10/18/24, found that the resident had reported she liked to go to bed whenever she wanted. A review of the comprehensive person-centered care plan for Resident #145 showed a focused area of Resident #145 as, While in the facility, resident/patient states that it is important that s/he has the opportunity to engage in daily routines that are meaningful relative to their preferences. Additionally, Resident #145 had the following intervention listed in her comprehensive care plan as it related to her daily routine, It is important for me to choose my bedtime and I prefer to go to bed (Delete all that do not apply) earlier than 7 pm, between 7-9 pm, or whenever I want. This intervention was created on 10/21/24. During an interview on 10/30/24 at 11:40 AM, the Administrator confirmed the care plan was not person-centered, and the reader would have no way of knowing what Resident #145's preference for bedtime would be by reading the intervention listed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on Interview and record review, the facility failed to contact the physician; and request a re-assessment of resident's capacity; after a Brief Interview for Mental Status (BIMS) evaluation revealed severe impairment. Resident identifiers: #18. Facility census: 47. Findings included: a) Resident #18: During a brief interview, on 10/28/24, at approximately 11:40 AM, Resident #18 was unable to state when she had entered the facility, or how long she had been there. The resident responded to other questions with unrelated answers. Record review on 10/28/24 at approximately 3:15 PM revealed a document by the resident's physician dated 08/29/24, that stated the resident had capacity. Further record review revealed the following note on 8/23/24 at 10:44 AM by Social Worker (SW) #23: BIMS Summary score: 12.0 Record review further revealed that Resident #18 had been admitted to the hospital on [DATE] for an acute urinary tract infection (UTI). A note by Physician #62 on 9/21/2024 at 8:13 PM stated the following: Resident is an (age/gender) who presents to the Pineview Center in Harrisonville, [NAME] Virginia after an acute hospitalization from 9/14/2024 through 09/14/2024 at (name of acute care hospital) due to adult failure to thrive secondary to a acute urinary tract infection. She was evaluated by orthopedics who recommended against any further workup or interventions. They recommended PT/OT in order to help mobilize. Neurosurgery was consulted for T6 compression fracture in which they felt that this was more chronic in nature. Blood cultures eventually grew gram-negative rods and urine cultures grew Klebsiella. ID had been consulted and recommended broad-spectrum antimicrobials. Concern for lower extremity blood clot which was unable to be confirmed by ultrasound but treated with empiric heparin drip. Patient did have positive fecal occult blood test and GI was involved. Due to risks outweighing the benefits, heparin drip was discontinued and Protonix 40 mg IV twice daily was initiated. Palliative care had also evaluated the patient towards the end of admission, family and patient were agreeable to hospice. She was determined to be stable for discharge on [DATE] in which she re-presented to the Center for long-term care on hospice. A note by SW #23 on 9/24/2024 at 08:33 AM stated: - BIMS Summary score: 5.0 During an interview on 10/30/24, at approximately 1:30 PM, SW #23 was unable to explain why the facility failed to contact the physician and request a re-assessment of Resident #18's capacity following the BIMS evaluation. An interview with Administrator #41 on 10/30/24 at approximately 3:00 PM confirmed that the facility had not contacted the physician to request a reassessment of the resident's capacity.

Based on observation, staff interview, and clinical record review, the facility failed to follow physician orders regarding oxygen administration, and did not monitor residents on oxygen therapy as prescribed. Resident identifiers: #5, and #11. Facility census: 47. Findings include: a) Resident #5 During a brief interview and inspection on 10/28/24 at approximately 11:40 AM, the resident was observed to be on oxygen therapy. The resident continued to be observed throughout the survey, and the following readings were obtained: On 10/28/24 at approximately 11:55 AM an oxygen concentrator was observed to be set to two (2) liters per minute. On 10/29/24 at approximately 3:11 PM the oxygen concentrator was observed to be set to deliver two (2) liters per minute. Record review revealed a physician's order dated 09/29/24 at 7:09 PM that stated: Oxygen at 3 L/min via Nasal Cannula PRN; notify MD if more than 3 shifts in a row below 90% O2 sat or having symptoms of respiratory distress. On October 29, 2024, at approximately 3:14 PM, LPN #29 confirmed that the oxygen was not set to the prescribed dosage. After adjusting the concentrator to deliver the correct dose, she remarked, These are not my patients; I was just asked to cover this hallway a few minutes ago. On 10/30/24 at approximately 8:11 AM this surveyor requested a record of Resident #5's oxygen saturation, while on oxygen therapy. Administrator #41 submitted a record with the following information: O2 SATS SUMMARY: -10/21/24 at 11:13 AM 99% (Room Air) -09/19/24 at 9:42 AM 98% (Room Air) -09/06/24 at 12:38 AM 96% (Room Air) -09/04/24 at 11:41 PM 96% (Room Air) -09/03/24 at 2:41 PM 96% (Room Air) PULSE SUMMARY: -10/21/24 at 11:13 AM 70 bpm (Regular) -10/01/24 at 8:14 AM 69 bpm (Regular) -09/19/24 at 9:42 AM 68 bpm (Regular) -09/06/24 at 12:38 AM 80 bpm (Regular) -09/04/24 at 11:41 PM 78 bpm (Regular) -09/03/24 at 2:40 PM 76 bpm (Regular) -09/01/24 at 9:52 AM 72 bpm (Regular) RESPIRATION SUMMARY: -10/21/24 at 11:13 AM 18 Breaths/min -10/01/24 at 8:14 AM 18 Breaths/min -09/19/24 at 9:42 AM 18 Breaths/min -09/06/24 at 12:38 AM 18 Breaths/min -09/04/24 at 11:41 PM 18 Breaths/min -09/03/24 at 4:41 PM 18 Breaths/min -09/01/24 at 9:52 AM 20 Breaths/min These records indicated that monitoring was not consistently conducted as prescribed by the physician. Additionally, no records were available for the dates of 10/28/24, and 10/29/24. During an interview with Administrator #41 on October 30, 2024, at approximately 9:44 AM, she stated that she had submitted all available monitoring records. b) Resident #11 On 10/28/24, at approximately 1:20 PM, Resident #11 was observed receiving oxygen therapy. The resident was continuously observed throughout the survey, and the following readings were recorded: On 10/28/24 at approximately 1:23 PM an oxygen concentrator was observed to be set to two (2) liters per minute. On 10/29/24 at approximately 11:5 AM the oxygen concentrator was observed to be set up to deliver two (2) liters per minute. On 10/30/24 at approximately 10:40 AM the oxygen concentrator was observed to be set to deliver two point five (2.5) liters per minute. Record review revealed a physician's order dated 11/03/23 at 6:00 PM that stated: Oxygen at 3 L/min via Nasal Cannula, continuously. Every day and night shift Notify MD if Pulse Ox < 90% more than 3 shifts in a row or having symptoms of respiratory distress. On 10/30/24, at approximately 10:42 AM, LPN #49 confirmed that the oxygen was not set to the prescribed dosage. She adjusted the concentrator to deliver the correct dosage, and then stated that she would ensure the other oxygen concentrators in the hallway were also checked. On 10/30/24 at approximately 8:11 AM this surveyor requested a record of Resident #11's oxygen saturation while on oxygen therapy. Administrator #41 submitted a record on 10/30/24 at approximately 8:15 AM, with the following information: O2 SATS SUMMARY: -10/13/24 at 6:28 AM 98% (Oxygen via nasal cannula) -10/12/24 at 9:44 PM 98% (Oxygen via nasal cannula) -10/12/24 at 8:48 AM 98% (Oxygen via nasal cannula) -10/12/24 at 12:51 AM 98% (Oxygen via nasal cannula) -10/10/24 at 10:43 PM 97% (Oxygen via nasal cannula) -10/10/24 at 4:30 PM 97% (Oxygen via nasal cannula) -10/09/24 at 9:37 PM 98% (Oxygen via nasal cannula) -10/09/24 at 9:34 PM 98% (Oxygen via nasal cannula) -10/12/24 at 12:51 AM 98% (Oxygen via nasal cannula) -10/10/24 at 10:43 PM 97% (Oxygen via nasal cannula) -08/19/24 at 1:00 AM 96% (Oxygen via nasal cannula) -08/17/24 at 11:18 PM 96% (Oxygen via nasal cannula) -06/28/24 at 9:32 AM 96% (Oxygen via nasal cannula) -06/27/24 at 11:40 PM 95% (Oxygen via nasal cannula) -06/27/24 at 10:41 AM 95% (Oxygen via nasal cannula) -06/26/24 at 11:55 PM 96% (Oxygen via nasal cannula) -06/26/24 at 5:01 PM 98% (Oxygen via nasal cannula) -06/25/24 at 12:57 AM 98% (Oxygen via nasal cannula) -06/25/24 at 12:17 AM 97% (Oxygen via nasal cannula) -06/20/24 at 2:17 AM 96% (Oxygen via nasal cannula) This record showed that while the resident was continuously on oxygen, monitoring was not consistently conducted daily, as prescribed by the physician. Furthermore, there were no records available for 10/28/24, 10/29/24, and 10/30/24. During an interview with the Administrator #41 on 10/30/24 at approximately 9:44 AM she confirmed that the monitoring had not been consistent.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident representative interview, record review, and staff interview, the facility failed to collaborate with resident trauma survivors, and as appropriate, the resident's family, to identify triggers which may re-traumatize the resident, and develop care plan interventions to minimize or eliminate the effect of the trigger on the resident. This was true for one (1) of two (2) residents reviewed with a Post Traumatic Stress Disorder (PTSD) diagnosis. Resident identifier: #27. Facility census: 47. Findings included: a) Resident #27 During a resident representative interview, completed on [DATE] at 11:02 AM, Resident #27's wife reported his PTSD diagnosis stemmed from a work event when he was in his mid-20's. She went on to report that there was a disaster in 1978 in (name) County when a cooling tower under construction at the power plant collapsed, killing 51 construction workers. Resident #27 remembered the incident vividly and recalled people going around and just collecting the severed left arms of the deceased construction workers. He explained the way the scaffolding fell meant the majority of the workers lost their left arms during the fall. This image was something that had stuck with Resident #27 and something he would frequently talk about later in his life and prior to his admission to the facility. A record review completed on [DATE] at 10:39 AM revealed the following details: -A significant change in status Minimum Data Set (MDS), dated [DATE], revealed resident had a Brief Interview for Mental Status (BIMS) score of 02. A BIMS score of 0-7 is suggestive of a person having severe cognitive impairment. -A review of the comprehensive person-centered care plan for Resident #27 showed a focused area as, Resident/Patient reports past experience of trauma as evidenced by: Other Dx: PTSD. -Resident #27 had the following goal listed, Resident/Patient will identify stressors and report to staff through the next review. This goal had a revision date of [DATE]. -Additionally, Resident #27 had the following intervention listed in his comprehensive care plan as it related to his PTSD diagnosis, Encourage Resident/Patient to identify personal trauma and triggers and take steps to eliminate/minimize. During an interview on [DATE] at 11:00 AM, the Social Worker reported she did not have knowledge of why Resident #27 had a PTSD diagnosis and could not readily identify any triggers that might re-traumatize the resident. The Social Worker acknowledged that asking a resident with severe cognitive impairment to identify his personal trauma and triggers would be unrealistic and that a conversation should have been held with the resident's family to gain the information.

Based on personnel file record reviews review and staff interview, the facility failed to provide a completed performance review of every nurse aide at least once every 12 months. This failed practice had the potential to affect more than a limited number of residents. Employee identifiers: #49, #5. Facility census: 47. Findings included: a) Employee performance reviews were not available for #49 or #5. During an interview, on 10/30/2024 at 11:34 AM, the Scheduling/payroll Manager #35 confirmed the yearly performance reviews were not on file for employee #49 and #5.

Based on record review and staff interview, the facility failed to ensure the consulting pharmacist performed a medication regimen review, which included a review of the resident's medical record, at least monthly. This was true for two (2) of five (5) residents reviewed under the unnecessary medication's pathway throughout the Long-Term Care Survey Process. Resident identifiers: #27 and #28. Facility census: 47. a) Resident #27 A record review, completed on 10/29/24 at 1:33 PM, revealed there was no evidence in the electronic medical record that a monthly medication regimen review had been completed for Resident #27 during the months of November 2023 and December 2023. During an interview on 10/30/24 at approximately 3:15 PM , the Administrator reported the facility was unable to produce any evidence the monthly medication regimen reviews had been completed by the consulting pharmacist and/or reviewed by the attending physician. b) Resident #28 A record review, completed on 10/29/24 at 1:15 PM, revealed there was no evidence in the electronic medical record that a monthly medication regimen review had been completed for Resident #87 for the month of August 2024. During an interview on 10/30/24 at approximately 3:15 PM, the Administrator reported the facility was unable to produce any evidence the monthly medication regimen review had been completed by the consulting pharmacist and/or reviewed by the attending physician.

Based on interviews and record review, the facility failed to provide privacy for visitation. This is true for one (1) of one (1) resident reviewed during the Long-Term Care Survey Process (LTCSP). Resident identifiers: #1, #40. Facility census: 47. Findings Included: a) Resident #1 On 10/29/24 at 10:55 AM during an interview with Resident 1's Medical Power of Attorney, she stated that all Resident 1's visitor's including her, have issues with Resident #40 opening the door, cursing the visitors and trying to come into the room. A record review on 10/29/24 of grievances revealed no grievance form was filled out for these issues. A medical record review of progress notes revealed multiple occasions 10/22/2024 3:35 PM A note stated Resident #1's sister came to a nurse and stated Resident #40 came to resident's room opened the door and just laughed then left at 3:05 PM and 3:15 PM. 10/27/2024 2:37 PM Resident #1's sister came to the chart room notifying the nurse that Resident #40 came down the hallway opened Resident #1's door started laughing and went back into his room. 10/5/2024 11:59 AM A note revealed that Resident #40 was asked by another resident's family member to stay away from the room door. This Resident has chosen not to comply with the other resident family's wishes. This resident chose to curse and speak loudly at the other resident's family members when they asked him to be respectful. This resident did not respond to verbal redirection and continued to attempt to look in another resident's room. 10/6/2024 2:40 PM A note revealed that Resident #40 was found in Resident #1's room. When the nurse approached the room and asked Resident #40 to leave, he immediately left the room quickly. Resident#40 refused to stop moving his chair to be questioned as to why he was in the room, nor would he listen when they tried to redirect him. 10/6/2024 6:00 PM A progress note stated Resident #40 had been verbally aggressive toward the staff due to his being redirected to stay out of Resident #1's room. Resident #1 had multiple family members coming in and out of her room which has caused an increase in Resident #40's behavior. Staff tried to redirect Resident #40, but he refused to listen or follow directions. 10/6/2024 4:43 PM A progress note stated Resident #40 was in the hallway screaming, (fxcx) them, I can see her if I want, in response to a resident #1's family coming in to see her. The family of Resident #1 has asked that this resident not come in the room and to stay away from her. Resident #1 was upset and verbalizing his aggravation in response. When Resident #40 was asked to stop yelling he responded with, hell no. Resident could not be redirected at this time. 10/20/2024 2:00 PM Resident #40 became verbally and physically aggressive when Resident #1's family came to visit her. He tried to kick and hit me with his fist as I walked down the hall. The resident believed that I called the family of Resident #1 to come in. Resident #40 had to be redirected by two other staff members due to he wasn't listening to what I had to say. He was removed from the area in order for him to settle down. He made multiple trips down the hall and stopped in front of Resident #1 door. When he would see someone coming down the hall, he moved on quickly. During an interview with the Administrator on 10/29/24 at 1:52 PM, she stated she was aware of the complaint about the issues for Resident #1, She verified that Resident #1 and her visitors were not provided privacy during visitation. She stated that she would offer a room change now.

b) Resident #5 During an interview with Resident #5 on 10/2824, at approximately 11:55 AM, the resident stated that she had filed a verbal grievance against a staff member on 09/03/24. She mentioned that she had not received any response from the facility regarding the status of the investigation. A telephone interview was conducted with the Medical Power of Attorney (MPOA) for Resident #5 on 10/28/24, at 2:44 PM. During the conversation, the MPOA noted the facility had not yet responded to the grievance. She expressed her desire to understand whether the facility had conducted an investigation and, if so, what the outcome was. Further investigation, interviews, and record review revealed that the facility conducted an investigation, interviewed staff and residents, and concluded that the grievance could neither be substantiated nor refuted. Record review of the facility's policy titled, Grievance/Concern, revised on 10/15/24, showed that the department manager would notify the person filing the grievance in a timely manner, and written resolution for grievances would be offered per the resident's rights and will include: Date the grievance was received; Summary statement of the grievance; Steps taken to investigate the grievance; Summary of the pertinent findings or conclusions regarding the grievance; Statement as to whether the grievance was confirmed or not confirmed; Any corrective action(s) taken or to be taken by the center as a result of the grievance/concern; and Date the written resolution was issued. During an interview with Administrator #41 and Director of Nursing #46 on 10/30/24, at approximately 3:18 PM, they confirmed the facility had not submitted a written resolution of the grievance to the resident. Based on interview, record review and policy review the facility failed to making prompt efforts to resolve a grievance and to keep the resident notified of progress toward resolution. This is true for two (2) of two (2) reviewed during the Long-Term Care Survey Process (LTCSP). Resident identifiers: #1 and #5. Facility census: 47. Findings included: a) Resident #1 Record review of the facility's policy titled, grievance /concern, showed: -Upon receipt of the grievance / concern, the grievance / concern form will be initiated by staff member receiving the concern. -Upon receipt of the grievance /concern form, the Administrator or designee will document the grievance / concern on the grievance / concern log. - Immediate action will be taken to prevent further potential violations of any patient right while the alleged violation is being investigated. -Notify the person filing the grievance of resolution in a timely manner. Resident #1 On 10/29/24 at 10:55 AM during an interview Resident #1's Medical Power of Attorney, she stated that all Resident 1's visitors including her have issues with Resident #40 opening the door, cursing the visitors and trying to come into the room. A record review on 10/29/24 of grievances revealed no grievance form were filled out for these issues. A medical record review of progress notes revealed multiple occasions During an interview with the Social Services Director (SSD) on 07/12/22 at 9:52 AM, she stated she was aware of the complaint about the noise of the other resident but had never offered a room change to Resident #45 or completed a grievance form. She stated that she would offer a room change now. 10/22/24 3:35 PM Resident #1's sister came to this nurse stated resident #40 came to resident's room opened the door and just laughed then left at 3:05 PM and 3:15 PM. 10/27/24 2:37 PM Resident #1's sister came to chart room notified this nurse Resident #40 came down the hallway opened Resident #1's door started laughing and went back into his room. 10/05/24 11:59 AM Note: Resident was asked by another Resident family member to stay away from their room door. This Resident has chosen not to comply with the other Resident family's wishes. This resident chose to curse and speak loudly at the other Resident family members when they asked him to be respectful. This Resident did not respond to verbal redirection and continued to attempt to look in other Resident room. 10/06/24 3:40 PM A note revealed Resident #40 was found in Resident #1s room. When the nurse approached the room to ask Resident #40 to leave, he immediately left the room quickly. Resident#40 refused to stop moving his chair to be questioned as to why he was in the room, nor would he listen when the nurse was trying to redirect him. 10/06/24 6:00 PM A note revealed Resident #40 had been verbally aggressive toward the staff due to being redirected to stay out of Resident #1's room. Resident #1 had multiple family members coming in and out of her room. This caused an increase in Resident #40's behavior. Staff tried to redirect Resident #40 but he refused to listen or follow directions. 10/06/24 4:43 PM Resident #40 was in the hallway screaming fuck them, I can see her if I want, in response to Resident #1's family coming in to see her. Family of Resident #1 asked that this resident not come in the room and to stay away from other resident. Resident #40 was upset and verbalizing his aggravation in response. Resident #40 was asked to stop yelling and he responded with, hell no. Resident #40 could not be redirected at this time. 10/20/24 2:00 PM Resident #40 became verbally and physically aggressive when Resident #1's family came to visit her. He tried to kick and hit me with his fist as I walked down the hall. Resident believed that the nurse called the family of Resident #1 to come in. Resident #40 had to be redirected by two (2) other staff members due to he wasn't listening to what I had to say. He was removed from the area in order for him to settle down. He made multiple trips down the hall and stopped in front of Resident #1 door. When he would see someone coming down the hall, he moved on quickly. During an interview with the Administrator on 10/29/24 at 1:52 PM, she stated she was aware of the complaint about the issues for Resident #1, She verified no one completed a grievance form. She stated that she would offer a room change now.

Based on observation, staff interview and record review, the facility failed to store and label food in accordance with professional standards for food service storage. This failed practice had the potential to affect more than a limited number of residents. Facility Census: 47. Findings included: a) Observation in the pantry area of the kitchen revealed small unlabeled what appeared to be vanilla ice cream. No dates were present on the cups. b) Observation in the freezer revealed cooked frozen sausage with a date labeled 10/28/24 and use by date of 04/22/24. These findings were confirmed by the Dietary Manager on 10/28/24 during the kitchen investigation.

Based on interview and record review the facility failed to making prompt efforts to resolve a grievance and to keep the resident notified of progress toward resolution also, failed to provide residents a confidential way to file a grievance. This can affect more than a limited number of residents. Resident identifier: #1. Facility census: 31. Findings included: a) Resident #1 06/13/23 a record review Resident Council Minutes from 05/04/23, revealed Resident #1 reported nursing staff and nurse aids (NAs) treat him and other residents like they are beneath them. Also reported, two nurses (with stated names) that ignore the Residents and one NA that is disrespectful to the residents. Subsequent review reveled Resident #1 reported these issues were reported to the Director of Nursing (DON) on two occasions and nothing was resolved. A continued record review of Resident #1's Quarterly 05/16/23 Minimum Data Set (MDS), found the resident's brief interview for mental status was fifteen (15) the highest score obtainable. Resident #1 had capacity. On 06/14/23 at 11:50 AM an interview with Administrator confirmed, Resident #1's grievances were not followed up on or reported. b) Grievance Forms On 06/15/23 at 11:23 AM an observation found no grievance forms available throughout the facility. During an interview on 04/11/23 at 8:56 AM the Social Work Director stated the residents must come to a staff member to file the grievance or receive a form. She stated there were no grievance forms available for residents to file a grievance anonymous.

Based on record review, staff interview, and operational policy review, the facility failed to thoroughly investigate all allegations of abuse and neglect. This had the potential to affect all residents that reside at the facility. Resident identifier: Resident #1. Facility census: 31. Findings included: Record review of the facility's policy titled, Resident Abuse, showed: -The facility will identify and investigate all suspicions or allegations of abuse. Any allegations of abuse to the residents shall be reported immediately to the supervisory person in charge and to the Administrator. A report will be made immediately to the appropriate state agencies as required. Findings included: a) Resident #1 06/13/23 a record review Resident Council Minutes from 05/04/23 revealed Resident #1 reported nursing staff and nurse aids (NA) treat him and other residents like they are beneath them. Also reported, two nurses (with stated names) that ignore the Residents and one NA that is disrespectful to the Residents. Subsequent review revealed Resident #1 reported these issues were reported to the Director of Nursing (DON) on two occasions and nothing was resolved. A continued record review of Resident #1's Quarterly 05/16/23 Minimum Data Set (MDS), found the resident's brief interview for mental status was fifteen (15) the highest score obtainable. Resident #1 has capacity. On 06/14/23 at 11:50 AM an interview with Administrator confirmed, Resident #1's Grievances were not followed up on or reported to the required state agencies.

Based on record review and staff interview, the facility failed to report alleged violation related to, neglect, or abuse, and report the results of all investigation to the proper authorities within prescribed timeframes. This was a random opportunity for discovery. Resident identifier: #3, #12, #37 and #38. Facility census: 31. Findings include: a) Grievance Reports During a complaint investigation a review of grievance/complaint reports revealed: a) Resident #3 Resident #3 reported on 05/30/23 that a staff member stated that they did not have time to empty his urinal causing him to urinate himself. Continued review found the resolution of grievance was unsubstantiated due to conflicting statements. b) Resident #12 Resident #12 reported on 05/11/23 a staff member (Named) came in her room and said you should not be worried about your hands there is a guy here with no legs in a wheelchair and he can get around fine. So, you should not be upset about your hand. Resident very upset and requested a grievance form. Continued review the resolution revealed that the staff member received one on one in-service. c) Resident #37 Resident #37 reported on 05/11/23 she reported on 05/10/23 a night shift aide or maybe a nurse put her on the toilet, left and never came back she stated that she thought she was going to pass out or even die. Continued review of the resolution revealed that the staff was informed and educated on performance. d) Resident #38 Resident #38 reported on 04/07/23, she was treated unkind and yelled at by nurse aides (NA) that answered her call light by saying What do you want now. She also states that she has been told, she puts her call light on too much. She continued to state the NA treat her rude and ignore her needs. Continued review of the resolution revealed this allegation could not be substantiated due to Resident no longer available. On 06/14/23 at 11:55 AM an interview with Administrator confirmed, Residents #3, #12, #37 and #38 were not reported to the required state agencies.

. Based on review of facility documentation and staff interview, the facility failed to maintain an infection prevention and control program which provided an environment to help prevent the development and transmission of communicable diseases and infections. The facility failed to provide education to all facility staff when surveillance identified a problem with infections in the facility in an attempt to control the facility's infection rate. This failed practice was identified based on a random opportunity for discovery and had the potential to affect more than a limited number of residents residing in the facility.Resident Identifiers: Residents #22, #25, #16, #10, #12, #32 and #27 Census: 31. Findings included: A review of the monthly Infection Control Line listings, maintained by the infection control program, for May 2023, showed five (5) residents who had been identified as developing an urinary tract infection (UTI). These residents were identified as Residents #22, #25, #16, #10 and #27. An interview with the Infection Preventionist (IP), on 06/15/23 at 03:20 PM, revealed based on the infection rate for UTIs and the location of the rooms, it was determined there could have been a problem with staff performance with care relating to the infection increase and education was provided in attempt to control the spread of infection. The IP provided the surveyor a list of staff inserviced which included education and a performance check off. The list of who was trained included three (3) facility Nursing Assistants (NAs), re-trained 06/03/23, and 06/05/23, when 14 facility NAs were included on the roster that were assigned to work the unit. The 14 facility NAs who had not received training in the prevention of infections related to the UTI issue identified through May 2023 surveillance included NA #19, #8, #9, #16, #17, #10, #18, #14, #11, #12 and #6. During the interview, with the IP, on 06/15/23 at 03:20 PM, It was revealed, two (2) additional residents had developed UTIs in June 2023 which included Resident #12 and #32. The IP confirmed all staff had not been trained based on the surveillance data indicating a need for training on the prevention of UTIs. The IP added the facility should have been more aggressive to train all staff that were assigned and working direct care on the unit.

. Based on observation and staff interview, the facility failed to provide care in a manner that protected personal and medical resident information for each resident. Resident care sheets were noted laying in the hallway, easily accessible and information not secured and the medical information entry kiosk had a code for entry access posted above the kiosk which when entered allowed access to resident medical and personal information. The observations were based on a random opportunity for discovery and had the potential to affect more than a limited number of residents residing in the facility. Resident identifiers: Residents #2, #5, #15, #12, #17, #20, #27, #22, #21, #18, #8, #31, #10, #29, #25, #26, #28, and #32. Census: 31 Findings included: a) Policy review A review of the policy titled:: Electronic Health Record Documentation, dated, 01/2015, showed the facility must maintain clinical recorders on each resident in accordance to accepted practices. A review of the policy titled: Confidentiality of Computerized Medical Records #19, dated 07/2012, noted only authorized users will be able to gain access to the records and an assigned user code would be kept confidential. Employees were responsible for ensuring security and confidentiality of all resident information created, obtained or maintained by the facility. b) Resident care sheets An observation, on 06/13/23 at 12:35 PM, revealed 18 resident forms laying on top of two (2) of two (2) documentation stations on the Orange Hall, unsecured with resident identifying and personal and health information listed on the forms. Diet orders, special equipment required for the resident's care were noted for Residents' #2, #5, #15, #12, #17, #20, #27, #22, #21, #18, #8, #31, #10, #29, #25, #26, #28, and #32. c) Access code for electronic medical record access An observation, on 06/13/23 at 12:40 PM, revealed a kiosk where medical information was entered by staff utilizing a special and secure code. Above the kiosk, an observation was made of information which included an employee's name and access code posted above the kiosk in plain view. When the individual's name and access code was entered, the electronic medical information appeared for residents and was easily accessible for review of the medical information of each resident. d) Staff interview An interview, with Licensed Practical Nurse (LPN) #31, on 06/13/23 at 12:50 PM, verified the forms with personal and health information were laying at both Orange Hall documentation stations, currently being utilized for documentation in plain view and should have been secured. Additionally, LPN #31 verified during the interview, on 06/13/23 at 12:50 PM, the employee names and access codes were posted in an ability observed and accessible area and when entered would allow access to the resident matrix which included the electronic medical record for each resident. LPN #31 stated That is a problem. An interview with the Administrator, on 06/14/23 at 08:20 AM, confirmed staff were not to place any confidential resident information in plain view and the access code to the kiosk should be maintained in a confidential manner and was not acceptable practice for names and codes to gain access to the electronic health record being posted. .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . b) Resident #125 Review of Resident #125's medical records showed a Physician's Determination of Capacity dated 12/01/22 stating the resident did not have capacity to make medical decisions. Further review of Resident #125's medical records showed a Physician Orders for Scope of Treatment (POST) form signed by the resident's health care surrogate on 12/01/22. A POST form is a set of medical instructions for health care professionals to recognize and honor a resident's treatment preferences for life-sustaining measures. Resident #125's POST form stated resuscitation was not to be attempted in the event of cardiopulmonary arrest. Additionally, the resident was to have comfort-focused treatments to maximize comfort through symptom management and allow for a natural death. Review of Resident #125's physician's orders showed an order written on 12/01/22 for the resident to be a full code, meaning resuscitation, mechanical ventilation, defibrillation, and cardioversion were to be performed in the event of a cardiopulmonary arrest. During an interview on 01/04/23 at 11:21, the Director of Nursing (DON) confirmed Resident #125's full code order did not match the wishes on the resident's POST form. The DON stated the resident's order would be corrected. No further information was provided through the completion of the survey. Based on record review and staff interview, the facility failed to ensure the physician's orders correctly conveyed the resident's/resident's representative's wishes regarding end of life treatment for two (2) of 14 residents reviewed for the care area of advance directives. Resident identifiers: #223 and #125. Facility census: 24. Findings included: a) Resident #223 Record review found the resident was admitted to the facility on [DATE]. On 01/02/23, the physician wrote a Do Not Resuscitate (DNR) order. Review of the medical record found a copy of the [NAME] Virginia Physician's Orders for Scope of Treatment (POST) form had been completed and signed by the physician indicating the resident was a DNR, comfort focused treatment, and no artificial means of nutrition desired. The POST form had not been signed by the resident or responsible party indicating this was the advance directives desired. There was no indication the resident/responsible party conveyed these wishes for end of life care. On 01/03/23 at 3:18 PM, the Director of Nursing (DON) said the DNR order was written based on information from the discharging hospital noting the resident was a DNR, not the information on the POST form. The DON provided a copy of the hospital information provided to the facility. At the bottom of page 1 on the hospital discharge information, the following was found: !!Provider: Please complete the orange DNR card and the POST form or place consult to Care Management for assistance. This information indicated the hospital did not have confirmation of the resident's wishes for advance directives. On 01/05/23 at 9:36 AM, the DON said she had not been able to obtain any further information from the hospital. The DON confirmed there was no information available at the facility to indicate the resident/responsible party had formulated any advance directives, including a DNR order. .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, resident interview, and staff interview, the facility failed to ensure water temperatures were comfortable for bathing activities. This was a random opportunity for discovery. Facility census: 24. Findings included: a) Water temperatures On 01/03/23 at 12:02 PM, Resident #12 stated, she doesn't always want a shower because the water is too cold. On 01/04/23 at 8:43 AM, the resident's nurse aide (NA) #20 said, we have to turn the water on and let it run for half an hour before it gets warm. She said with the recent cold spell you really had to let the water run. On 01/04/23 at 9:00 AM, the facility's medical secretary #57 provided copies of the resident's bathing schedule and confirmed the Resident receives 2 showers a week, Tuesdays and Saturdays. In December 2022 the resident had 8 opportunities to receive a shower before being diagnosed with COVID-19. The resident received 6 showers. In November 2022 the resident had nine (9) opportunities for showers. The resident received six (6) showers. On 01/05/23 at 9:32 AM, the Director of Nursing (DON) said, We are having an issue with the hot water, this was a recent issue. On 01/04/23 at 9:06 AM, Employee #52, a maintenance worker was asked to obtain the temperatures of the water at the hand sink in the last room on the 400 hallway: room [ROOM NUMBER] The temperature was 79 degrees. The temperature climbed to 124 degrees then began to drop to 107 degrees. After several minutes the temperature climbed to 115.9 degrees. The Resident in this room observed the staff member obtaining the temperature and said, That water is very cold. On 01/04/23 at 9:22 AM, observations found the water pressure and the water temperature in the sink in the shower room was fluctuating. The water finally reached 104.7 degrees. The temperature fluctuated from 104.7 degrees to 103.3 degrees. The water pressure fluctuated while obtaining the temperature. Employee #52 said he had ordered a mixing valve last Friday because there is a problem with the water temperature. He said, I can't get the water stable, I have to adjust it every day. .

**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 one (1) resident reviewed for the care area of discharge had a discharge planning process in place, involving the resident, which addressed the resident's discharge goals and needs. Resident identifier: #22. Facility census: 24. Findings included: a) Resident #22 Record review revealed the resident was admitted to the facility on [DATE]. The resident was discharged to his home on [DATE]. The admission minimum data set (MDS) with an assessment reference date (ARD) of 10/04/22 noted the resident participated in his discharge plan and was expected to return home. Review of the current care plan found the resident's discharge to the community was not care planned. On 01/04/23 at 12:00 PM, Registered Nurse (RN) #63 was unable to locate any discharge paperwork or verification the residents discharge was care planned with the resident. On 01/04/22 at 3:50 PM, the Director of Nursing (DON) verified no interdisciplinary team (IDT) discharge planning was located in the resident's chart. The DON was unsure if the resident was evaluated by a durable medical equipment (DME) company to determine what if any discharge equipment needs were met. A progress note written on 10/12/22 noted an order was faxed to a DME company for the possible need of a walker and a wheelchair. .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review and staff interview, the facility failed to complete a discharge residents recapitulation of stay, which included the course of treatment at the facility. This was true for one (1) of one (1) resident reviewed for the care area of discharge during the long-term care survey process. Resident identifier: #22. Facility census: 24. Findings included: a) Resident #22 Record review revealed the resident was admitted to the facility on [DATE]. The resident was discharged to his home on [DATE]. The admission minimum data set (MDS) with an assessment reference date (ARD) of 10/04/22 noted the resident participated in his discharge plan and was expected to return home. On 01/04/23 at 12:00 PM, Registered Nurse (RN) #63 was unable to locate any discharge paperwork including a recapitulation of the residents stay at the facility. On 01/04/22 at 3:50 PM, the Director of Nursing (DON) verified a recapitulation of the residents stay at the facility had not been completed. At the close of the survey, no further information had been provided. .

. Based on record review and staff interview, the facility failed to administer a medication used to treat high blood pressure per the physician's orders for one (1) of five (5) residents reviewed for unnecessary medications. Resident identifier #7. Facility census: 24. Findings included: a) Resident #7 Record review found a physician order, dated 12/30/22 for Metoprolol tartrate 25 milligrams. Give 1 table twice a day, hold if heart rate is less than 50. The medication administration record (MAR) was reviewed with the Director of Nursing (DON) on 01/05/23 at 9:25 AM, who verified the following information: On 12/31/22 the nurse did not administer the 8:00 PM dose of medication. There MAR did not include the resident's pulse/heart rate was obtained. On 01/01/23 the 8:00 AM dose was again held for a pulse/heart rate of 60. The DON confirmed holding the medication is not per the physician's orders, the medication should have been administer. On 01/02/23 the 8:00 AM dose was held. The nurse made the comment of the MAR, b/p (blood pressure) below parameter. The DON confirmed again the medication is not held based on the resident's blood pressure. There was no indication the resident's pulse/heart rate was obtained. On 01/03/23 the 8:00 PM dose was administered for a pulse/heart rate of 46. The DON confirmed the medication should not have been administered. The DON said she was going to call the physician for clarification. The DON thought nurses were holding the medication when the resident's blood pressure (b/p) was low instead of administering the medication based on the resident's heart rate as directed by the physician's order. .

. Based on record review and staff interview, the facility failed to ensure that residents who are trauma survivors receive trauma-informed care in accordance with professional standards of practice. This was true for one (1) of two (2) residents reviewed for the care area of mood and behavior. Resident identifier: #20. Facility census: 24. Findings included: a) Resident #20 Review of Resident #20's physician's orders showed an order for paroxetine (Paxil) for post-traumatic stress disorder (PTSD). The resident was on this medication since admission to the facility. The medical records contained no assessment of Resident #20's PTSD experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization to the resident. Additionally, Resident #20's comprehensive care plan did not contain a focus/problem related to PTSD. During an interview on 01/05/23 at 08:33 AM, the Director of Nursing (DON)confirmed Resident #20's medical records contained no assessment of the resident's PTSD. The DON also confirmed Resident #20's comprehensive care plan was not developed for PTSD. No further information was provided through the completion of the survey. .

. Based on record review and staff interview, the facility failed to ensure one (1) of five (5) residents reviewed for the care area of unnecessary medications was free from antipsychotic medication use. Resident identifier: 7. Facility census: 24. Findings included: a) Resident #7 Record review found the resident was admitted to the facility from the hospital on 1/28/22 with instructions to administer the antipsychotic medication, Olanzapine 2.5 milligrams at bedtime for 30 days. The hospital did not inform the facility of the diagnosis for the use of the medication. The medication was given for 30 days and a new prescription was written on 12/30/22 by the facility physician to continue the medication with no time limits. On 12/01/22 the facility physician saw the resident and noted the antipsychotic, Olanzapine was being given for a diagnosis of anxiety. The facility physician noted the medication was used at the hospital for acute delirium (acute delirium is temporary confusion and a change in consciousness.) When the physician continued the medication on 12/30/22 the resident had only experienced the following behavior as charted in the nurses notes: On 5 occasions 11/29/22, 11/30/22, 12/08/22, 12/12/22, and 12/29/22, the behavior was documented as, declining to eat. On 12/02/22 the resident's behavior was insomnia, getting out of bed and self transferring. On 01/03/23 the Registered dietician wrote: Weight is up by 2 pounds after being ill with decreased appetite. On 01/05/23 at 8:49 AM, Registered Nurse (RN) #63 author of the resident's care plan confirmed the resident was not care planned for the use of the antipsychotic. The care plan does not discuss the diagnosis of anxiety, or any mood or behaviors exhibited by the resident. On 01/05/23 at 9:25 AM, the Director of Nursing (DON) said the resident has anxiety. When asked what are the behaviors indicating anxiety, she stated the resident will say, Oh, I can't wait to go home. (The resident was planning to return home but did not go due to contracting the flu.) On 01/05/23 at Licensed Practical Nurse (LPN) #38 said at times the resident doesn't like to take her medications. On 01/05/23 at 9:23 AM, Physical Therapy Assistant (PTA) #71 said the resident participated in therapy and she was not aware of any behaviors. Nurse aide (NA) #25 said he was not aware of any behaviors exhibited by resident #7 on 01/05/23 at 9:40 AM.

. Based on record review and staff interview, the facility failed to ensure medications in the medication storage room were stored and labeled in accordance with currently accepted professional principles. One (1) vial of insulin was not dated to indicate when opened. Additionally, several medications in the intravenous cart were past the manufacturer's expiration date. Facility census: 24. a) Medication storage and labeling On 01/04/23 at 8:45 AM, inspection of the medication storage room was conducted with Licensed Practical Nurse (LPN) #43 in attendance. The refrigerator in the medication storage room contained a vial of insulin that had not been dated when opened to indicate when the insulin should be discarded. LPN #43 stated she thought the insulin had been opened last night, but confirmed the vial was not dated. Additionally, the cart containing floor-stock intravenous medication and supplies contained the following medications that were past the manufacturer's expiration dates: - Six (6) vials of the antibiotic Ceftriaxone containing powder for reconstitution, expiration date October 2022 - Two (2) vials of the antibiotic Cefuroxime containing powder for reconstitution, expiration date September 2022 - Two (2) vials of sodium chloride to flush intravenous access devices, expiration date October 2022 - One (1) vial of xylocaine, an anesthetic, expiration date September 2022 LPN #43 confirmed the above-mentioned medications were past the manufacturer's expiration dates. No further information was provided through the completion of the survey. .

. Based on record review and staff interview the facility failed to ensure resident's Physician Orders for Scope of Treatment (POST) were complete and accurate. This was discovered for two (2) of 14 POST forms reviewed during the Long Term Care Survey Process. The POST forms for Residents #18 and #4 were incomplete. Resident identifiers: #18 and #4. Facility census: 24. Findings included: a) Resident #18 During a medical record review on 01/04/23, the POST form completed on 11/17/22 for Resident #18 did not have the physician's phone number or the resident's name on the second page. An interview with the Director of Nursing (DON) on 01/04/23 at 11:45 AM, verified the POST form did not have the physician's phone number or the resident's name on the second page. b) Resident #4 During a medical record review on 01/05/23, the POST form completed on 11/16/20 for Resident #4 did not have a trial period for intravenous (IV) fluids or the name and signature of the preparer. An interview with the DON on 01/0/23 at 11:45 AM, verified the POST form was incomplete and did not include a time frame for IV fluids and the preparer's name and signature. .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review and staff interview, the facility failed to ensure a complete and accurate care plan was developed for four (4) of 14 residents reviewed in the long-term care survey sample. For Residents #13 and #20, the care plan was not developed for psychotropic medication. For Resident #7, the care plan was not developed for psychotropic medication and dementia care. For Resident #4, the care plan was not developed for Post-Traumatic Stress Disorder. Resident identifiers: #13, #20, #7, #4. Facility census: 24. Findings included: a) Resident #13 Review of Resident #13's physician's orders showed the resident was prescribed the antipsychotic medication quetiapine (Seroquel) upon admission [DATE]. Review of Resident #13's comprehensive care plan reviewed and revised 12/06/22 showed the problem psychotropic drug use. Approaches were to administer Seroquel and Risperidone (also an antipsychotic medication). Another approach was to assess for and incorporate non-pharmaceutical interventions. However, specific non-pharmaceutical interventions, including non-pharmaceutical interventions successful for this resident, were not documented. Another approach was to discuss dose reduction when target behaviors were absent or easily altered. However, the resident's target behaviors were not documented. Staff caring for this resident would not know what specific non-pharmaceutical interventions should be attempted or what specific behaviors should be monitored. During an interview on 01/05/23 at 11:08 AM, the Director of Nursing (DON) confirmed Resident #13's comprehensive care plan did not specify non-pharmaceutical interventions or target behaviors. Additionally, the DON was unable to provide evidence Resident #13 had been on the medication Risperidone, as indicated on the comprehensive care plan. No further information was provided through the completion of the long-term care survey process. b) Resident #20 Review of Resident #20's physician's orders showed the resident was prescribed the antipsychotic medication olanzapine (Zyprexa). The resident was also prescribed psychotropic medications buspirone (Buspar) for anxiety and escitalopram oxalate (Lexapro) for depression. Review of Resident #20's comprehensive care plan reviewed and revised on 10/18/22 showed the problem psychotropic drug use, for the medications Zyprexa, Lexapro, and Buspar. An approach was to assess for and incorporate non-pharmaceutical interventions. However, specific non-pharmaceutical interventions, including non-pharmaceutical interventions successful for this resident, were not documented. Another approach was to discuss dose reduction when target behaviors were absent or easily altered. However, the resident's target behaviors were not documented. Staff caring for this resident would not know what specific non-pharmaceutical interventions should be attempted or what specific behaviors should be monitored. During an interview on 01/05/23 at 11:08 AM, the Director of Nursing (DON) confirmed Resident #20's comprehensive care plan did not specify non-pharmaceutical interventions or target behaviors. No further information was provided through the completion of the long-term care survey process. c) Resident #7 (part 1) Record review found the resident was admitted to the facility on [DATE]. Review of the medical record found the resident is receiving the antipsychotic medication, olanzapine for a diagnosis of anxiety. Review of the current care plan with Registered Nurse (RN) #63, (author of the care plan) at 8:49 AM on 01/05/23, found no mention of anxiety or the use of an antipsychotic medication in the care plan Resident #7 (part 2) Record review found the resident was admitted to the facility on [DATE]. The resident is receiving Aricept for a diagnosis of Dementia. Review of the current care plan with Registered Nurse (RN) #63, (author of the care plan) at 8:49 AM on 01/05/23, verified the care plan did not address the resident's dementia. d) Resident #4 During a medical record review on 01/04/23, the Diagnosis Section of the Minimum Data Set (MDS) with and Annual Reference date (ARD) of 11/18/22, revealed Resident #4 had a diagnosis of Post-Traumatic Stress Disorder (PTSD). Upon further investigation there was no indication the current care plan had been developed to include the diagnosis of PTSD. An interview with the Director of Nursing (DON) on 01/05/23 at 10:13 AM, verified the diagnosis of PTSD had not been developed on the care plan. .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review and staff interview, the facility failed to ensure the physician identifed and reported medication irregularities for Residents #13, #20, and #7. Additionally, the physician failed to respond to the pharmacist's reported irregularity for Resident #9. These deficient practices had the potential to affect four (4) of five (5) residents reviewed for the care area of unnecessary medications. Resident identifiers: #13, #20, #7, #9. Facility census: 24. Findings included: a) Resident #13 Review of Resident #13's physician's orders showed the resident was prescribed the antipsychotic medication olanzapine (Zyprexa) on 11/24/22. The order did not include the reason Zyprexa was prescribed. Review of Resident #13's progress notes showed the resident had been having behaviors, including aggression. Further review of Resident #13's medical records showed the pharmacist had performed a monthly medication regimen review on 12/05/22. The pharmacist did not identify the lack of diagnosis for the medication Zyprexa and made no recommendations for changes. During an interview on 01/05/23 at 9:04 AM, the Director of Nursing (DON) confirmed Resident #13's orders did not contain a diagnosis for Zyprexa. The DON also confirmed the pharmacist did not identify the lack of diagnosis during the monthly medication regimen review. No further information was provided through the completion of the survey. b) Resident #20 Review of Resident #20's physician's orders showed the resident had been receiving the antipsychotic medication quetiapine (Seroquel) every evening since admission. The order stated the indication for the medication was Alzheimer's disease. During an interview on 01/05/23 at 8:23 AM, the pharmacist confirmed Seroquel did not treat Alzheimer's disease but could be used to treat behaviors due to Alzheimer's disease. Further review of Resident #20's medical records showed the pharmacist had performed a monthly medication regimen review on 12/03/22. The pharmacist made a recommendation for laboratory testing to be performed due to the resident receiving antipsychotic medication. However, the pharmacist did not identify the incorrect indication for Seroquel. During an interview on 01/05/23 at 9:04 AM, the Director of Nursing (DON) confirmed Resident #20's orders contained an incorrect indication for Seroquel. The DON also confirmed the pharmacist did not identify the incorrect indication during the monthly medication regimen review. No further information was provided through the completion of the survey. c) Resident #7 Record review found the resident was admitted to the facility from the hospital on [DATE] with instructions to administer the antipsychotic medication, Olanzapine 2.5 milligrams at bedtime for 30 days. The hospital did not inform the facility of the diagnosis for the use of the medication. The medication was given for 30 days and a new prescription was written on 12/30/22 by the facility physician to continue the medication with no time limits. On 11/30/22 the facility pharmacist reviewed the resident's medication and recommended the following: For a patient receiving an anti-psychotic medication to receive the following lab tests every 6 months: 1. BMP (basic metabolic panel) 2. Serium lipid levels 3. Liver function tests 4. CBC (complete blood count) On 12/01/22 the facility physician saw the resident and noted the antipsychotic, Olanzapine was being given for a diagnosis of anxiety. The pharmacist reviewed the resident's medication again on 12/03/22 and the recommendation was the same as 11/30/22. On 01/05/23 at 8:24 AM, the pharmacist was contacted by telephone. He stated, anxiety is not a diagnosis for the use of an antipsychotic and added, I don't like to see an antipsychotic for dementia residents. The pharmacist said his January recommendation will be to alert the physician about obtaining a diagnosis for the use of Olanzapine an antipsychotic. On 01/05/23 at 9:25 AM, the above information was discussed with the Director of Nursing (DON). No further information was provided. d) Resident #9 During a medical record review on 01/04/23, the current physician's orders for Seroquel was 25 milligrams (mg) to be given at bedtime for anxiety. On 08/01/22 the pharmacist had requested a diagnosis for the use of Seroquel on the monthly pharmacy review. Upon further review the physician had reviewed the pharmacy recommendation on 08/03/22 and had failed to respond to the requested diagnosis for the usage of Seroquel. In an interview with the DON on 01/05/23 at 11:55 AM verified the physician had not checked the diagnosis for utilizing the usage of Seroquel. .

. Based on staff interview and record review, the facility failed to ensure the required members attended the 4th quarter Quality Assessment and Assurance (QAA) meeting. This had the potential to affect more than a limited number of residents at the facility. Facility census: 24. Findings included: a) QAA meeting Review of the monthly sign in sheets by the members attending the meeting with the administrator on 01/05/23 at 10:02 AM, confirmed the required members did not attend the 4th quarter (October, November, and December 2022) meetings. The administrator, director of nursing, infection preventionist, and the physician attended the meetings. However, the facility did not meet the requirements for two (2) additional staff members to be in attendance, the facility had only one (1) additional staff member in attendance. .

. Based on record review and staff interview, the facility failed to develop policies and procedures for immunization of residents against pneumococcal disease in accordance with national standards of practice. This deficient practice had the potential to affect more than a limited number of residents eligible to receive pneumococcal vaccination. Facility census: 24. Findings included: a) Pneumococcal vaccine review The facility's policy and procedure entitled Pneumococcal Vaccine with revision date January 2017 stated the facility would identify residents in need of vaccination with pneumococcal vaccine PCV-13. The PCV-13 vaccination is no longer recommended by the Center for Disease Control (CDC). During an interview on 01/04/23 at 1:54 PM, the Infection Preventionist provided documentation that the facility was providing the pneumococcal vaccine PCV-20 to residents eligible for vaccination. PCV-20 is one of the pneumococcal vaccines recommended by the CDC. The Infection Preventionist acknowledged the facility's policy and procedure regarding pneumococcal vaccines was not up-to-date and stated the policy would be updated. No further information was provided through the completion of the survey. .

. Based on record review, staff interview, and resident interview, the facility failed to support a Resident's preference, of declining to get up out of bed and be assisted into resident's wheelchair, for one (1) of out two (2) residents reviewed for choices. Resident identifiers: R #19. Facility census: 24. Findings included: a) Resident Interview During the initial screening process on 09/13/21 at 11:47 a.m., Resident #19 was asked if anyone in the facility has ever been disrespectful to him or treated him unfairly? Resident #19, stated, Yea, its being taken care of, I've had issues with one of the aides [Nurse Aide] yelling at me. I told my counselor [Facility's Social Worker] and she is taking care of it. Resident #19 further explained the NA was pushy and told Resident #19 that getting out of bed was a requirement of Physical Therapy. b) Record Review Review of the facility's grievances and complaints showed a complaint filed by the Social Worker (SW) on 09/09/21 for Resident #19. The SW's statement contained the following documentation verifying the incident: Today, September 9, 2021 between 11:30am and 12pm, I was in my office and heard some yelling coming from [Resident #19's name] room. I heard [Resident #19 first name] yelling and [Certified Nursing Assistant (CNA) #16's first name] yelling. I went into the room and [CNA #15's first name] and [CNA #16 first name] had [Resident #19 first name] in the Hoyer lift with intent to transfer him to his wheelchair. Resident #19's statement contained in the complaint for the incident on 09/09/21 showed the following: I, [Resident's first and last name], was lying in bed when [CNA #16 first name] and [CNA #15 first name] came in room to get me up and into my wheelchair. I told them I did not feel like getting up today. I was tired and I was hurting today. [CNA #16's first name] said I had to get up because that was the agreement with therapy, and I told therapy I would get up. I was tired and hurting and didn't feel like getting up. c) Staff interview On 9/14/21 at 3:31 p.m., during an interview the Person In Charge (PIC) was shown the grievance dated 09/09/21 pertaining to Resident #19's altercation with Nurse Aide (NA) #16 and was asked if she was aware of the incident? The PIC stated, Yes I talked to [NA #16's first name] and she refused to write a statement. The PIC stated no further action had been taken regarding the incident, and Resident #19 and NA #16 have a history of not getting along. During an interview on 09/15/21 at 8:46 a.m., the Social Worker, stated, My office is right beside the Resident's room [Resident #19], I heard CNA #16 yelling at the Resident that she [CNA #16] did not have to put up with him and the Resident needed to get up. The SW further stated, So basically they were in an argument because the Resident [Resident #19] didn't want to get out of bed. On 9/15/21 at 9:30 a.m., Nurse Aide #16 was asked if she remembered getting into any arguments with Resident #19 recently? NA #16, stated, Yea, a few days ago we got into an argument over getting out of bed, [Social Worker's first name] came into the room to see what was wrong. [Resident's name] didn't want to get up out of bed for therapy. NA #16 stated Resident #19 was hard to deal with sometimes and needed to get up for Physical therapy that day but was being stubborn. .

. Based on Record review and staff interview the facility failed to identify and report all allegations of abuse and neglect to appropriate state agencies within appropriate time frames for two (2) of three (3) grievances reviewed for the previous nine (9) months, one (1) of three (3) reportable incidents reviewed for the previous nine (9) months was not reported within required time frames. Resident #225's family made an allegation of abuse on 01/12/21 which was not reported until 01/15/21. Resident #15 and #24 both made allegations of abuse and neither were reported to appropriate state agencies prior to surveyor intervention. Resident Identifiers: #225, #24 and #15. Facility Census: 24. Findings included: a) Resident #225 A review of the reportable incidents for the previous nine (9) months on the afternoon of 09/14/21 found an Immediate Fax Reporting of Allegations: Nursing Home Program. form dated 01/15/21. under the section titled Allegation information the following was found: Date of Incident:01/12/21 Time of Incident: after 8:00 pm. Location of Incident: Resident Room. Brief description of the incident: Resident states she was made to do some of her care. Remove or assist with changing her clothes. Only doing what she can to maintain mobility ROM (Range of Motion) She and son do not believe she should be asked to do this. A review of the investigation related to this reportable incident found a nursing progress note dated 01/12/21 at 8:46 pm. This note read as follows: Spoke to resident's son this evening he stated he had received several phone calls from his mother. His mother has been complaining that she has had to change herself and use her arms in positions she cannot use them. He stated that his mother has had degenerative disease in her shoulders for 30 years and that she should not be asked to perform these tasks herself. He also state that if he receives more phone calls he will be contacting the ombudsman person and complaining. This nurse relayed the message to on coming shift and am also recording it here. This note indicates the staff was aware of this allegation at 8:46 pm on 01/12/21 but failed to report it until 01/15/21 three days later. This was not within the 24 hours requirement for the reporting of alleged allegations. During an interview with the Person in Charge (PIC) on 09/14/21 at 3:38 pm this reportable incident was reviewed with her. She provided no additional insight or information regarding the late reporting of this incident. b) Resident #24 A review of the complaints and concerns for the previous nine (9) months on the afternoon of 09/14/21 found the following compliant form completed for Resident #24. The form was dated 07/27/21 and the attached document read as follows: On 07/27/21, resident (name of Resident #24), was needing to speak with me. I went to her room and she was telling me about an incident that happened with the night shift crew. She stated, I rang my bell about 5 am this morning to go to the bathroom. The two girls came in. they always put my shoes on me and get my walker and I walk to the bathroom. This what the girls did for her. She then continued telling me more, I was on the commode and they brought my clothes into me. I told them it was only 5 am and I was not planning on staying up. I wanted to lay back down. She was very upset telling me about this incident. She went on to say, They told me they were getting me up in my wheelchair because they had other things to do. I asked her if she wanted to file a grievance. She stated no as she was afraid of making things worse and afraid of retaliation. The shift nurse, (name redacted) came in to take (Resident #24's name) blood pressure while we were talking. (Name of Resident #24)'s blood pressure was extremely high. (Nurses Name Redacted) stated she wanted to take it again since (First Name of Resident #24) was so upset. (Name of Resident #24) and I started talking about happier things and (Name of Resident #24) started calming down. (Nurse Name Redacted) took her blood pressure again. It went down some, but was still way to high. (Name of Resident #24) did not know the names of the girls on night shift. According to the schedule, (Name of Nurse Aide (NA) #18) and (Name of NA #13) were scheduled for that shift. This attached statement was written by the Social Worker on 07/28/21. It was attached to the complaint form and the complaint form had the following wrote on it, not wanting grievance filed. Review of the reportable incidents for the previous nine (9) months found no evidence this was reported as an allegation of abuse for forcing the resident to get out of bed before she was ready because they, Had other things to do. The PIC was interviewed about this allegation on 09/14/21 at 03:38 pm when asked if this was reported she stated, No because the resident did not want to file a grievance. c) Resident #15 A review of the complaints and concerns for the previous nine (9) months on the afternoon of 09/14/21 found the following compliant form completed for Resident #15. The form was dated 09/09/21 and the attached document read as follows: Today, September 9, 2021 between 11:30 am and 12:00 pm, I was in my office and heard yelling coming from (Name of Resident #15)'s room. I heard (First name of Resident #15) yelling and CNA (First and Last name of NA #16) yelling. I went into the room and CNA (First name of NA #15) and CNA (First Name of NA #16) had (First name of Resident #15) in the hoyer lift with intent to transfer him to his wheelchair. At this time (First name of Resident #15) and (First Name of NA #16) were yelling back and forth to each other. Both were very upset. I heard (First name of Resident #15) tell (First name of NA #16) he was not talking to her and she needs to quit putting her nose where it doesn't belong and that he doesn't work for her, she works for him. I heard CNA (First name of NA #16) tell him she doesn't have to put up with him treating her that way. I stepped over and put my head on (First name of Resident #15)'s arm and asked him what was going on. I was attempting to calm him down. He looked at me and asked me if I was going to jump him too. I told him no, I came to see what all the yelling was about. CNA (First Name of NA #16) at this time left the room briefly, leaving CNA (First Name of NA #15) and I with (First name of Resident #15) in the hoyer lift. She came back in a few minutes later and helped put (First name of Resident #15) in his wheelchair. I was present the rest of the time they were working with (First name of Resident #15) and no other confrontations occurred. I have spoken with (First name of Resident #15) had he has agreed to write his statement up, he will review it, if he agrees he will sign in. I have also asked CNA (First Name of NA #16) and CNA (First Name of NA #15) for their statements regarding this incident. This attachment was written by the Social worker. Also attached to the complaint form was a statement signed by Resident #15. It read as follows, I, (First and Last name of Resident #15), was lying in bed when (First name of NA #16) and (First Name of NA #15) came in to get me up and into my wheelchair. I told them I did not feel like getting up today. I was tired and I was hurting today. (First name of NA #16) said I had to get up because that was the agreement with therapy and I told therapy I would get up. I was tired and hurting and didn't feel like getting up. They came in the room with the machine and I said, there is that fucking thing. (Name of NA #15) told me I couldn't talk to her like that and she doesn't have to put up with that. I told her I don't work for her she works for me and I was not talking to her I was talking to the machine and she needed to mind her own business. She stormed out of the room and then came back in. (Name of Social Worker) came in the room to see what was going on and she said my name and put her hand on my arm. I looked at her and asked if she wanted to jump me too. She said no she was here to see what was going on. A review of the reportable incidents for the previous nine (9) months was reviewed. There was no evidence this allegation of abuse was reported to the appropriate state agencies. The PIC in an interview on 09/14/21 at 03:38 pm confirmed this allegation had not been reported. She stated she had asked NA #16 to give her a statement and she refused. When asked why she had refused the PIC stated, I don't know. She then indicated. NA #15 was also supposed to write a statement but she had not received it yet either. An interview with NA #16 on 09/15/21 at 10:00 am revealed she had not given the PIC a statement because she was told by the PIC not to worry about it. .

. Based on observation, staff interview, and record review the facility failed to provide activities of daily living (ADL) care for two (2) of (2) residents reviewed during the long - term care survey process. Baths and P.M. care were not provided as ordered. Resident identifier: #17 and #4 Facility Census 24. Findings Included: a) Resident #17 On 09/13/21 at 12:00 p.m., this surveyor observed Resident #17 to still be in bed and in night clothes. Facility staff were in the process of passing lunch trays. A Review of the Orange and Blue Wing Bath Schedule reveals Resident # 17 should receive a bath on Tuesday and Fridays in the a.m. Further review of the Point of Care History form from 07/01/21 to 08/31/21 revealed Resident # 17 did not receive a bath on the following days: 07/02/21 07/09/21 07/13/21 07/16/21 07/20/21 07/30/21 08/03/21 08/10/21 08/17/21 08/20/21 08/27/21 On 09/14/21 at 4:02 PM, the Person In Charge (PIC) acknowledged the facility failed to provide ADL care to Resident #17 on the above mentioned days. b) Resident #4 On 09/14/21 at 9:25 a.m., this surveyor observed Resident #4 to be in the same clothes worn on 09/13/21. An interview , on 09/14/21 at 9:29 a.m., with Social Worker (SS)#49, confirmed that resident #4 was still in the same clothes worn on 09/13/21 and that p.m. care was not given. A Review of the Orange and Blue Wing Bath Schedule reveals Resident # 4 should receive a bath on Wednesday and Saturdays in the p.m. Further review of the of the Point of Care History form from 08/01/21 to 08/31/21 revealed Resident # 4 did not receive a bath on the following days: 08/04/21 08/07/21 08/11/21 08/14/21 08/18/21 The PIC at 10:30 a.m. on 09/14/21, acknowledged on the above-mentioned dates Resident #4 did not receive ADL care or p.m. care. .

. Based on medical record review, observation, and staff interview, the facility failed to ensure Resident's received treatment and care in accordance with professional standards of practice. Specifically, physician's orders were not followed. This practice affected one (1) of five (5) residents reviewed for unnecessary medications, during the Long-Term Care Survey Process (LTCSP). Resident identifier #1. Facility census: 24. Findings included: a) Resident #1 Review of Resident #1's medical record on 09/14/21 at 08:22 a.m., showed Physicians orders for the following laboratory tests: --Magnesium, Serum; every six (6) months in August and February with the start date 09/11/21. --A blood Urea Nitrogen (BUN) and Creatinine level; every six (6) months in August and February with the start date 09/11/21. Further review of the resident's medical record showed it did not contain the ordered laboratory reports for Magnesium, Serum, BUN and Creatinine levels. An interview on 09/14/21 at 9:45 a.m., with Registered Nurse (RN) # 46 confirmed the laboratory tests were not obtained as ordered. No further information was provided to the surveyor prior to the exit of the annual survey on 09/15/21 at 1:30 p.m. .

. Based on observation and staff interview the facility failed to complete labeling and dates on refrigerator and freezer items in accordance with professional standards for food service safety related to storage. This has the ability to affect a limited number of residents that get their nutrition from the kitchen. Facility Census: 24. Findings Included: Record review of the facility's policy titled, Food Storage, showed that All food should be covered, labeled, and dated. All food will be checked to assure that foods will be consumed by their safe use by dates or discarded. a) Kitchen During the initial kitchen tour on 07/26/21 at 11:35 a.m., an observation found: --Walk-in refrigerator - 24 poured cups of fruit cocktail, not labeled or dated. --Walk-in Freezer- two (2) clear bags of broccoli, not labeled or dated. -- Reach in refrigerator - one (1) sandwich on a plate and one (1) gallon size zip lock bag of grapes, not labeled or dated. During an interview on 09/13/21 at 11:40 a.m., staff #22, Dietary Assistant, confirmed the items were not labeled. Staff #22 stated that all food items should be labeled and dated. .

. Based on record review and staff interview the facility failed to ensure they thoroughly investigated the background of each employee to make sure they did not have a history of abuse, neglect, exploitation, misappropriation of property, or mistreatment of residents. The facility had four (4) active employees who did not have a background check in place. Additionally one (1) former nurse aide (NA) who had allegations of abuse made against her while employed did not have a background check prior to being hired by the facility. This practice had the potential to affect more than a limited number of residents currently residing in the facility. Facility Census: 24. a) WV Clearance for Access: Registry & Employment Screening (WV CARES) WV CARES uses web-based technologies to provide employers a single portal for checking state and national abuse registries and the state and national sex offender registries. The web-based system also provides employers access to Nurse Aide Registries for all 50 states and professional licensure registries where available. The web-based system provides an efficient and effective means for an employer to check an applicant's status prior to paying the cost of a criminal history background check. Through fingerprinting, this program provides a comprehensive criminal history records search of national and state criminal history records that was not available under the previous reliance on name-based records searches. The program relies on new technology to monitor criminal histories and alert officials when a subsequent change in criminal history occurs (i.e., rap back). A monitored criminal history record means the cost of re-fingerprinting is not required for employees who change employers in this industry (or apply for work at more than one employer) within the timeframe of a valid background check. All fitness determinations will be performed by WV CARES for individuals who have cleared state and federal background check requirements. Employers will receive a notice of the applicant's employment eligibility once the fingerprint-based background check results are reviewed. Facilities cannot hire an applicant until the applicant has been cleared through the required registry check within the WV CARES system. Facilities will access the required registry check via the web-based WV CARES system. The fingerprint-based background check is a report that provides criminal history record information on an applicant. A facility must request a fingerprint-based background check before hiring an individual. An applicant may be provisionally employed for up to 60 days while the WV CARES fitness determination is pending. All provisional employees must be supervised by an employee who has cleared both the criminal background and the required registry checks. The [NAME] Virginia State Police contracts with a private agency to securely capture and transmit fingerprints to be processed through the State Police and the FBI. Any nursing home that knowingly hires or retains a person who has been convicted of a disqualifying offense will be in violation of [NAME] Virginia State Code §16-5C-21 and 64 CSR 13 Nursing Home Licensure Rules. All information listed above was obtained from the WV CARES website located at web address: https://www.wvdhhr.org/oig/wvcares.html. b) Facility Staff On 09/14/21 the WV CARES eligibility determination letter was requested for all current staff and former Nurse Aide (NA) #100. The facility was unable to provide the WV CARES eligibility determination letter for Licensed Practical Nurse (LPN) #26, Hospitality Aide (HA) #32, Social Worker #49 and the Registered Dietician. They were also not able to provide the eligibility determination letter for NA #100. An interview with the Person in Charge (PIC) on 09/14/21 at 3:38 pm confirmed she had not checked the aforementioned staffs eligibility through the WV CARES program. When asked if any other background check had been performed she indicated they had not. Former NA #100 worked at the facility from 05/03/21 until 08/20/21. During which time she had an allegation of physical abuse made against her related to her forcibly removing a residents hand from the hand rail in an attempt to redirect them. When the PIC was asked why her WV CARES was not checked she stated, I asked her to go get her fingerprints and she never did. The PIC offered no other explanation at to why the four (4) current employees had not been determined eligible through the WV CARES system. Social Worker #49 has been an active employee at the facility since 02/03/21. LPN #26 has been an active employee at the facility since 01/04/21. HA #32 has been an active employee at the facility since 05/20/20. The Registered Dietician date of hire was not provided by the facility even though it was requested by the surveyor. .

. Based on record review and staff interview the facility failed to ensure they developed and implemented abuse policies in regards to investigating the back ground of potential new hires, and reporting all allegations of abuse and neglect. This practice had the potential to affect more than a limited number of residents currently residing in the facility. Facility Census: 24. a) Policy A review of the facility's policy titled: Resident Abuse (Prohibition ) found the following, . Implementation: 1. All potential new employees and volunteers will be screened for a history of abuse, neglect, or mistreatment of residents 8. The facility will identify and investigate all suspicions or allegations of abuse. Any allegations of abuse to the residents shall be reported immediately to the supervisory person in charge and to the Administrator. A report will be made immediately to the appropriate state agencies as required b) Employee Background Checks 1) WV Clearance for Access: Registry & Employment Screening (WV CARES) WV CARES uses web-based technologies to provide employers a single portal for checking state and national abuse registries and the state and national sex offender registries. The web-based system also provides employers access to Nurse Aide Registries for all 50 states and professional licensure registries where available. The web-based system provides an efficient and effective means for an employer to check an applicant's status prior to paying the cost of a criminal history background check. Through fingerprinting, this program provides a comprehensive criminal history records search of national and state criminal history records that was not available under the previous reliance on name-based records searches. The program relies on new technology to monitor criminal histories and alert officials when a subsequent change in criminal history occurs (i.e., rap back). A monitored criminal history record means the cost of re-fingerprinting is not required for employees who change employers in this industry (or apply for work at more than one employer) within the timeframe of a valid background check. All fitness determinations will be performed by WV CARES for individuals who have cleared state and federal background check requirements. Employers will receive a notice of the applicant's employment eligibility once the fingerprint-based background check results are reviewed. Facilities cannot hire an applicant until the applicant has been cleared through the required registry check within the WV CARES system. Facilities will access the required registry check via the web-based WV CARES system. The fingerprint-based background check is a report that provides criminal history record information on an applicant. A facility must request a fingerprint-based background check before hiring an individual. An applicant may be provisionally employed for up to 60 days while the WV CARES fitness determination is pending. All provisional employees must be supervised by an employee who has cleared both the criminal background and the required registry checks. The [NAME] Virginia State Police contracts with a private agency to securely capture and transmit fingerprints to be processed through the State Police and the FBI. Any nursing home that knowingly hires or retains a person who has been convicted of a disqualifying offense will be in violation of [NAME] Virginia State Code §16-5C-21 and 64 CSR 13 Nursing Home Licensure Rules. All information listed above was obtained from the WV CARES website located at web address: https://www.wvdhhr.org/oig/wvcares.html. 2) Facility Staff On 09/14/21 the WV CARES eligibility determination letter was requested for all current staff and former Nurse Aide (NA) #100. The facility was unable to provide the WV CARES eligibly determination letter for Licensed Practical Nurse (LPN) #26, Hospitality Aide (HA) #32, Social Worker #49 and the Registered Dietician. An interview with the Person in Charge (PIC) on 09/14/21 at 3:38 pm confirmed she had checked the aforementioned staffs eligibility through the WV CARES program. When asked if any other background check had been performed she indicated they had not. Former NA #100 worked at the facility from 05/03/21 until 08/20/21. During which time she had an allegation of physical abuse made against her related to her forcibly removing a residents hand from the hand rail in an attempt to redirect them. When the PIC was asked why her WV CARES was not checked she stated, I asked her to go get her fingerprints and she never did. The PIC offered no other explanation at to why the four (4) current employees had not been determined eligible through the WV CARES system. Social Worker #49 has been an active employee at the facility since 02/03/21. LPN #26 has been an active employee at the facility since 01/04/21. HA #32 has been an active employee at the facility since 05/20/20. The Registered Dietician date of hire was not provided by the facility even though it was requested on multiple occasions. c) Reporting of Alleged Abuse 1) Resident #225 A review of the reportable incidents for the previous nine (9) months on the afternoon of 09/14/21 found an Immediate Fax Reporting of Allegations: Nursing Home Program. form dated 01/15/21. under the section titled Allegation information the following was found: Date of Incident:01/12/21 Time of Incident: after 8:00 pm. Location of Incident: Resident Room. Brief description of the incident: Resident states she was made to do some of her care. Remove or assist with changing her clothes. Only doing what she can to maintain mobility ROM (Range of Motion) She and son do not believe she should be asked to do this. A review of the investigation related to this reportable incident found a nursing progress note dated 01/12/21 at 8:46 pm. This note read as follows: Spoke to resident's son this evening he stated he had received several phone calls from his mother. His mother has been complaining that she has had to change herself and use her arms in positions she cannot use them. He stated that his mother has had degenerative disease in her shoulders for 30 years and that she should not be asked to perform these tasks herself. He also state that if he receives more phone calls he will be contacting the ombudsman person and complaining. This nurse relayed the message to on coming shift and am also recording it here. This note indicates the staff was aware of this allegation at 8:46 pm on 01/12/21 but failed to report it until 01/15/21 three (3) days later. This was not within the 24 hour requirement for the reporting of alleged allegations. During an interview with the Person in Charge (PIC) on 09/14/21 at 3:38 pm this reportable incident was reviewed with her. She provided no additional insight or information regarding the late reporting of this incident. 2) Resident #24 A review of the complaints and concerns for the previous nine (9) months on the afternoon of 09/14/21 found the following compliant form completed for Resident #24. The form was dated 07/27/21 and the attached document read as follows: On 07/27/21, resident (name of Resident #24), was needing to speak with me. I went to her room and she was telling me about an incident that happened with the night shift crew. She stated, I rang my bell about 5 am this morning to go to the bathroom. The two girls came in. they always put my shoes on me and get my walker and I walk to the bathroom. This what the girls did for her. She then continued telling me more, I was on the commode and they brought my clothes into me. I told them it was only 5 am and I was not planning on staying up. I wanted to lay back down. She was very upset telling me about this incident. She went on to say, They told me they were getting me up in my wheelchair because they had other things to do. I asked her if she wanted to file a grievance. She stated no as she was afraid of making things worse and afraid of retaliation. The shift nurse, (name redacted) came in to take (Resident #24's name) blood pressure while we were talking. (Name of Resident #24)'s blood pressure was extremely high. (Nurses Name Redacted) stated she wanted to take it again since (First Name of Resident #24) was so upset. (Name of Resident #24) and I started talking about happier things and (Name of Resident #24) started calming down. (Nurse Name Redacted) took her blood pressure again. It went down some, but was still way to high. (Name of Resident #24) did not know the names of the girls on night shift. According to the schedule, (Name of Nurse Aide (NA) #18) and (Name of NA #13) were scheduled for that shift. This attached statement was written by the Social Worker on 07/28/21. It was attached to the complaint form and the complaint form had the following wrote on it, not wanting grievance filed. Review of the reportable incidents for the previous nine (9) months found no evidence this was reported as an allegation of abuse for forcing the resident to get out of bed before she was ready because they, Had other things to do. The PIC was interviewed about this allegation on 09/14/21 at 03:38 pm when asked if this was reported she stated, No because the resident did not want to file a grievance. 3) Resident #15 A review of the complaints and concerns for the previous nine (9) months on the afternoon of 09/14/21 found the following compliant form completed for Resident #15. The form was dated 09/09/21 and the attached document read as follows: Today, September 9, 2021 between 11:30 am and 12:00 pm, I was in my office and heard yelling coming from (Name of Resident #15)'s room. I heard (First name of Resident #15) yelling and CNA (First and Last name of NA #16) yelling. I went into the room and CNA (First name of NA #15) and CNA (First Name of NA #16) had (First name of Resident #15) in the hoyer lift with intent to transfer him to his wheelchair. At this time (First name of Resident #15) and (First Name of NA #16) were yelling back and forth to each other. Both were very upset. I heard (First name of Resident #15) tell (First name of NA #16) he was not talking to her and she needs to quit putting her nose where it doesn't belong and that he doesn't work for her, she works for him. I heard CNA (First name of NA #16) tell him she doesn't have to put up with him treating her that way. I stepped over and put my head on (First name of Resident #15)'s arm and asked him what was going on. I was attempting to calm him down. He looked at me and asked me if I was going to jump him too. I told him no, I came to see what all the yelling was about. CNA (First Name of NA #16) at this time left the room briefly, leaving CNA (First Name of NA #15) and I with (First name of Resident #15) in the hoyer lift. She came back in a few minutes later and helped put (First name of Resident #15) in his wheelchair. I was present the rest of the time they were working with (First name of Resident #15) and no other confrontations occurred. I have spoken with (First name of Resident #15) had he has agreed to write his statement up, he will review it, if he agrees he will sign in. I have also asked CNA (First Name of NA #16) and CNA (First Name of NA #15) for their statements regarding this incident. This attachment was written by the Social worker. Also attached to the complaint form was a statement signed by Resident #15. It read as follows, I, (First and Last name of Resident #15), was lying in bed when (First name of NA #16) and (First Name of NA #15) came in to get me up and into my wheelchair. I told them I did not feel like getting up today. I was tired and I was hurting today. (First name of NA #16) said I had to get up because that was the agreement with therapy and I told therapy I would get up. I was tired and hurting and didn't feel like getting up. They came in the room with the machine and I said, there is that fucking thing. (Name of NA #15) told me I couldn't talk to her like that and she doesn't have to put up with that. I told her I don't work for her she works for me and I was not talking to her I was talking to the machine and she needed to mind her own business. She stormed out of the room and then came back in. (Name of Social Worker) came in the room to see what was going on and she said my name and put her hand on my arm. I looked at her and asked if she wanted to jump me too. She said no she was here to see what was going on. A review of the reportable incidents for the previous nine (9) months was reviewed. There was no evidence this allegation of abuse was reported to the appropriate state agencies. The PIC in an interview on 09/14/21 at 03:38 pm confirmed this allegation had not been reported. She stated she had asked NA #16 to give her a statement and she refused. When asked why she had refused the PIC stated, I don't know. She then indicated. NA #15 was also supposed to write a statement but she had not received it yet either. An interview with NA #16 on 09/15/21 at 10:00 am revealed she had not given the PIC a statement because she was told by the PIC not to worry about it. .

. Based on record review, observation, and staff interview the facility was not administered in a manner that enabled it to use its resources efficiently and effectively to enable each resident to attain and/or maintain the highest practicable physical, mental, and psychosocial well being. The facility failed to implement their abuse policy. They failed to hold quarterly Quality assurance meetings with all required attendees. They failed to ensure back ground checks for each employee was conducted prior too the employee starting to work at the facility. They failed to complete the required facility assessment. Finally, the facility failed to implement their infection control program to prevent the spread of COVID - 19. These failed practices had the potential to affect all residents currently residing in the facility. Facility Census: 24. Findings included: a) F606 On 09/14/21 the WV CARES eligibility determination letter was requested for all current staff and former Nurse Aide (NA) #100. The facility was unable to provide the WV CARES eligibility determination letter for Licensed Practical Nurse (LPN) #26, Hospitality Aide (HA) #32, Social Worker #49 and the Registered Dietician. They were also not able to provide the eligibility determination letter for NA #100. An interview with the Person in Charge (PIC) on 09/14/21 at 3:38 pm confirmed she had not checked the aforementioned staffs eligibility through the WV CARES program. When asked if any other background check had been performed she indicated they had not. Former NA #100 worked at the facility from 05/03/21 until 08/20/21. During which time she had an allegation of physical abuse made against her related to her forcibly removing a residents hand from the hand rail in an attempt to redirect them. When the PIC was asked why her WV CARES was not checked she stated, I asked her to go get her fingerprints and she never did. The PIC offered no other explanation at to why the four (4) current employees had not been determined eligible through the WV CARES system. Social Worker #49 has been an active employee at the facility since 02/03/21. LPN #26 has been an active employee at the facility since 01/04/21. HA #32 has been an active employee at the facility since 05/20/20. The Registered Dietician date of hire was not provided by the facility even though it was requested by the surveyor. b) F607 A review of the facility's policy titled: Resident Abuse (Prohibition ) found the following, . Implementation: 1. All potential new employees and volunteers will be screened for a history of abuse, neglect, or mistreatment of residents 8. The facility will identify and investigate all suspicions or allegations of abuse. Any allegations of abuse to the residents shall be reported immediately to the supervisory person in charge and to the Administrator. A report will be made immediately to the appropriate state agencies as required On 09/14/21 the WV CARES eligibility determination letter was requested for all current staff and former Nurse Aide (NA) #100. The facility was unable to provide the WV CARES eligibly determination letter for Licensed Practical Nurse (LPN) #26, Hospitality Aide (HA) #32, Social Worker #49 and the Registered Dietician. An interview with the Person in Charge (PIC) on 09/14/21 at 3:38 pm confirmed she had checked the aforementioned staffs eligibility through the WV CARES program. When asked if any other background check had been performed she indicated they had not. Former NA #100 worked at the facility from 05/03/21 until 08/20/21. During which time she had an allegation of physical abuse made against her related to her forcibly removing a residents hand from the hand rail in an attempt to redirect them. When the PIC was asked why her WV CARES was not checked she stated, I asked her to go get her fingerprints and she never did. The PIC offered no other explanation at to why the four (4) current employees had not been determined eligible through the WV CARES system. Social Worker #49 has been an active employee at the facility since 02/03/21. LPN #26 has been an active employee at the facility since 01/04/21. HA #32 has been an active employee at the facility since 05/20/20. The Registered Dietician date of hire was not provided by the facility even though it was requested on multiple occasions. A review of the reportable incidents for the previous nine (9) months on the afternoon of 09/14/21 found an Immediate Fax Reporting of Allegations: Nursing Home Program. form dated 01/15/21. under the section titled Allegation information the following was found: Date of Incident:01/12/21 Time of Incident: after 8:00 pm. Location of Incident: Resident Room. Brief description of the incident: Resident states she was made to do some of her care. Remove or assist with changing her clothes. Only doing what she can to maintain mobility ROM (Range of Motion) She and son do not believe she should be asked to do this. A review of the investigation related to this reportable incident found a nursing progress note dated 01/12/21 at 8:46 pm. This note read as follows: Spoke to resident's son this evening he stated he had received several phone calls from his mother. His mother has been complaining that she has had to change herself and use her arms in positions she cannot use them. He stated that his mother has had degenerative disease in her shoulders for 30 years and that she should not be asked to perform these tasks herself. He also state that if he receives more phone calls he will be contacting the ombudsman person and complaining. This nurse relayed the message to on coming shift and am also recording it here. This note indicates the staff was aware of this allegation at 8:46 pm on 01/12/21 but failed to report it until 01/15/21 three (3) days later. This was not within the 24 hour requirement for the reporting of alleged allegations. During an interview with the Person in Charge (PIC) on 09/14/21 at 3:38 pm this reportable incident was reviewed with her. She provided no additional insight or information regarding the late reporting of this incident. A review of the complaints and concerns for the previous nine (9) months on the afternoon of 09/14/21 found the following compliant form completed for Resident #24. The form was dated 07/27/21 and the attached document read as follows: On 07/27/21, resident (name of Resident #24), was needing to speak with me. I went to her room and she was telling me about an incident that happened with the night shift crew. She stated, I rang my bell about 5 am this morning to go to the bathroom. The two girls came in. they always put my shoes on me and get my walker and I walk to the bathroom. This what the girls did for her. She then continued telling me more, I was on the commode and they brought my clothes into me. I told them it was only 5 am and I was not planning on staying up. I wanted to lay back down. She was very upset telling me about this incident. She went on to say, They told me they were getting me up in my wheelchair because they had other things to do. I asked her if she wanted to file a grievance. She stated no as she was afraid of making things worse and afraid of retaliation. The shift nurse, (name redacted) came in to take (Resident #24's name) blood pressure while we were talking. (Name of Resident #24)'s blood pressure was extremely high. (Nurses Name Redacted) stated she wanted to take it again since (First Name of Resident #24) was so upset. (Name of Resident #24) and I started talking about happier things and (Name of Resident #24) started calming down. (Nurse Name Redacted) took her blood pressure again. It went down some, but was still way to high. (Name of Resident #24) did not know the names of the girls on night shift. According to the schedule, (Name of Nurse Aide (NA) #18) and (Name of NA #13) were scheduled for that shift. This attached statement was written by the Social Worker on 07/28/21. It was attached to the complaint form and the complaint form had the following wrote on it, not wanting grievance filed. Review of the reportable incidents for the previous nine (9) months found no evidence this was reported as an allegation of abuse for forcing the resident to get out of bed before she was ready because they, Had other things to do. The PIC was interviewed about this allegation on 09/14/21 at 03:38 pm when asked if this was reported she stated, No because the resident did not want to file a grievance. A review of the complaints and concerns for the previous nine (9) months on the afternoon of 09/14/21 found the following compliant form completed for Resident #15. The form was dated 09/09/21 and the attached document read as follows: Today, September 9, 2021 between 11:30 am and 12:00 pm, I was in my office and heard yelling coming from (Name of Resident #15)'s room. I heard (First name of Resident #15) yelling and CNA (First and Last name of NA #16) yelling. I went into the room and CNA (First name of NA #15) and CNA (First Name of NA #16) had (First name of Resident #15) in the hoyer lift with intent to transfer him to his wheelchair. At this time (First name of Resident #15) and (First Name of NA #16) were yelling back and forth to each other. Both were very upset. I heard (First name of Resident #15) tell (First name of NA #16) he was not talking to her and she needs to quit putting her nose where it doesn't belong and that he doesn't work for her, she works for him. I heard CNA (First name of NA #16) tell him she doesn't have to put up with him treating her that way. I stepped over and put my head on (First name of Resident #15)'s arm and asked him what was going on. I was attempting to calm him down. He looked at me and asked me if I was going to jump him too. I told him no, I came to see what all the yelling was about. CNA (First Name of NA #16) at this time left the room briefly, leaving CNA (First Name of NA #15) and I with (First name of Resident #15) in the hoyer lift. She came back in a few minutes later and helped put (First name of Resident #15) in his wheelchair. I was present the rest of the time they were working with (First name of Resident #15) and no other confrontations occurred. I have spoken with (First name of Resident #15) had he has agreed to write his statement up, he will review it, if he agrees he will sign in. I have also asked CNA (First Name of NA #16) and CNA (First Name of NA #15) for their statements regarding this incident. This attachment was written by the Social worker. Also attached to the complaint form was a statement signed by Resident #15. It read as follows, I, (First and Last name of Resident #15), was lying in bed when (First name of NA #16) and (First Name of NA #15) came in to get me up and into my wheelchair. I told them I did not feel like getting up today. I was tired and I was hurting today. (First name of NA #16) said I had to get up because that was the agreement with therapy and I told therapy I would get up. I was tired and hurting and didn't feel like getting up. They came in the room with the machine and I said, there is that fucking thing. (Name of NA #15) told me I couldn't talk to her like that and she doesn't have to put up with that. I told her I don't work for her she works for me and I was not talking to her I was talking to the machine and she needed to mind her own business. She stormed out of the room and then came back in. (Name of Social Worker) came in the room to see what was going on and she said my name and put her hand on my arm. I looked at her and asked if she wanted to jump me too. She said no she was here to see what was going on. A review of the reportable incidents for the previous nine (9) months was reviewed. There was no evidence this allegation of abuse was reported to the appropriate state agencies. The PIC in an interview on 09/14/21 at 03:38 pm confirmed this allegation had not been reported. She stated she had asked NA #16 to give her a statement and she refused. When asked why she had refused the PIC stated, I don't know. She then indicated. NA #15 was also supposed to write a statement but she had not received it yet either. An interview with NA #16 on 09/15/21 at 10:00 am revealed she had not given the PIC a statement because she was told by the PIC not to worry about it. c) F838 On 09/14/21 at 4:32 p.m., Maintenance Staff (MS)#39 brought an incomplete facility assessment to the survey team. The assessment was a computer generated form with blank areas to insert facility specific information. All the blank areas where facility specific information was to be inserted was blank. On 09/15/21 at 10:00 a.m., it was brought to the Person In Charge's (PIC) attention the facility assessment was not completed. The PIC stated they printed out the wrong one and indicated they would get the completed version to the survey team. At 11:34 a.m. on 09/15/21, The PIC confirmed they did not have a completed Facility Assessment. She indicated the first copy which was provided was the only copy they had. d) F868 During an interview on 09/14/21, at 4:45 p.m. the Person in Charge (PIC) stated, We [the facility] met in December [December of 2020], then not again until June or July due to Covid. The PIC was asked if they held virtual meetings or phone conferences during the time period of Covid that was specified for meeting purposes, the PIC stated, No we just didn't have them [QA meetings]. Review of Quality Assurance (QA) sign-in sheets provided by the Person in Charge (PIC) showed QA meetings were held the following dates in 2020 and 2021: 02/26/20 07/17/20 12/23/20 07/30/21 08/13/21 The sign-in sheet for the QA meeting held on 07/17/20 only showed three (3) attendees present, Administrator, Director of Nursing and Medical Director. The sign-in sheet for the QA meetings held on 07/30/21 and 08/13/21 showed the Registered Nurse that was in attendance was not functioning in the role as the Director of Nursing (DON) for the meetings; therefore, the committee was without a DON in attendance. e) F880 Based on observation, record review and staff interview the facility failed to establish and maintain an infection control program designed to provide a safe, sanitary, comfortable environment and to help prevent the development and transmission of communicable diseases and infection, including Covid-19. Facility staff improperly donned personal protective equipment and failed to effectively screen and educate individuals on Covid-19 precautions that were permitted entry to the facility. The facility's Covid-19 policy was not updated or reviewed annually. These failed practices have the potential to affect all residents currently residing at the facility. Facility census: 24. During an interview on 09/15/21 at 9:23 a.m., the Infection Control Nurse (ICN) stated the facility does not have a policy for Covid-19. The ICN was asked how staff knew what to do in the event of an outbreak of Covid-19 among the Residents, the ICN stated, We have nothing written other than resource material I have gathered up along the way. We are told to call [Person in Charge's first name] if we need to know where to put quarantined residents. During an interview on 09/15/ 21 at 11:11 a.m., the Registered Nurse (RN) #47 stated the facility does a few policies kept in the Occupational Safety and Health Administration (OSHA) book that the previous Administrator had started working on before leaving. RN #47 provided surveyor with copy of policies titled, Covid-19 Pre-Pandemic Monitoring and Precautions, and Covid-19 Reporting Requirements for Covid-19. RN #47 stated, These are the polices I use for education, that's why I keep them here are the nurse's station in the OSHA book. RN #47 was asked if an updated version or reviewed version of the policy existed, and RN #47 stated, I doubt it we are lucky to have these. Record review of the facility's policy titled, Covid-19 Pre-Pandemic Monitoring and Precautions, was dated 06/2020, with no review date listed. Record review of the facility's policy titled, Covid-19 Reporting Requirements for Covid-19, was dated 06/2020, with no review date listed. Observations made throughout the day on 09/14/21 found the Medical Secretary (MS) #42 was wearing a blue surgical mask under a white N95 mask. The blue surgical masks edges were sticking out from under the edges of the white N95 mask therefore preventing the N95 from properly sealing. During the day on 09/14/21 MS #42 was seen screening employees and visitors to the building at the front door as they entered the building. She was also seen going room to room delivering supplies to the residents rooms. Also during the day of 09/14/21 the facility's Physical Therapy Assistant and the Occupational Therapist was seen moving through out the facility also wearing a blue surgical mask under a white N95 mask. The blue surgical masks edges were sticking out from under the edges of the white N95 mask therefore preventing the the N95 from properly sealing. The facility is in an active out break of COVID - 19 among the staff. The first positive staff member was identified on 09/10/21 and as of 09/14/21 they have three (3) staff members who have tested positive for COVID - 19. An interview with Registered Nurse (RN) #46 and RN # 47 on 09/14/21 at 4:30 pm confirmed the staff members should not be wearing a surgical mask under their N95. RN #46 went out of the room and spoke with MS #42 and the staff members from therapy and stated they were doing this because the N95 breaks their face out. She stated, We will try to order some different types of masks for them. According to the Centers for Disease Control (CDC) wearing two (2) disposable masks is not recommended. On 09/15/21 at 8:39 a.m. Housekeeping staff (HS) #38 was being screened for entry by Social Service (SS)#49. Upon entry HS#38 did not use alcohol based hand rub (ABHR) , nor was HS #38 directed to use ABHR before entering. HS#38 did not have a facemask and was given a surgical mask. Register Nurse (RN) #47 stated it will be alright HS#38 does not need an N95 mask since he will not be around patients. An interview on 09/15/21 at 8:45 a.m., SS #49 acknowledged that ABHR should be used before entering the facility, and HS#38 and all staff will need a N95 mask due to the recent COVID-19 outbreak in the facility. f) F885 On 09/13/21 at 11:15 AM it was identified upon survey teams arrival the facility was in a COVID-19 outbreak due to the three confirmed positive staff members. Staff Members #41 from Maintenance, Staff Member #31 Hospitality Aid and Staff Member #10 Activities. An interview on 09/15/21 at 9:30 a.m., Social Service (SS) # 49 acknowledged that they had not contacted any family or family representatives of the COVID-19 outbreak at the facility. Regulation 483.80(g)(3) states that the facility must Inform residents, their representatives, and families of those residing in facilities by 5 p.m. the next calendar day following the occurrence of either a single confirmed infection of COVID-19, or three or more residents or staff with new-onset of respiratory symptoms occurring within 72 hours of each other. The first (1st) positive staff member was identified on 09/10/21. The facility had until 5:00 pm on 09/11/21 to notify the resident's , their representatives, and families of the positive staff member. This was not completed. .

. Based on record review,and staff interview the facility failed complete the required facility assessment. This failed practice had the potential to affect all residents currently residing in the facility. Facility Census: 24. Findings included: a) Facility Assessment On 09/14/21 at 4:32 p.m., Maintenance Staff (MS)#39 brought an incomplete facility assessment to the survey team. The assessment was a computer generated form with blank areas to insert facility specific information. All the blank areas where facility specific information was to be inserted was blank. On 09/15/21 at 10:00 a.m., it was brought to the Person In Charge's (PIC) attention the facility assessment was not completed. The PIC stated they printed out the wrong one and indicated they would get the completed version to the survey team. At 11:34 a.m. on 09/15/21, The PIC confirmed they did not have a completed Facility Assessment. She indicated the first copy which was provided was the only copy they had. .

. Based on staff interview and record review, the facility failed to meet at least quarterly for Quality Assurance (QA), with the required Quality Assessment Assurance committee members, in order to identify and correct quality deficiencies effectively. This failed practice had the potential to affect all residents residing at the facility. Facility census: 24. Findings included: a) Staff Interview During an interview on 09/14/21, at 4:45 p.m. the Person in Charge (PIC) stated, We [the facility] met in December [December of 2020], then not again until June or July due to Covid. The PIC was asked if they held virtual meetings or phone conferences during the time period of Covid that was specified for meeting purposes, the PIC stated, No we just didn't have them [QA meetings]. b) Record Review Review of Quality Assurance (QA) sign-in sheets provided by the Person in Charge (PIC) showed QA meetings were held the following dates in 2020 and 2021: 02/26/20 07/17/20 12/23/20 07/30/21 08/13/21 The sign-in sheet for the QA meeting held on 07/17/20 only showed three (3) attendees present, Administrator, Director of Nursing and Medical Director. The sign-in sheet for the QA meetings held on 07/30/21 and 08/13/21 showed the Registered Nurse that was in attendance was not functioning in the role as the Director of Nursing (DON) for the meetings; therefore, the committee was without a DON in attendance. .

. Based on observation, record review and staff interview the facility failed to establish and maintain an infection control program designed to provide a safe, sanitary, comfortable environment and to help prevent the development and transmission of communicable diseases and infection, including Covid-19. Facility staff improperly donned personal protective equipment and failed to effectively screen and educate individuals on Covid-19 precautions that were permitted entry to the facility. The facility's Covid-19 policy was not updated or reviewed annually. These failed practices have the potential to affect all residents currently residing at the facility. Facility census: 24. a) Covid-19 Policy During an interview on 09/15/21 at 9:23 a.m., the Infection Control Nurse (ICN) stated the facility does not have a policy for Covid-19. The ICN was asked how staff knew what to do in the event of an outbreak of Covid-19 among the Residents, the ICN stated, We have nothing written other than resource material I have gathered up along the way. We are told to call [Person in Charge's first name] if we need to know where to put quarantined residents. During an interview on 09/15/ 21 at 11:11 a.m., the Registered Nurse (RN) #47 stated the facility does a few policies kept in the Occupational Safety and Health Administration (OSHA) book that the previous Administrator had started working on before leaving. RN #47 provided surveyor with copy of policies titled, Covid-19 Pre-Pandemic Monitoring and Precautions, and Covid-19 Reporting Requirements for Covid-19. RN #47 stated, These are the polices I use for education, that's why I keep them here are the nurse's station in the OSHA book. RN #47 was asked if an updated version or reviewed version of the policy existed, and RN #47 stated, I doubt it we are lucky to have these. Record review of the facility's policy titled, Covid-19 Pre-Pandemic Monitoring and Precautions, was dated 06/2020, with no review date listed. Record review of the facility's policy titled, Covid-19 Reporting Requirements for Covid-19, was dated 06/2020, with no review date listed. b) Masks Observations made throughout the day on 09/14/21 found the Medical Secretary (MS) #42 was wearing a blue surgical mask under a white N95 mask. The blue surgical masks edges were sticking out from under the edges of the white N95 mask therefore preventing the N95 from properly sealing. During the day on 09/14/21 MS #42 was seen screening employees and visitors to the building at the front door as they entered the building. She was also seen going room to room delivering supplies to the residents rooms. Also during the day of 09/14/21 the facility's Physical Therapy Assistant and the Occupational Therapist was seen moving through out the facility also wearing a blue surgical mask under a white N95 mask. The blue surgical masks edges were sticking out from under the edges of the white N95 mask therefore preventing the the N95 from properly sealing. The facility is in an active out break of COVID - 19 among the staff. The first positive staff member was identified on 09/10/21 and as of 09/14/21 they have three (3) staff members who have tested positive for COVID - 19. An interview with Registered Nurse (RN) #46 and RN # 47 on 09/14/21 at 4:30 pm confirmed the staff members should not be wearing a surgical mask under their N95. RN #46 went out of the room and spoke with MS #42 and the staff members from therapy and stated they were doing this because the N95 breaks their face out. She stated, We will try to order some different types of masks for them. According to the Centers for Disease Control (CDC) wearing two (2) disposable masks is not recommended. c) Entrance Screening On 09/15/21 at 8:39 a.m. Housekeeping staff (HS) #38 was being screened for entry by Social Service (SS)#49. Upon entry HS#38 did not use alcohol based hand rub (ABHR) , nor was HS #38 directed to use ABHR before entering. HS#38 did not have a facemask and was given a surgical mask. Register Nurse (RN) #47 stated it will be alright HS#38 does not need an N95 mask since he will not be around patients. An interview on 09/15/21 at 8:45 a.m., SS #49 acknowledged that ABHR should be used before entering the facility, and HS#38 and all staff will need a N95 mask due to the recent COVID-19 outbreak in the facility. .

. Based on Record Review, and Staff Interview the facility failed to inform residents and resident representatives of the COVID-19 out break. This has the potential to effect all residents in the facility. Facility Census: 24 Findings Included: a) COVID-19 information On 09/13/21 at 11:15 AM it was identified upon survey teams arrival the facility was in a COVID-19 outbreak due to the three confirmed positive staff members. Staff Members #41 from Maintenance, Staff Member #31 Hospitality Aid and Staff Member #10 Activities. An interview on 09/15/21 at 9:30 a.m., Social Service (SS) # 49 acknowledged that they had not contacted any family or family representatives of the COVID-19 outbreak at the facility. Regulation 483.80(g)(3) states that the facility must Inform residents, their representatives, and families of those residing in facilities by 5 p.m. the next calendar day following the occurrence of either a single confirmed infection of COVID-19, or three or more residents or staff with new-onset of respiratory symptoms occurring within 72 hours of each other. The first (1st) positive staff member was identified on 09/10/21. The facility had until 5:00 pm on 09/11/21 to notify the resident's , their representatives, and families of the positive staff member. This was not completed. .