**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview the facility failed to ensure the Minimum Data Set (MDS) record was completed correctly for a resident's discharge. This was true for one (1) of 24 residents whose MDS records were reviewed during the long-term care survey process. Resident Identifier: #78. Facility Census: 78. a) Resident # 78 During a medical record review on 09/05/24 at approximately 9:00 AM the MDS dated [DATE] was reviewed and identified the following; * Section (A) A 0310- (f) that the discharge assessment anticipated the resident to return. * Section (A) A 2105 the resident is discharged to home/community. * Section (A) A 2123 was not completed to identify if the provision of the current reconciled medication list for the resident at discharge was provided at time of discharge. A review of the notes by Social Services Designee (SSD) #90 dated 09/17/24 at 9:03 AM revealed the resident admission paperwork was unable to be completed by the Social Services Designee (SSD) #90 because the resident had discharged against medical advice (AMA) shortly after arriving to the facility and that the discharge planning had not been completed. SSD #90 noted the resident discharged was unplanned/AMA on 06/15/24. An additional note was entered on 06/17/24 at 8:55 AM that an Adult Protective Services (APS) referral was completed due to the discharge being AMA. During an interview on 09/05/24 at approximately 12:50 PM the Director of Nursing and the Administrator agreed the MDS was not coded correctly and that the discharge was AMA.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to implement Resident #77's care plan. For Resident #77, the facility failed to implement the care plan to educate on end-of-life decisions. This was true for one (1) of two (2) residents reviewed for the Long-Term Care Survey Process. Resident identifier: #77. Facility census: 78. Findings include: a) Resident #77 On [DATE] at 11:37 AM, a review of Resident #77's medical record was conducted revealing that on [DATE], Resident #77 had been seen by the facility Nurse Practitioner (NP) after an acute hospitalization for urinary tract infection, pneumonia and chronic obstructive pulmonary disease. At that time, the facility Nurse Practitioner documented, Unable to perform complete chart review due to no hospital documentation available at this time. Code status was discussed with facility leadership and resident made decision to change Physician's Order for Scope of Treatment (POST) form to DNR-CC (Do Not Resuscitate-Comfort Care), no labs, no weights and do not send to hospital. In addition, a review of Resident #77's POST form revealed No CPR, comfort focused treatments, no artificial means of nutrition, no labs, no weights, do not transfer to hospital an no appointments. At this time, Resident #77's care plan was also reviewed revealing the following care plan: Focus: Resident has a DNR code status with comfort care. Goal: Resident's code status will be honored through review date. Interventions: Code status will be established at time of admission/readmission. To be reviewed quarterly and as needed (PRN). Obtain copies of advanced directives from resident/resident representative to have on file. Obtain medical provider order for code status. Obtain the state specific form regarding code status (state specific DNR forms). Provide resident/resident representative with education as needed regarding end-of-life decisions. On [DATE] at 12:40 PM, a review of the Policy and Procedure entitled, Advanced Directive (Resident's Right to Choose) revealed that should the resident refuse treatment of any kind, the facility will document what the resident refused, the reason for the refusal, the education provided to the resident about the consequences of refusing, offering of alternative treatments and the continuing of all other services provided in the resident's medical record. On [DATE] at 09:23 AM, an interview was conducted with the facility NP. At this time the NP stated that when educating resident's and/or resident representative's related to end-of-life decisions, I focus on the heart stopping and what they would want done. When asked if the resident or resident representative was educated on the risks verses benefits of discontinuing care such as weights, labs and sending to the hospital for an acute event, the NP responded, I document what I review with the resident and/or resident representative and their preference on what care to continue. If I see something on my end, that the resident is not doing well and they have all these co-morbidities, and the likelihood of surviving a cardiac arrest is poor, that's when I discuss what to do if the heart stops. On [DATE] at 01:53 PM, an interview was conducted with the facility Director of Nursing (DON), Administrator and Regional Director of Clinical Operations (RDCO). The Administrator acknowledged that the facility was unable to provide documentation related to the education provided to Resident #77 regarding end-of-life decisions.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview the facility failed to revise the comprehensive care plan for anxiety. This was true for 1 of 5 residents reviewed for unnecessary medications, psychotropic medications, and medication regimen review during the long term care survey process. Resident Identifier: #60. Facility Census: 78. a) Resident #60 During a medical record review on 09/05/24 it is identified that Resident #60 has a diagnosis of anxiety order date 03/09/23. It is further identified that the resident has a past medical history of anxiety, depression, insomnia, mood disorder and inappropriate sexual behaviors. It is identified that the resident has been seen for psychiatric services since 01/26/24 due to behaviors including but not limited to sexual behaviors. The physician visit encounter note documented in Gehrimed on 04/16/24 under the clinical education section referenced to the anxiety disorder for non-pharmacological interventions recommendations is noted: (Typed as written) Offer a calm environment, offer own support as well as from family and peers, reassurance during panic attacks, music therapy, pet therapy, massage, art therapy or other relaxing activities, relaxation training, breathing exercises to encourage relaxation, guided imagery, exercise, outdoor walks, and aromatherapy. A care plan review identified that the resident was care planned for the behaviors of (typed as written) Resident #60 [Residents first name written] has been observed to have sexually inappropriate behaviors including grabbing at staff and making inappropriate sexual and derogatory comments to staff and masturbating when others are present. Resident has been observed to masturbate and leave his penis out of the brief and in view of others. Resident has a behavior of voiding in inappropriate places. Resident has a behavior of being resistant to care, with physical and verbal behaviors exhibited. This care plan is dated 08/21/23 and was revised on 02/29/24 Further review of the residents care plan, it is identified that Resident #60 had been care planned upon admission [DATE] for the use of medications for the anxiety disorder diagnosis. It is further identified that the care plan was not revised to reflect the recommended non-pharmacological interventions of (Typed as written) Offer a calm environment, offer own support as well as from family and peers, reassurance during panic attacks, music therapy, pet therapy, massage, art therapy or other relaxing activities, relaxation training, breathing exercises to encourage relaxation, guided imagery, exercise, outdoor walks, and aromatherapy documented on 04/16/24. Medical record review further identifies that the anxiety medication was discontinued on 07/02/24 and the care plan for the use of the anxiety medication was resolved on 07/02/24. During an interview with the Director of Nursing (DON) on 09/09/24 at approximately 1:30 PM the DON stated Resident #60's care plan had been resolved when the medication was discontinued. The DON further agreed that with the ongoing behaviors of the resident that she could see where it would be appropriate to care plan non-pharmacological interventions for the anxiety disorder.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to ensure care and services provided to one (1) of three (3) resident's were in accordance with professtional standards of practice to meet the resident's highest possible level of functioning and well being of the resident. Resident #67 received enteral feeding. The resident experienced a weight loss. The facility had not ensured the resident's enteral feeding volume was being documented and the nurse practitioner did not follow up for concerns regarding the resident's weight loss. Resident identifier: #67. Facility census: 78. Findings include: a) Resident #67 On 09/03/24 at 02:03 PM, a record review was conducted for Resident #67. On 03/03/2024, Resident #67 weighed 199 pounds (lbs.). On 09/02/2024, Resident #67 weighed 178 lbs., which was a -10.55 % Loss. A review of Resident #67's physician's orders was then performed, Resident #67 was noted to be receiving the following orders for nutrition: 1. Regular diet, Dys Puree texture, Honey Thickened Liquids consistency, Double Portions, Kennedy cup with meals and at bedside. No oatmeal. 2. Med Pass Product (2 Cal), two times a day 4 oz (110 ml) Thickened to Honey Consistency Supplement 3. Frozen Nutritional Treat, two times a day with lunch and dinner Supplement 4. Enteral Feed, at bedtime for weight loss Formula: 2 TwoCal via indicate: Peg Tube. Enteral Feed In addition to the following care plan: Focus: The resident has a feeding tube r/t Dysphagia. He was ordered a PO diet post swallow study and progress with Speech Therapy. Enteral feedings and a PO diet are ordered at this time. Goal: Resident will maintain adequate nutrition and hydration status though review date. Resident will remain free of complications through review date. Interventions/Tasks: Administer flushes per medical provider's order. Administer medications via tube, per orders. Check for placement and residuals per policy. Head of bed elevated 30 degrees or higher. Resident will lower his head of bed frequently, discourage this if observed and assist with elevation as he allows. Monitor intake of enteral tube feeding--- if ordered. Notify medical provider and resident representative of unplanned weight changes. Nutritional consult on admission, quarterly, and as needed. Obtain labs per medical provider's order. Obtain weights as ordered/indicated. Provide diet as ordered. Provide flushes per medical provider orders. Provide insertion site care, per orders. Provide oral care. Secure tube to prevent dislodging. ST/OT eval and treat, as ordered/needed. Furthermore, a review of Resident #67's progress notes was conducted which revealed the following weight change notes: 03/08/24 2:18 PM Weight Change Note Value: 200 (pounds) Res (Resident) with sig (significant) weight loss x 1 month and x 6 months. Originally weight loss had been felt to be therapeutic however current goal to maintain. IDT (interdisciplinary team) have identified Resident to seem more withdrawn and refusing to get up out of bed. After further investigation Resident requests a room move r/t (related to) incompatibility. Resident's intake at meals continues to be good at 76-100% most meals on Regular diet, Dys Mech texture, Thin liquids consistency, [NAME] Cup with meals and at bedside. Res had been ordered 8 oz Glucerna QD with 100% intake so recommend changing supplement to 8 oz Boost Glucose control BID (twice a day). Res (resident) also ordered ProSource QD (everyday) with good intake. Recommend d/c'ing (discontinuing) ProSource and starting double entrée portions with meals. Resident's order for Remeron also being increased from 7.5 mg (milligram) to 15 mg. Will continue to follow. 03/26/24 2:03 PM Weight Change Note Value: 187.7 lbs. (pounds) Note Text: WEIGHT WARNING: Res (resident) RA w/dx acute metabolic encephalopathy, severe sepsis, pyelonephritis, bronchopneumonia, HCAP (healthcare-associated pneumonia), AKI (acute kidney injury), A-Fib (atrial fibrillation) , T2DM, (Type 2 Diabetes Mellitus) Seizure d/o, HLD (hyperlipidemai), and dysphagia. Skin is intact per documentation. Regular diet, Dys Puree texture, Honey Thickened Liquids consistency- 63% intake average. Res requires total assistance with meals. Res lost weight while oof with acute illness. Meds include: Pantoprazole, Senna-Dok, Linezolid, PEG, Metformin 500mg BID, Maalox, DOK, and Lactobacillus. Recommend starting 4 oz MedPass 2.0 Thickened to Honey consistency BID and Frozen nutritional treat BID with lunch and dinner.'' 05/15/24 9:20 AM Weight Change Note Note Text: WEIGHT WARNING: Value: 185.4 6 months. Majority of loss r/t acute illness requiring hospitalization. Resident's PEG tube remains intact however currently on PO diet with current order: Regular diet, Dys Puree texture, Honey Thickened Liquids consistency, Double Portions- 76-100%. Double portions added on 5/7 r/t additional weight loss with most recent weight obtained showing a trend up. Res is also being encourage (encourage) to sit up in chair for meals. Other supplements ordered include a Frozen Nutritional Treat with lunch and dinner, and 4 oz MedPass 2.0 thickened to honey consistency- both with 100% intake per EMAR (electronic medical record). Skin is intact per documentation. Meds include Pantoprazole, Senna, PEG, Metformin 500 mg BID, DOK, and Maalox TID (three times a day). Will continue to follow weekly weights making recs (recommendations) as appropriate. 07/09/24 2:45 PM Weight Change Note Note Text: WEIGHT WARNING: Value: 177.9 Res with a 10% weight loss x 6 months. Weight stable x 2 months with weights being obtained twice weekly for close monitoring. Food preferences obtained via Resident, and Resident's sister. Regular diet, Dys Puree texture, Honey Thickened Liquids consistency, Double Portion entree and Kennedy cup with meals and at bedside- intake is 76-100% most meals. Resident is encouraged to take meals in dining room with assistance as needed. Resident is able to feed self past setup most meals. Resident is also ordered Frozen Nutritional Treat BID and 4 oz MedPass thickened to honey consistency BID- with 100% intake most passes. Res is ordered TwoCal 2 Bolus via Peg tube QHS, flushing 60 mls (milliliters) before and after each bolus. No recs at this time. 08/09/24 8:56 AM Weight Change Note Note Text: WEIGHT WARNING: Value: 177.0 Res weight seems to be stabilizing at this time. Diet is Regular diet, Dys Puree texture, Honey Thickened Liquids consistency, Double Portions, and Kennedy cup with meals and at bedside- intake is 76-100% most meals. Resident is also ordered a frozen nutritional treat BID with lunch and dinner and 4 oz MedPass thickened to Honey consistency BID. Supplemental enteral nutrition order is 237mls TwoCal before bedtime flushing 60mls before and after. With current diet order, supplements and snacks as well as enteral nutrition Resident is exceeding est. nutritional needs. Resident is weighed twice weekly for monitoring. No recs at this time. Will continue to follow. On 09/10/24 at approximately 10:00 AM, a review of Resident #67's Medication Administration Record was conducted revealing that while the facility staff documented that Resident #67's enteral feed was administered. The amount given was not documented. On 09/10/24 at approximately 11:20 AM, a review of the Policy and Procedure entitled, Enteral General Nutritional (tube feeding) Guidelines was conducted revealing that flush volumes were to be recorded. On 09/10/24 at 01:03 PM, an interview was conducted with the facility Dietician. At this time, the Dietician acknowledged she monitored Resident #67's intake related to food consumption, however, the volume of enteral feed consumed by Resident #67 was not documented. At that time, this Surveyor asked the facility Dietician if the entire enteral feed was not consumed, how she was able to know, to which the facility dietician responded, I guess the staff would make a note, I am assuming he (Resident #67) is receiving the full bolus. The facility Dietician then stated, His (Resident #67) caloric intake far exceeds his (Resident #67) needs. This Surveyor then asked the facility Dietician if there could be an underlying cause not yet identified that could be causing Resident #67's weight loss to which the facility Dietician stated, I have not talked with the physician since May, when the TwoCal was started back. Since then, I have just been monitoring his weight. So, I really couldn't answer that question. On 09/10/24 at 01:53 PM, an interview was conducted with the facility Director of Nursing (DON), Administrator and Regional Director of Clinical Operations (RDCO). At this time, an encounter note was given to this Surveyor documented by the facility Nurse Practitioner (NP) dated for 05/13/24 at 01:00 AM. The NP documented that Resident #67 was seen this date for a stop & watch visit for eating less. During visit, resident was sitting up in gerichair. During chart review, resident ate 51-75% of previous date at lunchtime. Resident then noted to eat 75-100% of other meals. In addition the weight loss experienced by Resident #67 was discussed. In addition, Resident #67's orders, care plan and progress notes were reviewed. At this time, the Administrator acknowledged the following: 1. Resident #67's enteral feeding volume was not being monitored as per the care plan. 2. It would be reasonable to assume if the flush volume is to be recorded, the enteral feeding volume would be also. 3. Resident #67 had been seen by the facility NP, however, the NP had acknowledged Resident #67's weight loss,. Resident #67 was not examined or treated for the weight loss by the NP.

Based on a review of the facility records and staff interviews, the facility failed to ensure the staff posting forms were accurate with direct care nursing staff totals and direct care nursing staff hour totals. The facility also failed to retain the staff posting form for 18 months. This was identified during the long term survey process and had the ability to affect a limited number of residents. Facility Census: 78. Findings included: a) Inaccurate total count of direct care nursing staff and the direct care nursing staff total hours; During a review of the staff posting forms on 09/09/24 at approximately 11:00 AM it is identified that the total count of direct care nursing staff and the direct care nursing staff total hours includes nursing staff with administrative duties and their nursing staff administrative hours. -09/04/23 Registered Nurse (RN) count of staff total 3 RN hours 24 During a review with Medical Records (MR) #44 on 09/09/24 at approximately 11:45 AM the total count of direct care staff included 8 hours of the RN Unit Manager hours. MR #44 agreed that the RN count of staff total and the RN hours was inaccurate. -02/12/24 Licensed Practice Nurse (LPN) with administrative duties - 1 (one) total count with 8 administrative hours. RN with administrative duties - 3 (three) total count with 24.25 administrative hours. During a review with MR #44 09/09/24 at approximately 11:45 AM, MR #44 agreed that 1 (one) LPN with administrative duties and the 8 LPN administrative hours as well as the 3 (three) RN with administrative duties total count with 24.25 administrative hours should not have been added as direct care staff to the staffing posting form. During an interview with the Administrator on 09/09/24 at 2:37 PM a review was completed of the Labor Classification/ Job Title section of the Centers for Medicare & Medicaid Services- Electronic Staffing Data Submission- Payroll-Based Journal- Long-Term Care Facility- Policy Manual Version 2.6. This section defines that the Labor Classification/Job Title Reporting shall be based on the employee's primary role and their official categorical title. It is understood that most roles have a variety of non-primary duties that are conducted throughout the day (e.g., helping out others when needed). Facilities shall still report just the total hours of that employee based on their primary role. CMS recognizes that staff may completely shift primary roles in each day. For example, a nurse who spends the first four hours of a shift as the unit manager, and the last four hours of a shift as a floor nurse. In these cases, facilities can change the designated job title and report four hours as a nurse with administrative duties, and four hours as a nurse (without administrative duties). During this review, the Administrator agreed that the Nursing staff with administrative duties and the Nursing staff with administrative duties hours should not have been included in the staffing posting form. b) Maintaining staffing posting forms During a review of the staff posting forms on 09/09/24 at approximately 11:00 AM it was identified that documents did not have any specific information for call outs or changes in the daily staffing activities. During an interview with Medical Records (MR) #44 she stated that the facility did not keep the staffing posting forms that were posted as they did not know they needed to. MR #44 stated the corporate office has them to enter the data in the computer of any changes each shift and to dispose of the forms. MD #44 agreed the staffing forms should have been maintained but that the facility does not have them. During an interview with the Administrator on 09/09/24 at approximately 2:40 PM the Administrator agreed the original staffing posting forms were required to be maintained for 18 months but the facility did not do that.

Based on medical record review and staff interview the facility failed to ensure the residents medical record was completed accurately when completing the skilled documentation. This was true for one (1) of 24 residents' medical records reviewed during the long-term care survey process. Resident Identifier: #56. Facility Census: 78. a) Resident #56 During a medical record review on 09/10/24 at 12:31 PM it is identified that the Skilled Documentations (User Defined Assessment) UDA's from 08/15/24 through 09/02/14 was completed with the functional status under section (A), number four (4), that Resident #56 was receiving occupational and physical therapy services per each day from 08/15/24 through 09/02/14. Further review of the resident's orders, the occupational and physical therapy services had been discontinued as of 08/14/24. The occupational and physical therapy services were not identified in the resident's care plan. During an interview, with the Director of Nursing and the Administrator, on 09/10/24 at approximately 10:00 AM it was agreed that the Skilled Documentations (User Defined Assessment) UDA's from 08/15/24 through 09/02/14 was completed inaccurately under section (A), number four (4) as the residents occupational and physical therapy services had been discontinued as of 08/14/24.

Based on observation, resident interview and staff interview, the facility failed to maintain an effective pest control program for flies. This was a random opportunity for discovery during the long term care survey process. This had the opportunity to affect a limited number of residents. Resident #55. Facility Census. 78. Findings included: a) Resident #55 On 09/05/24 at 01:56 PM during an interview with Resident #55, the resident was observed to be lying in her bed with her lower legs uncovered. A fly was identified to be sitting on the inside of her left ankle. The resident stated, The flies are terrible here. During an interview, on 09/05/24 at approximately 2:00 PM, with Licensed Practice Nurse (LPN) LPN #87 acknowledged the fly as it was still sitting on the residents leg and would fly around and land again on the residents leg/ankle on different areas. LPN # 87 stated the flies stay in there and that she would notify maintenance. During an interview with the Administrator on 09/05/24 at approximately 3:20 PM the Administrator stated that with the facility being so close to the [NAME] Virginia State Fair Grounds it creates an issue with flies because the Fair Grounds dumpster's set along the property line behind the facility. The Administrator further stated she has contacted their contracted company to come and treat for flies again.

Based on observation, record review and staff interview the facility failed to ensure food was stored and served under sanitary conditons and that food temperatures were logged for three (3) meals. There were items not labeled, opened and expired. Census 78. Findings included: a) Initial Tour of Kitchen-Freezer -On 09/03/24 at 11:15 AM a bag of breakfast sandwiches were observed in the walk-in freezer having no label and no date. -On 09/03/24 at 11:15 AM interview with Culinary Director #3 (three), revealed that this was food served at that mornings breakfast and someone failed to label it. b) Initial Tour of Kitchen-Walk in Cooler -On 09/03/24 at 11:30 AM observed a large container of unknown beverage not labeled or dated. -On 09/03/24 at 11:30 AM an interview with [NAME] #17 who stated the liquid in the large container was tea, and acknowledged it was not labeled or dated and disposed of it. c) Initial Tour of Kitchen- Dry Storage -On 09/03/24 at 11:35 AM it was observed that 4 bags of grits with best by date of 12/10/23 and marked 05/16/23 were in the dry storage. -On 09/03/24 at 11:35 AM Culinary Director #3 (three) reported to be honest, these are no longer on the menu, they have just been overlooked and I will throw them out now. d) Tour of Floor Pantry -On 9/04/24 at 3:00 PM, an open packet of coffee exposed to the air was found in the shelf with no dates. -On 09/04/24 at approximately 4:00 PM, during an interview, the Administrator acknowledged the coffee had since been disposed of and normally the entire bag would be used at time of opening or remainder disposed of. e) On 09/05/24 at 11:15 AM review of Service Line Checklist temperature logs in kitchen revealed that cooking temperatures and holding temperatures were not recorded for the following days between 06/01/24 to 09/04/24 -06/21/24 Dinner meal Chicken salad and peaches. -07/08/24 BBQ Chicken, Macaroni and cheese, fruit and pea salad. -09/02/24 Pork, Potatoes, and Lima Beans On 09/05/24 at 11:30 AM interview with Culinary Director #3 (three) who acknowledged the temperatures had been taken but failed to be recorded. He stated the person was new and he, himself should have ensured it was completed. On 09/05/24 a review of facility policy form titled Healthcare Services Group Policy 016 revealed under Food Preparation included the following: -Procedure #9 (nine) the cook will prepare all cooked food items in a fashion that permits rapid heating to appropriate minimum internal temperature. -Procedures #14 temperature for Time/Temperature Control for Safety (TCS) will be recorded at time of service and monitored periodically during meal and service periods. f) Staff handling of used cups. During a dining room observation in the second floor dining area on 09/04/24 at 12:00 PM a staff member was observed to assist a resident who had requested a refill of their thickened drink. The staff member was observed to take the adaptive equipment cup in her left hand and the staff member then asked another resident if they needed another thickened drink in their adaptive equipment cup. The staff member then placed both used adaptive cups together in her bare left hand. The staff member took the adaptive cups into the nutritional room adjacent to the dining room. When exiting the nutritional room with the refilled adaptive cups, Activities Leader (AL) #79 stated she had prepared the refill for both thickened drinks and acknowledged that she had held them together in her bare left hand into the nutritional room and prepared the refill of the thickened drinks. AL #79 stated she should have taken one cup at a time to refill and that she was returning both adaptive cups to the nutritional room to obtain clean adaptive cups for the requested refill of thickened drinks.

Based on observation and staff interview, the facility failed to ensure trash and debris were stored in a safe and sanitary manner to prevent harborage of pests. The facility failed to keep the dumpster closed when not in use. This failed practice had the potential to affect more than a limited number of residents. Facility census: 78. Findings included: a) On 09/09/24 at 12:43PM observation revealed the facility dumpster lid was open while not in use and no staff present. b) On 09/09/24 at 12:46PM during an interview, the Administrator acknowledged the dumpster lid was open on facility dumpster and that it should be closed. She had dumpster door closed after interview. c) 09/09/24 at 3:55 PM, during an interview the Culinary Director reported there was no policy or procedure on waste disposal regarding the dumpster or otherwise.

Based on Resident interview, Resident council meeting members, observation and review the facility Grievance/ Concerns forms found the facility failed to ensure all meals served were palatable, attractive, and served at a safe and appetizing temperature. This failed practice had the potential to affect more than a limited number of residents who reside at the facility. Resident identifiers: #42, #6, #52, #15, #77, #68, #48, #76, #39, #9, #13, #2, #8, #14, #56, #55, and #7. Facility census 77. Findings include: a) Resident Council members On 09/28/23 at 10:00 AM, the following Residents attended the Resident Council meeting, #42, #6, #52, #15, #77, #68, #48, #76, #39, #9, #13, #2, #8, and #14. All 14 of the residents complained about the food being cold when they receive it in addition to the potatoes being under cooked and hard, not receiving condiments like butter, crackers, ketchup, mayo, and mustard. In addition, other food on their plates are getting soggy from the watery vegetables. The crust on the bread is hard. There are not enough veggies in the vegetable soup. Not enough food for seconds and there is no tomatoes or cucumbers in salads. b) Review of Grievance/Concerns A review of the last six (6) months of the Grievance/Concerns forms revealed: On 07/11/23 Resident #6 and #3 filed a grievance about their meals not being served with tray warmers, resulting in food not being as warm as it should be. Resident #55 On 08/23/23 Resident #55 reported she ordered two (2) eggs and two (2) for breakfast and received one (1) egg and one (1) piece of bacon. For lunch the onion rings were cold, not crispy and looked uncooked. The potatoes were hard. At Dinner the steak was hard and unable to chew, burnt on outside. On 09/03/23 Resident #26 wrote: The quality of my food has sunk! Are many times cold, and incomplete meal. I order in the morning; I use substitute many times due to my allergies and digestive tract. Rarely get what I ordered. I'm taking photos of my meals. On 09/13/23 Resident #15 wrote on the Grievance form: Food is not good. Potatoes to much season. [NAME] beans with onions are not good. The fat on ham was to much and not good. c) Resident interviews On 09/27/23 at 1:10 PM, Resident #56 stated her meals are not always warm enough. On 09/27/23 at 1:15 PM, Resident #9 said the food is not always hot when she gets it and the taste of the food is either undercooked or over cooked. Resident #9 also said condiments are not available. On 09/27/23 at 1:20 PM. Resident #7 was asked if his meals were hot when served. Resident #7 shook his head to indicate no and said no. d) Food temperatures Food temperatures, at the time of service to the resident, were obtained with the Culinary Director (CD) #28 at 5:15 PM on 09/27/23, on the first floor of the facility. The temperatures of the food items on Resident #35's tray were: Corned beef and cabbage - 132.5 degrees Potatoes - 130.8 degrees Ice Cream was 16 degrees.

Based on resident interview, and staff interview the facility failed to implement written policies and procedures that: promptly report, investigate and protect the resident from an alleged abuser in a timely manner. This had the potential to affect all Residents at the facility. Resident identifier: #9. Facility census 77. Findings included: Facility Policy titled, West Virginia Abuse, Neglect and Misappropriation. Immediately: Means as soon as possible, in the absence of a shorter State time frame requirements, but not later than 2 hours after the allegations are made. Corporal Punishment: which is physical punishment used as a means to correct or control behavior. Involuntary Seclusion: the separation of a resident from other residents or confinement to his/her room Metal Abuse: is the use of verbal or nonverbal conduct which causes or has the potential to cause the resident to experience humiliation, intimidation, fear, shame, agitation, or degradation. a) Resident #9 On 09/27/23 at 1:10 PM, Resident #9 asked if the people here at the facility were allowed to threaten to close her door if she does not do as she is told. She went on to say she is very claustrophobic and does not like her door closed and the staff know that. Resident #9 said she reported this two (2) days ago to the Social Worker (SW) #95. The resident identified NA #80 was the person who threatened to close her door if she did not do as told. During an interview on 09/27/23 at 2:15 PM, the Social Worker #95 was asked if Resident #9 had talked to her about Nurse Aide (NA) #80 closing her door? SW #95 said yes, she did, however; I have not had time to get NA #80's side of the story yet. SW #95 was asked what if anything has, she done about this allegation? SW #95 said nothing yet. On 09/27/23 at 2:25 PM, the Administrator was informed about the above information. When the survey team entered the facility on 09/27/23 at approximately 1:00 PM, NA #80 was working. The event reported by the Resident two (2) days ago had never been addressed or investigated. Due to the urgency of the situation the surveyor immediately alerted the administrator, and the employee was suspended after surveyor intervention. The SW never told anyone about the resident's report. No investigation was started, and no action was taken to protect the residents. During a brief telephone interview with SW #95 on 09/28/23 at 2:12 PM, SW said she spoke to Resident #9 sometime on 09/25/23 approximately mid-morning between 10 AM and noon about her allegation.

Based on resident interview, and staff interview the facility failed to promptly report an allegation of alleged verbal abuse and mistreatment to the proper State authorities. This had the potential to affect all residents at the facility. Resident identifier: #9. Facility census 76. Findings included: a) Resident #9 On 09/27/23 at 1:10 PM Resident #9 asked if the people here at the facility were allowed to threaten to closed her door if she does not do as she is told. She went on to say she is very claustrophobic and does not like her door closed and the staff know that. Resident #9 said she reported this two (2) days ago to the Social Worker (SW) #95. That NA #80 was the person that did that. During an interview on 09/27/23 at 2:15 PM, the Social Worker #95 was asked if Resident #9 had talked to her about Nurse Aide (NA) #80 closing her door? SW #95 said yes, she did, however, I have not had time to get NA #80's side of the story yet. SW #95 was asked what if anything has, she done about this allegation? SW #95 said nothing yet. On 09/27/23 at 2:25 PM, the Administrator was informed about the above information. When the survey team entered the facility NA #80 was working. The event that was reported by the Resident 2 days ago had never been addressed or investigated. Due to the urgency of the situation the surveyor immediately alerted the administrator, and the employee was suspended after surveyor intervention. The SW never told anyone about the resident's report. No investigation was started, and no action was taken to protect the residents. During a brief telephone interview with SW #95 on 09/28/23 at 2:12 PM. SW said she spoke to Resident #9 sometime on Monday mid-morning between 10 AM and noon.

**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 copy of the Notice of Transfer was sent to the Office of the State Long-Term Care Ombudsman. This was true for one (1) of three (3) reviewed for the care area of hospitalization during the Long-Term Care Survey Process. Resident Identifiers: Resident #62. Facility Census: 71. Findings Included: a) Resident #62 A review of a facility policy titled Transfer of a Resident with an effective date of 10/01/22 found the following. .8. The facility will send a copy of the notice to the State Long-Term Care Ombudsman as directed by state law. A medical record review on 10/31/22 at 3:24 PM revealed Resident # 62 had the following hospital stays: -On 07/10/22 Resident #62 was sent to the local emergency room for behaviors, admitted to another hospital then returned to facility on 07/25/22. -On 08/30/22 Resident #62 was sent to the local emergency room for behaviors, admitted to another hospital then returned to the facility on [DATE] -On 09/22/22 Resident #62 was sent to the local emergency room for altered mental mental status. -On 10/14/22 Resident #62 was sent to the local emergency room for stomach pain, admitted to the hospital then returned to the facility on [DATE]. During an interview on 11/02/22 at 3:36 PM Social Worker #54 stated, Medical Records faxes a copy of the transfers to the Ombudsman. I keep the binder in my office. Social Worker #54 indicated Resident #62's transfer on 10/14/22 was sent to the Ombudsman as required. During an interview on 11/02/22 at 3:39 PM Medical Records Licensed Practical Nurse (LPN) #86 stated I am unable to find evidence the transfer dated 10/14/22 for Resident # 62's was sent to the Ombudsman. During an interview on 11/02/22 at 4:01 PM, LPN #86 stated she could not find evidence of the transfer being sent to the Ombudsman. I just faxed it to them, here is the confirmation. .

. Based on medical record review and staff interview the facility failed to accurately code the minimum data set (MDS) in the area of a ventilator for Resident #47. This was true one (1) of 23 resident MDS assessments reviewed during the Long Term Care Services Process. Resident identifier: #47. Facility census: 71. Findings included: a) Resident #47 A medical record review on 10/31/22, revealed the MDS indicator was incorrect for Resident #47 for the Special Treatment Section O: Resident #47 was coded as being on a ventilator. During an interview on 11/02/22 at 2:15 PM, with the MDS Coordinator reported the MDS for Resident #47 was coded incorrectly for a ventilator. .

. Based on observation, resident interview, record review and staff interview the facility failed to ensure a resident received treatment and care in accordance with professional standards of practice and the comprehensive care plan. This was true for two (2) of 23 sampled residents during the Long-Term Care Survey Process. Resident Identifiers: Resident #61 and Resident #28. Facility census: 71. Findings Included: a) Resident #61 During an interview on 10/31/22 at 11:52 AM Resident # 61 stated I can't hear you. I don't have my hearing aides in. During an interview on 10/31/22 at 11:53 AM Activity Assistant #28 stated No Resident #61 does not have her hearing aides in, I will let someone know. During an interview on 10/31/22 at 11:54 AM Licensed Practical Nurse (LPN) #30 stated she only wears them at times. She refuses to wear them a lot. During an observation on 11/01/22 12:19 PM Resident # 61 was sitting the 2nd floor Dining Room, This surveyor asked Resident # 61 Did the staff help you put your hearing aids in today? Resident # 61 stated no I don't have them in. During an interview on 11/01/22 at 1:45 PM Nurses Aide (NA) #60 stated Resident # 61 usually asks us to assist her to put the hearing aids in her ear. She keeps the hearing aids in her room. NA#60 acknowledged the resident did not have hearing aides in at this time. NA #60 asked Resident # 61 Do you want me to put your hearing aides in? Resident # 61 stated yes, you need to help me. A review of Resident # 61 care plan with an initiated date of 06/01/22 found a focus statement which read Resident #61 has impaired hearing. -The goal associated with this focus statement read as follows: Patient will be able to make basic needs known on a daily basis through the review date Interventions related to this focus statement and goal included: HEARING DEFICIT: Patient requires hearing aid to both ears. Patient has difficulty hearing. Assist patient with placing in AM, and charging at bedtime. b) Resident #28 Review of Resident #28's comprehensive care plan showed a focus related to the potential for pressure ulcer development. An intervention for this focus was to float the resident's left heel while in bed. Floating means elevating the heel off the bed to prevent pressure from the mattress that could lead to pressure ulcer development. The implementation date for this intervention was not specified on the care plan. On 11/03/22 at 10:08 AM, Licensed Practical Nurse (LPN) #79 accompanied the surveyor into Resident #28's room. The resident was resting on her back in bed. The resident's left heel was in a sock and was not elevated off the bed. LPN #79 stated she would elevate the resident's heel. No further information was provided through the completion of the survey. .

. Based on observation, resident interview, medical record review and staff interview the facility failed to provide care to a resident that required assistance for hearing aid placement, for a resident who is dependent for Activities Of Daily Living (ADL) care. This was true for one (1) of two (2) review in the care area of ADL's. Resident Identifiers: Resident #61. Facility Census: 71 Findings Included: a) Resident #61 During an interview on 10/31/22 at 11:52 AM Resident # 61 stated I can't hear you. I don't have my hearing aides in. During an interview on 10/31/22 at 11:53 AM Activity Assistant #28 stated No Resident #61 does not have her hearing aides in, I will let someone know. During an interview on 10/31/22 at 11:54 AM Licensed Practical Nurse (LPN) #30 stated she only wears them at times. She refuses to wear them a lot. During an observation on 11/01/22 12:19 PM Resident # 61 was sitting in the 2nd floor Dining Room, This surveyor asked Resident # 61 Did the staff help you put your hearing aids in today? Resident # 61 stated no I don't have them in. During an interview on 11/01/22 at 1:45 PM Nurses Aide (NA) #60 stated Resident # 61 usually asks us to assist her to put the hearing aids in her ear. She keeps the hearing aids in her room. NA#60 acknowledged the resident did not have hearing aides in at this time. NA #60 asked Resident # 61 Do you want me to put your hearing aides in? Resident # 61 stated yes, you need to help me. A review of Resident # 61 care plan which was initiated on 06/01/22 found a focus statement which indicated Resident #61 has impaired hearing. -Goal: Patient will be able to make basic needs known on a daily basis through the review date Intervention: HEARING DEFICIT: Patient requires hearing aid to both ears. Patient has difficulty hearing. Assist patient with placing in AM, and charging at bedtime. A review of Resident #61's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) 08/14/22 Section G Titled Functional Status-G0110 Activities of Daily Living (ADL) Assistance --G. Dressing Self-Performance coded (3) needed extensive assistance Support coded (2) one person physical assist --J. Personal hygiene Self-Performance coded (3) needed extensive assistance, Support (2) one person physical assist During an interview on 11/02/22 at 8:35 AM 2nd floor Registered Nurse Assessment Coordinator (RNAC) Resident # 61 needs one (1) assist with her Activities of Daily Living (ADL)'s, due to her cognitive impairment needs assistance with her Hearing aides by placing them in her ears. During an interview on 11/02/22 at 12:34 PM LPN #30 stated Resident #61 refuses to wear her hearing aids the piece that goes around her ear rubs when she wears her glasses. I guess I should have been charting that she refuses them. .

. Based on observation, record review, and staff interview, the facility failed to ensure residents received necessary treatment and services to promote the healing of a pressure ulcer, prevent complications, and prevent new ulcers from developing. This deficient practice had the potential to affect one (1) of four (4) residents reviewed for the care area of pressure ulcers. Resident identifier: #28. Facility census: 71. Findings included: a) Resident #28 Review of Resident #28's medical records showed the resident developed a wound under the top of the hard cast to her right ankle fracture on 10/12/22. On 10/14/22, Resident #28's wound was assessed by the orthopedic surgeon. The handwritten consultation report stated the surgeon recommended daily dressing changes with Xeroform gauze and well-padded sterile dressing. The consultation report also stated the surgeon wanted to check the resident again the next Tuesday. The appointment/outing return progress note written by the nurse on 10/14/22 at 10:57 AM stated, Wound dressing with Xeroform and sterile dressing. Order to keep dressing in place until follow-up appointment on Tuesday. The orthopedic surgeon's typed progress note from the 10/14/22 visit gave no orders for dressing changes. On 10/18/22, Resident #28 was seen by the orthopedic surgeon again. The handwritten consultation report again gave orders for daily dressing changes with Xeroform gauze and well-padded sterile dressing. The orthopedic surgeon's typed progress note from the 10/18/22 visit stated, Unfortunately, they did not change the dressing until today, although we wrote for it to be changed daily. The Director of Nursing, Administrator, Clinical Care Specialist (CCS) #35 and CCS #36 were interviewed on 11/03/22 at 11:30 AM. CCS #35 stated the handwritten consult notes were sent from the orthopedic surgeon's office when the resident returned from the appointments. The type-written notes were received from the orthopedic surgeon's office approximately 48 hours after the appointment. CCS #35 stated the nurse reading the handwritten note from 10/14/22 thought the note said to wait to change the dressing until Resident #28 was seen by the orthopedic surgeon again. CCS #35 acknowledged the orthopedic surgeon's handwriting was difficult to read and the facility has called his office for clarification of the notes in the past. Review of Resident #28's comprehensive care plan showed a focus related to the potential for pressure ulcer development. An intervention for this focus was to float the resident's left heel while in bed. Floating means elevating the heel off the bed to prevent pressure from the mattress that could lead to pressure ulcer development. The implementation date for this intervention was not specified on the care plan. On 11/03/22 at 10:08 AM, Licensed Practical Nurse (LPN) #79 accompanied the surveyor into Resident #28's room. The resident was resting on her back in bed. The resident's left heel was in a sock and was not elevated off the bed. LPN #79 stated she would elevate the resident's heel. No further information was provided through the completion of the survey. .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, staff interview and record review the facility failed to ensure the resident's environment was as free from accident hazards as possible. The facility failed to complete a post fall investigation for one (1) of (3) three residents reviewed for falls. During a random opportunity for discovery, a Medication cart was found to be left unlocked while unattended by staff. These failed practices had the potential to affect a limited number of residents. Resident identifier: #28. Facility census: 71. Findings incuded: a) Medication Cart Observation on 11/03/22 at 12:12 PM found the Long Hall Medication cart on the first floor sitting outside of the dining room in the hallway, the medication cart was unlocked and unattended by staff. Registered Nurse (RN) #4 returned to the medication cart at 12:13 PM. RN #4 was asked, Is your med cart locked? RN #4 replied, No and locked the cart. During an interview on 11/03/22 at 12:40 PM, Corporate Register Nurse (RN) #106 was informed that the medication cart was found to be unlocked on first floor. Corporate RN #106 stated, They know better than that, I'll get you the policy. Record review of the facility's policy and procedure titled Oral Mediation Administration Procedure, revised on 02/17/20, showed the Medication cart is to remain locked if not in the license nurse's direct line of sight. Review of the list of wandering residents provided on 11/03/22 at 2:00 PM by the Director of Nursing, showed the following residents had the potentail to have access to the unlocked medication cart: Resident (R) #51, R #37, R #38, R #39, R #16, R #36, R #35, and R #52. b) Resident #28 Review of Resident #28's medical records showed the resident had a fall on 08/27/22 at 4:20 PM. The occurrence note written on 08/27/22 at 4:20 PM stated, Resident found lying on left side/back. Resident assessed for injury and assisted to shower chair to transfer to bed. EMS [emergency medical services] notified as resident unable to bear weight to right ankle with noted bruising. Resident was diaphoretic but blood sugar was at 85. Actions Taken: Resident assessed for injury and assisted back to bed. Resident sent to ER [emergency room] for evaluation as noted bruising to right ankle with inability to bear weight. An incident report dated 08/27/22 at 4:20 PM stated, Resident was found lying on right side/back in the bathroom. Skid resistant shoes in place. Resident was diaphoretic. Immediate action taken was Resident was assessed for injury and assisted to shower chair. Resident then transferred to bed. Resident blood sugar was 85 after she was given orange juice and cookies. Resident has noted bruising to right ankle. Swelling noted to bilateral ankles which is normal for resident. The root cause analysis was weak from acute illness and transferring independently. The incident report gave no predisposing environmental factors. A predisposing physiological factor was impaired memory. A predisposing situation factor was ambulating without assist. A care plan review note written on 08/29/22 at 5:01 PM stated as follows: Resident was noted to have had a fall on 8/27/2022 at 1620. Interventions in place prior to fall were: -Assure strap is behind heel when wearing crocs -Bathroom light to remain on at night as resident will allow. -Encourage resident to utilize her lights to help her see while ambulating. -Ensure call light is within reach. [NAME] prefers to keep her call light on the table beside her bed. -Provide walker for resident to utilize when ambulating. -Toilet in the morning prior to breakfast as tolerated. -Anticipate and meet patient's needs. Ensure frequently used items are within patient's reach. -Non-skid socks as tolerated. -Offer snacks between meals. New intervention is to increase assistance for transfers from independent to assistance of one. The Director of Nursing, Administrator, Clinical Care Specialist (CCS) #35 and CCS #36 were interviewed on 11/03/22 at 11:30 AM to discuss the evaluation and analysis of Resident #28's fall on 08/27/22. CCS #35 stated post-fall incident reports contain information designed to guide the investigation of falls and the implementation of interventions to eliminate additional falls. CCS #35 stated the interdisciplinary team meets after falls to analyze the fall and evaluate the care plan, current interventions, and new interventions. CCS #35 stated Resident #28's fall on 08/27/22 was possibly caused by a stroke. CCS #35 provided Computed Tomography (CT) Scan results from the resident's emergency room visit on 08/27/22. The results showed a lacunar infarct, or stroke. Additionally, the primary care physician's progress note on 08/31/22 stated the resident had a lacunar infarct and possible cerebral vascular accident. CCS #35 acknowledged the root cause analysis of Resident #28's fall on 08/27/22 was not updated to include a stroke as the possible cause. CCS #35 also stated the new intervention to increase the resident's assistance for transfers from independent to assistance of one was not implemented due the resident's decline in condition required assistance of two. No further information was provided through the completion of the survey. .

. Based on observation, record review, and staff interview, the facility failed to ensure enteral (tube) feeding was administered in accordance with professional standards of practice. The bags containing enteral tube feeding and enteral water flush were not labeled to indicate when the bags and tubing had been hung. This failed practice had the potential to affect one (1) of two (2) residents reviewed for care area of tube feeding. Resident identifier: #27. Facility census: 71. Findings included: a) Resident #27 The facility's procedure titled Enteral Tube Feeding via Continuous Pump with effective date 11/18/19 and revision date 02/17/20 recommended the bag or container containing the feeding be labeled with the date. Observation of Resident #27 on 11/01/22 at 10:32 AM showed the resident was receiving enteral feeding and water flush through a continuous pump. Neither the bag of enteral feeding nor the bag of water flush were labeled with the date to indicate when the bags and tubing had been hung. Licensed Practical Nurse #51 verified the bags had not been labeled with the date hung. No further information was provided through the completion of the survey. .

. Based on observation, staff interview, and record review the facility failed to use proper infection control measures during the storage of Bilevel Positive Airway Pressure (BiPap) mask for Resident #29. This failed practice was random opportunity for discovery and was true for Resident #29. Resident identifier: #29. Facility census: 71. Findings included: Observation on 10/31/22 at 11:45 AM showed Resident #29's Bilevel Positive Airway Pressure (BiPap) mask to be laying on top of a tissue box face down on the Resident's bedside table. The BiPap mask was not stored in a bag. Resident #29 stated, I used last night, I use it every night. Sometimes it's [Bipap mask] in a bag and sometimes not, they [facility staff] got bags but I guess we both forget. At 11:46 Registered Nurse (RN) #8 verified the mask was not stored properly and stated they should have changed it [storage bag] last night because they do it on Sundays. Record review showed an order to apply BiPAP at IPAP of 15, EPAP of 5, 3L of oxygen at bedtime every night. Date order intiated 09/12/22. During an interview on 11/01/22 at 9:20 AM, Infection Prevention Nurse agreed staff know the BiPap mask should have been stored in a bag. .

. Based on record review and staff interview, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice. The physician's orders were not followed regarding the amount of nutritional supplement to be given. This deficient practice had the potential to affect one (1) of three (3) residents reviewed for the care area of nutrition. Resident identifier: #19. Facility census: 71. Findings included: a) Resident #19 Review of Resident #19's physician's orders showed an order written on 06/24/22 for the nutritional supplement Resource 2.0, 60 milliliters (ml), twice a day for abnormal weight loss. Review of Resident #19's medication administration record (MAR) for October 2022 showed 17 times the resident was administered more than the amount of resource ordered. These dates and times were as follows: - On10/02/22 at 9:00 AM, 240 ml was administered. - On10/04/22 at 9:00 PM, 100 ml was administered. - On10/05/22 at 9:00 AM, 120 ml was administered. - On10/05/22 at 9:00 PM, 240 ml was administered. - On10/06/22 at 9:00 PM, 240 ml was administered. - On10/07/22 at 9:00 PM, 240 ml was administered. - On10/08/22 at 9:00 AM, 100 ml was administered. - On10/13/22 at 9:00 PM, 240 ml was administered. - On10/17/22 at 9:00 AM, 120 ml was administered. - On10/18/22 at 9:00 AM, 120 ml was administered. - On10/18/22 at 9:00 PM, 240 ml was administered. - On10/19/22 at 9:00 PM, 240 ml was administered. - On10/21/22 at 9:00 PM, 100 ml was administered. - On10/25/22 at 9:00 PM, 75 ml was administered. - On10/26/22 at 9:00 PM, 240 ml was administered. - On10/27/22 at 9:00 PM, 240 ml was administered. - On10/29/22 at 9:00 PM, 75 ml was administered. On 11/02/22, the Director of Nursing confirmed Resident #19 received more Resource 2.0 supplement than the physician ordered. No further information was provided through the completion of the survey. .

. Based on record review and interview, the facility failed to provide notices of Skilled Nursing Facility Advance Beneficiary Notice of Noncoverage (SNFABN), Centers for Medicare and Medicaid Services (CMS-10055) forms to beneficiaries and/or representatives for two (2) out of three (3) residents reviewed. Both residents were discharged from skilled services, with skilled days remaining and both resident's continued to reside at the facility. Resident identifiers: #31 and #38. Facility census: 57. Findings included: a) Resident #31 Record review found CMS form 10123 was issued to residents' representative on 06/21/21. The resident was discharged from skilled care due to reaching the maximum potential in therapy. The last day of covered services was 06/28/21. The resident was discharged from skilled care but continued to reside at the facility with Medicare benefit days remaining. b) Resident #38 Record review found CMS form 10123 was issued to residents' representative on 06/18/21. The resident was discharged from skilled care due to reaching the maximum potential in therapy. The last day of covered services was 06/21/21. The resident was discharged from skilled care but continued to reside at the facility with Medicare benefit days remaining. c) Interview During an interview with the Executive Director (ED) on 07/13/21 at 04:07 PM, the ED stated, We did not provided SNFABN (CMS-10055) because they plateaued. On 07/14/21 at 10:27 AM, the guidelines for F582 were reviewed with the ED. The guidlines are as follows: The Notice of Medicare Non Coverage (NOMNC) CMS for 10123 is issued when all covered services end for coverage reasons. If after issuing the NOMNC, the SNF (Skilled Nursing Facility) expects the beneficiary to remain in the facility in a non-covered stay, the SNFABN (CMS form 10055) must be issued to inform the beneficiary of potential liability for the non-covered stay. The ED provided no further information. .

. Based on observation and interview, the facility failed to ensure resident equipment was in good repair. This was a random opportunity for discovery. This was true for one (1) of four (4) residents who utilize a Broda chair. Resident #16. Facility Census: 57. Findings included: a) Resident #16 On 07/13/21 at 1:15 PM, observation found a Broda chair to be in poor condition. Resident #16 had a ripped cushion by the right side of his head and bilateral arm rests were broken with jagged edges. On 07/13/21 at 3:45 PM , the Director of Nursing (DON) confirmed Resident #16's Broda chair was damaged and not in good repair. .

. Based on observation, record review and interview, the facility failed to follow the physician's order regarding oxygen therapy. This failed practice had the potential to affect one (1) of one (1) resident reviewed for the care of oxygen therapy during the long-term survey process. Resident identifier: #34. Facility census: 57. Findings included: a) Resident #34 On 07/12/21 at 1:35 PM, Resident's (#34) oxygen setting was 2.5 liters per minute via nasal canula (LPM/NC) upon observation. The physician's order is written for oxygen at 2 LPM/NC continuously. Registered Nurse #19 verified the oxygen setting was incorrect at 2.5 LPM/NC and RN #19 stated the oxygen should be set at 2 LPM/NC. RN#19 changed the setting to 2 LPM/NC. .

. Based on interview and record review, the facility failed to communicate appropriate information to a resident's responsible party to ensure the resident was not inappropriately charged for dental services for lost dentures and failed maintain a dental policy identifying those circumstances. This was true for one (1) of one (1) residents reviewed for the care area of dental. Resident identifier: #35. Facility census: 57. Findings included: a) Resident #35 A review of a social services progress note dated 06/10/21 at 11:16 AM, shows that social worker # 33 spoke with Resident's representative on the phone to follow up on Resident's missing dentures. The note states the contact person would like the facility to schedule a dental appointment for Resident to check into getting new dentures. Appointment will be scheduled. A further review of the medical records reveals an Addendum note dated 06/15/21 at 10:57 AM that Licensed Practical Nurse (LPN) #56 called and spoke with Resident's representative about the cost of the dentures. The total cost will be $1,375 and payment of half of the cost will be required for tomorrow's appointment for fitting. The representative responded that she wanted to cancel the appointment at this time as she feels Resident wouldn't wear the dentures and she would hate to pay that kind of money for her not to wear them. She also stated Resident has hearing an aid that she will not wear. Appointment was canceled. LPN # 56 stated in an interview on 07/13/21 at 12:48, regarding Resident's lost dentures, the dentures were lost due to the Resident taking the dentures out of her mouth and laying them down. LPN#56 stated that she called the Resident's representative for the out of pocket money needed for the fitting of the dentures and to let the representative know the Resident had the money in her account. LPN#56 reported the representative stated that she did not want to use the Resident's money or her own money and the Resident's family needs to come up with the money. Further review of the medical records finds a Multidisciplinary Care Conference note dated 06/18/21 at 1:20 PM by Registered Nurse (RN) Assessment Coordinator #19 under the heading of Patient/Responsible Party Concerns/ Compliments: Representative has now decided that she does not want Resident to get her dentures. Representative states she probably won't wear them or she will throw them in the trash do to her confusion. CMS:§483.55(a)(3) states that a facility must have a policy identifying those circumstances when the loss or damage of dentures is the facility's responsibility and may not charge a resident for the loss or damage of dentures determined in accordance with facility policy to be the facility's responsibility During an interview conducted on 07/13/21, at 1:36 PM, with executive director (ED) #18, regarding the facility's policy on resident belongings. The executive director (ED) stated that the facility would be responsible for replacing the dentures and that they replace dentures all the time. The facility did not have a policy related to lost dentures and the procedure for replacement. The ED said it is not facility policy to ask the family to pay out of pocket. .

. Based on observation, interview and record review, the facility failed to ensure Resident # 44 had proper positioning with a table height for her size during meal time. This was a random opportunity for discovery during the annual Long Term Care Survey. Resident identifier: #44. Facility census: 57 Findings included: a) Resident #44 On 07/12/21 at 12:19 PM, an observation of the noon time meal found Resident #44 seated at a table that was too high for her to comfortably reach her food items. She was observed reaching up over the table to get her food and putting it down to her mouth. During an interview with Licensed Practical Nurse (LPN) #68 on 07/12/21 at 12:22 PM she stated, the table did not adjust height wise. She stated, I am going to go help her now so she can get her food. On 07/13/21 at 11:55 AM, observed service of the lunch meal. Resident #44 was sitting at the (4th) fourth table from the back, of the dining room. Again she was seated at a table that was too high for her to reach her food without difficulty. Staff set up resident's #44 tray. Licensed Practical Nurse (LPN) #60 offered assistance and stated, Do what you can alone, then I will come in and help you for what you need help with. Review of Resident #44's medical record on 07/12/21 found Resident #44's height was recorded as 48 inches and she utilizes a wheelchair. On 07/14/2021 at 11:56 AM, observed lunch being served. Resident #44 was in her wheelchair seated at a table in the dining room. Resident #44 had to lift her arm up over the table to get her drink. Resident #44 was having difficulty reaching her fruit cup located on the farthest part of her place setting. At 12:19 PM on 07/14/21, the Director of Nursing (DON) was asked if the table could be adjusted to accommodate the resident's size? The DON stated, They do adjust but we have to look into getting her a different table. She confirmed the table was too high for the resident to comfortably reach her food items and feed herself. At 12:24 PM the Executive Director (ED) was made aware of the table being too high for Resident #44. She stated, We can get that taken care of. That's no problem .

. Based on interview and observation, the facility failed to ensure the long term care survey results were readily accessible to the residents residing on the second floor of the facility. This failed practice had the potential to affect more than an isolated number of residents. Facility census: 57. Findings included: a) Resident Council Meeting On 07/14/21 the Resident Council meeting started at 11:03 AM. Two (2) state surveyors were present. The question was ask: --Without having to ask, are the results of the State inspection available to read? Resident # 12 stated, I do not know where to find them on second floor. Observation of second floor found no long term care survey results. The only results were posted on first floor. The second floor elevator requires a code to use the elevator. The residents residing on the second floor would have to ask permission to go to first floor to view the long-term survey results. On 07/14/21 at 1:14 PM, the executive director (ED) stated, The only state long-term survey result book is on first floor. I will put one on second floor. .

. c) Resident #28 On 07/13/21 at 7:59 AM Licensed Practical Nurse (LPN) #32 popped a pill from the medication card and the pill landed on the medication cart. LPN#32 put the pill in the medication cup with ungloved hands for Resident #28. Based on the facility policy entitled, Oral Medication Administration Procedure, medications are not to be touched with bare hands and if medication is dropped, the medication should be discarded. d) Resident #16 On 07/13/21 at 8:22 AM Licensed Practical Nurse (LPN) #32 popped a pill from the medication card and the pill landed on the medication cart. LPN#32 put the pill in the medication cup with ungloved hands for Resident #12. Based on the facility policy Oral Medication Administration Procedure, medications are not to be touched with bare hands and if the medication is dropped, the medication should be discarded. DON notified. On 07/13/21 at 9:33 AM, the observations from the medication administration for Residents #28 and #16 were discussed with the Director of Nursing (DON). No further information was provided. b) Resident #41 On 07/13/21 at 9:20 AM, Activity Aide (AA) #42 entered Resident #41 who was on contact precautions. Instructions posted on the door stated that a gown, face mask, face shield and gloves were to be worn when entering the room. AA #42 entered the room wearing a gown, mask and gloves but no face shield. Face shields were available at the door. When AA #42 was asked if the required attire was worn into the room, she stated No I forgot the face shield. I am so sorry. An interview with the Director of Nursing (DON) at 9:33 AM on 07/13/21 acknowledged that face shield/goggles were to be worn. Based on observation, record review and interview, the facility failed to ensure kitchen staff had proper hand washing facilities available in the dish room. A step on trash can was not available for paper towel disposal after washing hands. The facility failed to ensure staff donned the proper Personal Protective Equipment (PPE) before entering an isolation room. These practices had the potential to affect more than a limited number of residents. In addition, the facility failed to ensure proper infection control procedures were observed for two (2) of five (5) residents observed during medication administration. Resident identifiers: #41, #28 and #16. Facility census: 57. Findings included: a) Tour of the kitchen At 11:21 AM on 07/12/21, observation of the dish room (used to clean the dirty dishes) found a hand washing sink with hand soap and paper towels. There was no trash can beside the sink. A large 30 gallon trash can on rollers, with a lid that had to be removed by hand, was present about 3 feet from the sink. The dietary manager confirmed a trash can, with a step on lid, which would allow the staff to dispose of paper towels after washing their hands without touching the current trash can lid was not available. On 07/13/21 at 9:42, dietary employee #79 stated she washes dishes at times, We all do everything from serving the food to washing the dishes. When asked where she washes her hands after touching the soiled dishes in the dish room, she replied, At the sink in the dish room. When ask how she disposes of the paper towels she replied, We take the lid off and put the towels in the trash can. DM #79 pointed to the 30 gallon trash can, still present in the dish room, as the one used after washing her hands. On 07/13/21 at 10:05 AM, the Dietary Manager said, I put a step on trash can in the dish room. On 07/14/21 at 10:33 AM, the administrator stated she was aware the Dietary Manager replaced the trash can in the dish room. .