Based on record review and staff interview, the facility failed to obtain labs, as ordered by the physician, for Resident #41. This was true for one (1) of five (5) residents reviewed for unnecessary medications during the survey process. Resident identifier: #41. Facility census: 93. Findings include: A) Resident #41 During a review of Resident 41's record on 04/01/25, it was noted the resident had the following order- CBC, BMP and HGBA1C in the morning every three (3) months starting on the 2nd for one (1) day. This order was entered into the system on 11/4/24. Review of the resident's lab results, and progress notes indicated no labs were drawn in the month of March 2025. According to the order, the labs should have been taken on 03/02/25. Documentation regarding the labs was requested from the facility at approximately 11:45 AM on 04/01/25. On 04/01/25 at approximately 1:44 PM, the facility provided documentation related to Resident #41's labs. The only documentation for lab draws, were from labs completed on 12/02/24. Upon further review of Resident #41's orders, it was noted her orders for labs were changed at 12:38 PM on 04/01/25 to CBC, BMP, and HGA1C, every day shift every four (4) months starting on the 2nd for one (1) day. At approximately 1:50 PM on 4/1/2025, an interview was conducted with Registered Nurse Regional Director of Clinical Operations (RNRDCO) #120 regarding the labs and orders. RNRDCO #120 confirmed the labs were not drawn on 03/02/25, or any time in the month of March 2025, and that the order had recently been changed to every four (4) months, after surveyor intervention.

Based on record review and staff interview, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice. The facility failed to ensure a physician order for pain was correctly followed for Resident #4. This failed practice was true for one (1) of one (1) residents reviewed for pain. Resident identifier: #4. Facility census: 93. Findings included: a) Resident #4 A medical record review, completed on 05/09/23 at 11:27 AM, revealed the following physician order, dated 02/09/25, Hydrocodone-Acetaminophen Tablet 7.5-325 MG. Give 1 tablet by mouth every 6 hours as needed for moderate to severe pain (5-10) not to exceed 3gm Tylenol in 24hr. Review of the February and March 2025 Medication Administration Records (MARs) revealed the following dates and times the medication was not given in accordance with the physician's order: -On 02/13/25, the medication was given with a pain level of 4 -On 02/22/25, the medication was given with a pain level of 4 -On 02/22/25, the medication was given with a pain level of 4 -On 03/18/25, the medication was given with a pain level of 4 -On 03/19/25, the medication was given with a pain level of 4 -On 03/21/25, the medication was given with a pain level of 4 -On 03/22/25, the medication was given with a pain level of 4 -On 03/23/25, the medication was given with a pain level of 4 -On 03/24/25, the medication was given with a pain level of 0 -On 03/27/25, the medication was given with a pain level of 4 During an interview, on 04/01/25 at 2:16 PM, the Mobile Director of Nursing (DON) acknowledged nursing staff had failed to follow the physician's order correctly and had administered medications outside the parameters of the designated pain scale.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interviews, the facility failed to aid a resident and/or their legal representatives with advance care planning, including but not limited to completion of advanced directives per professional standards. This is true for one (1) of 27 reviewed for advanced directives. Resident identifier #75. Facility census: 93. Findings included: a) Resident #75 A medical record review for Resident #75 revealed an admission to the facility on [DATE]. An Encounter Summary provided to the surveyor from the transferring hospital found the capacity statements from 02/29/25. -- Demonstrates Capacity to make medical decisions was marked. Continued review found that physician determination of capacity was completed on 02/20/25. -- Demonstrates Capacity to make decisions was marked. Subsequent review found that the review of Resident 75's Minimum Data Set (MDS) with the ARD date of 02/26/25, finds the resident has a score of 03. A BIMS score of 3 indicates that the resident is severely impaired. A Physician Orders for Scope of Treatment (POST) form completed by the directions specified by the [NAME] Virginia Center for End-of-Life Care in conjunction with the [NAME] Virginia Health Care Decisions Act (16-30-1) was completed on 03/12/25 with the signature of Resident #75 by Social Worker #300. A nurse progress note was reviewed on 04/01/25. -- 4/1/2025 at 12:54 Note Text: Physician will be in on Thursday to see Resident and re-evaluate capacity due to BIMS of 3 per MDS. During an interview with the Regional Director of Clinical Operations, 121 confirmed that the BIMS score was 3 prior to Resident #75 signed the POST form.

Based on observation and staff interview, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food safety. The staff failed to use proper hand hygiene and don a hairnet while in the kitchen. Lastly, failed to maintain the equipment in safe operating condition. This practice had the potential to affect more than an isolated number of residents. Facility census: 93. Findings included: a) On 04/02/2024 at 12:49 PM, during a visit to the kitchen the following was observed: -Corn flakes found stored without label opening and used by date -Breaded fish found in freezer left open to air. In an interview with The Food Service Supervisor, at 1:10 PM on 04/02/2024, she acknowledged the both the corn flakes were found stored without an opening and used by dated label, and the breaded fish was found left open to air in the freezer. On 04/02/25 at 11:50 PM During lunch dining observation it was observed that NA #79 wheeled a male resident into the dining room to a table and walked into the kitchen. Observing through the window on the door, NA #79 stood in the kitchen for approximately 3 minutes. The back of her head and hair were not covered with a hairnet. The NA re-entered the dining room and waited by the resident for his tray. When the tray was ready, The NA then took the tray from the kitchen staff and returned to the resident and began to assist with tray set up. She did not wash her hands before taking the food tray from kitchen staff. In an interview with the food service supervisor (FSS), on 04/02/25 at 12:15 PM, FSS acknowledged the CNA did come into the kitchen but did not realize NA #79 had not placed the hairnet on correctly. She stated she did not see the back of NA's hair not covered, she could only see her from the front, in which she stated the NA did have a hairnet on the top and front of her head. She also stated she was unaware the NA did not wash or sanitized her hands before taking the food tray. She stated the CNA should have washed/sanitized her hands before taking the tray to the resident and assisting in tray set up. c) Ice Machines On 03/31/25 at 10:16 AM the tour with the Dietary Manager found the ice machines located in the Kitchen area did not have the required water filter on the ice machines. The continuation of the tour found the east and west unit ice machines did not have the required water filters. On 03/31/25, the Maintenance Director stated that he was unsure if the ice machines should have water filters in place. Review of the manufacture's guide and guidance at www.manitowocice.com found that the Manitowoc ice machine water filter plays a critical role in ensuring the water supplied to your ice machine is clean, free from impurities, and properly filtered. During an interview and observation, on 04/01/25 at 1:37 PM, the Service Supervisor from DSO Service Company was placing water filters on all the ice machines in the facility. During the interview he stated the Manitowoc Ice Machine does not have an internal water filter. He continued to say that the external water filter is required for safe, clean ice. During an interview, on 04/01/25 at 1:45 PM, the Administrator stated he called DSO company to make sure all ice machines were functioning safely for the residents.

Based on record review and staff interview, the facility failed to develop and/or implement the care plan for Resident #92, #84, #39 and #95, four (4) of four (4) residents reviewed. Resident identifiers: #92, #84, #39 and #95. Facility Census: 93. Findings included: a) Resident #92 On 04/03/24 at 9:00 AM, a record review was completed for Resident #92. The review found the care plan had not been developed to include all the interventions based on the physician's orders and the Treatment Administration Record (TAR) dated 03/01/24 through 03/31/24. The interventions that were not found were as follows: --Daily assessment of the unstageable (UN) wound on the right heel --Wound care as ordered On 04/03/24 at 10:00 AM, the Corporate Registered Nurse (RN) was notified and confirmed the interventions were not listed. b) Resident #84 On 04/03/24 at 9:15 AM, a record review was completed for Resident #84. The record review found the care plan had not been developed to include an Unstageable wound on the sacrum and the interventions found in the physician's orders and the TAR dated 03/01/24 through 03/31/24. The following interventions were not found as follows: --Daily wound assessment on the bullae of the right thumb, the unstageable wound of the sacrum, vascular wound of the lateral thigh, the vascular wound of the right lower extremity --Wound care as ordered --Float heels while in bed --Encourage to turn and reposition while in bed On 04/03/24 at 10:00 AM, the Corporate Registered Nurse (RN) was notified and confirmed the interventions were not listed. c) Resident #39 On 04/03/24 at 9:25 AM, a record review was completed for Resident #39. The review found the care plan had not been implemented based on the TAR dated 03/01/24 through 03/31/24. The following interventions were not implemented: --Administer preventative treatment as ordered --Administer treatments as ordered and monitor for effectiveness --Daily wound assessments per orders --Resident may use pillowcases between knees and to prevent skin breakdown due to contractures On 04/03/24 at 10:00 AM, the Corporate Registered Nurse (RN) was notified and confirmed the interventions were not implemented. d) Resident #95 On 04/03/24 at 9:40 AM, a record review was completed for Resident #95. The review found the care plan had not been implemented based on the physician's orders and the TAR dated 02/01/24 through 02/29/24. The following interventions were not implemented: --Daily wound assessment of the surgical wound of the right iliac crest --Turn resident every 2 (two) hours (alternate right side and left side and back for meals as tolerated On 04/03/24 at 10:00 AM, the Corporate Registered Nurse (RN) was notified and confirmed the interventions were not listed.

Based on record review and staff interview, the facility failed to follow physician's orders four (4) of four (4) residents. Resident identifiers: #92, #84, #39 and #95. Facility Census: 93. Findings included: a) Resident #92 On 04/03/24 at 9:00 AM, a record review was completed for Resident #92. The review found the physician's orders on the Treatment Administration Record (TAR) for 03/01/24 through 03/31/24 were not followed. The following treatments and dates were left blank: --Daily wound treatment to the stage III to the sacrum --03/02/24 day shift --Daily wound assessment for the stage III to the sacrum --03/02/24 day shift --Preventative treatment to the coccyx and bilateral buttocks twice daily --03/25/24 night shift --Bilateral palm guards on hands may remove twice daily to clean and monitor skin --03/25/24 night shift --Float heels when in bed twice daily for preventative measures --03/25/24 night shift --Resident may use pillow cases between knees to prevent skin breakdown due to contractures twice daily --03/25/24 night shift --Ensure resident has been turned and repositioned every 2 (two) hours for stage 2 (two) --03/03/24 at 12:00 AM, 2:00 AM, and 4:00 AM --03/15/24 at 6:00 PM --03/25/24 at 8:00 PM and 10:00 PM --03/26/24 at 12:00 AM, 2:00 AM, and 4:00 AM --03/28/24 at 4:00 AM On 04/03/24 at 10:00 AM, Corporate Registered Nurse (RN) #147 was notified and confirmed the TAR should have been completed as ordered. The Corporate RN #147 stated, I can't fix holes. b) Resident #84 On 04/03/24 at 9:15 AM, a record review was completed for Resident #84. The review found the physician's orders on the Treatment Administration Record (TAR) for 03/01/24 through 03/31/24 were not followed. The following treatments and dates were left blank: --Daily treatment to the bullae to the right thumb --03/03/24 day shift --03/06/24 day shift --03/12/24 day shift --Daily wound assessment of the bullae to the right thumb --03/03/24 day shift --03/06/24 day shift --03/12/24 day shift --Dressing change to Peripherally Inserted Central Catheter (PICC) line site every Tuesday --03/19/24 day shift --Daily wound care to the unstagable (UN) to the sacrum --03/03/24 day shift --03/12/24 day shift --03/15/24 day shift --03/19/24 day shift --Daily wound assessment to the vascular wound lateral thigh --03/03/24 day shift --03/06/24 day shift --03/12/24 day shift --03/15/24 day shift --03/19/24 day shift --03/20/24 day shift --03/21/24 day shift --Daily wound care to the vascular wound lateral thigh --03/03/24 day shift --03/15/24 day shift --03/19/24 day shift --03/21/24 day shift --Wound care to the vascular wound right lower extremity every other day --03/06/24 day shift --03/12/24 day shift --03/20/24 day shift --Daily wound assessment to the vascular wound right lower extremity --03/03/24 day shift --03/06/24 day shift --03/12/24 day shift --03/15/24 day shift --03/19/24 day shift --03/20/24 day shift --03/21/24 day shift --Encourage to turn and reposition while in bed every shift --03/06/24 day shift --Monitor Peripherally inserted central catheter (PICC) line site for signs/symptoms of infection every shift --03/06/24 day shift On 04/03/24 at 10:00 AM, Corporate Registered Nurse (RN) #147 was notified and confirmed the TAR should have been completed as ordered. The Corporate RN #147 stated, I can't fix holes. c) Resident #39 On 04/03/24 at 9:25 AM, a record review was completed for Resident #39. The review found the physician's orders on the Treatment Administration Record (TAR) for 03/01/24 through 03/31/24 were not followed. The following treatments and dates were left blank: --Daily wound care to the stage III sacrum --03/02/24 day shift --Preventative care to the coccyx and bilateral buttocks every shift --03/25/24 night shift --Bilateral palm guards on hands every shift --03/25/24 night shift --Float heels when in bed every shift --03/25/24 night shift --Pillow cases between knees to prevent skin breakdown every shift --03/25/24 night shift --Ensure resident has been turned and repositioned every 2 (two) hours for stage 2 (two) --03/03/24 12:00 AM, 2:00 AM and 4:00 AM --03/15/24 6:00 PM --03/25/24 8:00 PM and 10:00 PM --03/26/24 12:00 AM, 2:00 AM and 4:00 AM --03/28/24 4:00 AM On 04/03/24 at 10:00 AM, Corporate Registered Nurse (RN) #147 was notified and confirmed the TAR should have been completed as ordered. The Corporate RN #147 stated, I can't fix holes. d) Resident #95 On 04/03/24 at 9:25 AM, a record review was completed for Resident #95. The review found the physician's orders on the Treatment Administration Record (TAR) for 02/01/24 through 02/29/24 were not followed. The following treatments and dates were left blank: --Cleanse suprapubic catheter and apply drain sponge daily --02/03/24 day shift --Encourage resident to wear prevalon boots during the night --02/03/24 night shift --02/04/24 night shift --Daily wound assessment for surgical wound right iliac crest --02/03/24 day shift --02/04/24 day shift --Daily wound care to right iliac crest --02/03/24 day shift --02/04/24 day shift --Suprapubic catheter to BSD (bedside drain) document output every shift --02/03/24 day shift --02/03/24 night shift --0204/24 day shift --02/04/24 night shift --Encourage resident to wear gray fleece AFO (ankle foot orthosis) boots daily apply during AM (morning) medication pass and remove around 2:00 PM --02/03/24 application and removal --02/04/24 application and removal --Encourage resident to allow staff to turn and reposition every shift --02/03/24 day shift --02/03/24 night shift --02/04/24 day shift --02/04/24 night shift In addition, there were multiple physician's orders to encourage resident to turn and reposition every two (2) hours which at times did show on the TAR and other times the physician's orders did not. The following dates are the multiple times the physician's order was input: --01/12/24 to 02/05/24 The review under the task tab entitled Turn and reposition, the documentation was not complete or multiple duplicate times were documented. A review of the January, 2024 documentation found the following: --01/01/24 No documentation 12:00 AM 2:00 AM 4:00 AM 6:00 AM 8:00 AM 10:00 AM 2:00 PM 6:00 PM 10:00 PM --01/02/24 12:00 AM 2:00 AM 6:00 AM 8:00 AM 12:00 PM 2:00 PM 4:00 PM 8:00 PM 10:00 PM --01/09/24 No documentation found --01/10/24 No documentation found --01/11/24 No documentation except for 10:00 PM --01/13/24 12:00 AM 2:00 AM 4:00 AM 6:00 AM 8:00 AM 10:00 AM 2:00 PM 4:00 PM 6:00 PM 10:00 PM --01/14/24 12:00 AM 2:00 AM 6:00 AM 8:00 AM 10:00 AM 2:00 PM 6:00 PM 10:00 PM --01/15/24 2:00 AM 6:00 AM 8:00 AM 2:00 PM 4:00 PM 6:00 PM 8:00 PM 10:00 PM --01/16/24 12:00 AM 2:00 AM 6:00 AM 8:00 AM 12:00 PM 2:00 PM 4:00 PM 6:00 PM --01/17/24 6:00 AM 8:00 AM 2:00 PM 6:00 PM 10:00 PM --01/18/24 12:00 AM 2:00 AM 4:00 AM 8:00 AM 12:00 PM 6:00 PM 10:00 PM --01/19/24 12:00 AM 2:00 AM 4:00 AM 8:00 AM 10:00 AM 2:00 PM 6:00 PM --01/20/24 12:00 AM 2:00 AM 6:00 AM 8:00 AM 4:00 PM 6:00 PM 10:00 PM --01/21/24 12:00 AM 6:00 AM 10:00 AM 12:00 PM 4:00 PM 6:00 PM 10:00 PM --01/22/24 12:00 AM 2:00 AM 4:00 AM 6:00 AM 8:00 AM 12:00 PM 4:00 PM 6:00 PM 10:00 PM --01/23/24 12:00 AM 2:00 AM 8:00 AM 10:00 AM 2:00 PM 6:00 PM 8:00 PM --01/24/24 6:00 AM 8:00 AM 12:00 PM 4:00 PM 6:00 PM 10:00 PM --01/25/24 4:00 AM 8:00 AM 12:00 PM 4:00 PM 8:00 PM --01/26/24 12:00 AM 2:00 PM 4:00 PM 6:00 PM --01/27/24 12:00 AM 6:00 AM 8:00 AM 10:00 AM 2:00 PM 4:00 PM 8:00 PM 10:00 PM --01/28/24 12:00 AM 4:00 AM 8:00 AM 10:00 AM 12:00 PM 4:00 PM 6:00 PM 8:00 PM --01/29/24 12:00 AM 4:00 AM 2:00 PM 4:00 PM 6:00 PM 8:00 PM --01/30/24 6:00 AM 8:00 AM 2:00 PM 6:00 PM 8:00 PM --01/31/24 12:00 AM 2:00 AM 6:00 AM 8:00 AM 12:00 PM 4:00 PM 6:00 PM 10:00 PM On 04/03/24 at approximately 11:00 AM, the Corporate Registered Nurse (RN) #147 was notified and stated, I don't know why the physician's order is not showing on the TAR. --

Based on record review, review of legislative rule § 69-10-1 TITLE 69 Rule Department of Health and Human Resources, Series 10 [NAME] Virgnia Clearance for Access: Registry and Employment Screening and staff interview, the facility failed to implement the facility policies to prohibit and prevent abuse, neglect, exploitation of residents and misappropriation of resident property ensure provisional employment screening. The facility also failed to ensure completion of background checks before allowing staff to work and have direct access to the residents. All residents had the potential to be affected. The facility failed to provisionally employ staff pending the [NAME] Virginia Cares fitness determination and the facility failed to require a fingerprint-based background check before hiring staff. The facility had identified and corrected this issue prior to the survey. Staff identifiers: #28, #44, #80, #109, #110, #119 and #127. Facility Census: 93. Findings included: a) Certified Nursing Assistant (CNA) #28 CNA #28 was hired on 08/30/22. The [NAME] Virginia (WV) Cares Self-Disclosure Application and Consent Form was completed and signed on 01/15/24. The Notification of Eligible Fitness Determination was received 03/26/24. b) Certified Nursing Assistant (CNA) #44 CNA #44 was hired on 08/18/21. The [NAME] Virginia (WV) Cares Self-Disclosure Application and Consent Form was completed and signed on 02/23/24. The Notification of Eligible Fitness Determination was received 03/26/24. c) Maintenance Technician (MT) #80 MT #80 was hired on 12/05/23. The [NAME] Virginia (WV) Cares Self-Disclosure Application and Consent Form was completed and signed on 12/12/23. d) Receptionist #109 Receptionist #109 was hired on 02/05/23. The [NAME] Virginia (WV) Cares Self-Disclosure Application and Consent Form was completed and signed on 01/01/24. A Notification of Ineligible Fitness Determination was received on 02/21/24. A notification of variance request determination - Granted was received on 03/22/24. e) [NAME] #110 Cook #110 was hired on 05/11/22. The [NAME] Virginia (WV) Cares Self-Disclosure Application and Consent Form was completed and signed on 01/08/24. The Notification of Eligible Fitness Determination was received 03/27/24. f) Certified Nursing Assistant #119 CNA #28 was hired on 11/19/21. The [NAME] Virginia (WV) Cares Self-Disclosure Application and Consent Form was completed and signed on 01/20/24. The Notification of Eligible Fitness Determination was received 03/26/24. g) Receptionists #127 Receptionist #127 was hired on 04/04/23. The [NAME] Virginia (WV) Cares Self-Disclosure Application and Consent Form was completed and signed on 04/03/23. A Notification of Variance request Determination letter was provided that denied the variance request. This denial letter was dated 03/20/24 and had a copy of an email attached that was sent from the facility. Nursing Staff Scheduler #84 stated the denial letter for Receptionist #127 was attached and that she would need to have her termed out of the system and her job posted. This email was dated 03/21/24. A review of the facility policy titled Policies and Standard Procedures, [NAME] Virginia Abuse, Neglect & Misappropriation (Policy # NS-1018-03) section entitled Procedure, I. Screening identified the following facility Policies and Standard Procedures: #2. A pre-hire criminal background check will be performed for all potential [NAME] Virginia staff including but not limited to; a) Federally mandated Health and Human Services (HHS) Office of Inspector General's (OIG) List of Excluded Individuals/Entitles (LEIE) b) System for Award Management (SAM) formerly known as the General Services administrations (GSA). c) Criminal state, criminal federal, sex offender, Federal and State Excluding screening and Elder Abuse (NRDD) screenings. d) Criminal State Background checks. e) Criminal Federal Background checks. f) Sex offender background screen. g) Federal and State Exclusions screening. h) Elder Abuse screening § 69-10-1 TITLE 69 Legislative Rule Department of Health and Human Resources, Series 10 [NAME] Virgnia Clearance for Access: Registry and Employment Screening § 69-10-3. Prescreening. 3.1. A covered provider or covered contractor shall prescreen all direct access personnel applicants considered for hire for negative findings by way of an internet search of registries and licensure databases through the WV CARES website. The Department shall prescreen all applicants considered for hire for negative findings by way of an internet search of registries and licensure databases through the WV CARES website. The Secretary will charge a $20 fee for its use. 3.2. A covered provider shall ensure that all covered contractors who provide direct access personnel prescreen their applicants considered for hire for negative findings by way of an internet search of registries and licensure databases through the WV CARES website. 3.3. The Department shall ensure that all covered contractors who provide direct access personnel prescreen their applicants considered for hire for negative findings by way of an internet search of registries and licensure databases through the WV CARES website. 3.4. If the applicant has a negative finding on any required registry or licensure database, the Department, covered provider, or covered contractor shall notify the applicant, in writing, by regular U.S. mail, of such finding and shall not employ that applicant. § 69-10-5. Employment Fitness Determination. 5.1. If the Secretary's review of the criminal history record information provided by the State Police reveals the applicant does not have a disqualifying offense, the applicant may be employed. § 69-10-6. Provisional Employees. 6.1. Provisional basis employment for no more than 60 days may occur when: 6.1.1. An applicant does not have a negative finding on a required registry or licensure database, and the employment fitness determination is pending the criminal history record information; or 6.1.2. An applicant has requested a variance of the employment fitness determination and that decision is pending. On 04/08/24 at approximately 6:00 PM during an interview with the Administrator, the Administrator acknowledged there had been issues identified within the IDT team regarding the WV Cares background check completions not being timely. He also acknowledged that staff were permitted to work more than the provisional 60 days and they had been hired before the fingerprint-based background check. He further stated the facility had identified the issue and had put a plan in place to correct the issue and to monitor it to ensure the process is corrected. The Administrator provided the Quality Assessment and Performance Improvement (QAPI) Performance Improvement Team Documentation dated 02/21/24 and submitted the following narrative of the plan that was put in place. On 02/21/24 the Executive Director and Human Resource Director created a Performance Improvement Plan on compliance with WV Cares. It was identified that there were issues with employees getting WV Cares completed within the 60 days of hire. An Audit was completed to determine what employees had been missed. Those employees missing were submitted to WV Cares upon identification. The Human Resource Director along with eh Executive Director started monitoring WV Cares weekly to ensure all employees stayed in the 60-day window for compliance. Those employees that trigger a variance will be placed on leave until a final decision is made. All new hires are now being monitored by the Human Resource Director and/or Executive Director weekly. Any decision that takes longer than 60 days will result in the employee being suspended pending the WV Care results. Dated and signed by the Administrator (Executive Director) on 04/08/24. On 04/09/24 at approximately 10:30 AM a review of the completion of the [NAME] Virginia (WV) Cares notification of eligibility fitness determination for ten (10) staff with hire dates on or after 10/31/23 revealed there were no further issues identified with the [NAME] Virginia (WV) Cares Self-Disclosure Application and Consent Form completion, the Notification of Eligible Fitness Determinations, staff working in excess of the 60 provisional days permitted or with staff being hired before requiring the fingerprint-based background check.

Based on record review, review of legislative rule § 69-10-1 TITLE 69 Rule Department of Health and Human Resources, Series 10 [NAME] Virgnia Clearance for Access: Registry and Employment Screening and staff interview, the facility failed to operate and provide services in compliance with all applicable State and local laws, regulations, and codes, and with accepted professional standards and principles that apply to professionals providing services in such a facility. The facility failed to ensure provisional employment screening. The facility also failed to ensure completion of background checks before allowing staff to work and have direct access to the residents. All residents had the potential to be affected. The facility failed to provisionally employ staff pending the [NAME] Virginia Cares fitness determination and the facility failed to require a fingerprint-based background check before hiring staff. The facility had identified and corrected this issue prior to the survey. Staff identifiers: #28, #44, #80, #109, #110, #119 and #127. Facility Census: 93. Findings included: a) Certified Nursing Assistant (CNA) #28 CNA #28 was hired on 08/30/22. The [NAME] Virginia (WV) Cares Self-Disclosure Application and Consent Form was completed and signed on 01/15/24. The Notification of Eligible Fitness Determination was received 03/26/24. b) Certified Nursing Assistant (CNA) #44 CNA #44 was hired on 08/18/21. The [NAME] Virginia (WV) Cares Self-Disclosure Application and Consent Form was completed and signed on 02/23/24. The Notification of Eligible Fitness Determination was received 03/26/24. c) Maintenance Technician (MT) #80 MT #80 was hired on 12/05/23. The [NAME] Virginia (WV) Cares Self-Disclosure Application and Consent Form was completed and signed on 12/12/23. d) Receptionist #109 Receptionist #109 was hired on 02/05/23. The [NAME] Virginia (WV) Cares Self-Disclosure Application and Consent Form was completed and signed on 01/01/24. A Notification of Ineligible Fitness Determination was received on 02/21/24. A notification of variance request determination - Granted was received on 03/22/24. e) [NAME] #110 Cook #110 was hired on 05/11/22. The [NAME] Virginia (WV) Cares Self-Disclosure Application and Consent Form was completed and signed on 01/08/24. The Notification of Eligible Fitness Determination was received 03/27/24. f) Certified Nursing Assistant #119 CNA #28 was hired on 11/19/21. The [NAME] Virginia (WV) Cares Self-Disclosure Application and Consent Form was completed and signed on 01/20/24. The Notification of Eligible Fitness Determination was received 03/26/24. g) Receptionists #127 Receptionist #127 was hired on 04/04/23. The [NAME] Virginia (WV) Cares Self-Disclosure Application and Consent Form was completed and signed on 04/03/23. A Notification of Variance request Determination letter was provided that denied the variance request. This denial letter was dated 03/20/24 and had a copy of an email attached that was sent from the facility. Nursing Staff Scheduler #84 stated the denial letter for Receptionist #127 was attached and that she would need to have her termed out of the system and her job posted. This email was dated 03/21/24. A review of the facility policy titled Policies and Standard Procedures, [NAME] Virginia Abuse, Neglect & Misappropriation (Policy # NS-1018-03) section entitled Procedure, I. Screening identified the following facility Policies and Standard Procedures: #2. A pre-hire criminal background check will be performed for all potential [NAME] Virginia staff including but not limited to; a) Federally mandated Health and Human Services (HHS) Office of Inspector General's (OIG) List of Excluded Individuals/Entitles (LEIE) b) System for Award Management (SAM) formerly known as the General Services administrations (GSA). c) Criminal state, criminal federal, sex offender, Federal and State Excluding screening and Elder Abuse (NRDD) screenings. d) Criminal State Background checks. e) Criminal Federal Background checks. f) Sex offender background screen. g) Federal and State Exclusions screening. h) Elder Abuse screening § 69-10-1 TITLE 69 Legislative Rule Department of Health and Human Resources, Series 10 [NAME] Virgnia Clearance for Access: Registry and Employment Screening § 69-10-3. Prescreening. 3.1. A covered provider or covered contractor shall prescreen all direct access personnel applicants considered for hire for negative findings by way of an internet search of registries and licensure databases through the WV CARES website. The Department shall prescreen all applicants considered for hire for negative findings by way of an internet search of registries and licensure databases through the WV CARES website. The Secretary will charge a $20 fee for its use. 3.2. A covered provider shall ensure that all covered contractors who provide direct access personnel prescreen their applicants considered for hire for negative findings by way of an internet search of registries and licensure databases through the WV CARES website. 3.3. The Department shall ensure that all covered contractors who provide direct access personnel prescreen their applicants considered for hire for negative findings by way of an internet search of registries and licensure databases through the WV CARES website. 3.4. If the applicant has a negative finding on any required registry or licensure database, the Department, covered provider, or covered contractor shall notify the applicant, in writing, by regular U.S. mail, of such finding and shall not employ that applicant. § 69-10-5. Employment Fitness Determination. 5.1. If the Secretary's review of the criminal history record information provided by the State Police reveals the applicant does not have a disqualifying offense, the applicant may be employed. § 69-10-6. Provisional Employees. 6.1. Provisional basis employment for no more than 60 days may occur when: 6.1.1. An applicant does not have a negative finding on a required registry or licensure database, and the employment fitness determination is pending the criminal history record information; or 6.1.2. An applicant has requested a variance of the employment fitness determination and that decision is pending. On 04/08/24 at approximately 6:00 PM during an interview with the Administrator, the Administrator acknowledged there had been issues identified within the IDT team regarding the WV Cares background check completions not being timely. He also acknowledged that staff were permitted to work more than the provisional 60 days and they had been hired before the fingerprint-based background check. He further stated the facility had identified the issue and had put a plan in place to correct the issue and to monitor it to ensure the process is corrected. The Administrator provided the Quality Assessment and Performance Improvement (QAPI) Performance Improvement Team Documentation dated 02/21/24 and submitted the following narrative of the plan that was put in place. On 02/21/24 the Executive Director and Human Resource Director created a Performance Improvement Plan on compliance with WV Cares. It was identified that there were issues with employees getting WV Cares completed within the 60 days of hire. An Audit was completed to determine what employees had been missed. Those employees missing were submitted to WV Cares upon identification. The Human Resource Director along with eh Executive Director started monitoring WV Cares weekly to ensure all employees stayed in the 60-day window for compliance. Those employees that trigger a variance will be placed on leave until a final decision is made. All new hires are now being monitored by the Human Resource Director and/or Executive Director weekly. Any decision that takes longer than 60 days will result in the employee being suspended pending the WV Care results. Dated and signed by the Administrator (Executive Director) on 04/08/24. On 04/09/24 at approximately 10:30 AM a review of the completion of the [NAME] Virginia (WV) Cares notification of eligibility fitness determination for ten (10) staff with hire dates on or after 10/31/23 revealed there were no further issues identified with the [NAME] Virginia (WV) Cares Self-Disclosure Application and Consent Form completion, the Notification of Eligible Fitness Determinations, staff working in excess of the 60 provisional days permitted or with staff being hired before requiring the fingerprint-based background check.

. Based on record review, staff interview and resident interview the facility failed to ensure their policy as it pertained to abuse, abuse investigation, and abuse prevention was implemented. Two (2) residents were found to have been abused by being physically restrained. Resident #43 was physically and restrained by a nurse aide who held her head preventing movement so the nurse could perform a swab of the nose to test Resident #43 for COVID. Resident #11 became agitated and a nurse took the resident to her room where they locked the residents wheelchair and physically held the resident's wheelchair preventing her from moving and leaving her room. The state agency (SA) determined these failures caused Resident #11 and Resident #43 to suffer physically and mentally. Neither resident was able to verbalize how these actions made them feel. Not only did these failures harm Resident #11 and Resident #43 but they also placed the remaining 93 residents at risk for serious harm and/or death because both alleged perpetrators were still employed by the facility and actions were not taken to ensure these perpetrators did not abuse other residents in the future. This placed all 95 residents in an immediate jeopardy (IJ) situation. The facility was first notified of the IJ at 6:15 PM, on 02/20/24. The SA received the Plan of Correction (POC) at 10:23 PM on 02/20/24. The SA accepted the POC on 02/20/24 at 10:28 PM. The SA observed for the implementation of the POC and the IJ was abated on 02/21/24 at 2:00 PM. Resident Identifiers: #43 and #11. Facility Census: 95. Findings included: a) Abuse Policy A review of the facility's abuse policy titled: [NAME] Virginia Abuse, Neglect, & Misappropriation Policy # NS 1018-03 revealed the following definition of immediately read: means as soon as possible, in the absence of a shooter state time frame requirements, but not later than 2 hours after the allegations is made, if the events that cause the allegation involve abuse or result in bodily injury, or not later than 24 hours if the events that cause the allegation do no involve abuse and do result in serious bodily injury. Under section titled Protection: In the event an allegation is made the facility will take measures to protect residents from harm during an investigation. Accurate and timely reporting of incidents, both alleged and substantiated, will be sent to officials in accordance with state law. Under section II Training, Number 2 section B Read: Understanding behavioral symptoms of resident including those with dementia and related diseases that may increase the risk of abuse and neglect and how to respond (including interventions to deal with aggressive behaviors). Aggressive and/or catastrophic reactions to residents Wandering or elopement- type behaviors Resistance to care Outbursts of yelling out Difficulty in adjusting to new routines or staff. Under Prevention #4 read: An employee who is alleged or accused of being a party to abuse, neglect, misappropriation of property will be immediately removed from the area(s) of resident care, interviewed by facility leadership for a written statement and not left alone If multiple employees are involved, the employees will be separated until individual statements are completed. The employees will not be permitted to be alone in the facility at any time until the investigation is complete. #5 reads After completing statement(s), the employee(s) will be asked to vacate the facility until further investigation of the incident is completed. The employee(s) will be notified of the finding of the investigation Appropriate measures will be taken with the employee(s) post investigation including but not limited to: I. Returning to work including no change in regular pay during off time. Ii. Additional education and training III. Disciplinary action if appropriate including termination following facility HR termination policies and guidance. b) Resident #43 On 02/20/24 at 9:45AM a medical record review was completed for Resident # 43 regarding a reportable incident dated 11/21/23. The reportable was in regard to an incident on 11/17/23 were the resident's head was held by Nurse Aide (NA) #55 while Registered Nurse (RN) #40 completed a nasal swab for Covid testing. Upon reviewing RN #40's written statement it was determined NA #55 held Resident #43's heaad just to calm her down. The time of the of incident was documented as the 2 PM - 10 PM shift. The investigation included statements from RN #40, NA #13, and NA #66. Further review of the statements gathered by the facility as a result this investigation found the following statements: c) Registered Nurse #40 Registered Nurse (RN) #40 gave the following statement on 11/17/23: RN #40 (statement collected by the facility) In a statement collected by the facility, on 11/17/23, RN #40 stated she was doing medication pass when a resident came and asked her to check Resident #43.The resident said Resident #43 was complaining of a sore throat. RN #40 said she explained to Resident #43 that she would be doing a COVID test. According to RN #40, Resident #43 became agitated and was afraid of having her nose swabbed. RN #40 said she explained the protocol to the resident and tried to convince her she would be careful, and it would not hurt. RN #40 said Resident#43's roommate tried to calm her down too. RN #40 said NA #55 helped by holding the resident's hand and her head while she (RN#40) performed the test. d) NA#55 The surveyor obtained a statement from the facility for NA#55. NA#55 gave her statement to Nursing Staff Scheduler (NSS) #51 on 11/20/23 by phone. In her statement the NA said she was, Pulled to west for 1:1. Tried to calm the resident down by holding her hand and her head. Trying to relax resident. NA #55's statement also reflected (RN #40's name) was the nurse trying to administer the Covid test.(Activity Aide(AA)#143's name) was walking by and stopped to help.(AA #143name) was holding the resident's hand. NA #55 stated she was making the resident laugh and smile when it was over. f) NA #66 The statement from the facility for NA #66 was given by NA #66 on 11/20/23 to NSS #51 NA #66 stated she was in a room on front hall when she heard screaming. NA #66 said she went into the hall and saw RN#40, Activity Aide #143, and NA #55 with Resident #43. RN #40 had a swab in her hand. NA #55 was holding the resident's hands and Activity Aide #143 was holding the resident's head. NA #66 said by the time she got all the way to them they had finished the test. g) Activity Assistant (AA) #143 The surveyor received a statement taken by the facility from AA #143. AA #143's statement was taken on 11/20/23. I was walking down the hall and saw the nurse trying to give (Resident #43's name) a Covid test. I saw the aide holding head to assist the nurse with the test. h) Employee #145 The surveyor obtained a statement taken by the facility for Employee #145 on 11/20/23. I spoke to the resident, explained who I was and ask her if she recall attempting to get a Covid test on Friday(11-17-23).The resident was non-verbal/Did not indicate she remembered in anyway. i) Resident #8 The surveyor obtained a statement from Resident #8 dated 11/19/23.This statement was taken by an RN. Resident was asked in interview if he's ever seen resident being abused, he stated, 'The other night I was in my room and came out and seen the nurse and the CAN holding resident down to swab her. Resident was asked if he knew who they were he said he didn't know their names, but they were foreign. j) Employee#146 The surveyor obtained a facility statement from Employee #146. This statement was given by the employee on 11/19/23 to Clinical Manager/RN #109 They came to give her a covid test. She didn't want I told her it's okay, I was holding her hand. The one girl held her head and the nurse swabbed her nose, she was screaming the whole time. I told someone but I can't remember who. k) Certified Occupational Therapy Assistant(COTA)#139 The surveyor obtained a facility statement from COTA #139 During session with (Name of Resident #54) and (name of Resident #8) both in therapy room at same time at approx.12:30 PM on 11/19/2023, it was brought up that another patient (Resident #43's name) was being covid tested on Friday (11-17-2023) and that a nurse aide that talks funny with dark hair and a foreigner was holding (Resident #143's name) head back as she was screaming very loudly and that they were disturbed by the screaming and thought that she was allowed to refuse ea covid test if she wanted to refuse .Both patients reported that she could be identified if they saw her. l) NA#13 The surveyor obtained a statement taken by the facility from NA #13. The statement was dated 11/19/23. (NA#66'sname) & I were providing care to a resident on the front hall when we heard screaming. We finished with this resident and we nt to the hall to see (NA#55's name) holding (Resident#43's name) head back for (RN#40's name) to covid swab resident's nose. This incident happened Friday 11/17 after dinner. Further review of the reportable incident found a finding of unsubstantiated despite the multiple staff and resident statements who confirmed it did happen. The survey team completed staff interviews during the course of the survey with the following findings: m) Director of Nursing During an interview with the Director of Nursing (DON) on 02/20/24 at 9:20 AM she stated, I don't really know about it. Let me get the Administrator and Clinical Manager(CL)#109. An interview with CL#109 at 9:50 AM on 02/20/24 was conducted. CL#109,stated,I got the call about the incident .I came in and got statements, and completed this skin checks .Then I handed it over to the administration. n) Administrator An interview with the Administrator at 10:00 AM on 02/20/24 was conducted regarding Resident #43.The administrator reviewed d all the paperwork. The administrator stated, They held her head and hand to comfort her .I don't see a problem with this. o) Resident#8 During an interview on 02/20/24 at 10:37 AM with Resident #8 who has a BIMS of 15 the resident stated, I remember what happened. She was screaming. My room was across from hers at the time. I wanted to smack them off of her. An interview on 02/20/24 at 10:51 AM with NA #66 she stated, I feel like what I remember ,we heard screaming, and we came out, (Name of Activity Assistant #143) was behind her and (Name of RN #40) was in front of her. I don't remember much, but I did feel like it was an issue. I felt like she had the right to say no. An interview on 02/20/24 at 10:54 AM with NA #13 she states, I was in a room up the hall, and I heard screaming, I came out of the room and saw (Name of NA#55) was holding her head, and the nurse was putting a swab in her nose. I don't remember what nurse I reported it to but the east wing (Name of CL #109 came in and told me to write down what I had seen on the paper, So I did. Just the way she was screaming I felt like I needed to report it. They definitely did the swab ;she was taking the swab out of her nose when I went into the room. Telephone interview with NA #55 on 02/20/24 at 2:39 PM she stated, What I remember r is the nurse needed help. I went to help her. I was holding her head and hands to calm her down. If I knew I was going to be in trouble I would have never gone into the room. The nurse was so busy she was just trying to get it done. An attempt was made to contact RN #40 via telephone, as well as RN #26 pm 02/20/2 at 2:00 PM with no answer or return call. At the time of this survey NA #55 and RN #40 were both still employed at the facility and this allegation was unsubstantiated event though there were multiple witness statements confirming the incident did happen on11/17/23. p) Resident#11 A facility reportable incident (FRI) dated 10/03/23 in the (AM), was reviewed involving Resident #11. The allegations contained in this reportable was RN #40 , locked Resident #11's wheelchair and held the back of the wheelchair which prevented the resident from freely leaving the room which she was confined to. This allegation was reported as possible involuntary seclusion. The facility investigated and gathered the following statements: q) NA#141 The surveyor obtained a statement taken by the facility on10/02/23. NA #41 said while giving NA a lunch break and taking on the 1:1 she was stopped by the RN #40 and was asked to give another patient care while she took the 1:1. NA#41 said RN #40 forced Resident #11 back into her room locking her wheelchair and holding the back of the wheelchair so Resident #11was unable to leave her room. r) RN#40 gave a statement on10/03/23: RN#40 said she was doing her medication pass when a family member of one of the resident's asked her to call for Resident#101's nurse aide. RN #40 said she asked NA#141 if she was assigned to Resident #101. NA #141 said she was the aide for Resident #101. NA #141 also said she was watching Resident #11 because the nurse aide assigned to Resident#11 was on break and had asked her to watch Resident#11 while also attending Resident #101. NA #141 said she had a conversation with Resident #11 while walking around the facility. She said Resident #11 was as going to the exit door and kept saying she was going home. When RN #26, who was the assigned nurse to Resident#11 noticed this behavior she said she would take over Resident #11 so RN #40 could finish medication pass. Resident #11 started hitting and punching us and kept on saying bad words. The staff took Resident #11 to her room while RN #26 had a conversation with the resident trying to have her calm down. Then wrote at the bottom of this same statement was a short statement from RN #26. The summarization of the statement is: s) RN#26 agreed with RN#40's statement that the incident with the wheelchair was for a limited period and was therapeutic. This allegation was unsubstantiated by the facility. However, an in-service entitled Abuse and Neglect dated 10/03/23 was completed by Clinical Manager #7 for the staff. Further education was completed with RN#40 by Clinical Manager #7 on 10/03/23 which involved reviewing the facility policy entitled [NAME] Virginia Abuse, Neglect and Misappropriation. The section regarding involuntary seclusion was highlighted. Both RN#40 and the clinical manager #7 signed and dated the facility policy. Clinical Manager #7 verified RN#40 was still employed by the facility as a night shift nurse. During an interview with Clinical Manager (CL) #7 on 02/20/24 at approximately11:15 AM she stated, I was directed by the administrator to conduct an in-service and to do individual education with RN#40. I did not have any further action regarding this reportable. An attempt was made to contact RN #40 via phone, as well as RN#26 On 02/20/24 at 2:00 PM with no answer or call back at this time. t) NA#142 was not able to be interviewed because she no longer works at this facility. During an interview with the Administrator on 02/20/24 at 5:00 PM regarding the incident with Resident #11 he stated, During the investigation you have to weigh the totality of all the statements received and 2 RNs were in the room, versus an Activity Assistant. Sometimes you have to see what actually happened versus someone seeing what they think happened .The statement from both RN's does not conclude that the wheelchair was held. u) Plan of Correction On 02/20/24 the Nursing Home Administrator, Director of Nursing, and the Corporate Office implemented the following plan: Employee(RN) #40 was suspended pending investigation and legal review and HR review, if it determined that the employee could return to work, employee #40 will have extensive abuse and neglect training, by the Regional Team Member. Employee (NA) #55 was suspended pending investigation and legal review and HR review ,if is it determined that the employee could return to work Employee #55 will have extensive abuse and neglect training by the Regional Team Member. Residents with BIMS scores of 12 and above were interviewed for potential physical abuse. Residents with BIMS scores of 11 or below had a skin assessment completed for potential physical Abuse. Staff will be reeducated on the Abuse, Neglect, and Misappropriation Policy, through in person, text blast will be physically educated prior to the next shift with signatures. The training will be conducted by the Regional Team Member. There will be training for all staff on Resident Rights including the right to be free from any physical restraints imposed for purposes of discipline or convenience and not required to treat the resident medical symptoms. The training will be conducted by the Regional Team Member. Staff will be reeducated on restraint alternatives. There will be a team review of all reportable events to determine if physical abuse occurred, per state definitions. The team will include, Social Services, Director of Nursing or Designee, and Executive Director. After a thorough review the team will determine if substantiated. Audits will be conducted by the regional Director of Clinical Operations weekly x 4 weeks and monthly x 6 months and randomly thereafter with correction upon discovery. Audit results will be reviewed by the QAPI Committee monthly x 6months.

. Based on observation, record review and staff interview the facility failed to implement care plans related to fall interventions. This failed practice was found true for (2) two of (3) three residents reviewed for falls. Resident identifiers #44 and #1. Facility Census 95. Findings Include: a) Resident #44 A record review on 02/19/24 at 1:00 PM of Resident #44's care plan revealed the resident was at risk for falls and had a fall from bed on 02/10/24. Further record review of Resident #44's care plan found an intervention for, Fall mat to side of bed this intervention was initiated 02/13/24. An observation on 02/19/24 at 1:46 PM of Resident #44 found her lying in bed. No fall mat was beside the bed or in the room. An Observation on 02/21/24 at 11:30 AM of Resident # 44 in her bed, the fall mat was not at bedside. An interview on 02/21/24 at 11:40 AM with Clinical Manager (CM) # 109, confirmed the fall mat was not at bedside. b) Resident #1 A record review on 02/19/24 at 1:10 PM of Resident #1's care plan revealed Resident #1was at risk for falls and has had the following falls: 01/24/24 Fall in the dining room 02/13/24 Fall in the lobby 02/02/24 Fall in the room 02/18/24 Fall in the dining room Further record review of Resident #1's care plan reads, {recessed cup with lid to decrease spillage of hot liquids.} An observation on 02/21/24 at 11:30AM, Resident #1 was in the dining room. She had a cup of coffee in a regular coffee cup. During an interview on 02/21/24 at 2:30 PM with Occupational Therapy Assistant (OTA) # 139 describes a recessed cup as being a cup with a concave lid with a hole in the top . sometimes it has 2 handles and sometimes it has one handle. She confirmed that a regular coffee cup is not a recessed cup.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review and staff interview, the facility failed to maintain a complete and accurate medical record for Resident #97. This is true for one (1) of five (5) residents reviewed during the survey process. Resident Identifier: #97. Facility Census: 95. Findings Included: a) Resident #97 On 02/20/24 at 11:00 PM, a record review was completed for Resident #97. The record review found a Discharge summary dated [DATE]. The discharge summary under the section 3 Course of Illness/Progress stated, Resident has been unable to participate in getting up with therapy due to FX (fracture). (Typed as written.) After reviewing the physical therapy notes throughout the stay at the facility, the resident did participate fully and attended the therapy sessions in the facility gym while seated in a wheelchair. In addition, other therapy progress notes state, Pt (patient) propel wc (wheelchair) x (times) 75' (feet) sba (stand by assistance). On 02/20/24 at 1:30 PM, Clinical Manager (CM) #109 reviewed the discharge summary. CM #109 confirmed the statement was incorrect based on the therapy notes. No further information was obtained during the survey process.

Based on observation and staff interview, the facility failed to maintain appropriate infection control standards for the cleaning and disinfecting of the [NAME] Unit and maintaining the storage of clean linen. These were random opportunities for discovery. Facility Census: 95. Findings Include: a) Cleansing Dwell Time On 02/20/24 at 9:25 AM, Housekeeper (HK) #46 on the [NAME] wing was asked what type of cleanser does the facility use for surfaces and floors? HK #46 stated (Name of Cleanser) for the floors and surfaces. HK #46 was then asked, what is the dwell time? HK #46 stated, about 5 (five) minutes . On 02/20/24 at 9:40 AM, the Housekeeping Director (HKD) #41 confirmed the name of the cleanser and the dwell time was 10 minutes .it must remain wet . HKD #41 stated, we have reviewed the dwell times .I'm not sure why HK #46 didn't know. On 02/20/24 at 10:00 AM, the label and directions were reviewed for the facility cleanser. The directions state, Treated surfaces must remain visibly wet for 10 minutes. No further information was obtained during the survey process. b) Linen Cart On 02/20/24 at 1:45 PM, the linen cart on the East wing was observed. The linen cart was uncovered with a flap across the top the cart. On 02/20/24 at 1:50 PM, Nurse Aide (NA) #31 and NA #87 confirmed the linen cart had the flap across the top of the cart and was not covered. On 02/21/24 at approximately 3:00 PM, the Director of Nursing (DON) was notified and confirmed the linen cart should be covered. No further information was obtained during the survey process.

.Based on observation, staff interview, and record review the facility failed to report alleged violation related to, neglect, or abuse, and report the results of investigations to the proper authorities within prescribed time frames. This was true for three (3) of five (5) grievances reviewed during a complaint investigation. Resident identifiers: #2, #4 and #3. Facility Census: 89. Findings Included: a) Resident #2 A review of the facility's concern forms revealed a concern form from Resident #2 which read as follows: -Resident States on 06/11/23 and the morning of 06/12/23 he had to wait for up to two hours to receive a changing of a soiled adult brief. Subsequent review of the medical record revealed the complaint/concern on 06/12/23 for Resident #2 was not investigated or reported to the appropriate agencies as required. Resident #2's Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/03/23 noted the resident had a score for Brief Interview for Mental Status (BIMS) of 13. A BIMS score of 13 indicates the resident is cognitively intact and has capacity. An interview with the administrator on 08/28/22 at 3:13 PM verified the complaint/concern on 06/12/23 for Resident #2 was not reported to state agencies as an allegation of neglect. He stated he did not feel the concern rose to an allegation of neglect. b) Resident #4 A review of the facility's concern forms revealed a concern form from Resident #4 dated 06/25/23 which read as follows: -The morning bed Check presented with Resident #4's bed was saturated with urine and stool. The action to resolve the concern read as follows: -10:00 PM to 6:00 AM Nurse Aides (two named) had only completed one bed check/ change throughout the shift and left beds that were saturated with urine. Subsequent review of the medical record revealed the complaint/concern on 06/25/23 for Resident #4 was not reported to the appropriate state agencies. Resident #4's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/16/23 noted the resident had a score for Brief Interview for Mental Status (BIMS) of 15. A BIMS score of 15 indicates that the resident is cognitively intact and has capacity. An interview with the administrator on 08/28/22 at 3:13 PM verified the complaint/concern on 06/25/23 for Resident #4 was not reported. He stated he did not feel the concern rose to an allegation of neglect in resident care. c) Resident #3 During review of the concern form for Resident #3, dated 07/08/23, it was identified that a concern was expressed by Resident #3 stating she rang her call bell to let Employee #500, her nursing assistant, know she was wet. The Nursing Assistant #500 assisted Resident #3 to bed with her wet gown still on. Resident #3 also was incontinent of stool. Resident #3 alleged once she was placed in bed Employee #500, her assigned nursing assistant, changed her brief without cleaning her up, covered her with three (3) heavy blankets and left the room. Resident #3 stated she put her call light on again and Nursing Assistant #500, came to her room and put a wheelchair in the doorway and sat there and watched her for a specified amount of time. Review of Resident #3's medical record, revealed on 04/23/23, the physician determined by the physician Resident #3 had the capacity to make her own decisions. On 06/29/23, Resident #3 scored fifteen (15) out of possible fifteen (15) on the Brief Interview of Mental Status Assessment (BIMS). This score indicated the resident was cognitively intact. Review of incidents reported to the state agencies by the facility, revealed the allegation of neglecting to provide adequate care (putting to bed wet and not cleaning after changing a brief with feces) was identified on a concern form but was not investigated, or reported to the appropriate state agencies. During an interview with the Administrator, on 08/28/2023, at 4:10 PM, he was questioned about the reporting of this incident, it was identified he did not feel this rose to the level of reporting and investigating. The Director of Nursing was made aware of the incident at 5:00 PM and verified she would report this issue today. .

. Based on observation, staff interview, and record review, the facility failed to take actions to investigate an alleged violation related to neglect. This was true for three (3) of five (5) grievances reviewed during a complaint investigation. Resident identifier #2, #4 and # 3. Facility Census 89. Findings included: a) Resident #2 A review of the facility's concern forms revealed a concern form from Resident #2 which read as follows: -Resident States on 06/11/23 and the morning of 06/12/23 he had to wait for up to two hours to receive a changing of a soiled adult brief. Subsequent review of the medical record revealed the complaint/concern on 06/12/23 for Resident #2 was not investigated or reported to the appropriate agencies as required. Resident #2's Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/03/23 noted the resident had a score for Brief Interview for Mental Status (BIMS) of 13. A BIMS score of 13 indicates the resident is cognitively intact and has capacity. An interview with the administrator on 08/28/22 at 3:13 PM verified the complaint/concern on 06/12/23 for Resident #2 was not reported to state agencies as an allegation of neglect. He stated, he did not feel the concern rose to an allegation of neglect. b) Resident #4 A review of the facility's concern forms revealed a concern form from Resident #4 dated 06/25/23 which read as follows: -The morning bed Check presented with Resident #4's bed was saturated with urine and stool. The action to resolve the concern read as follows: -10:00 PM to 6:00 AM Nurse Aides (two named) had only completed one bed check / change throughout the shift and left beds that were saturated with urine. Subsequent review of the medical record revealed that the complaint/concern on 06/25/23 for Resident #4 was not investigated or reported to the appropriate state agencies. Resident #4's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/16/23 noted the resident had a score for Brief Interview for Mental Status (BIMS) of 15. A BIMS score of 15 indicates that the resident is cognitively intact and has capacity. An interview with the administrator on 08/28/22 at 3:13 PM verified the complaint/concern on 06/25/23 for Resident #4 was not reported. He stated, he did not feel the concern rose to an allegation of neglect in resident care. c) Resident #3 During review of the concern form for Resident #3, dated 07/08/2023, it was identified Resident #3 expressed she rang her call bell to let the Nursing Assistant, Employee #500, know she was wet. An allegation was made that revealed Employee #500, Nursing Assistant, put Resident #3 to bed with her wet gown still on. Resident #3 was also incontinent of stool and once she was placed in bed, Employee #500 changed her brief and did not clean her up, then covered her with three (3) heavy blankets and left the room. Resident #3 alleged she put her call light on again and Employee #500 came to her room and put a wheelchair in the doorway and sat there and watched her. (It was not determined how long Resident #3 specified she watched her because it was not legible on the concern form). Review of Resident #3's medical record, revealed 04/23/2023, it was determined by the physician Resident #3 had capacity. On 06/29/2023, Resident #3 scored fifteen (15) out of possible fifteen (15) on the Brief Interview of Mental Status Assessment (BIMS) indicating the resident is cognitively intact. Review of the facility investigations and reported allegations of abuse/incidents/investigations, identified this allegation was not thoroughly investigated by the facility. Actions to resolve the concern simply stated the Nurse Aide, Employee #500, denied the entire event. A corrective action form was completed for the employee, and education provided. The facility reviewed this with Resident #3. An interview with the Administrator on 8/28/2023, at 4:10 PM, revealed he did not feel this incident rose to the level of requiring further investigation and reporting. .

Based on record review and staff interviews, the facility failed to complete an accurate assessment of Resident #38's behaviors on the MDS. Resident identifier: #38. Facility census: 94. Findings included: a) Resident #38 On 06/21/23 a record review of Resident #38's Electronic Medical Record (EMR) was conducted. Resident #38's most recent Minimal Data Set (MDS) is a Quarterly MDS, with an Assessment Reference Date (ARD) of 04/10/23. This particular MDS, Section E, indicated the resident had physical, verbal, and other behaviors during the seven (7) day look back period, but did not indicate the resident had rejection of care. EMR reflected at least four (4) times, on the date of 04/04/23, that the resident refused care (such as medications) in the progress notes. On 06/22/23 at 9:45 AM, #149 Corporate MDS Trainer confirmed the Quarterly MDS, ARD 04/10/23, was inaccurate due to the Behavior Section not reflecting the multiple refusals of care on 04/04/23. #149 checked her MDS manual and confirmed the documented refusals should've been reflected in the MDS. #62 MDS LPN stated the Social Worker (SW) completed that section of the MDS. A staff interview was conducted with SW #62 on 06/22/23 at 9:59 AM. SW #62 stated she had been off sick the last month. Surveyor asked SW#62 to discuss the resident's behaviors and the SW stated she got aggressive when family was around. SW #62 stated she thought the resident was okay with passing on but the family was not. Surveyor asked about the Quarterly MDS, ARD 04/10/23 and why it did not reflect her refusal of care. SW said she was unsure why the MDS was not marked correctly because the resident refused care a lot. Surveyor explained the resident had multiple incidents of refusing care documented in the progress notes during the seven (7) day look back period, therefore the MDS was not accurate.

Based on record review and staff interviews, the facility failed to develop a behavior care plan for Resident #38, discovered during a long term care complaint survey. Resident identifier: #38. Facility census: 94. Findings included: a) Resident #38 On 06/21/23 a record review of Resident #38's Electronic Medical Record (EMR) indicated in the progress notes and on the Treatment Authorization Report (TAR), that the resident had numerous behaviors of refusing care, such as refusing medications, refusing repositioning, refusing treatments of wounds, and refusing care of her feeding tube. There was also documentation of physical and verbal aggressive behaviors toward staff. Resident #38's most recent Minimal Data Set (MDS) was a Quarterly MDS, with an Assessment Reference Date (ARD) of 04/10/23 also reflects behaviors. This particular MDS, Section E, indicated the resident had physical, verbal, and other behaviors during the seven (7) day look back period. When the resident's care plans were reviewed it was found the resident did not have a behavior care plan, even though she has countless documentation regarding her behaviors throughout her stay at the facility. On 06/22/23 at 9:45 AM, a staff interview with the MDS Licensed Practical Nurse (LPN) #62 stated the social worker (SW) the behavior care plans. A staff interview was conducted with SW #62 on 06/22/23 at 9:59 AM. SW stated she had been off sick the last month. Surveyor asked the SW to discuss the resident's behaviors. The SW stated Resident #38 became aggressive when family was around. SW stated she thought the resident was okay with passing but the family was not. Surveyor asked what the staff did when the resident had behaviors. The SW responded she goes in to talk with the resident and the activities department had been working with her. The surveyor stated the resident did not have a behavior care plan even though she had numerous refusals of care, verbal, and physical behaviors documented. The SW looked in the resident's EMR and confirmed that indeed the resident did not have a behavior care plan. The SW was unsure why there was no behavior care plan but stated it was probably because she usually had those behaviors when the family was here.

Based on record review and staff interview, the facility failed to ensure a resident with pressure ulcers received necessary treatment and services, consistent with professional standards of practice to promote healing. The facility failed to follow physician's orders for daily wound assessments and orders for wound care. This was true for one (1) of three (3) residents reviewed in the complaint survey process. Resident identifier: #87. Facility census: 94. Findings included: a) Resident #87 Review of Resident #87's medical record, completed on 06/22/23 at 9:00 AM, revealed the following details: Care Plan Goals: -Stage II to right heel will be resolved by the next review date. Date initiated: 04/14/23. -Stage II to left heel will be resolved by the next review date. Date initiated: 04/14/23. -Resident will be free from complications of Stage II to right buttock by the next review date. Date initiated: 06/06/23. -Resident will be free from complications of Stage II to left buttock by the next review date. Date initiated: 06/06/23. Physician Orders: -Stage II Right Buttock Daily wound assessment every day shift. Document abnormalities in Progress notes. -Stage II Left Buttock Daily wound assessment every day shift. Document abnormalities in Progress notes. -Right Lateral Heel: Daily wound assessment every day shift. Document abnormalities in progress notes. -Left Lateral Heel: Daily wound assessment every day shift. Document abnormalities in progress notes -Stage II Right buttock clean with wound wash pat dry, apply Hydrogel ointment, cover with clean bordered dressing every day shift. -Stage II to left buttock clean with wound wash, pat dry, apply Hydrogel ointment, cover with clean bordered dressing every day shift. -Right lateral heel stage II: cleanse with wound cleanser, pat dry, apply skin prep every day shift every Mon, Wed, Friday -Left lateral heel Stage II: cleanse with wound cleanser, pat dry, apply skin prep every day shift every Mon, Wed, Friday. b) Daily Wound Assessment for Right Lateral Heel Review of April 2023 - June 2023 Treatment Administration Records identified the following days there was no documentation of daily wound assessments for the right lateral heel: -05/05/23 -05/08/23 -05/19/23 -05/27/23 -06/09/23 c) Daily Wound Assessment for Left Lateral Heel Review of April 2023 - June 2023 Treatment Administration Records identified the following days there was no documentation of daily wound assessments for the left lateral heel: -05/08/23 -05/19/23 -06/09/23 d) Daily Wound Assessment for the Left Buttock Review of April 2023 - June 2023 Treatment Administration Records identified the following days there was no documentation of daily wound assessments for the left buttock: -06/09/23 e) Wound Care for Right Lateral Heel Review of April 2023 - June 2023 Treatment Administration Records identified the following days there was no documentation of wound care for the right lateral heel: -05/08/23 f) Wound Care for Left Lateral Heel Review of April 2023 - June 2023 Treatment Administration Records identified the following days there was no documentation of wound care for the left lateral heel: -05/08/23 g) Wound Care for Right Buttock Review of April 2023 - June 2023 Treatment Administration Records identified the following days there was no documentation of wound care for the right buttock: -06/09/23 h) Wound Care for Left Buttock Review of April 2023 - June 2023 Treatment Administration Records identified the following days there was no documentation of wound care for the left buttock: -06/09/23 i) Interview with the Director of Nursing During an interview with the Director of Nursing (DON) on 06/22/23 at 12:30 PM, the DON acknowledged the above-mentioned dates were left blank on the Treatment Administration Record (TAR). The DON conceded the nurse carrying out the order should always place his/her initials on the TAR to signify completion of the order. The DON also acknowledged that when following professional standards of documentation that undocumented translates to undone when it comes to having evidence the physician orders were followed.

Based on record review and staff interview, the facility failed to ensure a complete and accurate medical record. Specifically, nursing staff failed to ensure a physician order for scheduled pain medication was complete. This was true for one (1) of three (3) residents reviewed in the complaint survey process. Resident identifier: #87. Facility census: 94. Findings included: a) Resident #87 Review of Resident #87's medical record, completed on 06/22/23 at 9:00 AM, revealed the following order for scheduled pain medication, Hydrocodone-Acetaminophen Oral Tablet 5-325 MG (Hydrocodone-Acetaminophen) *Controlled Drug* Give 1 tablet by mouth every 8 hours for moderate to severe pain (5-10) do not exceed . During an interview with the Director of Nursing (DON) on 06/22/23 at 11:15 AM, the DON acknowledged this was an incomplete physician order that failed to list the parameter of how much acetaminophen Resident #87 was permitted to have in a 24-hour period. The DON reported the resident had previously been on Hydrocodone-Acetaminophen Oral Tablet 5-324 MG on an as needed basis and that order had directed not to exceed 3 GM in 24 hours. The DON reported the parameter of not to exceed 3 GM in 24-hours must have been left off the new order by accident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review and staff interview, the facility failed to ensure Advance Directive paperwork was part of the resident's medical record. This was true for one (2) of 19 residents reviewed in the Long-Term Care Survey process. Resident identifier: #31 and #72. Facility census: 93. Findings included: a) Resident #31 A medical record review, completed on 03/20/23 at 3:07 PM, indicated that Resident #31 was admitted to the facility on [DATE]. It also identified the following details: -A Physician Determination of Capacity was on file and indicated Resident #31 lacked capacity to make her own medical decisions. -A WV Physician Orders for Scope of Treatment (POST) form was on file and indicated Resident #31's legal representative had signed the form. -There was a copy of a Power of Attorney (POA) scanned into the electronic record. There was also a copy of the POA on the resident's paper chart at the nurses station. However, the POA specifically stated, This power of attorney does not authorize the agent to make health-care decisions for you. During an interview on 03/21/23 at 12:40 PM, LPN #100 confirmed the current POA document on file did not authorize the agent to make health-care decisions. Additionally, the Director of Social Services acknowledged, during an interview on 03/21/23 at 12:45 PM, the facility did not have the correct paperwork on file to prove who was the appropriate medical decision maker for resident. b) Resident #72 A medical record review, completed on 03/20/23 at 2:39 PM, indicated that Resident #72 was admitted to the facility on [DATE]. It also identified the following details: -A Physician Determination of Capacity was on file and indicated Resident #72 lacked capacity to make her own medical decisions. -A WV Physician Orders for Scope of Treatment (POST) form was on file and indicated Resident #72's Health Care Surrogate (HCS) had signed the form. -There was no copy of the HCS paperwork scanned into the electronic record. There was also no copy of the HCS paperwork on the resident's paper chart at the nurses station. During an interview on 03/21/23 at 11:57 PM, LPN #100 confirmed the HCS paperwork was not scanned into the electronic medical record nor was it part of Resident's paper chart at the nurse's station. The Director of Social Services also confirmed, during an interview on 03/21/23 at 12:08 PM, the facility did not have a copy of the HCS paperwork. The Director of Social Services stated she would contact the resident's family member and/or the admitting hospital and obtain it. .

. Based on observation, record review, and staff interview, the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain good nutrition. This was a random opportunity for discovery. Resident Identifier #33. Facility census: 93. Findings included: a) Resident #33 A record review, completed on 03/21/23 at 11:24 AM, found the following: -There was a Grievance/Concern Form on file that was dated 01/18/23. Description of concern read: Resident states she cannot see well enough to feed herself meals and that she doesn't get enough to eat because of this. States she would like to have assistance with meals. -The Annual Minimum Data Set (MDS), with an assessment reference date of 02/09/23, read Eating: One person physical assist. On 03/21/23 at 2:20 PM, visible from hallway outside of Resident #33's room, it was evident the noon meal was still at her bedside and Resident #33 had 1/2 of a dropped, uneaten grilled cheese sandwich resting on her chest. Once by the bedside, it was evident Resident #33 had accidentally knocked a bowl of brussels sprouts over onto her lap. Both the bowl and four (4) individual brussels sprouts were resting in the resident's lap. The brussels sprouts had rolled out of the bowl and were randomly on her lap. Resident #33's meal tray ticket indicated she was a DD [Dependent Diner]. At 2:30 PM, CNA #78 verified it was well after the noon meal and Resident #33 had accidentally dropped and/or spilled 1/2 her meal. CNA #78 agreed 1/2 of the grilled cheese sandwich resting on resident's chest was readily visible to anyone walking by and was a dignity concern. CNA #78 verified the lunch meal was still in the room at 2:30 PM and it appeared no staff member had offered assistance with eating on this date. During an interview on 03/22/23 at 11:50 AM, [NAME] #44 reported resident is to be considered a dependent diner and staff would know they need to feed her because her meal tray ticket indicates she is a DD [dependent diner]. Review of the Eating Task documentation in Resident's Electronic Medical record, completed on 03/22/23 at 12:00 PM, included documentation from the past 14 days and revealed the following dates which Certified Nurse Aide (CNA) staff had documented resident had been Independent - No help or staff oversight at any time: -03/09/23 -03/12/23 -03/14/23 -03/18/23 -03/20/23 -03/21/23 During an interview on 03/22/23 at 1:40 PM, CNA #50 reported, She [Resident #33] is a dependent diner which means she needs to be fed by staff. On 03/22/23 at 1:50 PM, the Director of Nursing acknowledged the facility did not have the appropriate documentation to indicate Resident #33 was consistently receiving the necessary services to maintain good nutrition. .

. Based on observation, record review, staff interview and resident interview, the facility failed to ensure respiratory care was provided according to professional standards of practice. These were random opportunities for discovery. Resident Identifiers: #6 and #49. Facility Census: 93. Findings Included: a) Resident #6 On 03/20/23 at 1:10 PM, a continuous positive airway pressure (CPAP) mask was observed hanging from the night stand for Resident #6. The CPAP mask was not stored in a respiratory bag which decreases the risk of infections. On 03/20/23 at 1:12 PM, Licensed Practical Nurse (LPN) #37 confirmed the CPAP mask was not stored in a respiratory bag. LPN #37 stated, let me go get a respiratory bag. On 03/20/23 at 3:00 PM, the Directory of Nursing (DON) was notified and confirmed the CPAP mask should be stored in a respiratory bag. b) Resident #49 On 03/20/23 at 1:05 PM, a nebulizer mask was observed hanging by the bed rail. The nebulizer mask was not stored in a respiratory bag which decreases the risk of infections. On 03/20/23 at 1:07 PM, LPN #37 confirmed the nebulizer mask was not stored in a respiratory bag. LPN #37 stated, I'll go get a respiratory bag. On 03/20/23 at 3:00 PM, the DON was notified and confirmed the nebulizer mask should be stored in a respiratory bag. No further information was obtained during the long-term survey process. .

. Based on resident interviews during resident council, and staff interview, the facility failed to ensure a substantial/nourishing snack was provided between the evening meal and breakfast. This had the ability to affect all residents who did not have a dietary order to receive an evening snack or the cognitive and/or physical ability to make their way to the nurse's station to request something to eat from the nourishment room. Facility Census: 93. Findings included: a) Resident Council Meeting During the resident council meeting with Surveyor on 03/21/22 at 1:00 PM, three (3) out of five (5) residents in attendance stated the facility did not offer an evening snack to residents. They went on to say they felt the majority of facility residents would enjoy a bedtime snack. One (1) resident stated, They used to do that, but they don't do it anymore. Another resident explained if he was hungry before bedtime, he independently made his way to the nurse's station and asked for something. When asked if all residents in the facility knew how to acquire something from the nourishment room at the nurses station, resident council members were not sure everyone understood. One resident in attendance stated that not everyone would feel comfortable requesting a snack or may not even remember if it was an option. b) Record Review A brief medical record review, completed on 03/21/22 at 8:05 PM, revealed all three residents who reported the facility did not offer an evening snack were cognitively intact. Additionally, review of the Eating Nights documentation in each resident's electronic medical record, which included documentation from the past 14 days, revealed the following dates which Certified Nurse Aide (CNA) staff had documented Activity did not occur: -03/09/23 -03/11/23 -03/12/23 -03/13/23 -03/15/23 -03/16/23 -03/17/23 -03/18/23 -03/19/23 -03/20/23 -03/21/23 -03/22/23 c) Administrative Interview The aforementioned details were reviewed with the Director of Nursing on 03/22/23 at 1:15 PM. No additional information was provided prior to Surveyor exit on 03/22/23 at 4:00 PM. .

. c) Resident #88 During the initial interview on 03/20/23 at 2:08 PM Resident # 88 stated I have no appetite, I was supposed to start getting a milkshake with my meals and I have not gotten it. During a record review on 03/20/23 at 3:00 PM, Resident #88's medical record revealed a physician order dated 03/10/23, for a House Supplement two times a day for house shake 118 ml kitchen to provide. 12:00 and 5:00 PM During an lunch meal observation on 03/21/23 at 12:43 PM Resident # 88's lunch meal tray did not have a house supplement. Nurse Aide (NA) #119 verified there was no house supplement on the lunch meal tray. A lunch meal tray ticket did not reveal a house supplement/shake was provided with the meal. NA #119 stated when the supplements are on the meal tickets they are listed below the drinks and there is nothing there. I did not know that he was supposed to get one. During a record review on 03/21/23 at 01:03 PM Resident #88 medical record revealed the Medication Administration Record with a physician order, house supplement two times a day for house shake 118 ml kitchen to provide Start Date 03/10/23 5:00 PM. The dates and precentages documented are as follows: -03/10/23 5:00 PM - 90% -03/11/23 12:00 PM - 100% -03/11/23 5:00 PM - 118% -03/12/23 12:00 PM - 100% -03/12/23 5:00 PM - 118% -03/13/23 12:00 PM - 240% -03/13/23 5:00 PM - 120% -03/14/23 12:00 PM - 118% -03/14/23 5:00 PM - 90% -03/15/23 12:00 PM - 100% -03/15/23 5:00 PM -100% -03/16/23 12:00 PM -237% -03/16/23 5:00 PM -120% -03/17/23 12:00 PM - 90% -03/17/23 5:00 PM - 90% -03/18/23 12:00 PM -118% -03/18/23 5:00 PM - 90% -03/19/23 12:00 PM -118% -03/19/23 5:00 PM - 0% -03/20/23 12:00 PM - 118% -03/20/23 5:00 PM - 90% During an interview on 03/21/23 at 1:09 PM, the Licensed Practical Nurse(LPN) #40 stated the house supplements are 120 ml. We get the amount the resident consumed off the NA task documentation and then we enter it into the MAR. During an interview on 03/21/23 at 1:17 PM, the Culinary Director (CD) stated I did not receive any diet order for Resident # 88 to receive a house supplement at meals. The CD revealed a list of orders she has received and Resident #88 house supplements were not present. During an interview on 03/21/23 at 1:31 PM, the Director of Nursing (DON) stated the LPN's document the amount of house supplement the resident consumes in the MAR. During the interview on 03/21/23 at 1:31 PM, the DON acknowledged the LPN's were documenting amount consuming of a house supplement Resident # 88 was not receiving. Based on record review and staff interview, the facility failed to maintain accurate and complete medical records for the Physician Orders for Scope of Treatment (POST) form for Resident #92 and Resident #39, a capacity form for Resident #92 and documentation of supplements for Resident #88. This is true for three (3) of 25 medical records reviewed during the long-term survey process. Resident Identifiers: #92, #39 and #88. Facility Census: 93. Findings Included: a1.) Resident #92 On 03/22/23 at 8:01 AM, a record review was completed for Resident #92. The review found the POST form was incomplete. The preparer's signature was not dated upon completion of the form. On 03/22/23 at 8:20 AM, the Director of Nursing (DON) was notified and confirmed the POST form was incomplete. No further information was obtained during the long-term survey process. a-2) Resident #92 On 03/22/23 at 8:01 AM, a record review was completed for Resident #92. The review found the capacity form was incomplete. The capacity form did not list the duration, nature or causes of the incapacity finding. On 03/22/23 the DON was notified and confirmed the capacity form was incomplete. No further information was obtained during the long-term survey process. b) Resident #39 A brief record review, completed on 03/21/23 at 8:44 AM, identified the following details: -Resident #39 had a 2021 Physician Orders for Scope of Treatment (POST) form on file which was dated 10/20/22. -Resident #39 began to receive hospice services on 02/2/23. -A care plan conference was held on 03/14/23. The POST form was not updated at that time to reflect Resident #39 was receiving Hospice services or the name and contact number of the Hospice agency. The 2021 POST Form Guidance instructs, this form should be reviewed whenever the patient: -Is transferred from one level of care to another -Has a substantial change in health status During an interview on 03/21/23 at 12:52 PM, the Director of Social Services reported it was an error that the POST form was not updated during the last care plan conference on 03/14/22. .

c) Resident #88 During the initial interview on 03/20/23 at 2:08 PM, Resident # 88 stated I have no appetite, I was supposed to start getting a milkshake with my meals and I have not gotten it. During a record review on 03/20/23 at 3:00 PM, Resident #88's medical record revealed a physician order dated 03/10/23 House Supplement two times a day for house shake 118 ml kitchen to provide. 12:00 and 5:00 PM During an lunch meal observation on 03/21/23 at 12:43 PM, Resident # 88's lunch meal tray did not have a house supplement. Nurse Aide (NA) #119 verified there was no house supplement on the lunch meal tray. A lunch meal tray ticket did not reveal a house supplement/shake was provided with the meal. NA #119 stated when the supplements are on the meal tickets they are listed below the drinks and there is nothing there. I did not know that he was to supposed to get one. During an interview on 03/21/23 at 1:17 PM, Culinary Director (CD) stated I did not receive any diet order for Resident # 88 to receive a house supplement at meals. The CD revealed a list of orders she has received and Resident #88 house supplement were not present. During the interview on 03/21/23 at 1:31 PM, Director Of Nursing acknowledge the facility failed to follow physician orders to provide Resident # 88 with house supplement two (2) times a day. Based on observation, record review and staff interview the facility failed to provide care/treatment and services in accordance with professional standards of practice. The facility failed to assess Resident #350 after a fall. The pharmacist and physician declined to complete the required Food and Drug Act (FDA) paper work to be able to continue to prescribe and administer Clozapine in a safe manner for Resident #395. Physician orders were not followed for house supplements for Resident #88. These findings are true for one of four reviewed for falls, one of six reviewed for psychotropic medications and one of two reviewed for food preferences. Resident identifiers: 350, 395, 88. Facility census: 93. Findings include: a) Resident (R) 350 Review of the medical record on 3/21/23 revealed a note by the nurse practitioner on 05/13/22 at 9:46 PM stating R#350 had a fall earlier at 2:00 PM which was not reported. The nurses notes lack any information related to this fall until a hematoma was identified by a nurse aide at 9:30 PM on 05/13/23. On 03/22/23 at 10:30 AM, Licensed Practical Nurse (LPN) #76 stated she was the nurse on duty the day R#350 fell. LPN #76 reported she was told the resident sat on the floor. LPN #76 acknowledged a resident sitting on the floor is considered a fall. LPN #76 agreed the medical record lacks any information related to the resident being assessed for injury until the hematoma was found on the next shift. b) Resident (R) #395 Because of the risk of severe neutropenia and infection, the FDA requires prescribers and pharmacists to complete a a Risk Evaluation and Mitigation Strategy to manage the risk of severe neutropenia associated with Clozapine treatment. Review of the medical record on 03/22/23, revealed R #395 was admitted to the facility in December 2021. Her diagnoses included dementia with behaviors, paranoid schizophrenia, mood affective disorder, depression, anxiety, seizures and developmental delay. Her admission medications included Clozapine (Clozaril) and antipsychotic used to treat schizophrenia. On 06/13/22, the attending physician began decreasing the Clozapine over a six week period. The Behavior note dated 06/13/22 states: Clarification order reviewed regarding changing CLozaril to a different medication. New order noted to reduce Clozaril to 150 milligrams (mg) for two weeks then 100 mg for two weeks, then 50 mg for two weeks then discontinue. Add Quetiapine (an antipsychotic) 25 mg twice a day for two weeks and increase 25 mg every two weeks to a 100 mg twice a day. Monitor the resident's response to medication changes. On 06/25/22, the attending physician was notified of R#395's behaviors including cursing and false accusations while weaning the Clozaril. The physician declined to increase the Clozaril back to 200 mg a day. On 06/27/22, there was a request made to sent the resident to a behavioral health facility. On 07/15/22 the resident was following staff and making false health complaints. On 07/24/22, another request to a behavioral health facility was faxed stating the physician saw R#395 and requested she be sent to a behavioral health unit immediately as paranoid schizophrenia and behaviors have worsened her condition. R#395 was transferred and admitted to an acute care center on 08/03/22. The acute care center's initial psychiatric consult dated 08/04/22, notes she was transferred for a decline in mentation over the past two weeks after she was completely taken off Clozapine on 07/19/22 due to the medical teams decision that Clozapine is to difficult to manage. Resident became loud, refused all intake and cares. The hospital's progress note dated 08/07/22, states the most likely cause to the resident's metabolic encephalopathy is due to a change in her antipsychotic medications. The medical director at (name of this facility) stopped her Clozapine because this takes a registry. There is a lot of paperwork involved. Psychiatry agreed to put her back on the registry and restart the Clozapine. During an interview on 03/22/23 at 2:13 PM the Director of Nursing (DON) and Assistant Director of Nursing (ADON) presented an undated portion of an email from the pharmacist with directions on how to wean the Clozaril. The ADON reported the Clozaril was no longer available from the pharmacy the facility used. When asked about getting the medication from another pharmacy she stated We only get our drugs from one pharmacy. The DON did not comment when shown the note from the acute care center stating the resident's change in condition was most likely due to the change in her antipsychotic medications and the medical director of the facility's decline to complete the paper work to continue to prescribe the Clozaril.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . b) Resident # 71 Medical record review found a State of [NAME] Virginia Medical Power of Attorney (MPOA) dated [DATE]. The Resident gave specific instructions for: CPR- Full interventions, 30 day IV fluid, no feeding tube. Resident #71 was admitted on [DATE] to the facility. On [DATE] Resident #71 completed a [NAME] Virginia Physician Orders for Scope of Treatment (POST) form. The following sections were completed as follows: On Section A the Resident selected - Attempt Resuscitation/Cardiopulmonary Resuscitation (CPR.) On Section B the Resident selected - Full Interventions: includes care above. Use intubation, advanced airway interventions mechanical ventilation, and cardioversion as indicated. Transfer to hospital is indicated include intensive care unit. Treatment plan: Provide all medically indicated treatment including mechanical ventilation. On Section C the Resident selected - Intervenious (IV) fluids for a trial period of no longer _____ (time period was not completed.) On Section D - The Resident did not select the box to give authorization for anyone else to make decisions if he would lose capacity The Post form was completed on [DATE] by verbal consent obtained from the resident and was signed by two (2) Registered Nurses (RN's.) The Physician signed the POST form on [DATE]. On [DATE] the physician determined Resident # 71 did not have capacity to make medical decisions. A review of the medical records revealed a second POST form dated [DATE]. This POST form was completed by the resident's Medical Power Of Attorney (MPOA.) The following sections were completed as follows: Section A - MPOA selected, Do not Attempt Resuscitation/Do not resuscitate (DNR.) Section B - MPOA selected, comfort-focused treatment. Goals: maximized comfort through symptoms management; allow natural death. Use oxygen, suction and manual treatment of airway obstruction as needed for comfort. Avoid treatments listed in full or select treatments unless consistent with comfort goal. Transfer to hospital only if comfort cannot be achieved in current setting Section D - MPOA selected, Provide feeding through new or existing surgically placed tubes. On [DATE] at 12:15 PM, in an interview with Corporate Nurse and Administrator, acknowledged that Resident # 71's POST form should reflect full interventions and the facility allowed the MPOA to change the resident's advance directives from a full code with full interventions to a no code without any authorization from the resident. Based on record review and staff interview, the facility failed to ensure the documented used by the facility to convey end of life care, the State's Physician Orders for Scope of Treatment (POST) form, was completed correctly. For Resident #28, the POST form contained conflicting documentation regarding placement of a feeding tube. For Resident #71, the facility changed the resident's wishes for end of life care without the residents consent. This was true for two (2) of three (3) Residents reviewed for the care area of advance directives. Facility census: 91. Findings included: a) Resident #28 Review of the resident's most recent POST form completed on [DATE], by the facility social worker SW #28, found Section D, Medically Assisted Nutrition, instructs only one of the following choices can be made and says- (PICK 1) 1. Provide nutrition through new feeding tube through new or existing surgically placed tube 2. Time limited trial of ______ days but no surgically placed tubes 3. No artificial means desired of nutrition desired 4. Discussed but no decision made. Both the first and second choice was checked which is conflicting information and notes to place a feeding tube and do not place a feeding tube. The resident signed the post form and the facility SW #28 signed the post form indicating she was the medical professional assisting with competition of the POST form on [DATE]. On [DATE] at 08:43 AM , the above issue was discussed with the administrator and a second facility social worker #78. On [DATE] at 11:00 AM, the above issue was discussed with SW #28. No further information was provided at the close of the survey. .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on resident interview, staff interview, and record review, the facility failed to ensure activities of daily living were completed for a dependent resident. This was true for one (1) of two (2) residents reviewed under the care area of activities of daily living during the long-term survey process. Resident Identifier: #63. Facility Census: 91. Findings included: a) Resident #63 Upon the initial interview on 01/03/22 at 11:22 AM, Resident #63 stated, I want my showers on my scheduled days. The staff don't ask me they just put down I refuse. On 01/04/22 at 10:55 AM, Licensed Practical Nurse (LPN) #54 stated the shower days would be located on the Plan of Care (POC) or the [NAME]. LPN #54 also stated Resident #63's shower days are Monday and Friday during the hours of 6:00 AM to 2:00 PM. On 01/04/22 at 11:00 AM, Resident #63 stated, I did not get a shower yesterday and they (staff) didn't even ask me. Review of the bath/shower documentation from 12/06/21 through 01/03/22, showed no documentation of any showers given. The documentation noted a bed bath was given daily except on 12/17/21 which had no documentation. On 01/04/22 at 11:19 AM, the Director of Nursing (DON) stated, If the resident refuses a shower the Nursing Assistant (NA) should notify the nurse. Under the tasks tab, a checkmark should be marked for a refusal. The DON also stated there are no restrictions on showers on the [NAME] Unit. On 01/04/22 at 2:20 PM, the DON verified the resident did not receive a shower on Monday (01/03/22) his scheduled shower day. The DON also stated I talked with [Name of Resident] and he was okay to get his shower today. The DON verified Resident #63 did not receive his shower on 01/03/22 and did not explain why it wasn't given. .

. Based on medical record review, observation, and staff interview, the facility failed to ensure Residents received treatment and care in accordance with professional standards of practice. Physician's orders were not followed for neurological checks after an unwitnessed fall for Resident #70. In addition, weights were not obtained for Resident #201. This practice affected two (2) of (20) residents reviewed, during the Long-Term Care Survey Process (LTCSP). Resident identifier #70 and #201. Facility census: 91. Findings included: a) Resident #70 Review of Resident #70's medical record on 01/04/22 at 08:33 AM, showed an unwitnessed fall on 12/10/21 at 7:30 PM. Further review revealed Resident #70 was found on the floor, face down with head turned to the right. Neurological checks (neuro checks) were initiated. Subsequent review of the neurological check evaluations found no neuro checks were completed after 12/11/21 at 2:00 AM in the medical record for the unwitnessed fall on 12/10/21. During an interview with the Clinical Manager Registered Nurse #60 verified the Neuro Checks were not complete for Resident #70's unwitnessed fall on 12/10/21. No further information was provided prior to the end of the survey on 01/06/22 at 11:15 AM. b) Resident #201 Review of Resident #201's medical records showed an order written on 12/20/21 for weekly weights every Monday for four (4) weeks. The order was to start 12/27/21. Further review of Resident #201's medical records showed the resident had been weighed on 12/21/21 and 01/03/22. No weight was documented for 12/27/21. Resident #201's Medication Administration Record (MAR) stated 9 for the weight on 12/27/21. According to the Chart Code, 9 indicates Other/See Nurse Notes. The Nurse Note for 12/27/21 stated, Weekly weights x 4 weeks every day shift every Mon [Monday] for 4 weeks. There was no weight documented. There was no reason documented as to why a weight was not obtained. During an interview on 01/04/22 at 3:28 PM, Clinical Manager #60 confirmed a weight had not been documented for Resident #201 on 12/27/21. Clinical Manager #60 also confirmed there was no documentation as to why a weight was not obtained. No further information was obtained through the completion of the survey. .

. Based on observation and staff interview the facility failed to ensure an environment free of accident hazards by leaving a refrigerator unlocked an unattended in the facility dinning room. This was a random opportunity for discovery. This has the potential to affect more than a limited number of residents. Facility Census 91 Findings Included: a) Unlocked refrigerator in dining room. On 01/04/22 at 11:01 AM, during a visit to the social service (SS) office in the dinning room this surveyor observed a refrigerator sitting in the corner unattended and unlocked. A second surveyor also observed the refrigerator. The refrigerator opened without difficulty. Upon opening the refrigerator several lunch bags and loose food items were noted. On 01/04/22 at 1:45 PM, Personal Care Attendant (PCA)# 74 , who was sitting in the dinning room eating lunch, confirmed the refrigerator in the dinning room was used for staff food and was left unattended. On 01/04/22 at 1:50 PM, the Clinical Manager #13 confirmed the refrigerator was for staff use and was left unattended at times and could be opened by a wondering resident. .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** a) Resident # 71 On 01/03/22 at 11:30 AM, this surveyor observed Resident #71's tube feeding was shut off and still hooked up to Resident #71's G-tube. On 01/03/22 at 11:36 AM, in an interview with License Practical Nurse (LPN) #96 when asked why Resident # 71's tube feeding was off, LPN #96 stated the feeding tube was off when she came on shift. LPN # 96 stated the night shift turned off the feeding. LPN # 96 stated the night shift told her, Resident #71 was complaining of being full. LPN # 96 stated that Resident # 96 has capacity and could make his own decisions. LPN # 96 was asked to confirm the active order for tube feeding. It was noted Tube feeding was to be running at 60 ml/hr (milliliter/hour). LPN #96 denies calling the Family Nurse Practioner (FNP) or facility Physician regarding shutting off Resident #71's tube feeding. On 11/03/2021, Resident # 71 weighed 125.2 pounds (lbs.) On 12/22/2021, Resident #71 weighed 117.0 pounds which is a -6.55 % loss for the month. A review of the medical records reveals an active order dated 12/03/21 for enteral feed every shift, Jevity 1.0 via enteral pump to infuse at 60/ml/hr 24 hrs per day. A further review of the medical records reveals a physician determination of capacity form dated 12/09/21 indicating Resident#71 demonstrates incapacity to make medical decisions. A review of medical record reveals a nursing note after surveyor intervention dated 1/3/2022 at 2:10 PM, which reads as follows: Dietician contacted per request of NP due to reports of feeling too full with current continuous feeding. Awaiting feedback from dietician. A review of the care plan focus reads: Resident #71 is at nutrition risk r/t (related/to) BMI (Body Mass Index) <22 for age: 80 years (yrs), dysphagia requiring nothing by mouth (NPO) status/enteral feeding as primary source nutrition/hydration, risk for altered fluid status, SDTI (Symptoms of Deep Tissue Injury) to Left heel/increased nutrient needs, CVA (cardiovascular accident) , COPD (chronic obstructive pulmonary disease) , HTN (hypertension ), & depression/anxiety. Weight fluctuations noted A review of the medication administration record for December shows on the following days Resident #71 did not receive enteral feed as ordered: 12/01/21 Enteral feed was documented at 55 ml/hr day 55 ml/hr night 12/02/21 Enteral feed was documented at 55 ml/hr day 55 ml/hr night 12/03/21 Enteral feed was documented at day (no documentation) 55 ml/hr night 12/04/21 Enteral feed was documented at 55 ml/hr day (no documentation)night 12/05/21 Enteral feed was documented at 55 ml/hr day 60 ml/hr night 12/06/21 Enteral feed was documented at 55 ml/hr day 55 ml/hr night 12/07/21 Enteral feed was documented at 55 ml/hr day 55 ml/hr night 12/08/21 Enteral feed was documented at 55 ml/hr day 55 ml/hr night 12/09/21 Enteral feed was documented at 55 ml/hr day 55 ml/hr night 12/10/21 Enteral feed was documented at 55 ml/hr day 55 ml/hr night 12/11/21 Enteral feed was documented at 55 ml/hr day 55 ml/hr night 12/12/21 Enteral feed was documented at 55 ml/hr day 60 ml/hr night 12/13/21 Enteral feed was documented at 55 ml/hr day 55 ml/hr night 12/14/21 Enteral feed was documented at 55 ml/hr day 55 ml/hr night On 01/04/22 ADON # 13 produced a written statement that reads as follows: This nurse interviewed Resident #71 at 1:23 PM regarding TF (tube feeding) pump being off yesterday morning. Interview was in the presence of Licensed Practical Nurse (LPN)# 96. Resident #71 indicated that he turned the pump off because it was beeping. Resident #71 also indicated that he initially clamped his feeding tube to see if that would stop the beeping but it did not. Resident showed this nurse that button that read off. Education was provided in the presence of both nurses. Resident # 71 also admitted that when he feels full has clamed his feeding tube to get it to stop. This note was signed by ADON # 13 and LPN # 96. In an interview on 01/04/22 at 2:00 PM, the ADON acknowledged that Resident #71's tube feeding was not running at the ordered rate. Based on observation, record review, and staff interview, the facility failed to ensure the administration of enteral nutrition followed the physician's orders. In addition, the facility failed to ensure direction for staff regarding how to manage and monitor the rate of flow of the feeding was consistent. This was true for two (2) of two (2) residents reviewed for tube feeding. Resident identifiers: #29 and #71. Facility census: 71. Findings included: a) Resident #29 Record review found the resident was sent to the hospital on [DATE]. The resident returned to the facility on [DATE] with a new feeding tube. On 10/14/21, the resident was receiving Jevity 1.0 to infuse at 70 milliliters (ml's) per hour. On 12/23/21, the physician increased the order to Jevity 1.0 calorie at 100 ml's / via g-tube per hour to equal 2400 ml daily. Observation of the feeding pump on 01/04/22 at 12:20 PM, found the pump was infusing at 70 ml's per hour instead of the 100 ml's ordered. Licensed Practical Nurse LPN #96 confirmed the feeding pump was infusing at 70 ml's per hour. LPN #96 was asked how many ml's the feeding tube should be infusing in an hour? The LPN said, I don't know. She went to the desk to look at the resident's orders. After several minutes, LPN #96 said the order says the feeding should be infusing at 100 ml's per hour. Further review of the medication administration record (MAR) from 12/24/21 forward found the new order, dated 12/23/21 to increase the ml's to infuse per hour from 70 to 100. A category was added to the MAR which required the nursing staff to record the amount of ml's of Jevity received for day and night shift. Documentation on the MAR recorded the following daily amount of Jevity received: 12/24/21, the resident received 820 ml's of Jevity 12/25/21, the resident received 205 ml's of Jevity 12/26/21, the resident received 200 ml's of Jevity 12/27/21, the resident received 270 ml's of Jevity 12/28/21, 12/29/21, 12/30/21, and 12/31/21 the resident received 140 ml's of Jevity daily. 01/01/22, the resident received 140 ml's of Jevity 01/02/22, the resident received 910 ml's of Jevity 01/03/22, the resident received 1680 ml's of Jevity No daily documentation from 12/24/21 to 01/03/22 confirmed the resident received 2400 ml's of Jevity per day. 01/04/22 at 2:11 PM, The Director of Nursing viewed the MAR and said the order needs to clarified. The DON said maybe some nurses are writing 70 ml's on their shift thinking that is the rate the pump is infusing. However, if that was the case on the days when 140 ml's were recorded for the day, the pump has not been infusing at 70 ml's since 12/23/21. The DON said she would get clarification for the order.

. Based on observation, medical record review, and staff interview, the facility failed to provide respiratory care services consistent with professional standards of practice. The physician's order for oxygen was not followed. This practice affected two (2) of four (4) residents reviewed for respiratory care services during the Long-Term Care Survey Process (LTCSP). Resident Identifier: #17 and #19 Facility census: 91 Findings included: a) Resident #17 A medical record review completed on 01/03/22 revealed Resident #17 had an physician's order to receive oxygen at three (3) liters per minute (LPM) via nasal cannula for shortness of breath every day and night shift with a start date of 10/07/21. During an observation on 01/04/22 at 9:42 AM, it was discovered the oxygen concentrator was set on four (4) LPM and not the prescribed three (3) LPM. The Licensed Practical Nurse (LPN) #96 verified the oxygen concentrator was set on four (4) LPM and not the prescribed three (3) LPM. b) Resident #19 An observation of Resident #19, on 01/03/22 at 12:17 PM, revealed the Resident was receiving oxygen at four (4) Liters via nasal cannula (an oxygen delivery device) from an oxygen concentrator. A review of the Resident's physician order, revealed the order: -- Oxygen at three Liters per Minute. Indicate: Nasal cannula. Continuous flow. May titrate to keep saturation at 90% or greater per nasal cannula. With a start date of 12/29/21. A second observation of Resident #19, on 01/04/22 at 9:15 AM, revealed the Resident was receiving oxygen at four (4) Liters via nasal cannula from an oxygen concentrator. During an interview on 01/04/22 at 9:20 AM Licensed Practical Nurse #54, verified that the oxygen level was running at four (4) liters per minute. A continued review of the Resident #19's Vital record showed Oxygen levels: --01/04/22 at 10:09 AM 92% via nasal cannula. --01/03/22 at 9:43 AM 98% room air. --01/02/22 at 6:39 PM 93% via nasal cannula. During an interview on 01/04/21 with the Clinical Manager Registered Nurse #60 verified, there was no documentation of Resident #19's oxygen levels below 90%. Clinical Manager Registered Nurse #60 stated that the oxygen flow rate was incorrect at four (4) liters per minute with the documented oxygen levels. No further information was provided prior to the end of the survey on 01/06/22 at 11:30 AM. .

. Based on observation and staff interview, the facility failed to maintain the kitchen in a safe and sanitary manner in accordance with professional standards of practice. During the kitchen tour it was discovered nectar thickening was not dated after opening and two (2) of four (4) reach-in refrigerators were dirty. This deficient practice had the potential to affect a limited number of residents receiving nourishment from the kitchen. Facility census: 91 Findings included: a) Kitchen tour During the kitchen tour on 01/03/22 at 10:48 AM, it was discovered nectar thickening was not dated after opening and two (2) of four (4) reach-in refrigerators had food debris on the bottom sections. An interview with the Dietary Manager on 01/03/22 at 10:55 AM, verified the nectar thickening was not dated after opening and the two (2) reach-in refrigerators needed to be cleaned. .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review and staff interview, the facility failed to ensure influenza and pneumonia immunizations were provided to one (1) of five (5) residents reviewed for the care area of immunizations. Resident identifier: #57. Facility census: 91. Findings included: a) Resident #57 Review of Resident #57's medical records showed the resident was admitted to the facility on [DATE]. There was no documentation in the medical records the resident had received or been offered influenza or pneumonia vaccines. During an interview on 01/04/22 at 3:30 PM, the Infection Control Nurse (ICN) presented an Influenza Vaccine Consent and Screen form and a Consent/Declination for Pneumonia Vaccine form that came from Resident #57's medical file. Both forms had a handwritten notification that stated, Says he wants it. The ICN stated he didn't know who wrote the notations or when they were written. The ICN acknowledged Resident #57 had not received influenza or pneumonia vaccines. The Infection Control Nurse stated he would follow up on providing immunizations for Resident #57. On 01/05/22 at 10:00 AM, the ICN stated Resident #57 received an influenza vaccine yesterday. He stated Resident #57 would receive a pneumonia vaccine when the vaccine was received from the pharmacy. No further information was provided through the completion of the survey. .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review and staff interview, the facility failed to ensure timely notification was made to a representative of the Office of the State Long-Term Care Ombudsman when residents were transferred to the hospital. This was true for three (3) of four (4) residents reviewed for the care area of hospitalization. Resident identifiers: #29, #192, #190, and #60. Facility census: 91. Findings included: a) Resident #29 Record review found the resident was transferred and admitted to a local hospital on [DATE]. On 01/05/22 at 3:06 PM, the corporate nurse #133 confirmed she had no documentation to verify the ombudsman was notified of the residents transfer to the hospital. b) Resident #192 Review of Resident #192's medical records showed the resident had been sent to an appointment at the wound care clinic on 06/02/21. The resident was transferred from the wound care clinic to the hospital, where she was admitted . On 01/05/22 at 10:06 AM, the Director of Nursing was asked for documentation that the Ombudsman was notified Resident #192 was transferred and admitted to the hospital on [DATE]. No documentation was provided through the completion of the survey. c) Resident # 190 Record review found Resident # 190 was transferred to a local hospital on [DATE]. On 01/05/22 at 3:06 PM, the corporate nurse #133 confirmed she had no documentation to verify the ombudsman was notified of the residents transfer to the hospital. d) Interviews On 01/05/22 at 3:21 PM, the administer acknowledged they were lax in giving notification to the ombudsman. He stated, I sent some notifications in October and some today. He was unable to get email confirmation due to email jail, which means the facilities email would go away after a certain time frame. .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review and staff interview, the facility failed to ensure residents/responsible party were made aware of the facility's bed-hold notice when transferred to the hospital. This was true for three (3) of four (4) residents reviewed for the care area of hospitalization. Resident identifiers: #29, #192, #190, and #60. Facility census: 91. Findings included: a) Resident #29 Record review found the facility transferred the resident to the hospital on [DATE]. On 01/05/22 at 3:06 PM, the corporate nurse #133 said the facility had nothing to verify a copy of the bed hold policy was sent with the resident at the time of discharge. b) Resident #192 Review of Resident #192's medical records showed the resident had been sent to an appointment at the wound care clinic on 06/02/21. The resident was transferred to the hospital from the wound care clinic. On 01/05/22 at 3:21 PM, Corporate Nurse #133 stated she had no documentation that Resident #192's representative had been made aware of the facility's bed hold policy on 06/02/21. No further information was provided through the completion of the survey. c) Resident # 190 Record review found Resident # 190 was transferred to a local hospital on [DATE]. On 01/05/22 at 3:06 PM, the corporate nurse #133 confirmed she had no documentation to verify a bed hold authorization form was given to the residents or responsible party at time of transfer to the hospital. d) Resident # 60 Record review found Resident # 190 was transferred to a local hospital on [DATE],12/10/21, and 06/29/21. On 01/05/22 at 2:06 PM, the corporate nurse #133 confirmed she had no documentation to verify a bed hold authorization form was given to the residents or responsible party at time of transfer to the hospital. .