Does Mountain View Care Center have any serious inspection findings?

Yes, Mountain View Care Center has 1 Immediate Jeopardy citation on record, which represent the most serious type of deficiency. The facility has 52 total deficiencies from recent inspections.

What are the staffing levels at Mountain View Care Center?

Mountain View Care Center has a one-star staffing rating from CMS with 0.45 RN hours per resident per day. This rating is based on registered nurse (RN), licensed practical nurse (LPN), and nurse aide staffing hours.

Where is Mountain View Care Center located?

Mountain View Care Center is located in RIPLEY, WV. It is a Medicare and Medicaid certified skilled nursing facility.

How many beds does Mountain View Care Center have?

Mountain View Care Center has 120 certified beds.

Who owns Mountain View Care Center?

Mountain View Care Center is a for profit - corporation facility and is part of the HILL VALLEY HEALTHCARE chain.

What questions should families ask when visiting Mountain View Care Center?

Families visiting Mountain View Care Center should ask about how serious violations have been addressed. Also ask to speak with current residents or families, tour during mealtime, and request a copy of the most recent inspection report.

How does Mountain View Care Center compare to other nursing homes?

Mountain View Care Center has a 1-star overall rating, which is below average compared to other nursing homes in WV. Families should carefully review inspection findings and consider alternatives.

Mountain View Care Center

Name: Mountain View Care Center
Address: 107 MILLER DRIVE, RIPLEY, WV, 25271, US
Telephone: (304) 633-4732
Rating: 1.0

107 MILLER DRIVE, RIPLEY, WV 25271 · (304) 633-4732

For profit - Corporation 120 Beds HILL VALLEY HEALTHCARE Data: November 2025 1 Immediate Jeopardy citation

Trust Grade

23/100

#108 of 122 in WV

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Last Inspection: February 2025

Within standard 12-15 month inspection cycle. Federal law requires annual inspections.

Overview

Mountain View Care Center in Ripley, West Virginia, has a Trust Grade of F, which indicates significant concerns about the facility's care quality. Ranking #108 out of 122 facilities in the state places it in the bottom half, and it is the second out of two options in Jackson County, meaning there are limited choices for families in the area. The facility's situation is worsening, with issues increasing from 16 in 2023 to 22 in 2025. Staffing is a major concern, as it received a 1-star rating and has a turnover rate of 47%, which is about average for West Virginia. There have been troubling incidents, including a critical finding where residents requiring mechanical soft diets were served whole meatballs and pasta, posing a choking risk, and another finding where an RN failed to follow proper infection control protocols by not wearing protective gear when entering a room with a resident under contact precautions. Overall, while there are some average quality measures, the significant issues regarding safety and care should be carefully considered by families.

Trust Score: F
In West Virginia: #108/122
Safety Record: High Risk
Inspections: Getting Worse
Staff Stability: 47% turnover. Above average. Higher turnover means staff may not know residents' routines.
Penalties: $33,033 in fines. Lower than most West Virginia facilities. Relatively clean record.
Skilled Nurses: Each resident gets only 27 minutes of Registered Nurse (RN) attention daily — below average for West Virginia. Fewer RN minutes means fewer trained eyes watching for problems.
Violations: 52 deficiencies on record. Higher than average. Multiple issues found across inspections.

★☆☆☆☆

1.0

Overall Rating

★☆☆☆☆

1.0

Staff Levels

★★★☆☆

3.0

Care Quality

★☆☆☆☆

1.0

Inspection Score

↔

Stable

2023: 16 issues

2025: 22 issues

The Good

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

Facility shows strength in fire safety.

The Bad

1-Star Overall Rating

Below West Virginia average (2.7)

Significant quality concerns identified by CMS

Staff Turnover: 47%

Near West Virginia avg (46%)

Higher turnover may affect care consistency

Federal Fines: $33,033

Below median ($33,413)

Moderate penalties - review what triggered them

Chain: HILL VALLEY HEALTHCARE

Part of a multi-facility chain

Ask about local staffing decisions and management

The Ugly 52 deficiencies on record

1 life-threatening

Feb 2025 22 deficiencies 1 IJ (1 affecting multiple)

CRITICAL (K)

Immediate Jeopardy (IJ) - the most serious Medicare violation

Deficiency F0805 (Tag F0805)

Someone could have died · This affected multiple residents

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Based on observation, record review, resident interview, and staff interview, the facility failed to provide each resident with a nourishing diet in a form prepared to meet their individual needs. This failed practice created an immediate jeopardy sitaution. There was an immediate risk of choking for residents who were supposed to be served mechanical soft diets. This immediate jeopardy situation had the potentail to affect more than an isolated number of residents. Resident identifiers: #86, #42, #36, #48, #19, #57, #53, #16, #60, #75 and #7. Facility census: 106. Findings included: a) During lunch pass, on 02/16/25 at 11:55 AM, Resident #86, #42, #36, and #48 with physician-ordered mechanical soft diets were noted to have whole meatballs and whole penne pasta. These These residents were consuming the meatballs and pasta. On 02/16/25 at 11:55 AM, [NAME] #74 said They (the meatballs) are whole today, but they are cutting them (the meatballs) for them (the residents) now. The residents had plastic utensils due to a broken dishwasher and were observed having difficulty cutting their food. On 02/16/25 at 12:05 PM, the Dietary Manager in training said either the kitchen or the nursing assistants can chop the food. She said most of the the kitchen chops the meals for mechanical soft diets. On 02/17/25 at 11:30 AM, the Certified Dietary Manager said the meatballs probably should have been ground, and fork-tender. He stated all meat for mechanical soft diets should be ground, unless they have an order for regular, chopped meat. The policy and procedure for Swedish meatballs over noodles with date 02/16/25 stated the chopped process for entrees was to process meatballs and noodles separately in a food processor until even ground texture is achieved with no pieces larger than 1/8 inch. The menu extension for baked penne and meat sauce was to ground meat sauce #10 with chopped pasta in six (6) ounce sauce. According to the menu extension, Swedish meatballs over noodles should have chopped Swedish meatballs sauce #8 over noodles. However, penne pasta was used instead of noodles. According to other recipes in the meal extension, penne pasta should be chopped for a mechanical soft diet. On 02/18/25 at 12:25 PM, NA #108 handed Resident #42 non-thickened chocolate milk. The resident took a drink. NA #88 stated the resident needed thickened liquids. The resident had an order for nectar-thickened liquids. During lunch meal pass on 02/18/25, residents with physician-ordered mechanical soft diets were served baked penne and meat sauce. The pasta was served whole. Nursing Assistant (NA) #108 confirmed residents on mechanical soft diets had received whole pasta today. She stated, We (the NAs) always chop it. Resident #42 was observed eating the pasta whole. During dinner meal pass, on 02/18/25 at 5:40 PM, four (4) residents with physician-ordered mechanical soft diets were served French Fries. These residents were Residents #19, #57, #53, and #42. These residents ate the French Fries. Additionally, Resident #35, #36, #42, and #86 had physician- ordered mechanical soft diets and were served ground meat without gravy. All these residents consumed some of the ground meat with no gravy. These were random opportunities for discovery. According to the facility's policy and procedure for mechanical soft diet with date 02/07/25, French fries on mechanical soft diet must be baked and soft, with no crisp edges. Instructions were given to follow the extension/production sheet for process or substitution. According to the facility's policy and procedure for mechanical soft diet with date June 2023, The addition of gravies or sauces may be needed to increase moisture content of meats to promote ease in swallowing. The policy also stated food characteristics should be soft, tender and moist throughout. The menu extension stated French fries must be baked and soft with no crisp edges. The menu extension also stated Salisbury steak with mushroom gravy should be chopped ½ inch #8 with pureed gravy . On 02/18/24, the Activities Director verified there was no gravy on the meat and obtained gravy for the meats. On 02/18/24 at 5:25 PM, a surveyor observed French fries in the deep-fryer. On 02/18/24 at 6:10 PM, Nurse Aide in Training #108 stated Resident #42 eats French fries all the time. Additionally, on 02/18/24 at 6:20 PM, Dietary Aide #104 stated the French fries were deep- fried. On 02/18/25 at 5:45 PM, Resident #58 was observed attempting to drink chocolate milk that was spoon thick. He had an order for nectar thick liquid. The resident nonverbally communicated that he could not drink the chocolate milk. Dietary Aide #104 said he was the one who did the drinks today. He stated, that is way too thick. He stated he used the wrong scoop in thickening the liquid. On 02/18/25 at 9:00 PM the facility was informed of the above interviews and observations and that an immediate jeopardy (IJ) siatatuion exisited due to the risk of residents choking. On 02/18/25 at 11:18 PM the following plan of correction for the IJ was accepted by the survey team. Immediate Actions Taken to Remove the Immediate Jeopardy 1.Resident Safety and Corrective Actions: As of 02/18/25, all residents on physician-ordered mechanical altered diets were immediately assessed by the assigned nurse for adverse effects related to improper texture-modified meals. Residents identified with incorrect liquid consistency (Resident #42 and Resident #58) were immediately provided with properly thickened liquids per physician order. Dietary staff and licensed nurses will be educated on proper thickening agent usage and correct measuring techniques to ensure appropriate liquid consistency. Nurses currently working have been educated on proper thickening agent usage and correct measuring techniques to ensure appropriate liquid consistency. Immediate discontinuation of serving deep-fried French fries for mechanical soft diets. Medical Director and resident responsible parties were notified of the diet inconsistencies by the nurse managers on 02/18/25. 2. Staff Education and Re-Training: Dietary Staff: Immediately or upon arrival to their next worked shift received in-service training conducted on 02/19/25 by the Dietary Manager and/or designee on: Proper preparation of mechanical soft diets, including the correct chopping and grinding procedures. Proper menu extension adherence and use of production sheets. Thickened liquid consistency for residents requiring nectar or pudding-thick liquids. Nursing Staff and CNAs: Re-educated on proper meal modifications and verifying consistency of food and beverages before serving. In-service was provided by the DON/designee. 3. Monitoring and Quality Assurance Measures: Daily Meal Audits: Beginning 02/19/25, the Dietary Manager and Nursing Supervisor will conduct meal service audits daily to ensure proper diet consistency compliance. Any discrepancies in meal preparation are immediately corrected, documented, and reviewed in daily safety huddles. Weekly audits of meal service by the Dietary Manager and Director of Nursing (DON) for four weeks, then ongoing monthly audits. QAPI Committee will review compliance data and discuss any identified trends or issues. Administrator and Medical Director notified of all corrective actions and ongoing monitoring efforts. 02/18/25 at 9:25 AM, the State Surveyor met with the Registered Dietician, Director of Nursing, Speech Language Pathologist (SLP) and Registered Nurse (RN) #145. The Hormel Thick and Easy Instant Food and Beverage Thickening Powder packet was reviewed for both nectar and honey liquid consistencies. The packet instructions stated to add one packet of food thickener to 4oz of liquid for nectar-like to honey-like consistency. The SLP reported they used to use gel, but the packets are new. The SLP uses one packet in 4 oz and uses the fork test. The SLP stated, I personally like the gel. RN #145 reported the facility will discontinue the use of the Hormel packets, educate the staff and will order the gel thickener. The nurse's will thicken liquids on the floor and dietary will thicken liquids for meals. On 02/19/25 at 12:20 PM, Resident #7 with a pureed diet order was served the wrong meal ( mechanical soft diet with coleslaw). Resident #7 began eating food off the tray before it was taken away. The Activity Director noted this herself with no surveyor intervention, but the resident had eaten some. Two additional resident's with mechanical soft diets were served coleslaw. After surveyor intervention and the residents starting to eating, the coleslaw was switched out for green beans. The residents were Residents #16, #60, #75, #7. The facility's menu extension, provided by the Registered Dietician,showed residents on mechanical soft diets should have received green beans and not creamy coleslaw. Coleslaw on the resident's trays was verified by Activities Assistant #34.

CONCERN (D)

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

Investigate Abuse (Tag F0610)

Could have caused harm · This affected 1 resident

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Based on record review and resident and staff interviews, the facility failed to thoroughly investigate an allegation of abuse involving Resident #39. This was true for one (1) of nine (9) residents reviewed for abuse and neglect during the survey process. Resident identifier: 39. Facility census: 106. Findings include: During review of a facility reported incident (FRI), on 02/25/25, it was noted the facility reported an allegation of staff to resident abuse on 02/07/25. According to the FRI, a staff member was alleged to have yelled at Resident #39 after she slid out of her recliner and into the floor, stating, You shouldn ' t be getting up without asking for help.Resident #39's daughter reported the incident to the facility, further stating the employee Very roughly jerked Mom's arm and pulled her up out of the bed. The resident's daughter was not present at the facility at the time of the incident. The staff member was determined to to be Nurse Aide (NA) #5. NA #5 was suspended pending investigation. During review of the investigation conducted by the facility, it was noted staff members present the night of the alleged incident were interviewed, as evidenced by statements supplied by the facility. However, it was noted there was no statement taken from Resident #39 during the course of the investigation, according to the documents provided by the facility. At approximately 2:10 PM on 2/25/2025 an interview was conducted with Resident #39 regarding the alleged incident and the facility's investigation. Resident #39 has a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognitive abilities. During the interview, Resident #39 stated I slid out of my chair and the girls came in and helped me get back up and helped me to the bathroom. When asked if the facility took a statement from her regarding the allegation of abuse, the resident stated, I remember a lady that works with you (this surveyor) came in a few days ago and asked me about me falling, but that's it. The resident, again, confirmed no one employed with the facility came in to obtain a statement regarding the incident. At approximately 10:30 AM during an interview with the Administrator, it was confirmed no statement was taken from Resident #39 during the course of the investigation. The Administrator stated I'll see what I can find. However, no further documentation was provided by the facility during the remainder of the survey process.

CONCERN (D)

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

Assessment Accuracy (Tag F0641)

Could have caused harm · This affected 1 resident

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Based on record review and staff interview, the facility failed to ensure accurate Minimum Data Set assessments for two (2) of 43 residents in the long-term care survey sample. Resident identifiers: #8 and #44. Facility census: 106. Findings included: a) Resident #44 Resident #44's Minimum Data Set (MDS) assessment with Assessment Reference Date (ARD) 12/31/24 coded a trunk restraint was used less than daily. Review of Resident #44's physician's orders showed no current or past orders for restraints. Review of the resident's comprehensive care plan showed no current or past focus or interventions related to restraints. On 02/18/25 at 4:57 PM, the Administrator acknowledged Resident #44's MDS with ARD 12/31/24 was incorrect in coding restraint use. b) Resident #8 Review of Resident #8's medical records showed the resident had a diagnosis of depression, unspecified, since 09/05/23. Review of Resident #8's physician's orders showed the resident had been receiving the medication trazodone for major depression since 08/14/24. Resident #8's Minimum Data Set (MDS) with Assessment Reference Date (ARD) 11/14/24 did not code the diagnosis of depression. On 02/19/25 at 10:32 AM, Minimum Data Set Coordinator Registered Nurse (MDSCRN) #15 acknowledged Resident #8 had a diagnosis of depression and was receiving medication for depression. She stated she would correct the MDS.

CONCERN (D)

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

Comprehensive Care Plan (Tag F0656)

Could have caused harm · This affected 1 resident

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Based on record review, observation and staff interview the facility failed to develop/implement a person centered care plan to meet and/or address the residents medical, physical, mental, and psychosocial needs. This failed practice was found true for (2) two of 43 care plans reviewed during the Long-Term Care Survey Process. Resident identifiers: #22 and #68. Facility census: 106. Findings include: a) Resident #22 The initial observation, on 02/17/25 at 10:25 AM, showed Resident #22 lying in bed with his head covered up with the sheet and his buttock sticking out of the sheet which revealed that Resident #22 was not wearing a brief. Further observation on 02/18 25 at 2:30 PM, revealed Resident #22 lying in bed with the sheet at his feet and no brief on at this time. An observation on 02/19/25 at 11:00 AM, revealed Resident #22 lying in bed with a sheet and his buttock sticking out of the sheet showing that Resident #22 did not have a brief on. An observation on 02/19/25 at 2:09 PM, revealed Resident #22 up to a Geri chair wearing a black, short sleeve one piece outfit. During an interview on 02/19/25 at 2:26 PM, Nursing Assistant (NA) #97 stated, When he is in bed, he does not wear briefs because he rips them up and chews on them. When he is up he has on a brief but also has on a one piece outfit so he cannot reach down and pull off his brief. A record review on 02/24/25 at 1:30 PM, revealed a care plan that did not address the one piece outfit, or the not wearing of briefs while in bed. During an interview on 02/25/25 at 10:10 AM, Cooperate Minimum Data Set Coordinator (CMDSC) #148 confirmed that the one piece outfit and the not wearing of briefs were not addressed in a current care plan. b) Resident #68 During review of Resident #68's record on 2/17/2025, it was discovered the resident had the following order: Regular diet, Regular texture, Regular/Thin consistency doesn't eat turkey, fish, or chicken for plateguard with meals The resident had the following focus and intervention listed on her care plan: Focus- Resident is at potential nutrition risk r/t (related to) underweight BMI; medical dx (diagnosis) that may affect weight; intakes and nutritional status. Date initiated: 01/31/24 Revision on: 01/07/25. Interventions/Tasks- Plateguard with meals. Date initiated: 02/21/24. During lunch service at approximately 12:15 PM on 2/18/25, Resident #68 was served lunch with no plateguard. The Administrator acknowledged the Resident did not have a plateguard, and reviewed the order calling for it. Upon further investigation, it was determined the plateguard was not listed on the resident's meal ticket. During dinner service, on 2/18/2025, at approximately 5:30 PM, Resident #68 received a tray without a plateguard. At this time, this was acknowledged by the Corporate Registered Registered Nurse (CRN). The meal ticket still did not have the plateguard listed for the resident. During lunch service on 2/19/2025, at approximately 12:15 PM, Resident #68 was served a meal with no plateguard on her plate. This was acknowledged by the Administrator. The Administrator confirmed the plateguard was still absent from the resident's meal ticket. At approximately 10:30 AM on 02/26/25, an interview was conducted with the Registered Dietitian (RD) regarding the orders for the plateguard and the process for adaptive equipment showing up on the residents' meal tickets. The RD stated the nursing staff at the facility would have to fill out a communication form, stating the need for the adaptive equipment and, once received by the dietary department, it would be placed on the ticket. The RD stated if the equipment was not on a ticket, it was likely the nursing staff did not supply the communication form.

CONCERN (D)

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

Deficiency F0657 (Tag F0657)

Could have caused harm · This affected 1 resident

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Based on record review, observation, and staff interview, the facility failed to revise the care plan for Resident #14 after the order for adaptive equipment during meals was not renewed. This was true for one (1) of 43 care plans reviewed during the survey process. Resident identifier: 14. Facility census: 106. Findings include: a) Resident #14 During review of Resident #14's record on 2/17/2025, it was noted the resident was care planned to have a Kennedy cup with all meals. However, no order for a Kennedy cup was found on the resident's record. Upon further review, it was noted the resident had a recent hospital stay and returned to the facility on 1/12/2025. Review of the resident's completed/discontinued orders revealed she had an order for a Kennedy cup with all meals before leaving for the hospital. After returning on 1/12/2025, the order for the Kennedy cup was not renewed, but the care plan was not updated. At approximately 12:45 PM on 2/25/2025, Licensed Practical Nurse (LPN) #21 confirmed Resident #14 did not receive a Kennedy cup with her meal. Resident #14 had not been observed with a Kennedy cup with any meals during the survey process. At approximately 11:35 AM on 2/26/2025, the Administrator confirmed the resident did not have an order for the Kennedy cup and the care plan had not been revised to reflect this change.

CONCERN (D)

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

Deficiency F0730 (Tag F0730)

Could have caused harm · This affected 1 resident

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Based on record review and staff interview, the facility failed to conduct yearly evaluations on Nurse Aides (NA). This has the potential to affect more than a limited number of residents. Employee idenifier: Nurse Aide (NA) #4 Facility census: 106. Findings include: a) NA #4 During review of facility staffing documentation on 2/25/2025, it was noted Nurse Aide (NA) #4 had a hire date of 11/19/18, with their last evaluation being completed on 1/25/24. At approximately 12:00 PM on 2/26/25, the Regional Director of Operations (RDO) confirmed there was not a current performance review on file for NA #4.

CONCERN (D)

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

Deficiency F0761 (Tag F0761)

Could have caused harm · This affected 1 resident

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Based on observation, record review, and staff interview, the facility failed to ensure medications were stored and labeled in accordance with currently accepted professional principles. An insulin pen had not been discarded 28 days after opening. This was a random opportunity for discovery during the facility task of medication storage and labeling. Resident identifier: #56. Facility census: 106. Findings included: a) Resident #56 On 02/18/25 at 8:44 AM, the D Hallway medication cart was inspected with Licensed Practical Nurse (LPN) #26 in attendance. In the medication cart was a Novolog insulin pen for Resident #56. On the pen packaging, the date of opening of 01/10/25 was written in marker. An expiration date of 02/06/25 was also written in marker on the pen packaging. A pharmacy label on the Novolog insulin pen packaging stated the medication could be stored at room temperature for up to 28 days after opening. LPN #26 stated Resident #56 was still prescribed Novolog insulin. She acknowledged the insulin pen had been opened for more than 28 days and should not be used. Review of Resident #56's physician's orders showed she was prescribed Novolog FlexPen insulin as needed twice a day for sliding scale coverage for elevated fingerstick blood glucose levels. Review of Resident #56's Medication Administration Record (MAR) showed the resident had received Novolog insulin on 02/07/25 at 6:00 AM, 02/09/25 at 6:00 AM and 4:00 PM, 02/12/25 at 4:00 PM, 02/13/25 at 4:00 PM, 02/14/25 at 6:00 AM and 4:00 PM, 02/15/25 at 4:00 PM, 02/16/25 at 4:00 PM, 02/17/25 at 4:00 PM, and 02/18/25 at 6:00 AM. According to the Novolog insulin packaging insert, available on-line on the Food and Drug Administration (FDA) Website, Once a cartridge or NovoLog FlexPen or NovoLog FlexTouch is punctured, it should be kept at temperatures below 30°C (86°F) for up to 28 days. No further information was obtained through the completion of the survey process.

CONCERN (D)

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

Laboratory Services (Tag F0770)

Could have caused harm · This affected 1 resident

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Based on record review and staff interview, the facility failed to perform laboratory testing according to physician's orders for two (2) of five (5) residents reviewed for the care area of unnecessary medications. Resident identifiers: #8 and #95. Facility census: 106. Findings included: a) Resident #8 Review of Resident #8's physician's orders showed an order written on 05/03/24 for laboratory testing consisting of a basic metabolic panel, complete blood cell count, lipid panel, and liver panel to be done every six (6) months, in April and October. On 02/19/25 at 2:25 PM, the Director of Nursing (DON) was asked to provide a copy of the laboratory testing results for October 2024, as it had not been scanned into the resident's electronic health record. The DON provided laboratory testing results for a basic metabolic panel, complete blood cell count, and lipid panel that had been performed on 10/08/24. The results did not contain liver panel studies. On 02/19/25 at 3:13 PM, the DON confirmed the physician's order to perform liver panel laboratory testing for Resident #8 in October 2024 had not been followed. No further information was obtained through the completion of the survey process. b) Resident #95 Review of Resident #95's physician's orders showed an order written on 01/02/25 for laboratory testing consisting of a Hemoglobin A1C (HgbA1C) to be done every four (4) months, and be performed in January, May and September. On 02/19/25 at 3:28 PM, the Director of Nursing (DON) was asked to provide a copy of the laboratory testing results for January, 2025, as it had not been scanned into the resident's electronic health record. The DON could not provide laboratory testing results for the HgbA1C that was ordered for 01/02/25. On 02/19/25 at 3:35 PM, the DON confirmed the physician's order to perform a HgbA1C for Resident #95 in January 2025 had not been followed.

CONCERN (D)

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

Infection Control (Tag F0880)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, The facility failed to establish and maintain an infection prevention and control program designed to help prevent the development and transmission of communicable diseases and infections. This was a random opportunity for discovery. Facility census: 106. Findings include: A) room [ROOM NUMBER] At approximately 1:50 PM on 2/17/2025, an observation was made in room [ROOM NUMBER] of the facility of dirty clothes lying on the floor of the bathroom. Housekeeping Aide #81 stated, One of the residents in there puts her clothes in the floor and the aides are supposed to pick them up when they go in there. At approximately 1:55 PM, MDS Nurse #15 confirmed the dirty clothes on the floor of the bathroom.

CONCERN (E)

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

Resident Rights (Tag F0550)

Could have caused harm · This affected multiple residents

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Based on observation and staff interview the facility failed to ensure a dignified dining experience. This was a random opportunity for discovery. Resident identifiers: #85, #547, #42. Facility census: #106. Findings include: a) Resident #85 On 02/17/25 at 12:35 PM Resident #85 was sitting with two (2) other residents at the dining room table. Resident #38 and #53 were served and being assisted with their meal at 12:35 PM. Staff continued to pass meal trays to other tables in the dining room. Resident #85 did not receive the meal until 12:43 PM after bringing it to the attention of the Director of Activities #41. It was confirmed with the Director of Activities #41 on 02/17/25 at 12:43 PM that Resident #85 had not been provided the right to a dignified dining experience. b) Resident #457 On 02/18/25 at 5:42 PM Resident #42 was a tablemate with Resident #457. Resident #42 was served her tray at this time, however Resident #457 was not served for thirty three (33) minutes afterwards, at 6:15 PM. At this time all other residents had left the dining room. This was confirmed with Licensed Practical Nurse Unit Manager (LPNUM) #12 who agreed that Resident #457 should have had her tray prior to this time. c) Resident #42 On 02/18/25 at 12:41 PM Resident #42 was not served their lunch meal tray until eighteen (18) minutes after her tablemate's were served causing her to be denied the right to a dignified dining experiences as she was watching the other residents eat their meal. Staff continued to pass meal trays to other dining room tables before serving Resident #42. Resident #42's tablemate, Resident #457, had her tray and Resident #42 consistently ask Where's my food? This was confirmed with Licensed LPNUM #12 who confirmed the meals should have come out together. e) Residents were served on styrofoam throughout the dining room observations. On 02/18/25 at 12:40 PM, the State Surveyor asked Dietary Aide #50 why styrofoam bowls were being used during the lunch meal. Dietary Aide #50 stated, They ran out. On 02/18/25 at 5:30 PM, the Dietary [NAME] #124 verified the kitchen ran out of plates and bowls for the dinner meal.

CONCERN (E)

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

Deficiency F0565 (Tag F0565)

Could have caused harm · This affected multiple residents

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Based on Resident Council meeting, record review, and staff interview the facility failed to act promptly upon the grievances/concerns from Resident Council. This failed practice was a random opportunity for discovery and had the potential to affect a limited number of residents during the Long-Term Care Survey Process. Facility census: 106. Findings include: a) Resident Council Meeting Minutes A review of the Resident Council Meeting Minutes on 02/18/25 at 10:00 PM, revealed a resident/family concern form dated 07/16/24 that had the following concerns listed from resident council: * Residents requesting drinks be passed with meals instead of before the meal trays make it to the hallways. * Repeated meals being served too frequently. * Directions not being followed on meal tickets. Likes/dislikes not being observed and/or monitored. * Menu does not match the meals being served. Would like an alternative on the menu also. Further review of the Resident Council Meeting Minutes revealed an impromptu (AD-HOC), Quality Assurance (QA) meeting was held on 07/25/24 at 2:00 PM as a response to the above concerns from Resident Council, and that the response did not match the concerns that were made by Resident Council. The AD-HOC, QA meeting listed the following to put in place for the Resident Council Concerns: * Eliminate frequency of the substitutions. * Asking for alternates, but not always receiving alternates. * Ensure that salads are coming with/being offered dressings. * Staff to continue to eat meals prior to sending them out. * Trays to be lined up by room number in the meal carts. * Pastas to be cooked a little longer and would like to see more sausage biscuits for breakfast. * Explained Manager on Duty program starting the first weekend in August to assist with weekend needs and activities. a1.) Lunch meal observation An observation of the lunch meal on A-hall on 02/18/25 at 12:00 PM, revealed that drinks for the meal were being passed. Continuous observation showed that the meal for A-hall did not start getting passed to residents until 1:15 PM. Further observations of Residents on A-hall revealed that (6) six residents' drinks were empty by the time they received their lunch tray. a2.) Resident Council Meeting During the Resident Council Meeting on 02/18/25 at 2:00 PM the Resident Council as a whole had the following concerns: * Drinks are not being served with our meals. They had brought this up several times and it continues to be a problem. * They serve drinks in the hallway, way before the meal comes. The coffee is cold by the time we get our meal. * We ask if we can have more and the kitchen response is no, we are out of food. * Very common not to have food that is on the menu. It happens a lot. * We were supposed to have a food meeting the second Tuesday of each month with the head guy in the kitchen and in the last four (4) months we have only had one. a3.) Supper meal observation An observation of the supper meal being served in the dining room on 02/18/25 at 6:00 PM, revealed that residents were being served Salisbury steak, spinach and scalloped potatoes. With (6) six residents left to serve in the dining room the kitchen ran out of the menu items and the remaining residents were served Salisbury steak, french fries and spinach. During an interview on 02/18/25 at 6:10 PM, Dietary Aide (DA) #104 stated, We ran out of food. A review on 02/18/25 at 6:30 PM, revealed that the menu posted for supper was to be Salisbury steak, mashed potatoes, and carrots. During an interview on 02/25/25 at 2:09 PM, Social Worker (SW) #90 stated, I do remember we made multiple attempts to try and fix it. If I have the documentation to show it, I do not know. She further agreed that if it is still happening then it is not resolved. Further interview on 02/25/25 at 2:41 PM, SW #90 stated, According to our resident council meeting minutes they did not have a complaint about it in December and January so it must be a problem that came back.

CONCERN (E)

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

Deficiency F0577 (Tag F0577)

Could have caused harm · This affected multiple residents

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Based on resident council interview, observation and staff interview the facility failed to have the results from the last standard survey posted in a place easily accessible by residents. This failed practice was a random opportunity for discovery and had the potential to affect a limited number of residents during the Long-Term Care Survey Process. Facility census: 106. Findings Include: a) Resident Council During the Resident Council (RC) Meeting on 02/18/25 at 2:00 PM, the RC as a whole said that they did not know they had access to the findings from the last standard survey. During an interview and observation on 02/18/25 at 3:45 PM, at the desk at the front door, The Administrator pulled a book out from behind the desk and stated, It usually sits on the desk not behind it. The Administrator then looked at Receptionist #78 and stated, This book has to stay right here. During an interview on 02/18/25 at 3:48 PM, Receptionist #78 stated, This book has always been behind this desk, since I started here (3) three months ago.

CONCERN (E)

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

Safe Environment (Tag F0584)

Could have caused harm · This affected multiple residents

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Based on observations and staff and resident interviews, the facility failed to ensure a safe, clean, comfortable, homelike environment by not cleaning and sanitizing Resident #10's wheelchair, cleaning the kitchen ceiling and exhaust fan and cleaning the shower room's ceiling and peeling paint. This failed practice was a random opportunity for discovery and had the potential to affect more than a limited number of residents. Resident identifier: #10. Facility census: 106. Findings included: a) Sanitary includes, but is not limited to, preventing the spread of disease-causing organisms by keeping resident care equipment clean and properly stored. Resident care equipment includes, but is not limited to, equipment used in the completion of the activities of daily living. On 02/26/25, Resident #10's wheelchair was found to have a dirty footboard with dried food-like substance and liquids. The dirty footborad was observed on 02/17/25 at 08:30 AM, 02/18/25 at 12:15 PM, 02/19/25 at 02:11 PM, and 02/24/25 at 9:20 PM. On 02/19/25 at 02:11, Licensed Practical Nurse (LPN) #111 was interviewed and confirmed Resident #10's wheelchair was still dirty and had not been cleaned. 02/24/25 at 09:10 AM, the Administrator stated there was no policy and procedure for cleaning wheelchairs or a cleaning schedule in place for the facility.

CONCERN (E) 📢 Someone Reported This

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

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

Accident Prevention (Tag F0689)

Could have caused harm · This affected multiple residents

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Based on observation and staff interviews the facility failed to ensure the resident environment over which it had control was as free from accident hazards as possible. These were random opportunities for discovery and had the potential to affect more than a limited number of residents. Resident Identifier: #8. Facility Census: #106. Findings included: a) Unlocked medication cart On 02/16/25 at 11:00 AM observation of the treatment cart was sitting in the hallway by the conference room at the beginning of the A hallway. There were no staff members near the cart. There were residents near the unlocked, unattended treatment cart. It was confirmed with Licensed Practical Nurse #7 on 02/16/25 at 11:05 AM this was an accident hazard, at which time she agreed. b) Resident #8 Observation of Resident #8 on 02/16/25 between the hours of 5:30 p.m. to 6:30 p.m., revealed the facility reported an elopement of resident on 10/01/24. Resident lacked capacity and had a BIMS score of 3. The resident was assessed as an elopement risk on 09/30/24, 10/23/24, and and 02/14/25. Resident had a wanderguard bracelet in place. Observation on 02/17/25 between the hours of 8:15 a.m. and 8:35 a.m., the wanderguard system did not function properly on the exit door in A Hallway. Record review on 02/17/25 at approximately 2:25 p.m., of the documentation from the Wanderguard repair vendor and the system had been repaired for A Hall and was back in working order as of 02/17/25 at 2:14 p.m. Interview with the Maintenance Director at the time of discovery verified the deficiency. The deficiency was also acknowledged by the Administrator upon exit on 02/26/25 at approximately 1:45 p.m.

CONCERN (E) 📢 Someone Reported This

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

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

Deficiency F0725 (Tag F0725)

Could have caused harm · This affected multiple residents

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Based on record review and resident and staff interview, the facility failed to deploy sufficient nursing staff in order to meet resident needs. This has the potential to affect more than an isolated number of residents residing in the facility. Facility census: 106. Findings include: a) Record review During review of the facility's Payroll Based Journal (PBJ) data, the facility flagged for excessively low weekend staffing from the time period of 10/1/24-12/31/24. b) Resident interviews Multiple interviews were conducted with residents who, during the survey process, relayed concerns about staffing at the facility. On 2/17/25 at approximately 11:37 AM, an interview was conducted with Resident #14. Resident #14 stated Sometimes it takes hours for them to answer my call light. I got to where I would scream and yell when they wouldn't answer my light and they won't answer that now. There are times I will press my light and I will have to wait three (3) to five (5) hours. On 2/16/25 at approximately 12:04 PM, Resident #45 stated the following about facility staffing, Sometimes I will wait a half an hour to an hour for someone to answer my call light. Day shift is the worst. Weekends aren't any different. On 2/16/25 at approximately 12:53 PM Resident #42 stated staff is slow to answer call lights at times. On weekends we wait 40 minutes sometimes. On 2/16/25 at approximately 02:00 PM, Resident #12 stated, Poor staffing day and night. On 2/16/25 at approximately 02:17 PM Resident #18 reported, They don't have enough people. - referring to staffing. During the Resident Council Meeting on 02/18/25 at 2:00 PM the Resident Council as a whole had the following concerns regarding call light response time: * Sometimes we wait for over an hour, and sometimes you just give up. * There have been days where they do not get people out of bed because there is not enough help. This happens a lot on weekends. * If you ring your call bell during meal time you might as well forget it. c) Staff interviews On 2/18/25 at approximatley 5:55 PM, Nursing Aide (NA) #55 was observed on the floor on D Wing during the evening meal tray pass. NA #55 stated, A girl left and I've been by myself for a few hours. At approximately 10:00 AM on 2/26/2025, an interview was conducted with Confidential Employee (CE) #1. During the interview, CE #1 stated, Staffing is horrible. Some of the halls are hard to manage with the number of people we have. Weekend staffing is bad. I have to stay over a lot because the night shift usually runs late. This has been an issue since I've been here. When call ins happen on the weekend they get ahold of the scheduler and they may answer and they may not. Sometimes they get staff and sometimes they don't; most of the time they don't. The residents are not getting the care they need and deserve. Sometimes we have to leave people in bed because there's not enough staff. That ' s happened quite a bit and it's not fair. These residents shouldn't have to be confined to their beds because we don't have enough staff to safely operate the lifts. At approximately 10:30 AM on 2/26/2025, an interview was conducted with Confidential Employee (CE) #2. During the interview, CE #2 stated, I'll be honest, the staffing is not good. We run short a lot of the time. I've been an aide for ten years and I think this is the least amount of staff I've worked with in a facility. So many don't know what they are doing. The night shift leaves people unchecked and soiled so we are always behind when we start our shifts, with not enough help. There are plenty of times we are not able to finish assigned tasks. We have had to leave people in bed because there was no staff to operate the lift to get them out of bed. This happens at least once a week, maybe more.

CONCERN (E) 📢 Someone Reported This

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

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

Menu Adequacy (Tag F0803)

Could have caused harm · This affected multiple residents

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Based on record review, staff interview and observation the facility failed to ensure residents were receiving food in the amount, type, and consistency to meet acceptable nutritional values. This failed practice was a random opportunity for discovery and had the potential to affect more than a limited number of residents during the Long-Term Care Survey Process. Resident identifier #58, #20. Facility Census 106. Findings include: a) Resident #58 An observation on 02/17/25 at 12:37 PM, of Resident #58 eating lunch, revealed a meal ticket that had typed on it { Puree, Nectar Thick, Double portion all meals.} During an interview on 02/17/25 at 12:38 PM, Resident #58 non-verbally communicated that he wanted double portions by giving a thumbs up. During an interview on 02/17/25 at 12:40 PM, Nursing Assistant (NA) #122 stated, No, that is not double portions. I will go get him some more. During an interview on 02/17/25 at 12:45 PM, Certified Dietary Manager (CDM) #67 confirmed that Resident #58's tray did not include double portions. A record review on 02/17/25 at 2:10 PM, revealed a diet order for Resident #58 had a diet order that reads as follows: Dysphagia - Pureed texture, Nectar liquids consistency, related to Dysphagia unspecified. Double portions at all meals. Further record review revealed a care plan for Resident #58 related to nutrition dated 11/06/24, revised on 01/30/25 that reads as follows: Focus: Nutrition risk due to history of (h/o) significant weight loss; h/o peg tube for alternate means of nutrition medical diagnosis that may affect weight, intakes and nutritional status. Goal: (Resident #58 name) will maintain a stable weight with no significant weight changes through the next review. Interventions: Double portions at all meals. Provide diet as ordered- Regular diet, Dysphagia-Pureed texture, Nectar liquids consistency. Double portions at all meals Provide supplements as ordered- Magic Cup Register Dietician (RD) consult as needed record meal percent intake review dietary preferences with the resident as needed. b) Resident #58 An observation of the supper meal being served in the dining room on 02/18/25 at 6:00 PM, revealed that residents were being served Salisbury steak, An observation on 02/18/25 at 12:15 PM, revealed that Resident #58 was eating his puree lunch meal, which consisted of pureed pasta with a marinara sauce and a roll. A review of the menu for the day on 02/18/25 at 12:20 PM, revealed that the vegetable for the lunch meal to be served was spinach. During an interview on 02/18/25 at 12:40 PM, RD #146 stated, The puree's do not get the spinach they are supposed to get V-8 Juice. c) On 02/18/25 12:00 PM, Dietary Aide #142 confirmed a four(4) ounce scoop was utilized for entree. The serving size was eight (8) ounces for a regular consistency diet and six( 6) ounces for a mechanical soft diet per the menu extension sheet. The State Surveyor consulted with the Registered Dietician (RD) concerning the four (4) ounce scoop utilized to serve at lunch this date. The RD stated, I would refer to the scoop sheet. A Resident Council Concern Form was completed on 07/16/25 from resident representing all hallways concerning drinks being passed with meal, repeated meals too frequent, directions not being followed on the meal tickets and menu not matching the meals. On 02/16/25, the dinner menu posting in facility's lobby listed: Chicken Tenders, Mashed Potatoes and Gravy, Corn, Fresh Baked Cookies. Broccoli was served instead of corn. Menu printed for residents listed Ham Salad as the entree for dinner. At lunch, the residents were served penne pasta in place of noodles. d) Resident #20 On 02/16/25, Resident #20 stated, lunch was good, but not enough. They never give you enough. On 02/17/25, the lunch menu included: BBQ Chicken Breast, Candied Sweet Potatoes, Capri Blend Vegetables, Cornbread, Pineapple Upside Down Cake. Mashed potatoes were also served. On 02/18/25 the lunch menu included: Baked Penne and Meat Sauce, Roasted Brussel Spouts, Dinner Roll, Mandarin Oranges. No pureed vegetables were served for Residents #58 and #457. No brussel sprouts were served per menu. Broccoli was substituted. Spinach was substituted. Pureed diets did not get pureed fruit (mandarin oranges). On 02/18/25 the dinner menu included: Salisbury Steak with mushroom gravy, Mashed Potatoes, Baby Carrots, Homemade Brownie. 02/18/25 04:00 PM, Dietary [NAME] #124 reported, Not enough mashed potatoes .so I improvised. -Scalloped potatoes and spinach to be served. No carrots served. Dietary [NAME] #124 reported the truck comes every Wednesday. On 0218/25 01:05 PM, a confidential family interview was completed. The family member reported the menus were not followed and plasticware was utilized frequently. Also, the family member reported the facility runs out of food and brings sandwiches to the rest of the residents. On 02/18/25 06:15 PM Resident #457 did not receive a vegetable for the dinner meal. Licensed Practical Nurse (LPN) #12 when asked about the vegetables went into the kitchen and the kitchen told her We don't have any, that's what she gets. LPN #12 came back and told a State Surveyor this is what the kitchen staff told her. This was confirmed with Administrator on 02/18/25 at 06:18 PM.

CONCERN (E)

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

Deficiency F0804 (Tag F0804)

Could have caused harm · This affected multiple residents

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Based on Record Review, Observations and Resident Interviews, the facility failed to hold or serve food at acceptable/palatable temperatures. This failed practice had the potential to affect more than a limited number of residents. Facility census: 106. Findings included: a) The facility's Policy and Procedure for Food Temperatures stated, all hot items held and served at a temperature of at least 135 degrees Fahrenheit, hold foods at or below 41 F (degrees Fahrenheit) for cold foods or above 135 F (degrees Fahrenheit) for hot foods (to keep food out of the temperature danger zone) and Foods sent to the units for distribution (such as meals, snacks, nourishments oral supplements) will be transported and delivered to unit storage areas to maintain temperatures at or below 41 F (degrees Fahrenheit) for cold foods and at or above 135 F ( degrees Fahrenheit) for hot foods. a) On 02/18/25 at 05:55 PM, the temperatures of food provided on the test tray for D hall were completed and verified by Dietary [NAME] #124 included: Regular Steak- 118.6 French fries-110.9 Spinach-120 Pureed meat- 114 b) 02/18/25 at 12:02 PM, the Dietary Manager in Training took the temperatures of the food on the holding cart, Temperatures were as follows: Pasta 162 Broccoli 101.2 Salad 54.5 The Dietary Manager in Training confirmed the temperatures of the food. The Dietary Manager in Training stated, Broccoli too low. Salad too high. On 02/18/25 at 12:25 PM, an anonymous resident stated, The food is not even hot. while eating lunch in the dining room. A review of food temperature logs was completed. Missing times included: no lunch and dinner temperatures for 02/26/25 and 02/17/25. No breakfast and lunch temperatures were documented for 02/18/25. No lunch temperatures for 02/02/25 were recorded. The missing temperatures were verified by Dietary [NAME] (DC) #124. DC #124 reported the kitchen didn't have food temperature logs when she started about six months ago. Dietary Aide (DA) #50 attempted to obtain food temperature logs for the State Surveyor, but they were from 2022. Food temperature logs were requested on 02/24/25 - Certified Dietary Manager reported he was going through them to get the dates requested. On 02/25/25 at 03:17 PM, food temperature logs for 1/2025, 9/2024, and 10/2024 were requested again. On 02/26/25 at 08:38 AM, the Administrator gave the State Surveyor 01/2025 temperature log and stated, They are so unorganized. On 02/26/25 at 09:30 AM Administrator stated, They cant find the other temp logs.

CONCERN (E)

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

Deficiency F0806 (Tag F0806)

Could have caused harm · This affected multiple residents

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Based on observation, record review, resident interview and staff interviews the facility failed to ensure residents' food likes and dislikes were honored and food substitutes of equal value were offered. Resident Identifiers: #25, #84, #79 and #68 Facility Census: #106 Findings Include: a) Resident #25 On 02/16/25 at 12:15 PM it was observed that Resident #25 had broccoli florets on the lunch tray. The meal ticket stated Dislikes/DO NOT SERVE as Broccoli Florets. It was confirmed with the Director of Activities #41 on 02/16/25 at 12:17 PM that Resident #25 should not have received broccoli, she agreed. On 02/18/25 at the lunch meal Resident #25 was served broccoli again as substitute for roasted Brussels sprouts. It was confirmed with Nurse in Training #108 that Resident #25 should not have received broccoli. On 02/18/25 at the dinner meal Resident #25 was served buttered spinach as a substitute for baby carrots. The meal ticket stated Dislikes/DO NOT SERVE as Buttered Spinach. It was confirmed with Licensed Practical Nurse Unit Manager #12 that Resident #25 should not have received spinach. Record review on 02/19/25 at 10:10 AM of the Dietary Profile dated 06/06/24 documents that Resident #25 dislikes all green vegetables. On 02/25/25 at the lunch meal Resident #25 received Brussels sprouts. He told Licensed Practical Nurse Unit Manager #12 to get those out of here and just bring me chicken noodle soup. It was confirmed with the Administrator on 02/25/25 at 1:50 PM that Resident #25 should not be served green vegetables. b) Resident #84 On 02/16/25 at 12:17 PM it was observed that Resident #84 had broccoli florets on the lunch tray. The meal ticket stated Dislikes/DO NOT SERVE as Broccoli Florets. It was confirmed with the Director of Activities #41 on 02/16/25 at 12:18 PM that Resident #84 should not have received broccoli, she agreed. c) Resident #79 On 02/18/25 at 12:10 PM Resident #79 received a dinner tray of Salisbury Steak with mushroom gravy. The tray was refused by the resident as he stated I hate gravy! and it was confirmed with the Director of Activities #41 that Resident #79 should not have received gravy on his tray. On 02/19/25 at 10:10 AM record review of a Dietary Profile completed on 10/23/24 documents that Resident #79 dislikes gravy among other items. An additional Dietary Profile was initiated on 01/29/25 by Dietary Corporate Diet Manager #67 but had not been completed in its entirety. Therefore the dislikes did not carry over to the dietary meal ticket. On 02/19/25 at 1:10 PM it was confirmed with the Administrator that the Dietary Profile needed to be completed as to reflect Resident #79's likes and dislikes. D) Resident #68 At approximately 12:20 PM on 2/19/2025, during lunch service, Resident #68 ' s meal ticket listed the following as a dislike: Pound cake with strawberry topping. During the meal service, Resident #68 was served pound cake with strawberry topping. This was acknowledged and confirmed by the Administrator at 12:25 PM.

CONCERN (E)

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

Deficiency F0810 (Tag F0810)

Could have caused harm · This affected multiple residents

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b) Resident #60 Resident #60 was observed eating in the dining room on 02/16/25 at 1:45 PM. She did not have any adaptive equipment. Review of Resident #60's physician's orders showed an order written on 11/19/24 for regular diet, mechanical soft texture, regular/thin consistency with grip bowl and plateguard related to dysphagia following cerebral infarction. On 02/17/25 at 12:22 PM, Resident #60 was noted to be eating in the dining room. She appeared to have difficulty getting her food onto her spoon. She had no adaptive equipment. The resident's tray ticket showed the resident was to have a grip bowl and plateguard. Restorative Aide #38 was informed that the resident did not receive the grip bowl and plateguard that was ordered for the resident. Restorative Aide #38 obtained a grip bowl and plateguard for the resident. She put Resident #60's dessert in the grip bowl. However, the plateguard did not fit on the resident's plate. Restorative Aide #38 went back into the kitchen and obtained a different plate that would fit the plateguard. The resident ate all of the dessert from the grip bowl and most of the chicken and approximately half of the sweet potato from the plate. On 02/18/25 at 12:04 PM, Resident #60 was observed eating in the dining room. She had no grip bowl or plateguard. Nursing Assistant (NA) #42 was informed that the resident did not receive the grip bowl and plateguard that was ordered. NA #42 went and got Resident #60 a plateguard and grip bowl. No further information was obtained through the completion of the survey process. Based on record review, observation, and staff interview, the facility failed to provide ordered adaptive equipment to Residents #68 and 60 during meals. These were random opportunities for discovery. Resident identifiers: #68, #60. Facility census: 106. Findings include: a) Resident #68 During review of Resident #68's record on 2/17/2025, it was discovered the resident had the following order: Regular diet, Regular texture, Regular/Thin consistency doesn't eat turkey, fish, or chicken for plateguard with meals Diet Active 2/21/2024 12:16 10/18/2024. The resident had the following focus and intervention listed on her care plan: Focus- Resident is at potential nutrition risk r/t (related to) underweight BMI; medical dx (diagnosis) that may affect weight; intakes and nutritional status. Date initiated: 1/31/2024 Revision on: 1/7/2025. Interventions/Tasks- Plateguard with meals. Date initiated: 2/21/2024. During lunch service at approximately 12:15 PM on 2/18/2025, Resident #68 was served lunch with no plateguard. The Administrator acknowledged the Resident did not have a plateguard, and reviewed the order calling for it. Upon further investigation, it was determined the plateguard was not listed on the resident ' s meal ticket. During dinner service, on 2/18/2025, at approximately 5:30 PM, Resident #68 received a tray without a plateguard. At this time, this was acknowledged by the Corporate Registered Registered Nurse (CRN). The meal ticket still did not have the plateguard listed for the resident. During lunch service on 2/19/2025, at approximately 12:15 PM, Resident #68 was served a meal with no plateguard on her plate. This was acknowledged by the Administrator. The Administrator confirmed the plateguard was still absent from the resident ' s meal ticket. At approximately 10:30 AM on 2/26/2025, an interview was conducted with the Registered Dietitian (RD) regarding the orders for the plateguard and the process for adaptive equipment showing up on the residents ' meal tickets. The RD stated the nursing staff at the facility would have to fill out a communication form, stating the need for the adaptive equipment and, once received by the dietary department, it would be placed on the ticket. The RD stated if the equipment wasn ' t on a ticket, it was likely the nursing staff did not supply the communication

CONCERN (E)

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

Food Safety (Tag F0812)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview, the facility failed to store and label food, store utensils and ensure food preparation equipment was clean and sanitary in accordance with professional standards for food service safety. This failed practice had the potential to affect more than a limited number of residents. Facility census: 106 Findings included: a) Kitchen Observation initiated 02/16/25 at 11:10 AM: Ice chest with scoop laying inside. Handwashing sink had soiled, wet cloth on it and eye wash station/sink had used gloves and a sponge in it. Dry Goods: a) Cart with open bag of Penne pasta was against the sinks - opened , not sealed and not dated. b) Three bags of pasta were found, not sealed and not dated. c) Dented can of pumpkin. d) Brownie base with no date e) Dry cereal in bowls and large plastic containers not labeled or dated. Contained: rice krispies. cornflakes, fruit loops and cheerios. f) Box of oil on the floor propping the door open to the dry goods pantry. g) Bread ([NAME] Brand) opened, not sealed and not dated: sandwich bread, dinner rolls and hotdog buns. h) Additional items opened and not dated in the pantry included: white vinegar, red wine vinegar, apple cider vinegar and soy sauce. Items were reviewed and confirmed by the Dietary Manager in Training (DMIT) at 11:25 AM. The DMIT stated, Okay, not dated. Refrigerator investigated at 11:30 AM: a) 3 ziploc bags of cheese - mozzarella x2 and cheddar x1 were not labeled or dated. b) Can of whip topping opened, no lid and not dated. c) Thawed hamburger patties -no labeled or dated. d) Pepperoni slices in a ziploc were not labeled or dated. e) Pickles with no lid and loose saran wrap were not dated. f) Cottage cheese was opened and not dated. g) Garlic in a jar was opened and not dated. h) Eggs out of the carton were not dated. i) Ranch dressing was opened, not labeled and not dated. j) Chopped salad in a large metal bowl was not labeled or dated. k) Hard cook eggs and plastic container with the lid opened- not sealed. Freezer investigation: a) Fries open, not sealed and not dated. b) Items in boxes on cart not dated when received included: Eggos, Pork Sausage, Tyson Chicken patties. c) Orange twin pop out of box Blue Ribbon pops were in a box not dated. d) Cookie dough in an open bag in an open box, not sealed or dated. On 02/17/25 at 11:20 AM, Dietary Aide #123 was not wearing a beard covering in the kitchen. Dietary Aide #123 stated, Okay. Additional observations completed 02/18/25 included: a) 03:25 PM - Dietary [NAME] #124 verified six light balusters were out in the kitchen. b) 03:45 PM - Oven was dirty and Dietary [NAME] #124 stated it was never used. c) Dietary Aide (DA) #50 verified the deep fryer was dirty with crumbs and grease around it. Dietary Aide #50 stated, I haven't had time to chance to clean. d) DA #50 verified serving utensils were in a plastic storage container and handles were not facing the same way. She stated, I didn't know that. e) DA #104 was not wearing a beard covering in the kitchen. Dietary Aide #104 confirmed he knew to wear a covering. f) 4:00 PM - Kitchen observation included: the food holding table had food crumbs and liquids dripping onto the floor. Dietary [NAME] #124 stated, I'll wipe it off.

CONCERN (E)

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

Garbage Disposal (Tag F0814)

Could have caused harm · This affected multiple residents

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Based on observation, record review and staff interview, the facility failed to properly dispose of garbage in accordance with professional standards for food service safety and to ensure garbage was not hanging out of the trash can and on the ground below. This failed practice had the potential to affect more than a limited number of residents. Facility Census: 106 Findings included: a) On 02/16/25 at 11:00 AM, the facility's trash dumpsters were observed with lids open, bags of trash overflowing and trash on the ground with items such as paper and gloves observed. This was confirmed by the Dietary Manager in Training (DMIT) at 11:10 AM. The DMIT reported the trash trucks ran on Mondays, Wednesdays, and Fridays. The Dietary Manager in Training (DMIT) asked if the dumpsters went against the kitchen.

CONCERN (E)

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

Medical Records (Tag F0842)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and resident and staff interview, the facility failed to maintain accurate records for three (3) of 43 residents. The record was inaccurate pertaining to blood pressures for Resident #52. There was discrepancies between orders and the care plan for Resident #457, and daily meal percentages for Resident #106. Facility census: 106. Findings include: a) Resident #52 Resident #52 was admitted to the facility on [DATE] with the following order: NO BLOOD PRESSURE OR LABS in LUE (Left Upper Extremity). Restricted limb d/t (due to) AV fistula. Every shift. Resident #52 confirmed in an interview on 02/17/25 at approximately 12:15 PM that she had a dialysis access on her left arm. Upon review of the resident ' s medical record, it was determined the facility listed twenty-two (22) times they had taken blood pressure from Resident #52 ' s left arm. Those days are: 1/15/2025 11:00 132 / 76 mmHg Sitting l/arm 1/15/2025 14:47 124 / 70 mmHg Sitting l/arm 1/16/2025 02:24 130 / 74 mmHg Sitting l/arm 1/17/2025 11:43 147 / 60 mmHg Sitting l/arm 1/20/2025 08:07 126 / 71 mmHg Sitting l/arm 1/20/2025 08:07 126 / 71 mmHg Sitting l/arm 1/21/2025 08:02 136 / 71 mmHg Sitting l/arm 1/21/2025 08:02 136 / 71 mmHg Sitting l/arm 1/21/2025 16:46 131 / 74 mmHg Sitting l/arm 1/23/2025 08:14 136 / 71 mmHg Sitting l/arm 1/23/2025 16:49 142 / 72 mmHg Sitting l/arm 1/26/2025 08:10 133 / 65 mmHg Sitting l/arm 1/26/2025 08:10 133 / 65 mmHg Sitting l/arm 1/29/2025 11:32 149 / 84 mmHg Sitting l/arm 1/30/2025 09:05 133 / 72 mmHg Sitting l/arm 2/9/2025 08:36 126 / 64 mmHg Sitting l/arm 2/8/2025 09:00 132 / 64 mmHg Sitting l/arm 2/14/2025 05:26 140 / 80 mmHg Sitting l/arm 2/22/2025 08:09 122 / 70 mmHg Sitting l/arm 2/22/2025 08:09 122 / 70 mmHg Sitting l/arm 2/23/2025 08:05 116 / 71 mmHg Sitting l/arm 2/23/2025 11:14 148 / 69 mmHg Sitting l/arm On 2/24/25 at approximately 1:20 PM, Resident #52 stated in an interview that the staff did not take blood pressure out of her left arm despite the fact they have documented they have multiple times. At approximately 2:00 PM on 2/24/2025, the Director of Nursing (DON) acknowledged the error in documentation regarding the blood pressures. b) Resident #457 Resident #457 had an order stating the resident was NPO, but may have ice chips. Resident # 457's care plan stated, the Resident receives a tray in addition to tube feedings. On 02/10/25 Resident #457's nursing note stated, Resident is currently NPO but able to have ice chips. On 02/16/25 1:33 PM, the Director of Nursing (DON) confirmed the care plan and orders did not match. The resident was NPO, but care plan stated, the resident receives a tray in addition to tube feedings. c) Resident #106 Record review on 02/24/25 between the hours of 11:00 a.m. and 11:30 a.m., revealed on the days of January 8th, January 11th, and January 15th 2025 where there was no nutrition amount eaten documented for the entire day. Interview with the facility's Regional Nurse on 02/24/25 at approximately 11:35 a.m. verified these findings. The findings were also identified with the Administrator upon the exit interview on 02/26/25 at approximately 1:45 p.m.

Jun 2023 16 deficiencies

CONCERN (D)

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

Deficiency F0578 (Tag F0578)

Could have caused harm · This affected 1 resident

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Based on medical record review and staff interview, the facility failed to ensure Advance Directive paperwork was part of the resident's medical record. This was true for one (1) of 26 residents reviewed in the Long-Term Care Survey Process. Resident identifier: #30. Facility census: 109. Findings included: a) Resident #30 An electronic medical record review, completed on 06/27/23 at 11:20 AM, identified there was a Physician Determination of Capacity, dated 05/08/23, indicating Resident #30 lacked capacity to make her own medical decisions. There was no Medical Power of Attorney (MPOA) or Health Care Surrogate (HCS) form scanned in the electronic medical record. On 06//28/23 at 9:45 AM, review of Resident #30's medical chart at nurses station found there was no Medical Power of Attorney (MPOA) or Health Care Surrogate (HCS) form on file. During an interview on 06/28/23 at 10:00 AM, the Social Worker confirmed Resident #30 had never completed a Medical Power of Attorney (MPOA) prior to losing capacity. The Social Worker then stated to her recollection a Health Care Surrogate had been appointed by Resident #30's physician. The Social Worker reviewed the electronic medical record, Resident #30's chart at the nurse's station, and spoke to the Medical Records department but could not produce evidence of the completed Health Care Surrogate (HCS) Form. The Social Worker then agreed there was no evidence the Health Care Surrogate (HCS) form was part of the medical record and readily retrievable by facility staff. 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 (1) of 26 residents reviewed in the Long-Term Care Survey Process. Resident identifier: #30. Facility census: 109. Findings included: a) Resident #30 An electronic medical record review, completed on 06/27/23 at 11:20 AM, identified there was a Physician Determination of Capacity, dated 05/08/23, indicating Resident #30 lacked capacity to make her own medical decisions. There was no Medical Power of Attorney (MPOA) or Health Care Surrogate (HCS) form scanned in the electronic medical record. On 06//28/23 at 9:45 AM, review of Resident #30's medical chart at nurses station found there was no Medical Power of Attorney (MPOA) or Health Care Surrogate (HCS) form on file. During an interview on 06/28/23 at 10:00 AM, the Social Worker confirmed Resident #30 had never completed a Medical Power of Attorney (MPOA) prior to losing capacity. The Social Worker then stated to her recollection a Health Care Surrogate had been appointed by Resident #30's physician. The Social Worker reviewed the electronic medical record, Resident #30's chart at the nurse's station, and spoke to the Medical Records department but could not produce evidence of the completed Health Care Surrogate (HCS) Form. The Social Worker then agreed there was no evidence the Health Care Surrogate (HCS) form was part of the medical record and readily retrievable by facility staff. .

CONCERN (D)

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

Notification of Changes (Tag F0580)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to notify the resident representatives in a timely fashion when a residents experienced changes in condition, appointments were scheduled, x-rays were done, and new medications were ordered. This was true for two (2) of 25 residents reviewed in the Long-Term Care Survey Process. Resident Identifiers: #30 and #101. Facility Census: 109. Findings included: a) Resident #30 A medical record review was completed on 06/28/23 at 10:00 AM. The review revealed a Physician Determination of Capacity, dated 05/08/23, which indicated, Resident lacks capacity to appreciate the nature and implication of health care decisions. Further record review found the following instances where Resident #30's Health Care Surrogate (HCS) was not notified: -05/16/2023 at 1:18 PM Plan of Care Note, IDT [Interdisciplinary Team] Review for unwitnessed fall on 05/13/23 at 1:15 PM. Resident is alert and verbal. Resident has a DX [diagnosis] of left artificial knee, age related physical debility, and muscle wasting and atrophy. Resident has a history of falls. Resident fall was not witnessed. Resident was doing a self transfer from w/c [wheelchair] to bed. Non-skid socks in place and room clutter free. Current interventions: Call light in reach, PT [physical therapy] evaluate and treat as needed, and follow facility fall protocol. New intervention: Visual aid in place to remind resident to use of call light. -05/18/2023 at 7:40 PM Nursing Note, Resident has c/o [complaint of] right hip pain. Resident had a fall on 5/13/23 she feel on her hands and knees but rolled over to right hip and states it starting hurting shortly after and continues to get worse. Would like to have an x-ray. PCP [Primary Care Physician] aware and waiting on response. -05/19/2023 at 12:38 AM, Nursing Note, New verbal order noted per Dr. [doctor's last name] to obtain right hip x-ray due to increased pain s/p [status post] fall on 05-13-23. -05/19/2023 at 2:47 PM, Nursing Note, X-ray completed. Awaiting results. -05/20/2023 at 2:18 PM, Radiology Note, Results from X-ray are in. No acute fracture or dislocation; osseous [bony] structures appear intact. Modest joint space narrowing, soft tissues are unremarkable. Radiologist recommends a repeat multi view imaging in 1 week or sooner if clinically warranted especially if symptoms continue or persist or progress. MD notified. -05/27/2023 at 8:19 AM, Restorative Program Note, [Resident's First Name] has completed RNS [Restorative Nursing Services] Ambulation Program. She continues to ambulate with FWW [front wheeled walker] and assistance from staff. She was referred to PT [physical therapy] on 05/15/23, due to a fall. No services needed due to no decline resulted from fall, and no decline in functional ambulation. Staff to continue to assist her as needed with ambulation. -06/13/2023 at 5:06 PM, Nursing Note, Resident returned to facility via facility transport. Resident returned with a new order for a CT [computed tomography] scan left knee without contrast. -06/23/2023 at 1:55 PM, Radiology Note, CT computed tomography] of Left Knee without contrast results: Total knee arthroplasty [Arthroplasty is a surgical procedure to restore the function of a joint.] Recommend close interval follow up to exclude loosening/infection. Notified PCP [Primary Care Physician] and [Orthopedic Doctor]. -06/25/2023 at 4:24 PM, Nursing Note, Resident productive cough (green sputum). States she has a sore throat also. Starting on late the 24th Remains afebrile [no fever]. Slight wheezes on left lower lobe. PCP [Primary Care Physician] aware. Awaiting response. -06/27/2023 4:41 AM, Alert Note, N.O. [new order] to obtain 2 view CXR [chest x-ray] and start Cefdinir 300mg PO BID [by mouth twice a day] x7 days; orders entered and noted; CXR [chest x-ray] ordered via MobileX for 06/27/23 confirmation #39462682; RP [responsible party] to be notified on dayshift. -06/27/2023 at 9:51 AM, Nursing Note, Resident continues on abx [antibiotic] Cefdinir 300mg BID [twice a day] x7 for productive cough and sore throat. Medication taken without difficulty. During an interview on 06/28/23 at 3:02 PM, Corporate RN #139 confirmed the facility had no evidence the Health Care Surrogate was notified regarding the above-mentioned instances. Based on record review and staff interview, the facility failed to notify the resident representatives in a timely fashion when residents experienced changes in condition: appointments were scheduled, x-rays were done, new medications were ordered, and when a resident was sent to the hospital. This was true for two (2) of 25 residents reviewed in the Long-Term Care Survey Process. Resident Identifiers: #30 and #101. Facility Census: 109. Findings included: a) Resident #30 A medical record review was completed on 06/28/23 at 10:00 AM. The review revealed a Physician Determination of Capacity, dated 05/08/23, which indicated, Resident lacks capacity to appreciate the nature and implication of health care decisions. Further record review found the following instances where Resident #30's Health Care Surrogate (HCS) was not notified: -05/16/2023 at 1:18 PM Plan of Care Note, IDT [Interdisciplinary Team] Review for unwitnessed fall on 05/13/23 at 1:15 PM. Resident is alert and verbal. Resident has a DX [diagnosis] of left artificial knee, age related physical debility, and muscle wasting and atrophy. Resident has a history of falls. Resident fall was not witnessed. Resident was doing a self transfer from w/c [wheelchair] to bed. Non-skid socks in place and room clutter free. Current interventions: Call light in reach, PT [physical therapy] evaluate and treat as needed, and follow facility fall protocol. New intervention: Visual aid in place to remind resident to use of call light. -05/18/2023 at 7:40 PM Nursing Note, Resident has c/o [complaint of] right hip pain. Resident had a fall on 5/13/23 she feel on her hands and knees but rolled over to right hip and states it starting hurting shortly after and continues to get worse. Would like to have an x-ray. PCP [Primary Care Physician] aware and waiting on response. -05/19/2023 at 12:38 AM, Nursing Note, New verbal order noted per Dr. [doctor's last name] to obtain right hip x-ray due to increased pain s/p [status post] fall on 05-13-23. -05/19/2023 at 2:47 PM, Nursing Note, X-ray completed. Awaiting results. -05/20/2023 at 2:18 PM, Radiology Note, Results from X-ray are in. No acute fracture or dislocation; osseous [bony] structures appear intact. Modest joint space narrowing, soft tissues are unremarkable. Radiologist recommends a repeat multi view imaging in 1 week or sooner if clinically warranted especially if symptoms continue or persist or progress. MD notified. -05/27/2023 at 8:19 AM, Restorative Program Note, [Resident's First Name] has completed RNS [Restorative Nursing Services] Ambulation Program. She continues to ambulate with FWW [front wheeled walker] and assistance from staff. She was referred to PT [physical therapy] on 05/15/23, due to a fall. No services needed due to no decline resulted from fall, and no decline in functional ambulation. Staff to continue to assist her as needed with ambulation. -06/13/2023 at 5:06 PM, Nursing Note, Resident returned to facility via facility transport. Resident returned with a new order for a CT [computed tomography] scan left knee without contrast. -06/23/2023 at 1:55 PM, Radiology Note, CT computed tomography] of Left Knee without contrast results: Total knee arthroplasty [Arthroplasty is a surgical procedure to restore the function of a joint.] Recommend close interval follow up to exclude loosening/infection. Notified PCP [Primary Care Physician] and [Orthopedic Doctor]. -06/25/2023 at 4:24 PM, Nursing Note, Resident productive cough (green sputum). States she has a sore throat also. Starting on late the 24th Remains afebrile [no fever]. Slight wheezes on left lower lobe. PCP [Primary Care Physician] aware. Awaiting response. -06/27/2023 4:41 AM, Alert Note, N.O. [new order] to obtain 2 view CXR [chest x-ray] and start Cefdinir 300mg PO BID [by mouth twice a day] x7 days; orders entered and noted; CXR [chest x-ray] ordered via MobileX for 06/27/23 confirmation #39462682; RP [responsible party] to be notified on dayshift. -06/27/2023 at 9:51 AM, Nursing Note, Resident continues on abx [antibiotic] Cefdinir 300mg BID [twice a day] x7 for productive cough and sore throat. Medication taken without difficulty. During an interview on 06/28/23 at 3:02 PM, Corporate RN #139 confirmed the facility had no evidence the Health Care Surrogate was notified regarding the above-mentioned instances. b) Resident #101 Record review found a nurse's note which stated the resident was sent to the hospital on [DATE] for visual distress, not voiding, and did not get out of bed which was abnormal for this resident. In addition, the Resident's vital signs were not within normal limits. Licensed Practical Nurse (LPN) #22 documented on 05/05/23 at 2:44 AM, the Sheriff's Department was contacted when the Resident was sent to the hospital. An automated system was reached and the nurse was unable to leave a voice message. Review of the medical record found a health care surrogate (HCS) selection, dated 12/19/21. The [NAME] Virginia Department of Health and Human Services (WVDHHR) was appointed as the (HCS.) A HCS can only make medical decisions for a resident. On 01/11/22, the WVDHHR petitioned the Circuit Clerk for an appointment of a Guardian/Conservator for this resident. The proposed Guardian was the WVDHHR. The sheriff was the proposed conservator. A Conservator is appointed by the court to manage the financial affairs of a resident. A Guardian is appointed to be responsible for personal affairs such as health care decisions. On 06/28/23 at 9:01 AM, the Director of Nursing (DON) #28, Unit Manager, Registered Nurse, #87, and Social Worker (SW) #109 were interviewed. No evidence was provided to confirm the DHHR was notified of the resident's change in condition and transfer to the hospital. SW #109 said the facility had never received a copy of the final appointment of a Guardian/Conservator. The SW said the WVDHHR should have been contacted when the resdent experienced a change in condition and was sent to the hospital. .

CONCERN (D)

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

Safe Environment (Tag F0584)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** b) room [ROOM NUMBER] - Slats Missing from Window Blinds During an interview on 06/27/23 at 9:02 AM, Resident 503 reported she had slats missing from her window blinds, I've mentioned it repeatedly. They say they are working on it. But nothing every happens. I've been here since the ninth (meaning since the 9th of June). Resident went on to say she found it very frustrating that the slats had not been replaced and it was her biggest issue. On 06/28/23 at 8:40 AM, the DIrector of Nursing (DON) confirmed multiple slats were missing from the blinds in room [ROOM NUMBER]. The DON confirmed the slats should have been replaced upon Resident #503's request. The DON stated she would address it and apologized to the resident for having to wait so long for the repair. Resident #503 reiterated it had been her biggest problem and she was happy to hear it would be resolved. c) room [ROOM NUMBER] - Resident #504's Nightstand During an observation on 06/27/23 at 9:08 AM in room [ROOM NUMBER] it was noted that the left corner of Resident #504's nightstand was chipped and broken off presenting as a potential accident hazard and creating a non-homelike environment. On 06/28/23 at 8:45 AM, the Directior of Nursing (DON) confirmed the left corner of the nightstand was chipped and broken off. She stated it definitely posed a problem and would have it replaced promptly. c) room [ROOM NUMBER] - Slats Missing from Window Blinds During an interview on 06/27/23 at 9:02 AM, Resident #503 reported she had slats missing from her window blinds. The resident said, I've mentioned it repeatedly. They say they are working on it. But nothing every happens. I've been here since the ninth (meaning since the 9th of June). The resident went on to say she found it very frustrating that the slats had not been replaced and it was her biggest issue. On 06/28/23 at 8:40 AM, the Director of Nursing (DON) confirmed multiple slats were missing from the blinds in room [ROOM NUMBER]. The DON confirmed the slats should have been replaced upon Resident #503's request. The DON stated she would address it and apologized to the resident for having to wait so long for the repair. Resident #503 reiterated it had been her biggest problem and she was happy to hear it would be resolved. c) room [ROOM NUMBER] - Resident #504's Nightstand During an observation on 06/27/23 at 9:08 AM in room [ROOM NUMBER] it was noted that the left corner of Resident #504's nightstand was chipped and broken off presenting as a potential accident hazard and creating a non-homelike environment. On 06/28/23 at 8:45 AM, the Director of Nursing (DON) confirmed the left corner of the nightstand was chipped and broken off. She stated it definitely posed a problem and would have it replaced promptly. b) Resident #90 An observation on 06/26/23 at 3:46 PM, found R#90 sitting in her wheelchair in her room. The left arm of the wheelchair was noted to be cracked and covered with paper tape. Licensed Practical Nurse (LPN) #62 confirmed R#90's wheelchair arm needed repaired during an interview on 06/28/23 at 1:50 PM. Based on resident interview, observation, and staff interview, the facility failed to ensure residents had a safe/functional/sanitary and comfortable environment. The call light did not work in room [ROOM NUMBER]. Slats were missing from window blinds for rooms [ROOM NUMBERS]. Resident #90's wheelchair was in disrepair as well as a night stand for Resident #504. Resident identifiers: #38, #98, #90, #504. Facility census: 109. Findings included: a) room [ROOM NUMBER] During the resident council meeting which began at 3:00 PM on 06/27/23, Resident #38 said she resides in room [ROOM NUMBER]. She said her window blinds had missing slats that would allow people from the road outside to see inside her room. She also said the blinds did not open and close easily. Observation with Registered Nurse (RN) #114 on 06/07/23 at 3:56 PM, confirmed she could not get the blinds to open and close correctly and 2 slats were missing from the left side of the double window blinds. RN #114 said she was calling the maintenance man to get it fixed. On 06/28/23 at 10:35 AM, observation of room [ROOM NUMBER] with the Administrator #56 found the administrator could not get the blinds to fully open once closed. In addition, the Administrator #56 found one slat was missing from the right side of the blinds, leaving a 2 -3 inch gap. The two missing slats visible from yesterday on the left side had been replaced but at this time a slat was missing from the right side of the blind. .

CONCERN (D)

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

PASARR Coordination (Tag F0644)

Could have caused harm · This affected 1 resident

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. Based on record review and staff interview, the facility failed to complete a new Pre-admission Screening and Resident Review (PASARR) for a resident with newly evident or a possible serious mental disorder. This was true for one (1) out of three (3) residents reviewed for the category of PASARR, during the long-term care survey. Resident identifier #1. Facility census 109. Findings included: a) Resident #1 A review of the medical record revealed Resident #1 last had a PASARR completed on 12/07/2015. No level II was needed. The PASARR noted the resident had a diagnosis of depression. On 01/26/23 Resident #1 received a new diagnosis of schizoaffective disorder and a new PASARR was not completed. During an interview with the Admissions Director (AD) on 06/28/23 at 11:44 AM, she confirmed the last PASSAR was completed on 12/07/2015. A new PASARR was not completed when the resident received a new diagnosis of schizoaffective disorder during her stay at the facility on 01/26/23. The AD said she was unaware that a new PASARR needed to be done. She went on to say she thought a resident only got one (PASARR) if they went out to a mental health facility and that facility would complete a new PASARR.

CONCERN (D)

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

Deficiency F0657 (Tag F0657)

Could have caused harm · This affected 1 resident

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. Based on resident interview, staff interviews, observation, and record review, the facility failed to revise a care plan, for one (1) of six (6) residents reviewed for the category of accidents , during the long term care survey. Resident identifier #47. Census 109. Findings Included: a) Resident #47 A resident interview was conducted on 06/26/23 at 11:53 AM. The resident stated he did not like the smoking situation at the facility. The resident admitted to going off the property to smoke. The resident also stated he knows he is not supposed to but he keeps his lighter and cigarettes in his murse, attached to his wheelchair. (He defined a murse as a man purse). A follow up interview with the resident on 06/26/23 at 1:00 PM, confirmed the resident had been smoking at the facility for a while. He stated a previous administrator, (name of administrator), had a conversation with the resident about not being allowed to smoke at the facility. During a staff interview with LPN #37, on 06/26/23 at 2:02 PM, LPN #37 stated this resident asked her to take him out to smoke this morning but she told him no because he is not supposed to be smoking. An observation on 06/26 2:48 PM, found social worker (SW) #109 looking for resident #47. Staff told the SW the resident had signed himself out. SW #109 found the resident sitting outside the main entrance of the building. The SW approached the resident and asked if he had cigarettes. The resident said, yes. The SW asked for the smoking materials and assured the resident she would lock them up in the safe and have his family pick them up. Resident #47 gave the SW a pack of Marlboro cigarettes and a red lighter out of his murse. The SW asked the resident if he had any more in his room and he responded, no. On 06/26/23 at 7:10 PM, a record review and interview with SW #109 found the following: The SW brought the surveyor a copy of a progress note from 09/13/22 at 8:28 AM, completed by the SW. In this progress note the SW stated she talked to him about the smoking policy within the facility. The SW also brought the surveyor a copy of a care plan for the resident's history of alcoholism and tobacco use, with an intervention of educating the resident of the smoking policy. The surveyor explained nowhere on his behavior care plan or his history of tobacco care plan does it mention he is non compliant with the smoking policy, nor do they provide interventions which staff are to initiate if he was non compliant with this policy. The SW confirmed he did not have a behavior care plan in place for his history of non compliance with the facility's smoking policy. Review of the resident's behavior care plan with the SW listed the following: Focus: (Name of Resident) has a behavior problem at times r/t resident was making inappropriate comments to female staff member. Has a history becoming verbally aggressive towards staff and throwing dirty briefs at them. He has a history of urinating in the floor of the hallway. Has a history of making false allegations against staff members reporting untrue things about his plan of care. Goals: Will have no evidence of behavior problems by review date. Interventions: · Anticipate and meet residents needs. · Assist Resident to develop more appropriate methods of coping and interacting. Encourage the resident to express feelings appropriately. If reasonable, discuss residents behavior. Explain/reinforce why behavior is inappropriate and/or unacceptable to the resident. · Intervene as necessary to protect the rights and safety of others. Approach/Speak in a calm manner. Divert attention. Remove from situation and take to alternate location as needed. Therefore, the facility has been aware since at least September of 2022 of the resident's noncompliance of the facility's non smoking policy, yet failed to update his behavior care plan to reflect his non compliance and to develop interventions that would assist the staff on knowing what to do if they were faced with his non compliant behavior. .

CONCERN (D)

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

Deficiency F0658 (Tag F0658)

Could have caused harm · This affected 1 resident

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. Based on observation and staff interview, staff failed to administer medications via percutaneous endoscopic gastrostomy (PEG) tube according to professional standards. Crushed medications and flushes were pushed into the PEG tube and not administered by gravity flow. This was a random opportunity for discovery which has the potential to affect only a limited number of residents. Resident identifier: #22. Facility census: 109. Findings include: a) Resident #22 On 06/26/23 at 8:20 PM, Registered Nurse (RN) #67 crushed the following medications and mixed each with five milliliters (ml) of tap water in separate medication cups: Baclofen 10 milligrams (mg), Norco 5-325 mg, Labetalol 100 mg, and Atorvastatin 10 mg. RN #67 stopped the continuous feeding, pushing five ml of tap water with a large piston irrigation syringe. RN #67 pushed each med diluted with five ml of tap water with a five ml push of tap water in between. RN #67 flushed the PEG tube with a push of 50 ml of tap water and then restarted the continuous feeding. During an interview on 06/27/23 at 1:47 PM, the Director of Nursing (DON) confirmed medications and fluids are not to be pushed into the PEG tube. Medications and fluids should be poured into the syringe and administered by gravity flow.

CONCERN (D)

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

Deficiency F0919 (Tag F0919)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on resident interview, observation, and staff interview, the facility failed to ensure two (2) of 109 Residents had a functioning call system to alert staff when assistance was needed. Resident identifiers: #98 and #38. Facility census: 109. Findings included: a) Resident #38's interview During the resident council meeting which began at 3:00 PM on 06/27/23, Resident #38 said the call light system was broken in her room. Resident #38 said some men came in here to work and tore it up. Resident #38 said she looked out after her roommate and in the past had called for help for the roommate. Observation with Registered Nurse (RN) #114 on 06/07/23 at 3:56 PM confirmed neither the call light for bed A (Resident #98) or bed B (Resident #38) was working. RN #114 said she was calling the maintenance man to get it fixed. On 06/28/23 at 10:35 AM, observation of the call light system in room [ROOM NUMBER] with the Administrator #56 found the call system was still not working. The Administrator said Resident #38 had a bell to ring for service. He stated the maintenance director was unable to fix the system.

CONCERN (E)

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

Quality of Care (Tag F0684)

Could have caused harm · This affected multiple residents

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Based on record review and staff interview, the facility failed to ensure residents with orders for insulin received necessary treatment and services as per their physician orders. The facility failed to recheck blood sugar levels when they were above 400. This was true for one (2) of seven (7) residents reviewed. Resident identifiers: #18 and #503. Facility census: 109. Findings included: a) Resident #18 During an interview on 06/27/23 at 2:08 PM, Resident #18 reported he received insulin on a sliding scale. A medical record review, completed on 06/28/23 at 2:15 PM, revealed the following physician order: HumaLOG KwikPen 100 UNIT/ML Solution pen-injector Inject as per sliding scale: if 151 - 200 = 2 units; 201 - 250 = 4 units; 251 - 300 = 6 units; 301 - 350 = 8 units; 351 - 400 = 10 units; 401 - 999 = 12 units administer 12 units and recheck within 2 hours; if remains > 400, notify PCP [primary care physician] for further instruction; subcutaneously before meals and at bedtime related to TYPE 2 DIABETES MELLITUS WITH KETOACIDOSIS WITHOUT COMA Start Date 05/30/2023 2100 Review of June 2023 Medication Administration Record (MAR) identified the following: -06/06/23 at 21:00 blood sugar was 430, the nurse administered 12 units, but there was no evidence resident's blood sugar was rechecked within 2 hours. -06/08/23 at 21:00 blood sugar was 470, the nurse administered 12 units, but there was no evidence resident's blood sugar was rechecked within 2 hours. -06/09/23 at 21:00 blood sugar was 459, the nurse administered 12 units, but there was no evidence resident's blood sugar was rechecked within 2 hours. -06/10/23 at 21:00 blood sugar was 469, the nurse administered 12 units, but there was no evidence resident's blood sugar was rechecked within 2 hours. -06/11/23 at 21:00 blood sugar was 402, the nurse administered 12 units, but there was no evidence resident's blood sugar was rechecked within 2 hours. -06/12/23 at 16:00 blood sugar was 423, the nurse administered 12 units, but there was no evidence resident's blood sugar was rechecked within 2 hours. -06/16/23 at 21:00 blood sugar was 452, the nurse administered 12 units, but there was no evidence resident's blood sugar was rechecked within 2 hours. -06/20/23 at 21:00 blood sugar was 431, the nurse administered 12 units, but there was no evidence resident's blood sugar was rechecked within 2 hours. -06/23/23 at 21:00 blood sugar was 407, the nurse administered 12 units, but there was no evidence resident's blood sugar was rechecked within 2 hours. Review of the June 2023 blood sugar vitals did not provide evidence the above mentioned blood sugars were rechecked. Review of the June 2023 nursing notes did not provide evidence the above mentioned blood sugars were rechecked. During an interview on 06/28/23 at 3:53 PM, Corporate RN #139 confirmed there was no evidence in the medical record the blood sugars were rechecked and the physician's order had not been implemented correctly. b) Resident #503 A medical record review, completed on 06/28/23 at 3:15 PM, revealed the following physician order: HumaLOG KwikPen 100 UNIT/ML Solution pen-injector Inject as per sliding scale: if 151 - 200 = 2 units; 201 - 250 = 4 units; 251 - 300 = 6 units; 301 - 350 = 8 units; 351 - 400 = 10 units; 401 - 999 = 12 units RECHECK WITHIN 2 HOURS; IF REMAINS > 400, NOTIFY PCP (primary care physician) FOR FURTHER INSTRUCTION;, subcutaneously before meals and at bedtime related to TYPE 2 DIABETES MELLITUS WITHOUT COMPLICATIONS Review of June 2023 Medication Administration Record (MAR) identified the following: -06/10/23 at 21:00 blood sugar was 409, the nurse administered 12 units, but there was no evidence resident's blood sugar was rechecked within 2 hours. -06/11/23 at 21:00 blood sugar was 442, the nurse administered 12 units, but there was no evidence resident's blood sugar was rechecked within 2 hours. -06/12/23 at 16:00 blood sugar was 471, the nurse administered 12 units, but there was no evidence resident's blood sugar was rechecked within 2 hours. -06/12/23 at 21:00 blood sugar was 519, the nurse administered 12 units, but there was no evidence resident's blood sugar was rechecked within 2 hours. -06/15/23 at 21:00 blood sugar was 422, the nurse administered 12 units, but there was no evidence resident's blood sugar was rechecked within 2 hours. -06/16/23 at 06:00 blood sugar was 455, the nurse administered 12 units, but there was no evidence resident's blood sugar was rechecked within 2 hours. Review of the June 2023 blood sugar vitals did not provide evidence the above mentioned blood sugars were rechecked. Review of the June 2023 nursing notes did not provide evidence the above mentioned blood sugars were rechecked. During an interview on 06/28/23 at 3:54 PM, Corporate RN #139 confirmed no evidence in the medical record the blood sugars were rechecked and the physician's order had not been implemented correctly. Based on record review and staff interview, the facility failed to ensure residents with orders for insulin received necessary treatment and services as per their physician orders. The facility failed to recheck blood sugar levels when they were above 400. This was true for one (2) of seven (7) residents reviewed. Resident identifiers: #18 and #503. Facility census: 109. Findings included: a) Resident #18 During an interview, on 06/27/23 at 2:08 PM, Resident #18 reported he received insulin on a sliding scale. A medical record review, completed on 06/28/23 at 2:15 PM, revealed the following physician order: HumaLOG KwikPen 100 UNIT/ML Solution pen-injector Inject as per sliding scale: if 151 - 200 = 2 units; 201 - 250 = 4 units; 251 - 300 = 6 units; 301 - 350 = 8 units; 351 - 400 = 10 units; 401 - 999 = 12 units administer 12 units and recheck within 2 hours; if remains > 400, notify PCP [primary care physician] for further instruction; subcutaneously before meals and at bedtime related to TYPE 2 DIABETES MELLITUS WITH KETOACIDOSIS WITHOUT COMA Start Date 05/30/2023 2100 Review of June 2023 Medication Administration Record (MAR) identified the following: -06/06/23 at 21:00 blood sugar was 430, the nurse administered 12 units, but there was no evidence the resident's blood sugar was rechecked within 2 hours. -06/08/23 at 21:00 blood sugar was 470, the nurse administered 12 units, but there was no evidence the resident's blood sugar was rechecked within 2 hours. -06/09/23 at 21:00 blood sugar was 459, the nurse administered 12 units, but there was no evidence the resident's blood sugar was rechecked within 2 hours. -06/10/23 at 21:00 blood sugar was 469, the nurse administered 12 units, but there was no evidence the resident's blood sugar was rechecked within 2 hours. -06/11/23 at 21:00 blood sugar was 402, the nurse administered 12 units, but there was no evidence the resident's blood sugar was rechecked within 2 hours. -06/12/23 at 16:00 blood sugar was 423, the nurse administered 12 units, but there was no evidence the resident's blood sugar was rechecked within 2 hours. -06/16/23 at 21:00 blood sugar was 452, the nurse administered 12 units, but there was no evidence the resident's blood sugar was rechecked within 2 hours. -06/20/23 at 21:00 blood sugar was 431, the nurse administered 12 units, but there was no evidence the resident's blood sugar was rechecked within 2 hours. -06/23/23 at 21:00 blood sugar was 407, the nurse administered 12 units, but there was no evidence the resident's blood sugar was rechecked within 2 hours. Review of the June 2023 blood sugar vitals did not provide evidence the above mentioned blood sugars were rechecked. Review of the June 2023 nursing notes did not provide evidence the above mentioned blood sugars were rechecked. During an interview on 06/28/23 at 3:53 PM, Corporate RN #139 confirmed there was no evidence in the medical record the blood sugars were rechecked and the physician's order had not been implemented correctly. b) Resident #503 A medical record review, completed on 06/28/23 at 3:15 PM, revealed the following physician order: HumaLOG KwikPen 100 UNIT/ML Solution pen-injector Inject as per sliding scale: if 151 - 200 = 2 units; 201 - 250 = 4 units; 251 - 300 = 6 units; 301 - 350 = 8 units; 351 - 400 = 10 units; 401 - 999 = 12 units RECHECK WITHIN 2 HOURS; IF REMAINS > 400, NOTIFY PCP (primary care physician) FOR FURTHER INSTRUCTION;, subcutaneously before meals and at bedtime related to TYPE 2 DIABETES MELLITUS WITHOUT COMPLICATIONS Review of June 2023 Medication Administration Record (MAR) identified the following: -06/10/23 at 21:00 blood sugar was 409, the nurse administered 12 units, but there was no evidence the resident's blood sugar was rechecked within 2 hours. -06/11/23 at 21:00 blood sugar was 442, the nurse administered 12 units, but there was no evidence the resident's blood sugar was rechecked within 2 hours. -06/12/23 at 16:00 blood sugar was 471, the nurse administered 12 units, but there was no evidence the resident's blood sugar was rechecked within 2 hours. -06/12/23 at 21:00 blood sugar was 519, the nurse administered 12 units, but there was no evidence the resident's blood sugar was rechecked within 2 hours. -06/15/23 at 21:00 blood sugar was 422, the nurse administered 12 units, but there was no evidence the resident's blood sugar was rechecked within 2 hours. -06/16/23 at 06:00 blood sugar was 455, the nurse administered 12 units, but there was no evidence the resident's blood sugar was rechecked within 2 hours. Review of the June 2023 blood sugar vitals did not provide evidence the above mentioned blood sugars were rechecked. Review of the June 2023 nursing notes did not provide evidence the above mentioned blood sugars were rechecked. During an interview on 06/28/23 at 3:54 PM, Corporate RN #139 confirmed there was no evidence in the medical record the blood sugars were rechecked and the physician's order had not been implemented correctly.

CONCERN (E)

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

Accident Prevention (Tag F0689)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on resident interview, observation, record review, and staff interview, the facility failed to ensure the resident environment over which it had control was as free from accident hazards as possible. Resident #47 expressed to the surveyor he smoked at the facility without staff supervision and kept his own cigarettes and lighter. An interview with the Resident's Licensed Practical Nurse (LPN) #37 confirmed the Resident had asked her earlier in the day to take him out to smoke. The LPN's only response was, you know you are not allowed to smoke. Twenty seven (27) additional residents were identified as lacking capacity and being able to ambulate/wander throughout the facility. Any of the 27 residents could have obtained access to the cigarettes or lighter, potentially causing serious harm and/or death to self or others due to their cognitive impairments and decreased safety awareness. In addition, Resident #47 was at risk of serious harm and/or death from possible burns resulting from smoking off the premises without staff supervision. The state agency (SA) determined this to be an immediate jeopardy (IJ) which placed Resident #47 and all 27 cognitively impaired and ambulatory residents at risk for serious harm and/or death. The facility was notified of the IJ on 06/26/23 at 6:26 PM. The facility submitted a Plan of Correction (POC) that was accepted by the SA on 06/26/23 at 9:31 PM. The plan of Correction read as follows: Upon reassessment by the Director of Nursing on 6/26/2023, Resident: #78, #97, #554, #11, #354, #72, #20, #40, #56, #32, #60, #80, #89, #63, #31, #53, #39, #42, #52, #98, #74, #84, #76, #81, #62, #28, and # 85 were asked if they currently had any smoking materials including lighters in their rooms. All residents of the facility could be affected. A letter was sent by the Administrator\designee on 6/26/23 to residents and families regarding the facility non-smoking policy. All staff will be reeducated on or before 6/26/23 regarding ensuring the resident's environment remains as free of accident hazards as is possible including providing re-education on facility non-smoking policy with a posttest to validate understanding. Center staff not available during this timeframe will be provided reeducation including posttest by the Administrator\designee upon return to work. New staff will be provided with education and posttests during orientation by the Administrator\designee. New residents and/or responsible parties will be provided information regarding the facilities smoking policy and sign acknowledgement by the admission Director/designee at the time of admission. The Administrator/designee will conduct random observations daily 4 X weeks then 3 x per week x 2 weeks then randomly thereafter to ensure residents are abiding by facility non-smoking per the center policy. Any trends identified will be reported monthly by the Administrator\designee to the Quality Improvement Committee (QIC) for any additional follow-up and\or in servicing until the issue is resolved then randomly thereafter as determined by the QIC committee. Upon return to the facility at 10:30 AM on 06/27/23, nurse aide (NA) #36 confirmed she clocked in at 7:00 AM on 06/27/23 and had not received any in - services since she began her shift. At 10:35 AM on 06/27/23, Social Worker (SW) #109 confirmed NA #36 had not received any in-services. SW #109 provided a list of employees who had been in -serviced and NA #36's name was not on the list. At 10:50 AM on 06/27/23, the above situation was presented to the Administrator, the Director of Nursing (DON), and a corporate Nurse #139. The Corporate Nurse #139 confirmed the facility's plan of correction directed that all staff present at the building would be in-serviced on 06/26/23. Any staff not currently working would receive in-servicing prior to beginning their next shift. The immediate jeopardy (IJ) could not be abated at this time because the plan of correction submitted by the facility was not completed. At 3:40 PM on 06/27/23, the Corporate Nurse stated the facility had in-serviced and educated all of their staff for POC. On 06/27/23, the SA interviewed all staff in the building and reviewed the in-service training. Observation and tour of the facility found no further issues. The IJ was abated on 06/27/23 at 4:10 PM. The IJ began at 6:26 PM on 06/26/23 and ended on 06/27/23 at 4:10 PM when the SA abated the immediacy. This failed practice was a random opportunity for discovery and had the potential to affect more than a limited number of residents. Resident identifiers: #47, #354, #78, #97, #554, #11, #72, #20, #40, #56, #32, #60, #80, #89, #63, #31, #53, #39, #42, #52, #98, #74, #84, #76, #81, #62, #28, and #85. Facility census: 109. Findings included: a) Resident #47 Resident #47 was interviewed on 06/26/23 at 11:53 AM, he stated he doesn't like the smoking situation here. The surveyor asked if he smoked. He said, yes he goes off the property to smoke. Surveyor asked if anyone helped him and he said staff used to help him but they got in trouble so they don't anymore. The surveyor asked where he keeps his lighter and cigarettes. He stated he can't say. Then he laughed and said, I know I'm not supposed to, but I keep them in my murse. (He defined a murse as a man's purse). He held up what appeared to be a black, leather fanny pack, he had attached to his wheelchair. A followup interview with resident #47 on 06/26/23 1:00 PM, was conducted. Resident #47 stated the old administrator, (administrator's name), had a conversation with him previously about not being allowed to smoke at the facility. He said he signs out, wheels himself passing the gazebo onto the paved pathway to a store lot next door which houses storage buildings. He said he signs back in when he is done and keeps his cigarettes and lighter in his murse He said he has had two (2) falls outside in the past but that was when he had his scooter. Resident stated that a few weeks ago his roommate woke him up in the middle of the night because a wandering resident (Resident #84) was in their bathroom smoking a cigarette. They told the resident to leave before he gets them in trouble and he left. He does not know where Resident #84 got the cigarettes from. Record review on 06/26/23 indicated the facility had a Smoking Policy that prohibited residents to smoke or possess any smoking paraphernalia. Resident #47 had signed this smoking policy on admission, dated 12/29/21. The surveyor was provided copies of the Sign Out forms that Resident #47 signed out when he was going off the property. It appeared the form was inconsistent. Sometimes he did not sign back in and sometimes a witness did not sign, and at times his condition was not documented on return. b) Interview with Resident # 57 A resident interview on 6/26/26 at approximately 1:45 PM Resident #47's roommate, Resident #57, who said he was not sure if Resident #47 smoked but he did confirm Resident #84 was in their bathroom smoking a few weeks ago. He did not know where Resident #84 got his smoking materials. c) Twenty-seven (27) residents were identified as lacking capacity and being able to ambulate/wander throughout the facility. Any of the 27 residents could have obtained access to the cigarettes or lighter, potentially causing serious harm and/or death to self or others due to their cognitive impairments. Resident #84 was identified as fitting this criteria and had been identified by Resident #47 as already having came into his room and gotten into the smoking materials. Resident #47 found Resident #84 smoking a cigarette in his bathroom. Out of the 27 residents the facility identified as having a cognitive deficit and having the ability to wander, seven (7) have a history of smoking. These residents were identified as Resident: #42, #56, #78, #84, #89, #97, and #354. The 27 residents identified and their most recent Brief Interview for Mental Status (BIMS) (BIMS scores are listed below: 13-15 suggests the resident is cognitively intact, 8 to 12 suggests the resident is moderately impaired, and 0-7 suggests severe impairment) are as follows: Resident #354 with a BIMS score of nine (9) on 06/25/23 Resident #78 did not have a BIMS score but her Annual Minimal Data Set (MDS), dated [DATE], indicated that her cognitive skills for daily decision making are severely impaired Resident #97 did not have a BIMS score but his admission MDS, dated [DATE], indicated that his cognitive skills for daily decision making are severely impaired Resident #554 did not have a completed BIMS/MDS yet, however, documentation in the medical record indicated the resident was cognitively impaired. Resident #11 with a BIMS score of five (5) on 05/01/23 Resident #72 with a BIMS score of six (6) on 06/06/23 Resident #20 with a BIMS score of zero (0) on 06/05/23 Resident #40 with a BIMS score of four (4) on 06/13/23 Resident #56 with a BIMS score of eight (8) on 04/05/23 Resident #32 with a BIMS score of three (3) on 06/11/23 Resident #60 with a BIMS score of six (6) on 05/10/23 Resident #80 with a BIMS score of three (3) on 06/01/23 Resident #89 with a BIMS score of two (2) on 06/21/23 Resident #63 with a BIMS score of seven (7) on 06/19/23 Resident #31 with a BIMS score of 10 on 06/20/23 Resident #53 with a BIMS score of four (4) on 06/06/23 Resident #39 with a BIMS score of 11 on 05/09/23 Resident #42 with a BIMS score of four (4) on 03/28/23 Resident #52 with a BIMS score of six (6) on 05/16/23 Resident #98 with a BIMS score of four (4) on 06/09/23 Resident #74 did not have a BIMS score but her Quarterly MDS, dated [DATE], indicated that her cognitive skills for daily decision making are severely impaired Resident #84 with a BIMS score of eight (8) on 03/22/23 Resident #76 with a BIMS score of five (5) on 06/01/23 Resident #81 with a BIMS score of 12 on 04/01/23 Resident #62 with a BIMS score of five (5) on 06/19/23 Resident #28 with a BIMS score of two (2) on 05/12/23 Resident #85 with a BIMS score of six (6) on 06/12/23 d) Staff interviews During a staff interview on 06/26/23 at 1:57 PM, with NA #133 the NA stated she did not know where the resident was supposed to go if he wanted to smoke. He signed himself out and back in. He would have to go off property. She was not sure where he would keep cigarettes and lighter if he were smoking. During a staff interview on 06/26/23 at 2:02 PM, with LPN #37 the LPN stated the resident was not supposed to smoke. She said she was not sure where the property perimeter was or what was considered off property. If a resident had capacity they were able to sign themselves out. LPN #37 said they only have to sign out if they are leaving the property, not if they are going to sit right out front. LPN #37 stated this resident asked her to take him out to smoke this morning but she told him no because he was not supposed to be smoking. She did not investigate any further to determine how the resident planned to smoke or if he had smoking materials in his possession. -Staff interview on 06/26/23 at 2:03 PM, with the DON revealed if a resident had capacity they could sign themselves out and leave the property. She said no resident was supposed to be in possession of smoking materials. She said previously there was an issue with a resident who had been discharged . This resident was smoking and other residents started smoking too. At that time they re-educated the staff through employee meetings, one on one education, new hires were educated on the smoking policy, and they were educated via the communication book. The DON stated if an employee had reasonable suspicion that a resident had smoking materials then they should report this to administration so administration could handle the situation. She said, I would think staff would be able to notice if a resident was smoking in the bathroom and they should notify the DON if so. The residents are allowed to leave the property if they have a physician order stating they can safely leave the property by themselves and they have to sign out. The DON denied knowing the Resident was smoking. When the interview with LPN #37 was presented, the DON stated that the staff should notify administration immediately if they have reason to believe that a resident has cigarettes or a lighter. On 06/26/23 at 2:18 PM the surveyors notified the Director of Nursing (DON) that the resident stated he had smoking materials on him. On 06/26/23 at 2:48 PM, SW #109 was looking for Resident #47 and staff told her he signed himself out. The SW found the resident sitting outside the main entrance. She approached him and asked if he had cigarettes. He said yes. She asked for them and assured him she would lock them up in the safe and have his family pick them up. He gave her a pack of Marlboros and a red lighter out of his murse. She asked him if he had any more in his room and he responded no. On 06/26/23 at 7:10 PM, SW #109 brought the surveyor a copy of a progress note written on 09/13/22 at 8:28 AM, by this SW. The note described when SW #109 talked to Resident #47 about the facility's smoking policy. She also brought the surveyor a copy of a care plan for history of alcoholism and tobacco use, with an intervention of educating the resident of smoking policy. Surveyor explained that nowhere in the behavior care plan or history of tobacco care plan did it mention the resident was non compliant with the smoking policy and what interventions to provide if he was non compliant with this policy. The SW confirmed Resident #47 did not have a behavior care plan in place for his history of non compliance with the facility's smoking policy. On 06/27/23, the facility provided a list/audit of residents they identified as having a history of smoking. They interviewed and searched the residents' rooms for smoking paraphernalia. They identified the following residents: #553, #78, #354, #47, #17, #56, #556, #89, #68, #358, #103, #42, #88, #23, #38, #44, #91, #25, #57, #84, #27, #94, #357, and #97. The facility smoking policy revealed the residents were not allowed to smoke but staff are allowed to smoke. Resident #47 signed acknowledgment of this policy upon his admission. Record review failed to show Resident #47 had been assessed to be an indepednet/safe smoker.

CONCERN (E)

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

Staffing Information (Tag F0732)

Could have caused harm · This affected multiple residents

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Based on facility record review, observations and staff interview the facility failed to display the daily staff posting at an accessible height for residents to view. This practice had the potential to affect more than a limited number. Facility census: 109. Findings included: a) Observations on 06/26/23 and 06/27/23 found the daily staff posting outside the Administrator's office approximately five feet from the floor. The CMS-672 form completed by the facility notes 50 of the current 109 residents are in a chair most of the time and only 20 of the 109 residents walk independently. On 06/28/23 at 11:58 AM, the Staffing coordinator reported there was only one staff posting in the facility and it is located outside of the Administrator's office. The staffing coordinator acknowledged the daily posting was approximately five feet from the floor and agreed it is too high for residents in wheelchairs to view.

CONCERN (E)

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

Deficiency F0761 (Tag F0761)

Could have caused harm · This affected multiple residents

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Based on observation and staff interview the facility failed to ensure all multiple use vials and/or pens of insulin were dated with the initial date they were opened. This was true for six (6) out of nine (9) vials and/or pens in the Medication cart on the A hall. Resident identifiers: #553, #50, #19, #1, #34, #70, and #97. Facility census 109. Findings included: a) observation of the medication cart During an observation of medications in the A Hall medication cart on 06/27/23 9:00 AM, in the presence of Licensed Practical Nurse (LPN) #138, found six (6) out of nine (9) insulin vials/pens did not have an open date on the pens and/or vials. The insulin belonged to the residents listed below: Resident # 553 Lispro vial Resident # 50 Humalog vial Resident # 19 Novolog vial Resident # 1 Novolog Pen Resident # 34 Humalog Pen Resident # 70 Humalog Kwik pen Resident # 97 Lantus vial On 06/27/23 at 11:35 AM, the above findings were presented to Corporate Nurse #139. No further information was provided.

CONCERN (E)

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

Deficiency F0804 (Tag F0804)

Could have caused harm · This affected multiple residents

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. Based on observation, staff interview and resident interview, the facility failed to ensure food items were served at the preferable temperature for the residents. This has the potential to affect more than a limited number of residents. Facility census: 109. Findings included: a) Food temperatures At 12:50 PM on 06/27/23, the last tray to be served on D hallway belonged to Resident #69. Interim Dietary Manager (DM) #118, obtained the temperatures of the following food items: Pears were 59 degrees Broccoli - 120 degrees Meatballs with gravy - 120 degrees Corn -115 degrees. Coffee - 117 degrees DM #118 said she would like the temperature of hot foods to be at least 140 degrees and cold foods to be no more than 40 degrees at the time of service. DM #118 provided a copy of the food item temperatures obtained before the tray left the kitchen: The corn and broccoli were 175 degrees Meatballs and gravy were 167 degrees Fruit was 36 degrees. Several residents attending the Resident Council Meeting at 3:00 PM on 06/27/23, complained of cold food and coffee served at times, especially if they were eating in their rooms. .

CONCERN (E)

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

Food Safety (Tag F0812)

Could have caused harm · This affected multiple residents

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. Based on observation and staff interview, the facility failed to maintain properly stored and dated food. This had the potential to affect more than a limited number of residents. Census 109. Findings included: a) Kitchen On 06/26/23 at 10:55 AM, an initial walk through of the kitchen was conducted with #118, Interim Dietary Manager (DM.) One of the walk-in refrigerators had opened tomato soup stored in a clear container with a lid that did not seal. This green lid did not appear to fit the container and would not close. DM #118 stated the staff must have used the wrong lid. She got the correct lid for the container. At 10:56 AM, the same refrigerator was observed to have a package of Natural Choice sliced ham that was opened and wrapped in cling wrap. There was no expiration or open date on the ham. DM #118 confirmed it was not dated and threw it in the trash. At 10:59 AM, observation of the pantry found a 6.4 oz bag of cornbread stuffing seasoning sitting on the shelf, not boxed, without an expiration date. DM #118 confirmed there wasn't a date of expiration and threw the bag in the trash. .

CONCERN (E)

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

Garbage Disposal (Tag F0814)

Could have caused harm · This affected multiple residents

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. Based on observation and staff interview, the facility failed to maintain proper garbage disposal. This had the potential to affect all residents residing at the facility. Census 109. Findings included: a) Dumpsters On 06/26/23 at 11:10 AM, the outside dumpsters were observed with Interim Dietary Manager (DM) #118. The top of the dumpster had two (2) missing lids, and one (1) lid was warped causing a gap of approximately 12 inches in length by approximately 8 inches in height between the dumpster rim and the lid. DM #118 confirmed the facility was aware of the missing lids and they were in the process of replacing them. DM #118 said that the missing lids had been like that for a week but she had not noticed the warped lid.

CONCERN (F)

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

Deficiency F0868 (Tag F0868)

Could have caused harm · This affected most or all residents

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. Based on record review and staff interview, the facility failed to ensure the medical director/designee attended quarterly Quality Assessment and Assurance (QAA) meetings. This had the potential to affect all residents that resided at the facility. Facility census: 109. Findings included: a) QAA meetings Review of the QAA sign in sheets, with the Administrator #56 at 2:40 PM, on 06/28/23 found the medical director/designee did not attend any QAA meetings in the first quarter of 2023. Meetings were held on 01/31/23 and 02/22/23. Review of the sign-in sheets found no indication the medical director or designee attended or was present by telephone, zoom, etc during these meetings. A meeting was not held in March 2023.

CONCERN (F)

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

Infection Control (Tag F0880)

Could have caused harm · This affected most or all residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** d) room [ROOM NUMBER] / Resident #75 A medical record review was completed on 06/28/23 at 11:45 AM and revealed the following: - A physician's order for Resident #75 dated 06/28/23 at 10:10 AM, Contact precautions. Every shift related to EXTENDED SPECTRUM BETA LACTAMASE (ESBL) RESISTANCE until 07/03/2023. Observation on 06/28/23 at 11:55 AM revealed there was Contact Precaution signage beside the door instructing, Before entering room: Perform hand hygiene. Put on gown. Put on gloves. On 06/28/23 at 12:00 PM, Surveyor observed RN #114 enter room [ROOM NUMBER] ungowned and ungloved. When RN #114 came out of the room she stated, I didn't think it was necessary if I was just putting something down and not providing direct care. The Infection Preventionist was interviewed on 06/28/23 at 12:06 PM and reported, Contact precautions should always be followed prior to entering room. e) room [ROOM NUMBER] / Resident #503 A medical record review was completed on 06/28/23 at 11:50 AM and revealed the following: -A physician's order for Resident #503 dated 06/09/23 at 12:55 PM, Contact precautions due to wound and Hx [history] of ESBL Observation on 06/28/23 at 11:57 AM revealed there was Contact Precaution signage on the door instructing: CONTACT PRECAUTIONS. EVERYONE MUST: Clean their hands, including before entering and when leaving the room. Providers and Staff must also: Put on gloves before room entry, Discard gloves before exit, Put on gown before room entry. Discard gown before room exit. Do not wear the same gown and gloves for the care of more than one person. Use dedicated or disposable equipment. Clean and disinfect reusable equipment before use on another person. On 06/28/23 at 12:29 PM, Surveyor observed CNA #45 enter room [ROOM NUMBER] without donning any Personal Protective Equipment (PPE). When CNA #45 came out of the room she stated, The only time I need to follow the Contact Precautions sign is if I'm doing something with them [referring to providing direct care]. The Infection Preventionist was interviewed on 06/29/23 at 9:05 AM and confirmed the CNA #45 failed to follow contact precautions. d) room [ROOM NUMBER] / Resident #75 A medical record review was completed on 06/28/23 at 11:45 AM and revealed the following: - A physician's order for Resident #75 dated 06/28/23 at 10:10 AM, Contact precautions. Every shift related to EXTENDED SPECTRUM BETA LACTAMASE (ESBL) RESISTANCE until 07/03/2023. Observation on 06/28/23 at 11:55 AM revealed there was Contact Precaution signage beside the door instructing, Before entering room: Perform hand hygiene. Put on gown. Put on gloves. On 06/28/23 at 12:00 PM, the surveyor observed RN #114 enter room [ROOM NUMBER] ungowned and ungloved. When RN #114 came out of the room she stated, I didn't think it was necessary if I was just putting something down and not providing direct care. The Infection Preventionist was interviewed on 06/28/23 at 12:06 PM and reported, Contact precautions should always be followed prior to entering room. e) room [ROOM NUMBER] / Resident #503 A medical record review was completed on 06/28/23 at 11:50 AM and revealed the following: -A physician's order for Resident #503 dated 06/09/23 at 12:55 PM, Contact precautions due to wound and Hx [history] of ESBL Observation on 06/28/23 at 11:57 AM revealed there was Contact Precaution signage on the door instructing: CONTACT PRECAUTIONS. EVERYONE MUST: Clean their hands, including before entering and when leaving the room. Providers and Staff must also: Put on gloves before room entry, Discard gloves before exit, Put on gown before room entry. Discard gown before room exit. Do not wear the same gown and gloves for the care of more than one person. Use dedicated or disposable equipment. Clean and disinfect reusable equipment before use on another person. On 06/28/23 at 12:29 PM, the surveyor observed CNA #45 enter room [ROOM NUMBER] without donning any Personal Protective Equipment (PPE). When CNA #45 came out of the room she stated, The only time I need to follow the Contact Precautions sign is if I'm doing something with them [referring to providing direct care]. The Infection Preventionist was interviewed on 06/29/23 at 9:05 AM and confirmed CNA #45 failed to follow contact precautions. Based on observation, staff interviews, and facility documents, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. The failed practices were found in the areas of monitoring and prevention of Legionella, establish and implementing a surveillance program, donning appropriate Personal Protection Equipment (PPE) while providing care for residents placed in Enhanced Barrier Precautions, and using proper PPE when entering a Contact Isolation room. These failed practices had the potential to affect more than a limited number of residents who currently reside at the facility. Facility census 109. Findings included: a) Water management A review of the facility documents found the facility failed to take measures to prevent the growth of Legionella and other opportunistic waterborne pathogens in the buildings' water systems that is based on nationally accepted standards. During an interview on 06/29/23 at 8:41 AM, Maintenance Assistant #80 stated he was not aware that he needed to be monitoring the cold-water temperatures. MA #80 also said he did not know he should have a diagram and text, to show how the water flows. The facility contracts an outside source for the water management; however, the contracted company does not do the monthly control measures that include visible inspection, disinfectant, and temperature control. MA #80 provided a white three ring notebook with the instructions on monitoring of the cold-water temperatures. MA #80 said he did not do any temperature checks of the cold water. MA #80 was asked if the outside contracted company had any records showing any of the monthly control measures? MA#80 stated they only come every six (6) months to a year. b) Establish/implement a surveillance plan. A review of the surveillance listings provided by the Infection Preventionist (IP) #77 found the following residents were listed as having been placed in Contact Precautions. However, it was blank in the boxes for the pathogen identified. During an interview on 06/28/23 at 1:10 PM, IP #77 it was asked why were Residents #503, #12, and #59 placed in Contact Precautions? IP #77 stated she would have to investigate that. On 06/29/23/at 9:28 AM, IP #77 stated she agreed she failed to follow up with the labs, outside facilities, and the attending physician to find out if there was a pathogen and if the residents needed to be in Contact Precautions or not. c. Enhanced Barrier Precautions The facility policy titled Enhanced Barrier Precautions (EBP) dated March 2023 notes EBP are used to reduce the spread of multi-drug resistant organisms (MDRO) to residents. EBP are indicated for residents with indwelling medical devices. A gown and gloves should be worn during high contact resident care. An observation of medication administration on 06/26/23 at 8:20 PM, found Registered Nurse (RN) #67 enter a room marked as EBP without donning a gown or gloves. RN #67 proceeded to R#22's bedside and administered medications and flushes through her percutaneous endoscopic gastrostomy (PEG) tube without donning a gown and gloves. On 06/27/23 at 1:47 PM the Director of Nursing confirmed staff should wear a gown and gloves to maintain EBP when administering medications to a resident with a PEG tube.

Feb 2022 14 deficiencies

CONCERN (D)

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

Deficiency F0561 (Tag F0561)

Could have caused harm · This affected 1 resident

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. Based on record review, staff interview, and resident interview the facility failed to ensure residents were given the opportunity to make choices regarding their bathing preferences and bathing schedules. Resident identifier: #78. Facility census: 83. Findings included: a) Resident #78 On 02/22/22 at 11:08 AM the Resident stated she was waiting on a shower and she is suppose to get one twice a week. The Resident wasn't sure if the showers were scheduled or not. Her hair was disheveled and she was in a night gown. Upon confirmation with the Director of Nursing (DON) on 02/24/22 at 10:14 AM a shower schedule for the Resident was provided. She only had one shower a week scheduled on Thursdays, day shift, although her choice was two showers per week on Tuesday and Thursday. On 02/24/22 at 10:14 AM the DON provided the Residents shower task sheet. Record review shows the resident only received two (2) showers from her admit date of 01/26/22 through 02/24/22. Resident #78 should have received nine (9) showers during this time period. This was confirmed with the DON on 02/24/22 at 10:17 AM. .

CONCERN (D)

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

Report Alleged Abuse (Tag F0609)

Could have caused harm · This affected 1 resident

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. Based on record review and staff interview the facility failed to report falls which resulted in serious bodily injury to appropriate state agencies as required. These were random opportunities for discovery. Resident Identifiers: # 336 and #30. Facility Census: 83. Findings included: a) Resident #336 A review of Resident #336's medical record found, Resident #336 had a fall in the facility in the shower room on 07/07/21. The facility obtained an order on 07/14/21 for: New order for x-ray to Left leg, Right leg, and pelvis. The facility received the xray results on 07/14/21 at 3:00 pm. The results were typed as written: Note Text: X-ray results obtained. Pelvis, Acute displaced Left femoral neck fracture noted. Right Femur, No acute osseous abnormality. Recommend repeat x-ray or CT (Computerized Tomography Scan) in 1 week or sooner if symptoms have not not resolved. Left Femur, fracture of the femoral neck with superior displacement of the distal fragment. PCP (primary care physician) notified. Review of the reportable incidents for the month of 07/2021 found no evidence this serious bodily injury had been reported to the appropriate state agencies as required. An Interview with the Administrator on 02/24/22 at 10:30 am verified the incident was not reported as required. b) Resident #30 A Medical Record review during the Long Term Care survey Process found Resident #30 sustained a fall with a fractured right hip on 07/25/21. A review of the reportable incidents for 07/2021, found no evidence this serious bodily injury had been reported to the appropriate state agencies . During an interview on 02/24/22 at 8:56 AM the Social Services Director stated No reportable was done, Sorry. An interview on 02/24/22 at 10:30 AM with the Administrator verified the incident was not reported. .

CONCERN (D)

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

Pharmacy Services (Tag F0755)

Could have caused harm · This affected 1 resident

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. Based on observation, record review and staff interview, the facility failed to ensure their narcotics were reconciled every shift. This was a random opportunity for discovery. This had the potential to affect more than an isolated number of residents. Facility Census: 83. a) Medication Administration On 02/24/22 at 8:20 AM, a review of the narcotic count book was completed. The following dates were missing signatures between shifts: --02/18/22 7:00 AM shift to 7:00 PM shift --02/22/22 7:00 AM shift to 3:00 PM shift A review of the Controlled Substances Policy states At the End of Each Shift: .Controlled medications are counted at the end of each shift. The nurse coming on duty and the nurse going off duty determine the count together . On 02/24/22 at 8:40 AM, the Director of Nursing (DON) confirmed the narcotic count book was missing signatures. The DON stated I'll get some education and in-services going right now. No further information was obtained during the survey process. .

CONCERN (E)

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

Deficiency F0578 (Tag F0578)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review and staff interview the facility failed to ensure the [NAME] Virginia Physician Orders for Scope of Treatment (POST) forms were completed correctly for eight (8) of nine (9) residents reviewed during the long term care survey process. Resident identifiers: #5, #18, #16, #79, #65, #73, #82 and #76. Facility census: 83 Findings included: a) Resident #5 On [DATE] at 10:00 AM a record review found the POST form dated [DATE] directed cardiopulmonary resuscitation (CPR) - Attempt resuscitation including mechanical ventilation, defibrillation and cardioversion with full treatments was not completed appropriately. On [DATE] at 10:15 AM an interview with the Director of Nursing (DON) confirmed the POST form was not completed correctly due to missing information relating to the residents address and social security number. On [DATE] at 10:49 PM a review of the Physician Determination of Capacity form dated [DATE] indicated the Resident does not have capacity. According to [NAME] Virginia Center for End-of-Life Care the following guidelines are to be followed. 2020 directions: The patient or representative/surrogate and physician/APRN/PA must sign the form in this section. These signatures are mandatory. A form lacking these signature is NOT valid. The physician/APRN/PA then prints his/her name, phone number, and the date and time the orders were written. The bottom of the form contains a written reminder that the form should accompany the patient/resident when transferred or discharged . It allows receiving healthcare professionals to have the same information regarding the person's preferences for life-sustaining treatment and increases the likelihood that these orders will be respected in the new care setting. 2021 edition: The signature section provides a declaration on behalf of the patient (or incapacitated patient's Medical Power of Attorney (MPOA) representative or health care surrogate) related to their voluntary participation in the completion of the POST form and agreement with the orders on the form. The patient (or incapacitated patient's MPOA representative or health care surrogate) must sign and date this section for the form to be legally valid. If the incapacitated patient's MPOA representative or health care surrogate is unavailable at the time of form completion, this section can be signed by two witnesses for verbal confirmation of agreement from the patient's MPOA representative or health care surrogate. The form should be signed at the earliest available opportunity. b) Resident # 18 A review of medical records on [DATE] at 3:34 PM, found a POST form which was signed and dated by the physician on [DATE]. The POST form was not completed in its entirety, Section D did not include the physician's printed name and no contact information was provided. On [DATE] at 8:54 AM, an interview with the DON acknowledged the POST was not completed. The DON stated We are starting a new process, (Social Services name) will start looking and checking them to see if they are completed correctly. c) Resident #16 A review of medical records on [DATE] at 3:34 PM, found a POST form which was signed and dated by the physician on [DATE]. The POST form was not completed in its entirety, the Resident's mailing address was not completed, Section D did not include the physician's printed name and no contact information was provided. On [DATE] at 8:54 AM, an interview with The DON acknowledged the POST was not completed. The DON stated We are starting a new process, (Social Services name) will start looking and checking them to see if they are completed correctly. d) Resident #82 A review of medical records on [DATE] at 3:34 PM, found a POST form which was signed and dated by the physician on [DATE]. The POST form was not completed in its entirety, the Resident's address was not completed and the person preparing the form section was void of a signature, preparer name (print) and the date prepared. On [DATE] at 8:54 AM, an interview with the DON acknowledged the POST was not completed. The DON stated We are starting a new process, (Social Services name) will start looking and checking them to see if they are completed correctly. e) Resident #65 On [DATE] at 2:30 PM, a review of the POST form was completed. The POST form dated [DATE] was missing the address of the resident, last four (4) digits of the social security number, the preparer's signature and the date of preparation. On [DATE] at 2:50 PM, the Assistant Director of Nursing (ADON) #109 confirmed the POST form was not completed correctly. f) Resident #79 On [DATE] at 2:34 PM, a review of the POST form was completed. The POST form dated [DATE] was missing the date the resident signed the form. On [DATE] at 2:50 PM, the ADON #109 confirmed the POST form was not completed correctly. g) Resident #73 On [DATE] at 2:38 PM, a review of the POST form was completed. The POST form dated [DATE] was missing a selection in section B for initial treatment orders, section D for medically assisted nutrition and the preparer's signature and the date of completion. On [DATE] at 2:50 PM, the ADON #109 confirmed the POST form was not completed correctly. h) Resident #76 Review of the medical record for Resident #76 found a POST form which did not have the last 4 digits of Resident #76's Social Security Number. An interview with the Social Service Director on [DATE] at 12:20 pm confirmed the last four (4) digits of Resident #76's social security number was not on the POST form, so it was not complete. .

CONCERN (E)

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

Safe Environment (Tag F0584)

Could have caused harm · This affected multiple residents

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. Based on observation and staff interview the facility failed to ensure the shower room was clean and homelike on the Bluebird Hall. This was a random opportunity for discovery and had the potential to affect more than an isolated number of residents. Facility Census: 83. Findings Included: During an observation of the Blue Bird Hall shower room on 02/23/22 beginning at 3:33 PM and ending at 3:43 PM with the maintenance director the following issues were observed: -- The vent in the ceiling after entering the shower room door was covered with dust. -- The vent in the corner in the ceiling by the toilet was covered in dust. -- The heater grate in the ceiling was covered in dust. -- The light fixture was broken and hanging down. It had three (3) pieces of medical tape on the fixture where someone had attempted to tape it back up, but it was still hanging down from the light. -- The Cove Base molding was peeling away from the wall and a black substance was observed underneath the molding on wall. The maintenance director agreed the bathroom needed some work. .

CONCERN (E)

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

Transfer Notice (Tag F0623)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review and staff interview the facility failed to notify the Long Term Care Ombudsman of resident discharges from the facility. This was true for three (3) of three (3) residents reviewed for the care area of hospitalizations during the long term care survey process. Resident Identifiers: #336, #79, and #68. Facility Census: 83. Findings included: a) Resident #336 A review of Resident #336's medical record found Resident #336 was discharged to the hospital on [DATE]. Review of the Social Worker's log of transfers from the facility for 07/2021, found Resident #336's name but no proof of Ombudsman notification. In an interview with the Social Worker on 02/24/22 at 12:20 pm she stated she does fax them to the Ombudsman, but has no record to indicate the Ombudsman received the fax. b) Resident #79 A review of Resident #79's record was completed on 02/22/22. The resident was sent to the emergency room on [DATE] at 9:15 AM for a decreased level of consciousness, increased blood pressure, increased pulse, and using accessory muscles to breath. The resident was admitted to the acute care facility. On 02/24/22 at 11:17 AM, the Social Services Director #16 stated the notifications are sent via fax monthly to the ombudsman. On 02/24/22 at 12:45 PM, the Social Services Director #16 could not provide evidence the ombudsman received a notification via fax. No further information was obtained during the survey process. c) Resident # 68 A medical record review during the Long Term Care Survey Process showed Resident #68 was discharged to the hospital on [DATE] and returned on 12/30/21. During an interview on 02/23/22 at 3:03 PM the Social Services Director stated we don't have a bed hold policy and I don't inform the ombudsman when they leave. An interview with the Social Services Director on 02/24/22 at 11:17 am, stated the Ombudsman notifications were sent out monthly per fax. No evidence of the fax confirmations were presented. .

CONCERN (E)

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

Deficiency F0625 (Tag F0625)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review and staff interview the facility failed to provide each resident and/or representative with the bed hold policy at the time of discharge. This was true for three (3) of three (3) residents reviewed for the care area of hospitalization during the long term care process. Resident Identifiers: #336, #79, and #68. Facility Census: 83. Findings included: a) Resident #336 Review of the medical record found no bed hold policy for Resident #336's transfer to the hospital on [DATE]. In an interview on 02/23/22 at 3:03 PM the Social Services Director stated we don't have a bed hold policy and I don't inform the ombudsman when they leave. During an interview with the Administrator on 02/23/22 at 3:12 PM, he stated we don't have a bed hold policy, we just keep their bed, we are never at 90% capacity so we don't need a policy. We always let them come back. b) Resident #79 A review of Resident #79's record was completed on 02/22/22. The resident was sent to the emergency room on [DATE] at 9:15 AM for decreased level of consciousness, increased blood pressure, increased pulse, and using accessory muscles to breath. The resident was admitted to the acute care facility. The resident nor the representative were given a notice of bed hold policy prior to the transfer. On review of the admission packet a bed hold policy was included which was typed as written: .-C. Bed Holds. Upon request, Facility shall hold Resident's bed while Resident is away from Facility for medical leave or on therapeutic leave, as long as the applicable bed-hold fee is paid. Except as provided below, the daily bed-hold fee is the current daily charge for the Resident's room and board. Medicaid will pay applicable bed hold charges for twelve (12) days for medical leave and up to six (6) days for therapeutic leave. If a Medicaid resident exceeds twelve (12) days of medical leave or six (6) days of therapeutic leave in a single year, the Facility may charge the Medicaid resident a bed-hold fee not to exceed the Medicaid daily rate only if there are no vacancies and there is a current wait list. However, no charges will be made for Medicaid resident on medical leave if the Facility is less than 95% occupied as of midnight on the day immediately before the time the resident leaves and a current wait list exists for admission to the Facility. The Resident will be notified if the bed-hold charges will be assessed and must consent in writing to the additional charge. After a hospitalization or leave of absence for which there is no bed-hold, Resident has the right to be re-admitted to the first available bed in a semi-private room in the Facility, if the Resident requires the services of the Facility . An interview on 02/23/22 at 3:03 PM with the Social Services Director #16 stated we don't have a bed hold policy and I don't inform the ombudsman when they leave. During an interview with the Administrator on 02/23/22 at 3:12 PM, stated we don't have a bed hold policy, we just keep their bed, we are never at 90% capacity so we don't need a policy. We always let them come back c) Resident #68 A medical record review during the Long Term Care Survey Process showed Resident #68 was transferred to the hospital on [DATE] and returned on 12/30/21. A review of the Medical record found no evidence a bed hold policy was provided to Resident #68 or their representative for the transfer to the hospital on [DATE]. An interview on 02/23/22 at 3:03 PM the Social Services Director stated we don't have a bed hold policy and I don't inform the ombudsman when they leave. During an interview with the Administrator on 02/23/22 at 3:12 PM, he stated we don't have a bed hold policy, we just keep their bed, we are never at 90% capacity so we don't need a policy. We always let them come back. On review of the Facilities admission packet a bed hold policy was included typed as written: .-C. Bed Holds. Upon request, Facility shall hold Resident's bed while Resident is away from Facility for medical leave or on therapeutic leave, as long as the applicable bed-hold fee is paid. Except as provided below, the daily bed-hold fee is the current daily charge for the Resident's room and board. Medicaid will pay applicable bed hold charges for twelve (12) days for medical leave and up to six (6) days for therapeutic leave. If a Medicaid resident exceeds twelve (12) days of medical leave or six (6) days of therapeutic leave in a single year, the Facility may charge the Medicaid resident a bed-hold fee not to exceed the Medicaid daily rate only if there are no vacancies and there is a current wait list. However, no charges will be made for Medicaid resident on medical leave if the Facility is less than 95% occupied as of midnight on the day immediately before the time the resident leaves and a current wait list exists for admission to the Facility. The Resident will be notified if the bed-hold charges will be assessed and must consent in writing to the additional charge. After a hospitalization or leave of absence for which there is no bed-hold, Resident has the right to be re-admitted to the first available bed in a semi-private room in the Facility, if the Resident requires the services of the Facility .

CONCERN (E)

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

ADL Care (Tag F0677)

Could have caused harm · This affected multiple residents

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. Based on record review, staff interview and resident interview the facility failed to provide care required to maintain adequate hygiene to residents who were dependent on staff for Activities of Daily Living (ADL) care. Resident identifiers: #78, #54, and #55 Facility census: 83 Findings included: a) Resident #78 On 02/22/22 at 11:08 AM the Resident stated she was waiting on a shower and she is suppose to get one twice a week. The Resident wasn't sure if the showers were scheduled or not. Her hair was disheveled and she was in a night gown. Upon confirmation with the Director of Nursing (DON) on 02/24/22 at 10:14 AM a shower schedule for the Resident was provided. She only had one shower a week scheduled on Thursdays, day shift, although her choice was two showers per week on Tuesday and Thursday. On 02/24/22 at 10:14 AM the DON provided the Residents shower task sheet. Record review shows the resident only received two (2) showers from her admit date of 01/26/22 through 02/24/22. She should have received nine (9) showers during this time period. This was confirmed with the DON on 02/24/22 at 10:17 AM. b) Resident #55 On 02/22/22 at 12:20 PM, an interview with the resident was completed. Resident #55 stated I'd like to have a shave I need one. The resident was unable to state how long it had been since he had shaved. On 02/23/22 10:18 AM during observation of the D hall, the resident was still unshaven. The Director of Nursing (DON) was notified at this time. After surveyor intervention, the DON instructed the nursing aides (NAs) to shave the residents requesting to be shaved. The Quarterly Minimum Data SET (MDS) with the Assessment Reference Date (ARD) of 01/29/22 was reviewed on 02/23/22. Under the activities of daily living section G0110 personal hygiene notes limited assistance with one person physical assistance required. The Care plan also addressed the Activities of Daily Living ( ADL) under the focus area of Self Care Performance Deficit r/t weakness and Osteoarthitis with an initial date of 05/15/17. The intervention listed was as follows: --Provide set up and clean up assistance for mouth care and personal needs such as hand washing, face washing, electric razor use, ect. (et'cetera). If resident is unable to fully complete task staff assist x1 to complete task. [Typed as written.] The goal listed was as follows: --Encourage [Name of resident] to assist to their fullest the initial date of 05/23/18. On 02/23/22 at 2:50 PM, the resident was observed to be clean-shaven. No further information was obtained during the survey process. c) Resident #54 During an interview on 02/23/22 at 3:10 PM with Resident #54, she stated, I have only had three (3) showers since admission to the facility a month ago, and would like to shower at least two (2) times per week. Review of the medical record for the prior 30 day period showed Resident #54 received a shower on 02/01/22, 02/03/22, 02/18/22, and 02/21/22. Review of the facility Side One Shower Schedule-Updated 04/21/21 verified Resident #54's assigned room was to be offered a shower every Monday, and every Thursday on night shift. In an interview on 02/23/22 at 3:30 pm the Director of Nursing (DON) confirmed the resident only had four (4) showers in the past thirty (30) days. Resident #54 should have received at least eight (8) showers during the last 30 days. .

CONCERN (E)

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

Deficiency F0679 (Tag F0679)

Could have caused harm · This affected multiple residents

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. Based on observation, record review, staff interview and resident interview, the facility failed to implement an ongoing resident centered activities program designed to meet the interest of and support the physical, mental and psychosocial well-being of each resident. This practice was found true for three (3) of three (3) Residents reviewed for the Activity Care Area during the long term care survey process. Resident Identifiers: #18, #16, and #82. Facility Census: 83 Findings Included: a) Resident #18 During an interview on 02/22/22 at 12:59 PM, Resident #18 stated what activities, we don't have activities. They do nothing around here. Maybe come talk to me in my room. A review of the monthly activity calendar for December 2021 showed no weekend activities. A review of the monthly activity calendar for January 2022 and February 2022, contained no times for any of the scheduled activities, there were no evening activities and no activities scheduled on Saturday and Sunday. During the Long-Term Care Survey Process, activities were being provided that were not on the large wall activity calendar in the hallway or the Resident room activity calendars. On 02/24/22 at 8:40 AM during an interview with the Activity Director #61, she stated we don't have weekend or evening activities. It's just me and the other girl, I work 7-4 or 5 and she works 7-4. Our church has not come because of COVID. It's always just been the two people. We only budget for two staff. b) Resident #16 During an interview on 02/22/22 at 1:15 PM, Resident #16 stated there are no activities, we don't get activities. I like church on Sunday, but we don't have it A review of the monthly activity calendar for December 2021 showed no weekend activities. A review of the monthly activity calendar for January 2022 and February 2022, contained no times for any of the scheduled activities, there were no evening activities and no activities scheduled on Saturday and Sunday. During the Long-Term Care Survey Process, activities were being provided that were not on the large wall activity calendar in the hallway or the Resident room activity calendars. On 02/24/22 at 8:40 AM an interview with the Activity Director #61, stated we don't have weekend or evening activities. It's just me and the other girl, I work 7-4 or 5 and she works 7-4. Our church has not come because of COVID. It's always just been the two people. We only budget for two staff. c) Resident #82 During a interview on 02/22/22 at 1:09 PM, Resident #82 stated I like to go to Bingo, but we don't have it a lot. A review of Resident #82 participation record sheet showed she did attend or invited to attend Bingo on Monday 02/21/22 or Tuesday 02/22/22. A review of the monthly activity calendar for December 2021 showed no weekend activities. A review of the monthly activity calendar for January 2022 and February 2022, contained no times for any of the scheduled activities, there were no evening activities and no activities scheduled on Saturday and Sunday. During the Long-Term Care Survey Process, activities were being provided that were not on the large wall activity calendar in the hallway or the Resident room activity calendars. On 02/24/22 at 8:40 AM an interview with the Activity Director #61, stated we don't have weekend or evening activities. It's just me and the other girl, I work 7-4 or 5 and she works 7-4. Our church has not come because of COVID. It's always just been the two people. We only budget for two staff. .

CONCERN (E)

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

Quality of Care (Tag F0684)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review, observation, and staff interview the facility failed to provide care in accordance with professional standards of care. This was true for four (4) of 30 sampled residents reviewed during the long term care survey process. Resident identifiers #79, #336, #67, and #136. Facility census: 83. Findings included: a) Resident #336 The facility failed to provide medical intervention for Resident #336 in a timely manner. Resident #336 had a fall on 07/07/21, the resident complained of pain after the fall on 07/07/21, and did not have an x-ray until 07/13/21 which showed a left hip fracture. In a late entry progress note dated 07/07/21 at 3:33 PM Resident #336 replied (typed as written) .No, I can't get up. I fell earlier and it will hurt if I stand up The Medication Administration Record (MAR) found on 07/11/22 at 8:02 pm Resident #336 received Tylenol 650 mg for leg pain. A progress note dated 07/13/21 at 7:58 pm (typed as written) Resident has been very tearful and emotional this shift. She was yelling at her roommate when she was unable to get out of her room due to her standing in the doorway. When the nurse entered the room and asked what was going on resident started yelling at this nurse stating her leg was hurting and it was due to a previous fall. Resident noted to have a fall 06-24-21. PCP notified An Interview with the Administrator on 02/24/2022 at 10:30 a.m. confirmed that the resident #336 was not sent to the hospital until 07/14/21. The Administrator stated the progress note dated 07/07/22 is a late entry that was entered 07/16/22, and confirmed Registered Nurse (RN) #45 was aware of the fall on 07/07/22 but no documentation was entered in the medical record at that time. b) Resident #67 On 02/22/22 at 11:03 AM an observation found a midline intravenous (IV) dressing to the right upper arm which was not dated. This was confirmed with the Director of Nursing (DON) on 02/22/22 at 11:25 AM. On 02/23/22 at 12:40 PM an observation found the midline IV dressing was now dated (Initials of Registered Nurse (RN) #45) 02/21/22 which was the day before the dressing was observed to have no date on it. This was confirmed with the DON on 02/23/22 at 12:40 PM. She states RN #45 changed the dressing on Monday (02/21/22) so she backdated it on 02/22/22 to reflect a change date of 02/21/22. The Physicians order was to change the midline dressing weekly, day shift by sterile procedure and as needed for loose, wet or soiled dressing. The Policy and procedure for Central Venous Access site care states to label the dressing with the nurses initials and date. This was not done on the day the dressing was scheduled to be changed. c) Resident #136 On 02/22/22 at 3:42 PM a record review revealed Resident #136 was admitted on [DATE] and has had seven (7) falls from 11/21/21 through 02/22/22. The Resident has a history of Cerebral Palsy (CP), falls, tremors, and no safety awareness. The following documented falls did not have the required documentation completed. The Risk Management System completed for a fall on 11/16/21 which was unwitnessed had no neurological checks (every 15 minutes X (times) 2 hours; every 30 minutes X 2 hours and every 8 hours X 72 hours) completed and only one (1) post fall assessment complete which should be completed every shift X 72 hours. The Risk Management System completed for a fall on 11/19/21 which was unwitnessed had no neurological checks (every 15 minutes X 2 hours; every 30 minutes X 2 hours and every 8 hours X 72 hours) completed and no post fall assessments completed which should be completed every shift X 72 hours. An interview with the Director of Nursing (DON) on 02/24/22 at 1:15 pm confirmed the neurological assessments and post fall assessments were not completed as required. d) Resident #79 On 02/23/22 at 11:31 AM, a record review was completed for Resident #79. The review found a physician's order dated 01/21/22 which read as follows: --Weekly weight every Thursday related to Dx (diagnosis ) of CHF (congestive heart failure); notify PCP (primary care physician) of three (3) or more pound weight gain in 7 (seven) days. [Typed as written.] The weekly weights were reviewed showing a weight gain of four (4) pounds on the following dates: --02/03/22 250 pounds --02/08/22 254 pounds There were no progress notes found indicating the physician was notified of the four (4) pound weight gain. On 02/23/22 at 2:50 PM, the Director of Nursing (DON) was notified of the physician's order not being followed as written. The DON stated a review of the medical record would be completed. No further information was obtained during the survey process.

CONCERN (E)

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

Respiratory Care (Tag F0695)

Could have caused harm · This affected multiple residents

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. Based on observation, medical record review and staff interview, the facility failed to deliver respiratory care services consistent with professional standards of practice. This was true for three (3) of three (3) residents reviewed during the long care survey process for the care area of Oxygen. Resident identifiers: #67, #74, and #28. Facility census: 83 Findings included: a) Resident #67 On 02/22/22 at 11:23 AM an observation found Resident #67's oxygen tubing for the nasal canula was not dated with a change out date. This was confirmed with the Director of Nursing (DON) on 02/22/22 at 11:25 AM. The Policy and Procedure states the oxygen tubing and storage containers for all respiratory supplies are to be changed weekly and dated with the date it was changed. b) Resident #28 Observation of Resident #28's room on 02/22/22 at 11:05 a.m. found oxygen tubing with a nasal canula laying on the resident's bed with no date that would verify when the tubing was changed. In an interview with temporary Nurse Aide (NA)#7 at 11:05 am on 02/22/22, NA #7 confirmed the tubing should have a date. Review of the facility policy titled Prevention of Infection While Providing Respiratory Care verified .oxygen canulas and tubing will be changed weekly and when soiled . c) Resident #74 On 02/22/22 at 11:00 AM, Resident #74's oxygen tubing was observed with the date of 02/01/22. On 02/22/22 at 11:05 AM, the Director of Nursing (DON) confirmed the oxygen tubing was dated as 02/01/22. The DON also confirmed the oxygen tubing should be changed every seven (7) days. The DON confirmed the tubing had not been changed since 02/01/22 since that was the date on the tubing. The oxygen therapy policy entitled Prevention of Infection While Providing Respiratory Care was reviewed. This policy states .the oxygen canulas and tubing will be changed weekly and when soiled . No further information was obtained during the survey process. .

CONCERN (E)

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

Food Safety (Tag F0812)

Could have caused harm · This affected multiple residents

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. Based on observation and staff interviews, the facility failed to store food in a safe and sanitary manner. The foods stored in the kitchen and nourishment refrigerators were not labeled correctly and foods were not discarded when they expired. The facility also failed to keep dishes in an sanitary area, and to keep kitchen equipment clean. This failed practice had the potential to affect more than a limited number of residents currently receiving nutrition from the facility's kitchen. Facility Census: 83 Findings Included: a) Walk-in Refrigerator During an initial tour of the kitchen with the Dietary Director (DD) beginning on 02/22/22 at 11:00 AM, the following issues were found in the walk-in refrigerator: --Minced Garlic in a jar with an open date of 02/04/22 and had no use by date. --Lemon Juice with an open date of 02/07/22 and had no use by date. --Soy Sauce with an open date of 09/24/21 and had no use by date. --Italian Dressing which was open and not dated to indicate when it was opened and had no use by date. --17 individual packages of cream cheese with a manufacturer stamped expiration date of 02/21/22. The DD indicated these things needed to be discarded because they were out of date. We can only keep them in the refrigerator for 7 days. A facility policy, titled Food Storage Labeling with a revision date of 10/2019 stated (Typed as written) 1. Labeling a. All temperature controlled foods and ready to eat foods that are prepared in the facility and held for longer than 24 hours will be labeled. Information included on the label: -Name of the Food -Date of Storage -Date by which it should be eaten or discarded (USE BY DATE) A facility policy titled, Recommended Food Storage Chart with a revision date of 10/2019 stated: Spices, Herbs, Condiments and Extracts keep in the refrigerator for six (6) months. The DD was not aware of the policy stating the condiments could be kept for six (6) months she felt they should all be discarded within seven (7) days. b) pantry A tour of the pantry with the DD on 02/22/22 found the following issues: --a small bag of Cheetos were opened and spilled out in the box which also contained (four) 4 additional closed bags of cheetos. --a small bag of potato chips were opened and spilled out in the box which also contained three (3) additional closed bags of chips. The DD indicated they needed to be discarded. c) Shelves in the food preparation area: Observation of the shelves in the food preparation area found the following issues: --Instant Oats which were not dated as to when they were opened nor did it contain a use by date. --Cajun Seasoning which was not dated as to when it was opened nor did it contain a use by date. --Italian Seasoning which was not dated as to when it was opened nor did it contain a use by date. --Rosemary Leaves which was not dated as to when it was opened nor did it contain a use by date. --Chili Powder which was not dated as to when it was opened nor did it contain a use by date. --Poultry Seasoning which was not dated as to when it was opened nor did it contain a use by date. --Black Pepper which was not dated as to when it was opened nor did it contain a use by date. --Kosher Salt which was not dated as to when it was opened nor did it contain a use by date. --lemon juice which was not dated as to when it was opened nor did it contain a use by date. --whole bay leaves which was not dated as to when it was opened nor did it contain a use by date. --Tarragon Leaves- dated 03/14/21, but did not have a use by date. --Sage-dated 03/14/21, but did not have a use by date. --Cayenne dated 03/17/21, but did not have a use by date. The DD indicated these things needed to be discarded because they were not dated or out of date. The DD stated the spices are good for six (6) months after opening. A facility policy titled, Recommended Food Storage Chart with a revision date of 10/2019 stated Spices, ground are good for 6 months. Spices, whole are good for 1-2 years. A facility policy, titled Storage of Canned and Dry Food with a revision date of 10/2019 stated (Typed as written) .9. Opened packages are labeled with name of product; date opened and used by date . d) Reach In Refrigerator in kitchen An observation of the reach in refrigerator found the following issues: --Pitcher of Apple juice with a date of 02/18/22. --Pitcher of unsweet tea with a date of 02/16/22. --Bottle of pomegranate juice with an open date of 12/29/21. The DD indicated these things needed to be discarded because they were out of date. The DD stated these items are only good for three (3) days. e) Walk in Freezer in kitchen An observation of the walk in freezer found a large cardboard container of vanilla ice cream which was opened, but not dated to indicate when it was opened or when it should be used by. f) Nutrition Room A tour of the nutrition room with the DD on 02/23/22 at 10:00 AM, found the following issues: The refrigerator: --an opened can of monster drink, with no name or date. --A container of opened chicken salad dated 02/21/22 with no resident name or discard date. --An open gallon of chocolate milk and a open gallon of white milk both dated 2/22/22. The DD indicated these things needed to be discarded because of the open monster drink which was placed in the resident refrigerator after it had been drank from. The freezer: --a garbage bag full of ice packs (it was uncertain if these ice packs were used for residents or not or where they even came from). -- two (2) containers of opened sherbet with a Resident name but no date to indicate when it was opened. It was also not dated to indicate when it was brought to the facility for the resident. -- two (2) containers of unopened sherbet with a resident name but no date to indicate when it was brought to the facility for the resident. The DD stated these are just ice packs in the garbage bag. On 02/23/22 at 10:08 AM, The DON acknowledge the ice packs should not be in the freezer and the sherbet was not dated. The DON discarded the items. The DON stated, the monster drink was probably my staff not the residents, I will do an inservice. The cabinets had a package of opened cookies with no date or name present. The DD discarded the cookies. g) Unsanitary equipment and dishes The Ice machine in the service hallway and in the kitchen area, did not have the one (1) inch air gap to prevent contamination of back flow. The steamer was leaking water onto a shelving unit containing clean steam table pans. The DD stated, the steamer is leaking around the seal. We need to get a new one. The steamer drip pan was full of a brown greasy liquid substance. The outside of the steamer had a greasy film build up. The DD stated they just cleaned it. The stove had grease spills in the burners, and the edge of the drip pan which pull outs was sticky with a residue. The ceiling vent above the food preparation area had an accumulation of dust and a dust covered piece of paper attached. The DD stated the Maintenance man cleans them monthly, They should be doing them this week, possibly Friday. Maybe it should be cleaned more often. The outside of the walk in freezer had a large amount of black substance. The inside of the walk in freezer had a bucket on the top freezer shelve with a hose draining into the bucket. The hose was covered in ice. The DD stated We were suppose to get a new freezer, but we were bought out and corporate is suppose to be working on getting a new one now. An additional visit to the kitchen on 02/23/22 at 9:53 AM showed less black substance on the outside of the walk in freezer. The DD stated,I tried to get some of the mold off, I just need to keep working on it. The bucket of ice cream with no date was not discarded. The DD acknowledged she forgot to discard the bucket of ice cream. During an interview with the Administrator on 02/23/22 at 1:54 PM, he stated I don't think the black substance is mold just wear on the outside of the freezer. The Administrator stated the ceiling vent gets cleaned monthly it must have been time for it, I will check with the maintenance dept for the cleaning schedule. The steamer needs a new seal that's a easy fix. The ice machines have been like this for 40 years and never had a problem or been cited. Why are you looking at them now. .

CONCERN (E)

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

Infection Control (Tag F0880)

Could have caused harm · This affected multiple residents

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. Based on observation and staff interview the facility failed to develop and implement an infection control program designed to prevent the spread of disease and illnesses. This process had the potential to affect more than an isolated number of residents. Resident identifiers # 75 and #76. Facility census: 83. Findings included: a) Resident # 75 During an observation of medication administration by Licensed Practical Nurse (LPN) # 94 on 02/24/22 at 8:30 am, LPN #94 failed to place a clean barrier on the bed of Resident #75 prior to sitting the plastic bag the eye drops were stored in, and the eye drops bottle on the bed. After administering the eye drops, the bottle was then placed back in the bag, and the bag was placed back into the medication cart where other resident's medication were stored. In an interview on 02/24/22 at 2:30 pm the Director of Nursing (DON) confirmed a clean barrier should have been used prior to placing medication on the resident's bed. b) Resident #76 An observation on 02/22/22 at 11:45 a.m. during the lunch meal pass on the Bluebird Lane hallway found Resident #76 to have signage on his door for Contact Precautions, and a cart full of personal protective equipment (PPE) to the left of the doorway. Nursing Assistant (NA) #7 took Resident #76 his lunch tray without wearing any PPE when entering the room. At 11:55 am during the same lunch pass, Registered Nurse (RN) #45 entered Resident #76's room without any PPE, and then came back out to put on PPE. RN #45 stated she forgot Resident #76 was now in contact isolation because the Resident had just been discharged from droplet precautions. RN #45 confirmed she should have put on a gown and gloves prior to entering Resident #76's room. Review of the facility policy titled Isolation-Categories of Transmission-Based Precautions under category Contact Precautions found .staff and visitors will wear gloves (clean, non-sterile) when entering the room .staff and visitors will wear a disposable gown upon entering the room and remove before leaving the room . c) Medication Administration On 02/24/22 at 8:08 AM, Licensed Practical Nurse (LPN) #4 was observed during medication administration. LPN #4 did not complete hand hygiene between residents during medication administration. LPN #4 also, did not use a barrier between nasal spray and the bedside table during the medication administration. On 02/24/22 at 8:30 AM, LPN #4 confirmed hand hygiene was not completed between residents and a barrier was not used between the nasal spray and the bedside table during medication administration. On 02/24/22 at 8:40 AM, the Director of Nursing (DON) was notified of the infection control issues observed during medication administration. The DON stated I'll get some education and in-services going right now. .

CONCERN (E)

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

Room Equipment (Tag F0908)

Could have caused harm · This affected multiple residents

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. Based on observation and staff interview, the facility failed to main equipment in a safe operating condition. Two (2) ice machines did not have a one (1) inch air gap for drainage. The steamer was leaking water around the seal and onto the a shelving unit containing clean dishes. The walk in freezer had a bucket on the top shelve for draining water because the drain to the outside of the freezer was not working properly. This failed practice had the potential to affect more than a limited number of residents currently receiving nutrition from the kitchen. Facility Census: 83 Findings Included: During an initial tour of the kitchen with the Dietary Director (DD) on 02/22/22 beginning at 11:00 am found the following issues. -- The ice machine in the service hallway and in the kitchen area, did not have a one (1) inch air gap to prevent contamination of back flow. --The steamer was leaking water onto a shelving unit containing clean steam table pans. The DD stated,The steamer is leaking around the seal. We need to get a new one. --The inside of the walk in freezer had a bucket on the top freezer shelve with a hose draining into the bucket. The hose was covered in ice. The hose was draining inside the freezer instead of to the outside of the freezer as designed. The DD stated We were suppose to get a new freezer, but we were bought out and corporate is suppose to be working on getting a new one now. During an interview with the Administrator on 02/23/22 at 1:54 PM he stated, .The steamer needs a new seal that's an easy fix. The ice machines have been like this for 40 years and never had a problem or been cited. Why are you looking at them now .

Understanding Severity Codes (click to expand)

Life-Threatening (Immediate Jeopardy)

J - Isolated K - Pattern L - Widespread

Actual Harm

G - Isolated H - Pattern I - Widespread

Potential for Harm

D - Isolated E - Pattern F - Widespread

No Harm (Minor)

A - Isolated B - Pattern C - Widespread

Questions to Ask on Your Visit

"What changes have you made since the serious inspection findings?"
"Can I speak with families of current residents?"
"What's your RN coverage like on weekends and overnight?"

Our Honest Assessment

Strengths

• Licensed and certified facility. Meets minimum state requirements.

Concerns

• Multiple safety concerns identified: 1 life-threatening violation(s), $33,033 in fines. Review inspection reports carefully.
• 52 deficiencies on record, including 1 critical (life-threatening) violation. These warrant careful review before choosing this facility.
• $33,033 in fines. Higher than 94% of West Virginia facilities, suggesting repeated compliance issues.
• Grade F (23/100). Below average facility with significant concerns.

Bottom line: Trust Score of 23/100 indicates significant concerns. Thoroughly evaluate alternatives.

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About This Facility

What is Mountain View Care Center's CMS Rating?

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

How is Mountain View Care Center Staffed?

CMS rates Mountain View Care Center's staffing level at 1 out of 5 stars, which is much below average compared to other nursing homes. Staff turnover is 47%, compared to the West Virginia average of 46%.

What Have Inspectors Found at Mountain View Care Center?

State health inspectors documented 52 deficiencies at Mountain View Care Center during 2022 to 2025. These included: 1 Immediate Jeopardy (the most serious level, indicating potential for serious harm or death) and 51 with potential for harm. Immediate Jeopardy findings are rare and represent the most serious regulatory concerns. They require immediate corrective action.

Who Owns and Operates Mountain View Care Center?

Mountain View Care Center is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility is operated by HILL VALLEY HEALTHCARE, a chain that manages multiple nursing homes. With 120 certified beds and approximately 106 residents (about 88% occupancy), it is a mid-sized facility located in RIPLEY, West Virginia.

How Does Mountain View Care Center Compare to Other West Virginia Nursing Homes?

Compared to the 100 nursing homes in West Virginia, Mountain View Care Center's overall rating (1 stars) is below the state average of 2.7, staff turnover (47%) is near the state average of 46%, and health inspection rating (1 stars) is much below the national benchmark.

What Should Families Ask When Visiting Mountain View Care Center?

Based on this facility's data, families visiting should ask: "What changes have been made since the serious inspection findings, and how are you preventing similar issues?" "Can you walk me through typical staffing levels on day, evening, and night shifts?" "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" These questions are particularly relevant given the facility's Immediate Jeopardy citations and the below-average staffing rating.

Is Mountain View Care Center Safe?

Based on CMS inspection data, Mountain View Care Center has documented safety concerns. Inspectors have issued 1 Immediate Jeopardy citation (the most serious violation level indicating risk of serious injury or death). The facility has a 1-star overall rating and ranks #100 of 100 nursing homes in West Virginia. Families considering this facility should ask detailed questions about what corrective actions have been taken since these incidents.

Do Nurses at Mountain View Care Center Stick Around?

Mountain View Care Center has a staff turnover rate of 47%, which is about average for West Virginia nursing homes (state average: 46%). Moderate turnover is common in nursing homes, but families should still ask about staff tenure and how the facility maintains care continuity when employees leave.

Was Mountain View Care Center Ever Fined?

Mountain View Care Center has been fined $33,033 across 1 penalty action. This is below the West Virginia average of $33,409. While any fine indicates a compliance issue, fines under $50,000 are relatively common and typically reflect isolated problems that were subsequently corrected. Families should ask what specific issues led to these fines and confirm they've been resolved.

Is Mountain View Care Center on Any Federal Watch List?

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

Facility Details

Beds: 120
Avg. Residents: 106
Occupancy: 88.5%
Ownership: For profit - Corporation
Chain: HILL VALLEY HEALTHCARE
Medicare: Yes
Medicaid: Yes
Sprinklers: Yes

Trust Score Breakdown

Base Score: 50
1-Star Rating: +0
1 Immediate Jeopardy citation: -12
52 Deficiencies: -10
Fines ($33,033): -5
Final Score: 23/100

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Data: CMS Medicare Care Compare

Updated: November 2025

Facility ID: 515065