Based on observation, staff interview and review of documentation the facility failed to ensure the right to personal privacy and confidentiality of personal and medical records by leaving Resident #34's electronic chart open and unattended on medication cart in hallway. This was a random opportunity for discovery. Facility Census 121. Findings included: On 04/21/25 at 4:12 PM observed Licensed Practical Nurse (LPN) #54 was administering medication in resident #34's room and her computer screen was open at the medication cart in the hallway. Resident's chart was open on the computer, unattended. On 04/21/25 at 4:15 PM an interview with LPN #54 she acknowledged that resident's chart was left open and unattended on the medication cart in the hallway. On 04/24/25 at 9:19AM a review of facility document titled Maintenance of Electronic Clinical Records stated the following: - Policy: This facility will maintain electronic clinical records for each resident in accordance with acceptable standards of practice. -7. The facility shall not release resident-identifiable information to the public. Information that is resident-identifiable may be release only in accordance with a contract under which the agent agrees to disclose information except to the extent the facility itself is permitted to do so. -8. Unauthorized persons are permitted to review records only with the signed permission of the resident or a legal document allowing such access.

Based on record review and staff interview, the facility failed to ensure the resident's Pre-admission Screening (PAS) reflected a pre-admission diagnosis for Resident #101 during the annual long-term care survey. This failed practice had the potential to affect a limited number of residents. Resident Identifier: #101. Facility Census: 121. Findings Included: a) On 04/23/2025, a record review was completed for Resident #101's PAS submitted 11/21/23. Sections III (MI/MR Assessment) and V (Supplemental Questions for Major Mental Illness or suspected MI) of the PAS indicated no diagnoses. Resident #101 had an admission diagnosis of Bipolar Disorder, Unspecified. b) On 04/23/2025 at 3:31, the Director of Nursing confirmed there was no bipolar diagnosis on the initital PAS and stated, it was an oversight on our part.

Based on staff interview and review of documentation the facility failed to develop and implement a comprehensive person-centered care plan to include trauma informed care for resident who had diagnosis of Post Traumatic Stress Disorder (PTSD). This is true for resident #59. Facility Census 121. Findings included: a) On 04/22/25 at 10:23 AM a reviewed resident's diagnosis list included: F43.10 Post-Traumatic Stress Disorder, Unspecified with an onset date of 08/26/24. b) On 04/22/25 at 10:30 AM review of resident's care plan and there was no evidence that Post Traumatic Stress Disorder was addressed on Resident #59's care plan. c) On 04/23/24 at 3:12 PM during an interview with social worker #97 who reported that she was not aware that resident had a diagnosis of Post Traumatic Stress Disorder (PTSD). She acknowledged that resident had a behavior management program and was not receiving trauma-informed care. She also acknowledged that PTSD was not addresses in resident's care plan.

Based on observation, inspection, and record review, the facility failed to follow a physician's order for the administration of oxygen. This was a random opportunity for discovery. Resident Identifier: #108. Facility Census: 121. Findings Include: a) Resident #108 During an interview with Resident #108 on 04/21/25 at approximately 2:37 PM, it was noted that the resident was receiving oxygen therapy. An inspection of the oxygen concentrator showed that it was set to deliver 3.0 liters per minute. The resident mentioned that she had just finished her breakfast and expressed that she was comfortable. Record review on 04/22/25 at 9:12 AM revealed a physician's order that stated: OXYGEN AT 2 LPM CONTINUOUS VIA NC D/T COPD Ongoing observation during the course of the survey revealed the following readings: On 04/22/25 at approximately 8:37 AM, the oxygen concentrator was observed to be set at 3.0 liters per minute. On 04/23/25 at approximately 11:29 AM the oxygen concentrator was observed to be set at 2.5 liters per minute. On 04/23/25, at approximately 11:31 AM, RN #73 was informed that the oxygen concentrator was not set to the prescribed dosage. The prescribed dose was 2.0 liters per minute, and RN #73 adjusted the concentrator to the correct setting. 04/24/25 at approximately 9:16 AM, the Director of Nursing (DON) stated that the oxygen concentrator in Resident #108's room had been tagged, and removed from service.

Based on record review and staff interview the facility failed to provide Trauma informed care for resident with a diagnosis of Post Traumatic Stress Disorder (PTSD). This is true for resident #59. Facility Census #121. Findings Included: a) On 04/22/25 at 10:23 AM a reviewed resident's diagnosis list included: F43.10 Post-Traumatic Stress Disorder, Unspecified with an onset date of 08/26/24. b) On 04/22/25 at 10:30 AM review of resident's care plan and there was no evidence that Post Traumatic Stress Disorder was addressed on Resident #59's care plan. c) On 04/23/24 at 3:12 PM during an interview with social worker #97 who reported that she was not aware that resident had a diagnosis of Post Traumatic Stress Disorder (PTSD). She acknowledged that resident had a behavior management program and was not receiving trauma-informed care. She also acknowledged that PTSD was not addresses in resident's care plan.

Based on observation, staff interview and review of facility policy, the facility failed to ensure waste was properly contained in dumpsters/compactors and were covered with lids. Facility Census 121. Findings included: a) On 04/23/25 at 01:43 PM an observation of dumpster/compactor below kitchen, was observed with lids removed and kitchen trash (plastic lid, plastic food cup, towels, mustard packet, pepper packet, paper etc.) surrounding the dumpster and on top of it. b)During an interview on 04/23/25 at 1:46 PM with Maintenance Staff #172 stated that the dumpster used to have a shoot that the trash was dropped in from the kitchen. He reported that they had to cut the shoot off due to trash getting stuck and smelling in the facility. He reported that if they close the lids on the dumpster, the kitchen still throw trash in the hole where the shoot was and it falls on the ground and they have to pick it up. He then found the lids and placed them on the dumpster/compactor. c) On 04/23/25 at 1:50PM observed the second dumpster on the other side of the building with lid open and latex gloves, drink lid, and multiple cigarette butts surrounding the dumpster. Further observation around the grounds of the facility revealed medical trash (such as latex gloves and masks as well as various other debris) along the edge of the parking lot. d) On 04/24/25 at 9:37 AM, review of form titled Policy #F011 Section: Sanitation and Infection Prevention/Control, Subject: Solid Waste Disposal a bulletin under Procedures: heading stated Keep lids closed on all outside receptacles.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** b) Resident #57 On 04/07/24 at approximately 7:30 PM, Resident #89 was near the nurse's station, at the table where books were laid out for the resident's use. She was selecting some books from the table when Resident #57 took exception to it. Resident #57 beckoned her over, grabbed her fingers and twisted hard, yelling Give me the books. Put them back! Resident #89 was a [AGE] year-old female diagnosed with dementia, short term memory loss, inability to process information, and a lack of capacity to make medical decisions. Resident has resided at the facility since March 2024. Her Minimum Data Set (MDS) assessment with Assessment Reference Date (ARD) 07/12/24 showed the resident had a Brief Interview for Mental Status (BIMS) score of 1, indicating severe cognitive impairment. On 04/07/24 at approximately 7:30 PM, Resident #89 was near the nurse's station, at the table where books were laid out for the resident's use. She was selecting some books from the table when Resident #57 took exception to it. Resident #57 beckoned her over, grabbed her fingers and twisted hard, yelling Give me the books. Put them back! Resident #89 was a [AGE] year-old female diagnosed with dementia, short term memory loss, inability to process information, and a lack of capacity to make medical decisions. The resident had resided at the facility since March 2024. Her Minimum Data Set (MDS) assessment with Assessment Reference Date (ARD) 07/12/24 showed the resident had a Brief Interview for Mental Status (BIMS) score of 1, indicating severe cognitive impairment. Resident #57 was an [AGE] year-old female diagnosed with bipolar disorder, cognitive communication disorder, and anxiety disorder. The resident had resided at the facility since 03/08/24. Her Minimum Data Set (MDS) assessment with Assessment Reference Date (ARD) 07/16/24 showed the resident had a Brief Interview for Mental Status (BIMS) score of 10, indicating moderate cognitive impairment. Per the physician's capacity determination, the resident did not have capacity to make medical decisions. Investigation revealed an eyewitness report by Nursing Assistant (NA) #14, on 04/07/24 at approximately 7:30 PM, which stated that Resident #89 was by the nurse's station, in the living room area at around 7:30 PM on 04/07/24, looking at books on the table to read. Resident #57 started yelling, those aren't her books; she needs to put them back! NA #14 intervened and separated the two residents. She explained to Resident #57 that the books belonged to the facility, and that it was okay if Resident #89 wanted to take them and return them later. NA #14 walked away but continued to observe them. A few seconds later Resident #57 beckoned Resident #89 to come closer. She had then grabbed Resident #57's index and middle fingers and twisted hard yelling, Give me the books. Put the books back! NA #14 had rushed over and separated them, and stated to Resident #57 that she could not place her hands on other residents. When NA #14 had asked Resident #57 why this happened, the resident had stated, Those aren't her books. NA #14 had then reported the incident to RN #43, and LPN #132, while NA #191 watched the residents. During an assessment of Resident #89's right hand on 04/07/24 at 8:27 PM by RN #43, she documented that resident had stated that her right hand hurt, but that she would be okay. RN noted that no swelling was visible, but the resident experienced slight pain upon movement of the hand. Resident #89's Medical Power of Attorney (MPOA) had arrived a few minutes later and had been notified of the incident. He had then accompanied Resident #89 to her room. MPOA later stated that Resident #57 had apologized to his mother. He further stated, things like this happen. The physician had been notified of the incident on 04/07/2024 at 8:36 PM. He had ordered an x-ray of the right hand for the next morning, and ice packs for swelling if needed. Review of the X-ray on 04/09/24 revealed no acute fractures, or other injuries. A note by RN #127 on 04/08/24 at 11:17 AM stated that Resident #57's urine had been tested to rule out a urinary tract infection. She documented that the test was negative for nitrates, leucocytes, and blood. Record review on 08/27/24 at 2:18 PM revealed that Resident #57 had demonstrated multiple episodes of aggressive behavior, anxiety and cognitive communication disorder. She had been care planned for aggressive behavior. Her care plan, initiated on 6/12/23 states: Intervene as needed to protect the rights and safety of others. Approach/speak in a calm manner, divert attention. Remove from the situation and take to another location as needed. Facility had implemented a behavior management plan for Resident #57 on 06/12/23. This plan was updated on 04/10/24 to include close supervision, encouraging resident to sit near nurses' station so that she could be observed, encouraging her to join activities, and taking her meals in the dining room. Care plan notes that the resident seeks constant attention from staff. Resident's husband visits almost daily. Facility staff were in-serviced on aggressive behavior when dealing with dementia residents. This in-service had been previously conducted on 08/228/23 by Social Worker (SW) #45. c) Resident #3 Resident #3 was noted with blood on her upper lip at the doorway to the solarium. She stated that Resident #11 had smacked her in the face. Activities Staff Member (ASM) #2 noted that Resident # 3's walker was beside a table where Resident #11 was sitting. Resident #3 is an [AGE] year-old female diagnosed with dementia, major depressive disorder, and anxiety disorder. The resident had resided at the facility since 11/28/2023. Her Minimum Data Set (MDS) assessment with Assessment Reference Date (ARD) 08/13/24 showed the resident had a Brief Interview for Mental Status (BIMS) score of 99, indicating that the resident could not complete the interview. Her physician's capacity determination revealed that the resident did not have capacity to make medical decisions. Resident #11 was a [AGE] year-old female diagnosed with dementia, major depressive disorder, insomnia and cognitive communication deficit. The resident had resided at the facility since 02/09/2021. Her Minimum Data Set (MDS) assessment with Assessment Reference Date (ARD) 06/18/24 showed the resident had a Brief Interview for Mental Status (BIMS) score of 10, indicating moderate cognitive impairment. Per the physician's capacity determination, the resident did not have capacity to make medical decisions. The resident had a long history of chest pain, resulting in placement of a neurostimulator for pain management with pre-installed settings. Care plan states that level of stimulation should be adjusted every shift based on the resident's physical, verbal or facial response to pain relief. This care plan was revised on 07/13/2023. Record review revealed the following: On 05/01/24 at approximately 5:20 PM, Resident #3 and Resident #11 were in the solarium. Licensed Practical Nurse (LPN) #207 was passing medications and had heard a noise coming from the end of the hall. She had asked Activities Staff Member (ASM) #2 to check the area. ASM #2 had noted Resident #3 walking up the hall, with blood on her upper lip. Resident #3 was tearful and had stated that Resident #11 had hit her. A nursing note by LPN # 207 on 05/01/24 at 5:20 PM stated that the cut on the resident's lip had been cleansed with soap and water and left open to air. LPN #207 had further noted that Resident #3 had calmed down quickly, and begun eating her dinner, showing no further signs or symptoms of distress. Upon being questioned, Resident #11 denied hitting Resident #3 and went back to her room to have dinner. Record review revealed that Social Worker (SW) #110 had been notified of the incident on 05/01/24 at 5:22 PM. SW #110 had interviewed Resident #3 at approximately 5:45 PM. She stated that the resident had stated That woman hit me. When questioned about what had happened, the resident had stated, I don't know, she just hit me. A social worker note dated 05/01/24 at 6:26 PM stated: . resident was showing no ill effects from the incident upon this social worker speaking to her. This social worker apologized to (Resident #3) that this happened. SW #110 had notified Resident #3's Medical Power of Attorney (MPOA) at 6:05 PM on 05/01/24 and explained that the incident would be reported and investigated. SW #110 revealed documentation that verified that the report to Office of Health Facility Licensure and Certification (OHFLAC), Adult Protective Services, and the Ombudsman was faxed on 05/01/24 at 7:19 PM, and that the five (5) day follow up report was faxed on 05/07/24 at 4:08 PM. Record review further revealed a nurses notes dated for the following days which stated: 05/02/24 at 4:36 AM: Resident has been awake periodically throughout this shift. Noted with increased tearfulness at times yelling out I don't want to live anymore. Redirection lasts for short intervals before yelling out again. Area to top lip remains. No active bleeding noted at this time.VSS. 05/02/24 at 11:01 AM: Alert and verbal, denies pain or discomfort. Area remains to left upper lip. No active bleeding noted. No bruising observed. Detailed fax to send to physician to update on previous resident to resident occurrence. Awaiting response 05/02/24 at 12:19 PM: Physician responded to fax sent regarding resident to resident with no new orders 05/02/24 at 6:46 PM: area remains to left upper lip, denies pain or discomfort. No acute distress noted. MPOA in for visit. No concerns voiced. 05/02/24 at 9:15 PM: Walking halls no c/o pain or distress at this time. Record review on 08/27/24 at 12:28 PM revealed an in-service to facility staff on 05/01/24 by SW #110, with instructions which stated: Due to the recent altercation, please do not allow residents to be alone together in the solarium or other locations without staff supervision. During an interview with SW #45 on 08/27/24 at 1:49 PM, she stated that due to the recent resident to resident altercations, facility staff were further in-serviced on aggressive behavior when dealing with dementia residents that had been previously conducted on 08/228/23 by Social Worker (SW) #45. A signed statement by SW #110 on 05/06/24 stated: Upon review of the security cameras in the solarium, it was noted that Resident #3 stood up off pf the couch, started walking toward the door with her walker, and approached Resident #11 who was sitting at a table putting a puzzle together. At this time, Resident reached out and grabbed the clothing protector that Resident #3 was wearing. Resident #11 didn't remove the protector but then reached out again and pulled the clothing protector off Resident #3. At this time Resident #11 began hitting out and swatting at Resident #3 several times making contact with Resident #3's face at one point. Resident #11 continued to swat at Resident #3 causing her to leave her walker behind and walk toward the door without it. As she went to go through the doorway, she turned around and re-entered the solarium. At this time, staff came into the solarium and assisted Resident #3 by giving her the walker and escorting her out of the solarium. c) Resident #105 On 05/05/24 at approximately 1:30 AM, Resident #69 was found in Resident #105's room, kissing her, and touching her breast over her shirt. NA #17 immediately attempted to redirect Resident #69 and get him out of the room. Resident #69 became combative and began punching NA #17 as she tried to redirect him. Eventually Resident #89 was redirected out of the room and began to walk toward the lobby. Record review revealed that on 05/5/24 at 1:32 AM, LPN #152 immediately performed a Head-to-toe assessment (Including vaginal assessment) of Resident #105. No marks or bruising noted. The Resident's Medical Power of Attorney (MPOA) was contacted by LSW and notified of the incident. Record review also revealed and in-service that had been conducted by SW #110 immediately after the incident, which instructed all staff that: Due to the recent incident (Resident #69) is to be supervised at ALL TIMES and not to be kept in the lobby unless supervised by staff. A note on 05/05/24 at 3:49 AM by Social Worker (SW) #110 stated: Administrator #94 was notified of the incident at 2:35 am. A review of facility records on 08/28/24 at 9:14 AM revealed that the facility staff had faxed a report to the Office of Health Facility Licensure and Certification (OHFLAC), Adult Protective Services, and the Ombudsman on 05/05/24 at 3:15 AM, which was within the required two (2) hour window for reporting allegations of sexual abuse. The five (5) day follow up report was submitted on 05/07/24 at 3:58 PM Record review revealed that the facility had conducted an investigation of the alleged sexual abuse on 05/05/24. The facility had substantiated the allegation through interviews with staff. Resident #105 was a [AGE] year-old female diagnosed with severe dementia, Parkinson's disease, Alzheimer's, and epileptic seizures. The resident has resided at the facility since December 2023. Her Minimum Data Set (MDS) assessment with Assessment Reference Date (ARD) 03/21/24 showed the resident was non reviewable, and unable to answer the questions. Facility conducted a staff interview and questioned staff on whether the resident was able to answer questions or make requests. It was revealed that the resident is unable to make her needs known, indicating severe cognitive impairment. Physicians' determination was that the resident does not have capacity to make medical decisions. Resident #69 was an [AGE] year-old male diagnosed with dementia, and depression. The resident had resided at the facility since November 2023. His Minimum Data Set (MDS) assessment with Assessment Reference Date (ARD) 05/01/24 showed the resident had a Brief Interview for Mental Status (BIMS) score of 1, indicating severe cognitive impairment. Based on the physician's capacity determination, the resident does not have capacity to make medical decisions. Record review revealed an eyewitness report by Nursing Assistant (NA) #17, on 05/05/24 which stated: Upon bed check me and another CNA were also passing linens. This CNA went into Resident #69's room to put linens in there, upon leaving and moving into the next room, me and said CNA were getting a two (2) assist up out of bed to the bathroom, when three (3) alarms started going off. The nurse was getting one on the other end of the hall, I had turned Resident #69's off because he was in the hallway already, then assisted other CNA with the assist off the toilet back into bed. This CNA came down the hallway to the other alarm, and upon coming down the hallway I found Resident #69 in a female resident's bed with her. He had his hand on her chest, on top of her shirt and was kissing female resident. This CNA tried to redirect Resident #69, and he became very combative with this CNA and was punching CNA as she continued to try to redirect him. Once resident was redirected out of female resident's bed and room he began to walk toward lobby. Once this CNA got Resident #69 redirected CNA went back to help with resident that had fallen out of bed, with the nurse and the second CNA. Resident #69 then made his way back down out of the lobby to the long hallway where this CNA tried to get him to turn back around into the lobby so he can be monitored by either CNA or nurse while bed check was completed. Resident #69 then began to swing on CNA balling his fists and saying Yeah, I got em Then he walked back into the lobby and sat in recliner chair and has since been calm Further record review revealed the following notes by facility staff: 05/05/24 at 01:30 AM a note by Licensed Practical Nurse (LPN) #152 which stated: During bed check resident alarm was going off, Resident #69 came out of room, started walking towards lobby, CNAs were getting up female peer to go to bathroom, who is a two assist. stopped in front of door of female peer. CNA told Resident #69 to keep going to lobby and he started walking towards lobby. CNAs were done in female peer room, a bed alarm was going off, CNA went to get it and saw Resident #69 in another female peer room, kissing her and touching breast on top of her shirt, CNA tried to redirect him out of room, Resident #69 got combative, started hitting CNA, he then tried going into another female peer room, he was brought out to lobby and is sitting in chair, Resident #69 has no bruising or marks on hands from hitting CNA. Social worker was called at this time. 05/05/24 at 3:45 AM a note by Social Worker (SW) #110 which stated: This social worker was informed by nursing at 1:58 am that Resident #69 was found kissing and fondling Resident #105's breasts while she was laying in bed. This social worker entered the building at 2:15 am and went to the dementia unit. This social worker spoke with nursing as well as the CNAs regarding the situation. Resident #69 was redirected to the lobby where he remains at this time. Staff instructed to provide 1:1 to him at this time to ensure the safety of his female peers. Incident was reported to APS Centralized Intake, APS local office, Ombudsman and OHFLAC as well as to Administrator #94 at 2:35 am. Weirton Police Department was called 3:15 am and arrived at the facility at 3:30 am. Report was filed- incident #2024050040. Resident #69's MPOA will be notified later this AM. (name of behavior health unit) and physician will be notified for further instruction/evaluation. 05/05/24 at 4:00 AM a note by SW #110 which stated: This social worker called and spoke with (name of behavior health unit) regarding a referral for admission. They requested a consent form be signed by Resident #69's MPOA. Form was faxed to this social worker (will obtain signature later this AM). They requested that the consent form and other documentation be sent (Face sheet, diagnosis list, physician order, covid and influenza vaccine records, MAR/TAR, H&P, nurse's notes, allergy list). They stated that once they receive the consent and information, their doctor will review everything to see if he will accept him as a patient. If he does, then Resident #69 will need to be sent to (name of hospital emergency department) for them to admit to behavioral health. 05/5/2024 at 08:30 AM a note by SW #110 which stated: This social worker placed a call to Resident #105's MPOA/husband 8:30 am to explain the situation that occurred regarding a male peer being sexual with resident. MPOA did not answer; message left to return the call at his earliest convenience. 05/05/24 8:15 AM a note by SW #110 which stated: This social worker called and spoke with Resident #69's MPOA regarding the incident. This social worker also explained that due to there being several incidents and an increase in aggressive behaviors and for the safety of his female peers, the facility would like to send him to the (name of behavior health unit). MPOA expressed many concerns about sending him to that facility and asked that his physician be notified. This social worker explained that physicians would be notified after ending the call with her. This social worker explained that a consent form would need to be signed by her. MPOA stated that she would need to speak with her children before making a decision. She stated she would call this social worker back. 05/05/24 at 9:00 AM a note by SW #110 which stated: This social worker received a call from Resident #69's daughter regarding the situation. This social worker explained everything to her. She expressed her concerns about the geri-psych facility as well as how long he might be there. All issues were addressed with her. Nursing paged physician and he returned call. This social worker and nurse on duty explained the situation of Resident #69 being sexual with a female peer The Physician stated to send the resident to (name of geriatric psychiatric unit). Nursing also paged physician with a return call. This social worker and nurse on duty spoke with the physician and explained the situation. He stated that prior to resident being admitted to Weirton Geriatric Center (WGC) he had seen him in the office and was very well aware of his aggressive behaviors and difficulty in being redirected and was concerned with his placement at that time but seems to have adjusted well although there has been an increase in sexual behaviors stating that he had his wife at home but now he doesn't and his behaviors are not acceptable in the current environment although he cannot control it due to his dementia. He stated that he was in agreement that resident be sent to a geri psych facility- either (name of towns). He stated that resident #69 requires 1:1 staff supervision at this time but stated that is not possible at Weirton Geriatric Center. This social worker asked if he would be willing to speak with resident's daughter, and he agreed. This social worker called resident's daughter and joined the calls. Physician spoke with resident's daughter and wife, who was also on the call, in length regarding the situation. He stated to them that it is in the best interest of all involved that resident be sent to the geri-psych facility. He reinforced that for the safety of the other residents that the transfer was necessary. He stated to them that if they needed anything at all to call him as he is available any time. Resident's daughter and wife thanked physician for speaking with them and physician ended the call on his end. This social worker continued to speak with resident's wife and daughter. Resident's daughter stated that she and her mom would come to the facility and sign the consent papers around 11 am. This social worker explained to them the process and that after the paperwork and consent would be signed and sent to the facility, their doctor would review it, and they would let this social worker/nursing know if they would accept him as a patient. They asked if WGC would transfer him, and this social worker stated yes. Resident's daughter and wife thanked this social worker for everything and ended the call. Administrator #94 updated. 05/05/24 at 10:41 AM a note by SW #110 which stated: Spoke with physician regarding the incident of male peer being sexual with Resident #105. No new orders received. 05/05/24 at 1:08 PM a note by SW #110 which stated: This social worker received a call back from Resident #105's MPOA/husband. This social worker explained to MPOA that a male peer was laying in bed with (name of Resident #105), kissing her and touching her breasts. This social worker informed him that the police were called, and a report was filed, that an investigation is being completed by this social worker, and that Resident #105 was assessed from head to toe including her vaginal area and no marks or bruising were noted. This social worker informed him that resident showed no ill effects from the incident. MPOA stated that he realizes that the male peer didn't know what he was doing and that he understands that things like this happen. He asked if resident seemed okay today, and this social worker stated she was in good spirits. He stated he understands that the residents have dementia and that they don't know what they are doing. MPOA stated that he would be visiting today and bringing Resident #105 some snacks. He thanked this social worker for calling to let him know what happened. This social worker stated that the staff will continue to ensure Resident #105's safety. 05/05/24 at 1:38 PM a note by SW #110 which stated: This social worker received a call from SW at East Liverpool Senior Behavioral Health Unit stating that they would accept Resident #69 as a patient. She stated that he could bring 3 outfits with no hoods or strings and 1 pair of shoes also without strings. She stated that they would provide everything else for him. She stated to take him first to (name of hospital emergency department) to be medically cleared. This social worker spoke with Resident #69's wife and daughter and informed them that the (name of behavior health unit) accepted him as a patient and relayed all the other information to them. They stated that they would transport resident to the hospital. This social worker and nurse on duty called (name of hospital emergency department) and gave report to their nurse. 05/05/24 at 2:48 PM a note by SW #100 stated: Resident #69 left the facility with his family at 2:36 pm in stable condition to be transferred to East Liverpool Hospital. Vitals obtained by nurse on duty and all vitals were within normal limits. Wander guard removed from left arm. No distress noted. Physician and Administrator #94 notified. 05/06/24 at 1:19 PM a note by SW #110 which stated: This social worker received a call from the discharge planner, from (name of behavior health unit). She asked if WGC would be taking resident back, and this social worker stated yes. Discharge planner then stated that they do not do the significant change PASSAR, and that WGC would need to complete that. This social worker stated that this would be communicated to our director of nursing. This social worker asked how Resident #69 was doing. She stated that he was very combative in the ER last night and was given Geodon. She stated that resident was up most of the night and is very sleepy today. She stated that physician at the facility started him on Celexa stating that it usually works for getting rid of sexual behavior. This social worker asked about a possible discharge time frame. She stated that on average, resident would be there for at least 5-7 days but that could vary. She stated that WGC would be notified 1 day before discharge. Discharge planner stated that she would be faxing updates and asked for the fax number which was provided by this social worker. She stated that she would be providing updates M-W-F. This social worker thanked her for calling with an update. Information was communicated to Director of Nursing (DON) #102, RN #183, and Administrator #94. 05/07/24 at 1:08 PM a note by SW 110 which stated: This social worker spoke with Resident #69's MPOA regarding how resident is doing. MPOA expressed her dissatisfaction of resident being in the (Name of behavior health unit) stating that she felt it was rushed and didn't understand why he had to go there. This social worker reiterated with MPOA that per resident's physicians, with whom MPOA spoke, they recommended that resident be sent to the behavioral health unit. MPOA stated that she has a lot of faith in physician, but that she is just still upset about the entire situation. She stated that she felt that resident #69 was being punished. This social worker explained that resident was not being punished in any way and reminded her that this wasn't the first incident as well as him masturbating frequently, and this social worker again reiterated to her that his physicians wanted resident sent to the behavioral health unit. MPOA then stated that the process of getting him there was not a good experience and that she felt they were forced to take him themselves. This social worker once again reiterated to MPOA that this social worker gave them the option of having WGC transport him there or her and her family could transport him, and they decided to transport him themselves. This social worker apologized to MPOA that it was such a bad experience. MPOA requested that WGC transport resident back once he is discharged from the behavioral health unit. This social worker stated that this would be discussed with Administration. MPOA stated that she and her family had to sit in the ER for 6 hours. This social worker apologized that they had to sit there that long; however, this was out of anyone's control. MPOA stated that she just wants him back at WGC as soon as possible but understood that the new medication takes time to work. MPOA stated that she felt better talking to this social worker as she needed to express how she was feeling. This social worker once again apologized that this whole situation occurred, but that it was necessary per resident's physicians. MPOA stated that it's over now and that she would be going to visit him today. She thanked this social worker for calling. 05/10/24 at 3:05 PM a note by Activities Staff Member (ASM) #7 which stated: admission completed the WV PAS based on two reports sent from (name of behavior health unit) on the second fax- discharge was asked for Monday 13th, but the WV PAS had not been signed by any physician. and with him being on new medication/diagnosis this needed reviewed. ASM #7 called E.L at 2:33pm and left a VM stating that we could not admit him on 13th, due to the above info. With no return call back. WV PAS was then signed by resident's physician at 2:45pm, I spoke to him on the phone and physician was not comfortable with a Monday return until a psych eval is completed by psychologist. The PAS triggered a level 2. Admin #94 and DON #102, SW #110 were updated. Once psych eval is completed and update is received from E.L. further discharge plans will be discussed. 05/10/24 at 3:22 PM a note by ASM #7 which stated: 3:30 pm on 5-10 VM (voicemail) was left for psychologist, asking to have an eval completed on Resident #69. since there was a lv.2 on WV PAS. Will try to call back on Monday, 13th. 05/13/24 at 2:11 PM a note by SW #110 stated: This social worker received a call from Resident #69's wife. She stated that she has been upset because she wants to know if WGC is going to accept him back or if she needs to figure something else out. This social worker explained to resident's wife that currently the admission coordinator is working on obtaining a psychological evaluation which is required for the Pre-admission screening which triggered for a level 2. This social worker explained that if or when resident returns to WGC, changes may have to be made such as a possible room change placing him closer to the nurse's station, etc. Resident's wife expressed her understanding. She then stated that she had spoken to the staff at (name of beahavior health unit), and they told her that he hasn't had any behaviors as opposed to the behaviors at this facility that was told to her by this social worker. This social worker explained that in the reports that this facility received from (name of behavior health unit), it was noted that he was having sexual behaviors there and had actually cornered a nurse on May 8th. Resident's wife asked this social worker why they told her he wasn't having behaviors. This social worker advised resident's wife to speak to someone at (name of behavior health unit) in regard to that situation as this social worker is unable to know why they didn't communicate the correct information to her. Resident's wife stated that she is still upset about the situation. This social worker again explained why it was necessary for resident to be transferred to the (name of behavior health unit) as it wasn't the first incident of sexual behavior toward his peers. Resident's wife thanked this social worker for talking with her and stated she was going to call (name of behavior health program) and ended the call. 05/16/24 at 1:15 PM a note by LPN #124 which stated: Returned to facility at this time via WGC transport. CNA assisted Resident #69 from transport van to unit, noted difficulty with transfer. Resident non-compliant with staff. Resident was transferred to a private room, room [ROOM NUMBER]. Assisted to bathroom, noted to be in poor state of cleanliness, unshaven facial hair along with body odor. Was inc of loose stool, staff provided care at[TRUNCATED]

b) Resident #89 On 04/07/24 at approximately 7:30 PM, Resident #89 was near the nurse's station, at the table where books were laid out for the resident's use. She was selecting some books from the table when Resident #57 took exception to it. Resident #57 beckoned her over, grabbed her fingers and twisted hard, yelling Give me the books. Put them back! During an assessment of Resident #89's, right hand on 04/07/24 at 8:27 PM, by RN #43, she documented that resident had stated that her right hand hurt, but that she would be okay. RN noted that no swelling was visible, but the resident experienced slight pain upon movement of the hand. Physician had been notified of the incident on 04/07/2024 at 8:36 PM. He had ordered an x-ray of the right hand for the next morning, and ice packs for swelling if needed. Review of the X-ray on 04/09/24 revealed no acute fractures, or other injuries. A review of facility records, on 08/28/24 at 9:42 AM, revealed that the facility staff had faxed an initial report to the Office of Health Facility Licensure and Certification (OHFLAC), Adult Protective Services (APS), and the Ombudsman on 04/08/24 at 8:50 AM, which was not within the required two (2) hour window for reporting allegations of abuse with injury. During an interview with SW #45, on 08/28/24 at 9:13 AM, she confirmed that the report was not faxed out in a timely manner. Based on record review and staff interview, the facility failed to ensure that all alleged violations involving abuse and the administration of physician ordered medication in excessive doses were reported in a timely fashion to all appropriate state agencies. This was true for two (2) out of seven (7) facility reported incidents (FRIs) reviewed. Resident identifier: #89. Facility census: 121. Findings included: a) On 07/17/24, RN #183 was notified of a rumor that LPN #406 may be administering extra melatonin to the residents on the dementia unit to help them sleep better. On 07/22/24, the Director of Nursing was notified by RN #183 of the rumor and was told that RN #183 believed it to be true. The facility reported the allegation on 07/25/24. During an interview on 08/27/24 at 11:25 AM, Assistant Administrator #130 reported that the facility had been so involved in investigating the validity of the allegation that it had been an oversight that the allegation had not been reported timely.

. Based on observation and staff interview, the facility failed to maintain a resident's room in a clean and homelike manner. Feeding tube supplies were in an open box on the floor and filling up the visitor chair in the room. This is true for one (1) of two (2) residents reviewed for feeding tubes. Resident identifier: #18. Facility census: 119. Findings included: a) Resident (R)#18 An observation on 03/27/23 at 10:23 AM, revealed an open box on the floor in R#18's room containing five unused feeding tube bags. In addition, the chair in the room contained two open and one closed case of Glucerna tube feeding bottles, leaving no place for a visitor to sit. At 10:25 AM on 03/27/23, Registered Nurse (RN) #26 confirmed these findings and immediately picked the feeding bags up off the floor and cleared the chair for visitors. .

. Based on Resident Council Meeting, observations and staff interview, the facility failed to post grievance forms in prominent locations throughout the facility. A resident or resident representative should have access to grievance forms, and freedom to file grievances anonymously. This had the potential to affect a limited number of residents. Facility census: 119. Findings included: a) Posting grievance forms The Resident Council President 03/28/23 at 11:05 AM, reported she was not aware of any grievance forms being available in the facility. She also reported if you wanted to file a grievance you needed to go through staff. During observations after the Resident Council Meeting, it was discovered the grievance forms were not accessible to residents or family in prominent locations on either the second or third floor. In an interview on 03/28/23 at 11:55 AM, with the Director of Social Services, verified the grievance forms were not located throughout the facility and were not accessible to residents and family. .

. Based on record review and staff interview the facility failed to develop a person-centered care plan to address the resident's medical, physical, mental and psychosocial needs. This was discovered for one (1) of five (5) residents reviewed for the area of unnecessary medications. The care plan for Resident #11 was not developed for the use of psychotropic medication. Resident identifier: #11. Facility census: 119. Findings included: a) Resident #11 A medical record review on 03/29/23, revealed Resident #11 had orders for Seroquel 25 milligrams (mg) once daily for paranoid thoughts and agitation, Zoloft 50 mg once daily for major depression, and Buspirone 5 mg twice daily for anxiety. Further medical record review, found there was no care plan developed for use of psychotropic medications. In an interview with the Director of Nursing on 03/29/23 at 11:21 AM, they verified there was no care plan developed for the psychotropic medications for Resident #11. .

. Based on record review, staff interview and policy review the facility failed to ensure residents receive treatment and care in accordance with professional standards of practice. The facility failed to complete neurological checks for an unwitnessed fall. This was true for one (1) of three (3) residents reviewed for falls during the Long Term Care Survey Process. Resident identifier: #72 Facility Census: 119 Findings Included: a) Resident #72 Record review on 3/29/23 at 11:31 AM shows Resident #72 had an unwitnessed fall on 11/26/22 at 7:00 PM. She obtained a left leg skin tear which was treated at the center with first aid. Upon review of the neurological policy and medical record documentation the facility did not complete any neurological checks until 11/26/22 at 11 PM, four (4) hours after the fall. The facility policy (not dated) for Events of a Fall states: . Neurological Assessment MUST be performed immediately and then every four (4) hours for seventy two (72) hours following the fall . This was confirmed with the Director of Nursing on 3/29/23 at 10:45 AM. .

. Based on observation, medical record review, and interview, the facility failed to deliver respiratory care services consistent with professional standards of practice. Oxygen supplies were not properly stored. This was a random opportunity for discovery, during the Long-Term Care Survey Process. Resident identifiers: #64, and #42. Facility census: 119. Findings Included: a) Resident #64 An observation on 03/27/23 at 11:23 AM found Resident #64's face mask for his bilevel positive airway pressure (BIPAP) laying on a shelf without being placed in a protective bag. An interview on 03/27/23 at 11:35 AM with License Practical Nurse (LPN) #145 confirmed that Resident #64's's BIPAP Mask should be placed and stored in a protective bag when not in use. Resident #42 b) On 3/27/23 at 1:40 PM, an observation was made of Resident #42's BiPap mask sitting on the bedside table, not in a protective storage bag. At this time Registered Nurse (RN) #102 confirmed the Bipap was not in the proper storage bag. .

. Based on record review and staff interview, the facility failed to ensure each medication order included an adequate indication for use. This is true for two (2) of nine (9) residents reviewed for medications during the long term care survey process. Resident identifiers: #111, #91. Facility census: 119. Findings include: a) Resident (R) #111 A review of the medical record on 03/28/23 at 9:00 AM revealed R#111 had physician orders and medication administration record lacked diagnoses or a reason for medication administration for the following drugs: Augmentin (antibiotic) 500-125 milligrams (mg) once a day Flomax (alpha-blocker used to treat benign prostatic hyperplasia) 0.4 mg once a day Gabapentin (controlled substance used to treat nerve pain) 100 mg three times a day Prilosec (proton-pump inhibitor for heart burn) delayed release 20 mg once a day Risperdal (antipsychotic) 0.5 mg once a day Tylenol 650 mg twice a day During an interview at 9:40 AM on 03/28/23, Licensed Practical Nurse (LPN) #108 reviewed the medical record including the electronic medication administration record and the monthly physician order report. LPN #108, confirmed R#111's medication orders were incomplete. The following medications lacked a diagnosis or indication for use: Augmentin, Flomax, Gabapentin, Prilosec, Risperdal, and Tylenol. b) Resident #91 Resident #91 has an order for Cipro (antibiotic) (Ciprofloxacin HCL) tablet; 250 milligrams; oral twice a day at 6:00 AM and 8:00 PM. Start date of 3/21/2023, ending on 3/28/2023. There was no diagnosis for this medication listed on the order. According to documentation provided, the resident presented confused on 3/16/23 at 9:00 AM. There is an order from the Physician on 3/16/23 at 11:30 am for a urinalysis with culture and sensitivity (U/A & C&S). Results of this U/A C&S was faxed to the physician on 3/20/23 at 10:55 AM and a order for the antibiotic was received on 3/21/23 at 3:00 PM for the Urinary Tract Infection (UTI). This was confirmed with the Director of Nursing on 3/28/23 at 1:30 PM. .

. Based on record review and staff interview, the facility failed to ensure each medication order included an adequate indication for use for psychotropic medications. Resident identifiers: #42 and #104. Facility Census: 119 Findings Included: a) Resident #42 Resident #42 has a diagnosis of anxiety and major depressive disorder. She has an order for Buspirone (anti anxiety) tablet 5 milligrams, oral, twice a day at 6:00 AM and 6:00 PM start date 11/09/22, and was current order at the time of this review. There was no diagnosis for this medication. This was confirmed with the Director of Nursing on 3/28/23 at 1:30 PM. b) Resident #104 Resident #104 has a diagnosis of major depressive disorder. She has an order for Citalopram (anti depressant) tablet 20 milligrams, oral, once a day at 6:00 AM for a diagnosis of Acute embolism and thrombosis of unspecified deep veins of the right distal lower extremity). This is an inappropriate diagnosis for this medication. Citalopram is used for depression , not deep vein thrombosis (DVT). This was confirmed with the Director of Nursing on 3/28/23 at 1:30 PM. .

. Based on Interview and record review the facility failed to ensure all qualified staff had their food handler's card. This has the ability to affect all Residents that get their nutrition from the kitchen. Facility census: 119. Findings included: a) Kitchen On 03/28/23 at 1:23 PM a review of training certificate for food handlers found: Dietary staff #65 - No documentation of Food Handlers Training prior to 03/27/23. During an Interview with the Assistant Administrator on 03/29/23 at 11:45 AM, verified the staff in question did not have Food Handlers Training until 03/27/23. .

. Based on observation and staff interview the facility failed to monitor temperatures on a resident's refrigerator. This was a random opportunity for discovery. Resident identifier: #18. Facility census: 119. Findings include: a) Resident (R) #18 An observation at 10:23 AM on 03/27/23 revealed an incomplete daily temperature log on the side of R#18's refrigerator. The last temperature documented was on 03/23/23. Registered Nurse #26 confirmed R#18's refrigerator temperature log was not up to date during an interview at 10:30 AM on 03/27/23. .

. Based on observation and staff interview the facility failed to store garbage and refuse in a proper manner. The compactor areas were polluted with garbage, debris and medical supplies with the potential to attract pests and vermin. This has the potential to affect a limited number of residents that reside in the facility. Facility census: 119. Findings included: a) Compactor areas An observation on 03/29/23 at 1:45 PM found the nursing compactor area had used medical supplies laying on the ground around the compactor. A continued observation on 03/29/23 at 1:53 PM found the kitchen compactor lid was open and the area was littered with kitchen debris, on the ground around the compactor. On 03/29/23 at 1:54 PM during an Interview the maintenance staff #150 they verified the trash and medical supplies should not be laying on the ground around the facility compactors. .

. Based on record review and staff interview, the facility failed to maintain a complete and accurate medical record for two (2) of 29 sampled residents during the Long-Term Care Survey Process. Specifically, the facility failed accurately record a written physician order in the electronic medical record for Resident #57 and Resident #108. The facility also failed to maintain a complete and accurate medical record for one (1) of two (2) residents reviewed for the area of dialysis during the Long-Term Care Survey Process. Resident identifiers: #57, #108, and #73. Facility census: 119. Findings included: a) Resident #57 A record review, completed on 03/28/23 at 1:34 PM, revealed the following: -Resident is prescribed Miralax. -The written physician order, dated 10/07/22, read Miralax, 17 gram/dose PO [by mouth] QD [once a day] for constipation. -The physician order in the electronic medical record, failed to include the medical diagnosis of constipation. During an interview, on 03/28/23 at 1:38 PM, the Director of Nursing (DON) stated when the order was placed in the electronic medical record the facility failed to ensure it was accurate and staff entering the order failed to include the diagnosis/reason for the medication. b) Resident #108 A record review, completed on 03/28/23 at 1:37 PM, revealed the following: -Resident is prescribed Biofreeze. -The written physician order, dated 07/07/22, read Biofreeze BID to effected areas d/t [due to] pain in back. -The physician order in the electronic medical record, failed to include the medical diagnosis/reason for the medication as pain in back. During an interview, on 03/28/23 at 1:39 PM, the DON stated when the order was placed in the electronic medical record the facility failed to ensure it was accurate and staff entering the order failed to include the diagnosis/reason for the medication. c) Resident #73 During a record review on 03/28/23, it was discovered there were incomplete Dialysis Communication forms for the dates of 01/30/23, 02/13/23, 02/24/23, 03.03/23, and 03/17/23. In an interview with the Unit Manager #102 on 03/28/23 at 11:00 AM, verified the dialysis communication forms were incomplete with no per and post weights or vitals. .

Based on observation and staff interview the facility failed to maintain resident's equipment in safe operating condition. During a random opportunity for discovery during the Long Term Care Survey Process, Resident #17's wheelchair was identified to be unsafe. Resident identifier #17. Facility census: 119. Findings included: a) Resident #17 During a random opportunity for discovery on 03/27/23 at 10:30 AM, revealed the wheelchair for Resident #17 had an exposed metal brake handle with a sharp edge, and foam padding taped on the right arm rest. In an interview with Unit Manager #102 on 03/28/23 at 9:40 AM, verified the wheelchair had an exposed metal sharp edge on the brake handle, which could cause injury for Resident #17. Also foam padding on the right arm rest was not easy to clean.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interview, the facility failed to ensure resident falls resulting in serious bodily injury were reported in a timely manner to the appropriate state agencies. The failure to make a timely report and to report to the appropriate state agencies was true for three (3) of three (3) sampled residents for falls resulting in serious bodily injury during the Long Term Care Survey Process. Resident identifiers: #57, #108, and #67. Facility census: 119. Findings included: a) Resident #57 A medical record review, completed on 03/28/23 at 08:10 PM, revealed the following details: -Resident #57 experienced a fall on 12/16/22. -An x-ray was obtained and on 12/17/22. -A nurses note on 12/17/22 at 2:15 PM noted, Received final x-ray report as follows: Acute fracture involving the femoral neck bone which indicated a hip fractured. -Resident #57 was then sent out to the hospital and admitted for surgical repair. -A review of the facility reportable's revealed the serious bodily injury was reported to the Office of Health Facilities Licensure and Certification (OHFLAC) on 12/17/22 at 8:18 PM, over 6 hours after the facility having knowledge of serious bodily injury. -There was no evidence the facility had reported the serious bodily injury to Adult Protective Services (APS). During an interview on 03/29/23 at 7:45 AM, Social Worker #42 reported she had never reported serious bodily injuries to APS. The Social Worker acknowledged this was an error on her part that she will correct. Social Worker #42 also acknowledged the facility's failure to report within 2 hours. b) Resident #108 A medical record review, completed on 03/28/23 at 7:16 PM, revealed the following details: -Resident #108 experienced a fall getting up from her bed on 03/20/23 at 5:05 PM. -A new physician order to send Resident #108 to the emergency room for evaluation was given on 03/20/23 at 5:45 PM. -On 03/20/23 at 8:30 PM, a family member called the facility and reported the following update, . has a fracture of right humerus. She is being admitted to hospital and will have a ortho [orthopedic consult] in morning. -A review of the facility reportable's revealed the serious bodily injury was reported to OHLFAC the following day on 03/21/23 at 9:06 AM, over 12 hours after the facility having knowledge of serious bodily injury. -There was no evidence the facility had reported the serious bodily injury to APS. During an interview on 03/29/23 at 8:00 AM, Social Worker #42 reported she had never reported serious bodily injuries to APS. The Social Worker acknowledged this was an error on her part that she will correct. Social Worker #42 also acknowledged the facility's failure to report within 2 hours. c) Resident #67 On 3/28/23 at 9:22 AM a record review found Resident #67 fell on [DATE] at 9:00 AM. She was sent to the local emergency room for evaluation. She returned to the facility at 12:00 PM. Discharge records from the local hospital shows she had a right humerus fracture. This was noted by the nurse on duty upon return on 11/20/22. Documentation shows this was reported to the appropriate state agencies twenty-two (22) hours after learning of a fractured humerus. The injury was reported on 11/21/22 at 10:11 AM (Adult Protective Services (APS) and 10:13 (Office of Health Facility Licensure and Certification (OHFLAC). On 3/29/23 at 9:46 AM it was confirmed with Social worker #170 the incident should have been reported within a two hour window frame once it was confirmed that this injury was a fracture. .

. Based on record review and staff interview, the pharmacist failed to identify incomplete medication orders during their Medical Record Review (MRR). Resident identifiers: #42, #91 and #104. Facility Census: 119 Findings Included: a) Resident #42 Resident #42 has a diagnosis of anxiety and major depressive disorder. She has an order for Buspirone (anti anxiety medication) tablet 5 milligrams, oral, twice a day at 6:00 AM and 6:00 PM start date 11/09/22 with no end date. There was no diagnosis listed for this medication order. The pharmacist failed to identify this incomplete medication order during their MRR. This was confirmed with the Director of Nursing on 3/28/23 at 1:30 PM. b) Resident #91 Resident #91 has an order for Cipro (antibiotic) (Ciprofloxacin HCL) tablet; 250 milligrams; oral twice a day at 6:00 AM and 8:00 PM. Start date of 3/21/2023, ending on 3/28/2023. There was no diagnosis for this medication order. According to documentation provided, the resident presented confused on 3/16/23 at 9:00 AM. There was an order from the Physician on 3/16/23 at 11:30 AM for a urinalysis with culture and sensitivity (U/A & C&S). Results of this U/A C&S was faxed to the physician on 3/20/23 at 10:55 AM with a new order on 3/21/23 at 3:00 PM for the Cipro for a Urinary Tract Infection (UTI). The pharmacist failed to identify this incomplete medication order during their MRR. This was confirmed with the Director of Nursing on 3/28/23 at 1:30 PM. c) Resident #104 Resident #104 has a diagnosis of major depressive disorder. She has an order for Citalopram (anti depressant) tablet 20 milligrams, oral, once a day at 6:00 AM for a diagnosis of Acute embolism and thrombosis of unspecified deep veins of the right distal lower extremity). This is an inappropriate diagnosis for this medication. Citalopram is used for depression , not deep vein thrombosis (DVT). The pharmacist failed to identify this incorrect medication order during their MRR. This was confirmed with the Director of Nursing on 3/28/23 at 1:30 PM. .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation and staff interview, the facility failed to ensure resident rooms were designed or equipped to assure full visual privacy for each resident. This was true for five (5) out of five (5) resident rooms during the long-term care survey process. Resident identifiers: #108, #57, #55, #12, and #103. Facility census: 119. Findings included: a) room [ROOM NUMBER] Observation, on 03/27/23 at 2:11 PM, revealed there was one (1) privacy curtain in the room that could extend in a straight line between the two (2) resident beds in the room. Resident #12 was placed in the A-bed, which is the bed closest to the door. During a second observation, on 03/28/23 at 10:17 AM, LPN #128 acknowledged there was nothing that would afford Resident #12 full privacy should her roommate enter the room in an attempt to get to the B-bed, which is the bed closest to the window. b) room [ROOM NUMBER] Observation, on 03/27/23 at 2:26 PM, revealed there was one (1) privacy curtain in the room that could extend in a straight line between the two (2) resident beds in the room. Resident #103 was placed in the A-bed, which is the bed closest to the door. During a second observation, on 03/28/23 at 10:14 AM, LPN #128 acknowledged there was nothing that would afford Resident #103 full privacy should his roommate enter the room in an attempt to get to the B-bed, which is the bed closest to the window. c) room [ROOM NUMBER] Observation, on 03/27/23 at 2:34 PM, revealed there was one (1) privacy curtain in the room that could extend in a straight line between the two (2) resident beds in the room. Resident #108 was placed in the A-bed, which is the bed closest to the door. Resident #55 was placed in the B-bed, which is the bed closeest to the window. During a second observation, on 03/28/23 at 10:15 AM, LPN #128 acknowledged there was nothing that would afford Resident #108 full privacy should her roommate enter the room in an attempt to get to the B-bed, which is the bed close to the window. Additionally, LPN #128 acknowledged there was nothing that would afford Resident #55 full privacy should her roommate attempt to look out of the window in the room. d) room [ROOM NUMBER] Observation, on 03/27/23 at 3:39 PM, revealed there was one (1) privacy curtain in the room that could extend in a straight line between the two (2) resident beds in the room. Resident #57 was placed in the A-bed, which is the bed closest to the door. During a second observation, on 03/28/23 at 10:17 AM, LPN #128 acknowledged there was nothing that would afford Resident #57 full privacy should his roommate enter the room in an attempt to get to the B-bed, which is the bed closest to the window. .

. Based on observation, interview, and record review, the facility failed to ensure a resident's right to self-determination, and the reassessment of mental capacity as evidenced by the resident's improved cognition. This failed practice was true for one (1) of 30 residents reviewed during the long-term care process. Resident identifier: #94. Facility census: 115. Findings included: a) Resident #94 During an interview on 11/15/21 at 1:43 PM, Resident #94 reported having a cerebral aneurysm and cerebrovascular accident (CVA) prior to being admitted to the facility. Resident reported she has come a long way since her admission a few years ago and has regained a lot of her physical abilities as well as experiencing a marked increase in her cognitive abilities. Resident #94 reported a family member had been appointed to act on her behalf when she was first admitted and that she is very close to that family member. Resident #94 expressed the fact that she and the appointed family member discuss her care openly and there has never been a time she has ever disagreed with her legal representative's decisions. A review of Resident #94's medical record was completed on 11/15/21 at 3:30 PM. --There was a Physician Determination of Capacity, dated 02/04/21, which reflected Resident #94 demonstrated incapacity to make medical decisions. The reason listed was CVA/Cerebral aneurysm. --A quarterly Minimum Data Set (MDS), with an assessment reference date of 08/05/21, revealed a Brief Interview for Mental Capacity (BIMS) score of 15. A score of 15 would indicate a person was cognitively intact. - A Mini Mental Status Exam (MMSE), completed on 10/19/21, reflected a score of 27. A score of 27 out of 30 would indicate a person had normal cognition. On 11/16/21 at 12:18 PM, Social Worker #180 was asked if Social Services had brought the BIMS and MMSE scores to the physician's attention and if a request had been made to reassess Resident #94's mental capacity. Social Worker #180 reported a request had not been made for the physician to reassess the resident's capacity to make medical decisions. On 11/17/21 at 1:20 PM, Social Worker #180 stated a new Physician Determination of Capacity had just been completed and it was determined Resident #94 demonstrated capacity to make her own medical decisions at this time. .

. Based on observation and interview, the facility failed to provide reasonable accommodation in regards to a call light being accessible to the resident. This failed practice had the potential to affect a limited number of residents. Resident identifiers: #39. Facility census: 115. Finding included: a) Resident #39 An observation on 11/15/21 at 2:00 PM found Resident #39 lying in bed without a call light in reach. This failure would make Resident #39 unable to call for help or assistance. On 11/15/21 at 2:15 PM with Registered Nurse (RN) #20 verified, Resident #39's call light was not in reach of resident and stated residents should always have their call system in reach. RN #20 placed the call light in reach at this time. On 11/18/21 at 9:15 AM, the findings were discussed with the Administrator. No other information was provided prior to the end of survey on 11/18/21 at 12:30 PM. .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review and interview, the facility failed to ensure two (2) of (30) residents reviewed during the long-term care survey process had a Physician Orders for Scope of Treatment (POST) form completed per directions specified by the [NAME] Virginia Center for End-of-Life Care in conjunction with the [NAME] Virginia Health Care Decisions Act (16-30-1). Resident identifiers: #45 and #104. Facility census: 115. Findings included: a) Resident #45 Record review on [DATE] at 03:16 PM, revealed section for Patient Information, Section D - (signature of Patient /Resident, Guardian/MPOA Representative/Surrogate -Mandatory) and Date on Resident #20's active Physician Order for Scope of Treatment Form (POST Form) was not completed. During an interview on [DATE] at 01:22 PM with Social Worker (SW) #180, confirmed Resident #45's POST form D was incomplete. b) Resident #104 Record review on [DATE] at 03:24 PM, revealed section A for Cardiopulmonary Resuscitation (CPR) -Marked Attempt Resuscitation/CPR) on Resident #104's active Physician Order for Scope of Treatment Form (POST Form). Further Review revealed, a Directive Sheet marked I wish to have a Do Not Resuscitate Order. During an interview on [DATE] at 01:39 PM with SW #180, confirmed there was a discrepancy in Resident #104's POST form and Directive Sheet. SW #180 stated the Post form should have been voided after Resident #104 returned from the last hospital stay. SW #80 removed the POST form during the interview. On [DATE] at 9:15 AM, the findings were discussed with the Administrator. No other information was provided prior to the end of survey on [DATE] at 12:30 PM. .

. Based on record review and staff interview, the facility failed to ensure a Minimum Data Set (MDS) was accurately completed. This is true for one (1) of 30 residents reviewed. Facility census 115. Resident identifier #52. Findings included: a) Resident #52 On 11/15/21 at 1:40 PM review of the MDS for Resident #52 found on 10/01/21 the accurate diet was not captured on MDS. Interview with MDS coordinator #36 on 11/16/21 at 2:17 PM in section K of MDS on 10/01/21 did not capture a therapeutic diet. MDS coordinator #36 reviewed MDS on that date and diet from that MDS review and agreed that it was not accurate and stated, I will have to modify the MDS. .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, record review, and staff interview, the facility failed to revise the comprehensive care plan when a change in condition occurred. This failed practice had the potential to affect two (2) of 30 residents reviewed during the long-term care survey process. Resident identifiers: #85 and #8. Facility census: 115. Findings included: a) Resident #85 Review of Resident #85's medical records showed the resident experienced weight loss while in the hospital from [DATE] to 11/1/21. On 10/07/2021, the resident weighed 142 lbs. On 11/02/2021, the resident weighed 132 pounds which is a 7% weight loss. On 11/09/21, Resident #85 continued to weigh 132 pounds. On 11/16/21 at 12:40 PM, Resident #85 was noted to be sitting in a chair with her lunch tray in front of her. The resident was not eating. The resident did not respond to the surveyor's questions. During an interview on 11/16/21 at 12:50 PM, Employee #151, who was noted to be distributing trays to residents, stated Resident #85 was independent in eating and does not like assistance with meals. Resident #85's quarterly Minimum Data Set (MDS) Assessment with Assessment Reference Date (ARD) 10/21/21 confirmed the resident was independent for eating. On 11/17/21 at 8:39 AM, Resident #85 was noted to be in bed eating breakfast. The resident's breakfast tray was on the over-bed table beside her bed, instead of over her bed. The resident was reaching over to obtain items from the tray. The resident also had a bowl of creamy substance in the bed beside her. The resident was using a spoon to eat from the bowl. Again, Resident #85 would not speak to the surveyor. On 11/17/21 at 8:45 AM, Licensed Practical Nurse (LPN) #125 stated Resident #85 preferred her over-bed table with her tray beside her bed, rather than over her bed. LPN #125 also stated the resident liked to place her bowl in her bed to eat. LPN #125 stated Resident #85 prefers to feed herself and may stop eating if staff intervenes or attempts to assist her with eating. Review of Resident #85's comprehensive care plan showed she was care planned multiple health problems related to history of weight gain. The care plan did not contain a focus for weight loss. Additionally, the care plan did not contain any approaches related to the resident's preferences in feeding herself. During an interview on 11/17/21 at 9:13 AM, the Director of Nursing (DON) was informed Resident #85 was not care planned for weight loss and was not care planned for the ways she preferred to feed herself. The DON had no additional information regarding the matter. No additional information was provided through the completion of the survey. b) Resident #8 On 11/15/21 at 1:17 PM, observation found the Resident had a contracture of the right hand and was wearing a palm protector on her right hand. The Resident said she has to wear the protector because she can't use her right hand after she had a stroke. Review of the current physician's orders found an order dated 03/31/21, for a right hand palm protector at all times, except for hygiene. Review of the current plan of care with unit manager Registered Nurse RN #67 on 11/18/21 at 8:50 AM, confirmed the care plan did not include the use of the palm protector to the right hand or any mention of removing the palm protector to clean the right hand. .

. Based on observation, record review and interview, the facility failed to ensure one of two residents reviewed for the care area of position/mobility received the equipment necessary to maintain proper positioning while using a geri-chair. Resident identifier: #83. Facility census: 115. Findings included: a) Resident #83. Observation of the Resident on 11/15/21 at 1:00 PM found the Resident in his room seated in a geri-chair. The Residents feet were dangling at least a foot above the floor. The chair had no leg rests. A second observation on 11/16/21 at 11:38 AM, with Unit Manager, Registered Nurse (RN) #7 found the resident was again in his room seated in his geri-chair with his feet dangling about 1 foot above the floor. RN #7 confirmed the Resident feet and ankles were swollen with edema. The Resident receives the medication, Lasix for edema. RN #7 said therapy would be contacted to assess the Resident for foot rests for the geri-chair. On 11/16/21 at 12:26 PM, observation found the manager of rehabilitation, certified occupational therapy assistant (COTA) #218 applying a foot rest to the Resident's wheelchair. On 11/16/21 at 2:57 PM, the above observation was discussed with the Director of Nursing (DON). On 11/18/21 at 7:51 AM the DON said the chair was fixed with foot rests. .

. b) Resident #104 An observation on 11/15/21 at 1:48PM found, Resident #104's catheter bag directly laying on the floor. During an interview with Registered Nurse (RN) #38, on 11/15/21 at 1:48 PM, verified the catheter bag was on the floor. RN #38 stated that a catheter bag should never touch the floor. At this time, RN #38 hung it at an appropriate height. This issue was discussed with the administrator on 11/18/21 at 9:15AM. No further information was provided prior to the end of the survey on 11/18/21 at 12:30PM. Based on staff interview, observation, and record review, the facility failed to ensure tubing and drainage bags were not resting on the floor of the facility for two of four residents reviewed for catheter care. Resident identifiers: #64 and #104. Facility census: 115. Findings included: a) Resident #64 During an interview with the Resident at 1:42 PM on 11/15/21, the Resident said she had a super pubic catheter which she had for about 10 years. She said, I had this before I came to the facility. The Resident was setting in her wheelchair in her room. Observation found the catheter drainage bag was hooked under the seat of her wheelchair. The bottom of the drainage bag and part of the tubing were resting on the floor. A second observation on 11/17/21 at 10:38 AM, found the Resident was setting in her wheelchair in her room. Observation found the catheter drainage bag was hooked under the seat of her wheelchair. The bottom of the drainage bag and part of the tubing were resting on the floor. Unit Manager, Registered Nurse (RN) #67 observed the resident and said, Its supposed to be hooked under the chair and not touching the floor. On 11/17/21 at 11:11 AM, two (2) Nursing Assistants (NA) #13 and #193 said catheter bags and tubing should not be on the floor. On 11/18/21 at 7:55 AM, the above observations were discussed with the Director of Nursing. .

. Based on observation, medical record review and interview, the facility failed to deliver respiratory care services consistent with professional standards of practice. A physician's order for oxygen was not followed. This is true for one of two reviewed during the Long-Term Care Survey Process (LTCSP). Resident Identifier: #93. Facility Census: 115. Findings included: a) Resident #93 An observation of Resident #93, on 11/15/21 at 10:15 AM, revealed the Resident #93 was receiving oxygen at three (3) Liters via nasal cannula (an oxygen delivery device) from an oxygen concentrator. A review of Resident #93's physician order, revealed the order Wear Oxygen at two (2) Liters Per Minute (LPM), via Nasal Cannula continuously, with an order date of 06/10/21. A second observation of Resident #93, on 11/17/21 at 10:50 AM, revealed the Resident was receiving oxygen at three (3) Liters via nasal cannula from an oxygen concentrator. An interview with Licensed Practical Nurse (LPN) #125 on 11/17/21 at 11:00 AM, verified the Resident was receiving oxygen at three (3) Liter Per Minute. LPN #125 confirmand that Resident #93 was ordered oxygen at two (2) Liters via nasal cannula and verified the oxygen level was wrong. (LPN) #125 changed Resident #93's oxygen to two (2) LPM on the concentrator. On 11/18/21 at 9:15 AM, the findings were discussed with the Administrator. No other information was provided prior to the end of survey on 11/18/21 at 12:30 PM. .

. Based on observation, interview and record review, the facility failed to ensure one of one resident reviewed for dental services received assistance with obtaining repairs to broken dentures. Resident identifier: #57. Facility census: 115. Findings included: a) Resident #57 On 11/15/21 at 12:25 PM, the resident said his dentures were broken and they needed repaired. He stated, I can't afford to buy a new pair. The resident said his teeth had been broken for quite some time. He believed they were broken while he was at the hospital, when a nurse dropped the denture cup by accident. He stated he had a good looking sandwich for lunch piled high with lettuce, tomato, and meat but he could not bite down on it due to not having his dentures. He said he took the sandwich apart to eat it but it would have been easier if he had his teeth in. The resident retrieved the dentures from his denture cup setting beside the sink. The dentures were soaking in water. A half moon shaped chunk the size of a quarter was missing from the upper denture, just above the teeth area of the denture. On 11/17/21 at 8:46 AM, the minimum data set coordinator Registered Nurse (RN) #36 said she wasn't aware the resident had any dentures, Nursing staff would have assessed the resident for dentures. The residents nursing assistant (NA ) #160 was interviewed on 11/17/21 at 11:50 AM. When ask if he was aware the residents teeth were broken, he stated no, but the resident, wears them if he wants. On 11/18/21 at 7:47 AM, the Director of Nursing (DON) said the resident didn't have any dentures when he came to the facility so she didn't know who brought his dentures into the facility. The observation of the dentures was made on 11/15/21; therefore, the dentures were broken for at least 3 days when reported by the surveyor. The DON said she would get him an appointment to have the dentures repaired. .

. Based on observation, record review and staff interview, the facility failed to provide food in a form to meet the needs of residents. This failed practice had the potential to affect two of six residents reviewed for the care area of nutrition. Resident identifiers: #69, #46. Facility census: 115. Findings included: a) Resident #69 Review of Resident #69's medical records showed an order written on 09/10/21 for soft diet with chopped meat with gravy/sauce. On 11/16/21 at 12:20 PM, Resident #69 was observed eating in the third-floor dining area. He had been served from the satellite kitchen on the third floor. Resident #69 was eating turkey with gravy on bread. Some of the turkey was cut into smaller pieces but two (2) pieces of turkey were intact and had not been cut into smaller pieces. The resident left the dining area without eating all the turkey that had already been cut into the smaller pieces. During an interview on 11/16/21 at 12:30 PM, Dietary Aide #41 stated she thought the turkey was soft enough to not need chopped into pieces. During an interview on 11/16/21 at 4:00 PM, the Certified Dietary Manager (CDM) stated when chopped meat was ordered, it should have been chopped by the dietary aide when it was served. The CDM stated the facility used diet recommendations by the Academy of Nutrition and Dietetics. The Academy of Nutrition and Dietetics information provided by the CDM stated cooked, moist, soft and tender poultry, including skinless turkey, should be chopped no larger than 1.5 cm x 1.5 cm pieces. Additionally, on 11/16/21 an order for Resident #69 was written to provide additional protein by giving double portions for lunch and dinner. On 11/17/21 at 12:40 PM, lunch service to Resident #69 was observed. Resident #69 received single portions of cottage cheese and macaroni and cheese. Resident #69's tray ticket did not specify that the resident was to receive double portions. On 11/17/21 at 1:25 PM, the CDM acknowledged the kitchen had received an order yesterday for Resident #69 to receive double portions. However, the CDM stated this order was not on Resident #69's tray ticket and the resident had not received double portions. No further information was provided through the completion of the survey. b) Resident #46 On 11/17/21 at 7:55 AM, observation found nursing assistant (NA) #167 serving the Resident a tray. Review of the tray card on the Residents tray found the Residents diet order listed was: soft diet, low purine, no bacon, no gravy, no fish or alcohol. No gelatine with fruit, pureed fruits and vegetables. The Resident was served biscuits and gravy. Also on the tray was a box of fruit loops. The tray card was reviewed with Unit Manager Registered Nurse (RN) #67 who stopped the tray service and said she would get another tray for the resident. On 11/17/21 at 9:31 AM, the Dietary Manager said the residents diet had been changed on 01/22/21 but no one had communicated the change to his department. The DM said the resident was supposed to have grits the hot cereal on the menu today not fruit loops. He stated he didn't know where the fruit loops came from because, We typically don't have fruit loops. When asked what is a low purine diet, the DM said it was a diet for gout. On 01/22/21 the physician ordered a soft diet with puree fruits and vegetable, thin liquids, staff supervision at meals, no jello mixed with fruit. On 11/18/21 at 7:53 AM, the Director of Nursing (DON) said she was working with the DM to make sure communications are improved. .

. Based on observation, staff interview, and record review, the facility failed to ensure adaptive eating equipment ordered by the physician was provided to the resident. This was a random opportunity for discovery. Resident identifier: #46. Facility census: 115. Findings included: a) Resident #46 Review of the physician's orders found an order, dated 01/21/21 for: Patient to use red built up handle for silverware and soup bowl, scoop plate and two handled cup with lid for meals. On 11/17/21 at 7:55 AM, observation found nursing assistant (NA) #167 serving the Resident a tray. The food was not in a scooped plate and no built up silverware was present on the tray. This observation was confirmed by Nursing assistant (NA) #167 and Unit Manager, Registered Nurse (RN) #67. The Resident received food in the wrong consistency, RN #67 stopped the tray service and obtained a second tray. Observation of the second tray served on 11/17/21 at 8:03 AM, found food was now served in a scooped plate but the Resident only had 1 red built up handle which was placed on the Residents fork. The Resident was eating eggs with the fork. The Resident needed a built up handle for his spoon so he could eat his hot cereal. RN #67 said she could only find one built up handle at this time. The above observations were discussed with the Director of Nursing and the Dietary Manager on 11/18/21 at 9:17 AM. No further information was provided. .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . b) Resident #14 Based on medical record review and staff interview, the facility failed to ensure a complete and accurate medical record. The facility failed to ensure Health Care Surrogate paperwork was kept on Resident #14's medical chart. Resident identifier: #14. Facility census: 115. A medical record review, completed on 11/15/21 at 3:22 PM, found a Physician Determination of Capacity which indicated Resident #14 lacked capacity to make her own medical decisions. There was a Durable Power of Attorney (DPOA) on file designating a family member who could make financial decisions on Resident #14's behalf. However, the DPOA wording did not address a legal right to make healthcare decisions. There was no Medical Power of Attorney or Health Care Surrogate on the chart. On 11/16/21 at 12:50 PM, it was brought to the attention of Social Worker #180 that only a Durable Power of Attorney was found on Resident #14's chart, and it did not appear to provide authorization for healthcare decisions to be made. Social Worker #180 read the DPOA and stated, It is unusual wording. I will need to look into it. Social Worker #180 reported on 11/16/21 at 2:15 PM, I spoke to the attorney and it [DPOA] was in effect immediately after being signed. When Surveyor questioned again if the DPOA authorized the named individual to make healthcare decisions, Social Worker #180 reported she had misunderstood the original question and would need to address that concern further. Social Worker #180 went on to say, Perhaps medical records might have something different. I will also check there. On 11/16/21 at 2:40 PM, Social Worker #180 produced Health Care Surrogate (HCS) paperwork dated 04/28/10, stating it was found in medical records. When questioned why was it not on the Resident #14's chart, Social Worker #180 stated, Perhaps it was accidentally sent with her if she went to the hospital and was never replaced. Social Worker #180 acknowledged failure to have the HCS on the resident's chart led to an incomplete and inaccurate medical record since nursing staff would not normally peruse information stored in medical records prior to sending resident out to the hospital for any form of emergency treatment. Based on record review and staff interview, the facility failed to ensure each resident's medical record was complete and accurately documented for two (2) of 30 residents records reviewed during the Long Term Care Survey Process (LTCSP). Resident identifiers: Resident # 72 and #14. Census: 115 Findings included: a) Resident #72 A review of the Minimum Data Set (MDS) dated , 10/21/21, noted Resident #72 transferred independently. A review of therapy progress notes dated ,10/21/21, noted Resident #72 to be independent for transfers in the room and bathroom and resident was able to take self to toilet. A review of the Nursing Assistant care plan ([NAME]) showed Resident #72 required two (2) person assist for mobility. An interview with Registered Nurse (RN#67), on 22/26/21 at 02:44 PM, verified the [NAME] is what the nursing assistants would utilize to provide care , however, the resident is now transferring independently and confirmed the directive was not correct. RN #67 stated further, the [NAME] should have been updated to reflect current orders and current plan of care for the resident and was not. .

. Based on observation and interview, the facility failed to ensure all rooms in the facility were adequately equipped to allow residents to call for staff assistance. This was a random opportunity for discovery during the initial tour of the Long Term Care Survey Process (LTCSP) and affected resident #105. Resident identifier: #105. Facility census: 115. Findings included: a.) Resident #105 An observation on 11/15/21 at 01:42 PM, revealed no operable call system was available in the bathroom for Resident #105. An interview, with Employee #325, on 11/15/21 at 01:51 PM, confirmed there was no functioning call system in Resident #105's bathroom and verified Resident #105 did go in the bathroom and could access a call system if available. An interview with RN # 67, on 11/15/21 at 01:56 PM, verified there should be a functioning call system in the residents bathroom and there was no functioning call light for Resident #105 to activate in case assistance was needed while in the bathroom. .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review and interview, the facility failed to provide evidence residents and/or resident representatives were provided a written Notice of Transfer for three (3) of three (3) records reviewed for an acute hospital transfer. The facility also failed to provide evidence the long-term care Ombudsman had been notified of the transfers. This had the potential to affect more than a limited number of residents transferred or discharged . Resident identifiers: #27, #102, and #107. Facility census: 115. a) Resident #27 A medical record review was completed on 11/16/21 at 11:15 AM. The record review revealed Resident #27 was transferred to the hospital on [DATE]. The record did not reflect the resident/resident's representative was provided a Notice of Transfer, nor did the record reflect the Notice of Transfer was sent to the Ombudsman. On 11/17/21 at 10:00 AM, Business Office Employee #166 reported the Notice of Transfer was not provided to resident / resident representative upon transfer or sent to the long-term care Ombudsman. b) Resident #102 A medical record review was completed on 11/16/21 at 11:25 AM. The record review revealed Resident #102 was transferred to the hospital on [DATE]. The record did not reflect the resident/resident's representative was provided a Notice of Transfer, nor did the record reflect the Notice of Transfer was sent to the Ombudsman. On 11/17/21 at 10:03 AM, Business Office Employee #166 reported the Notice of Transfer was not provided to resident / resident representative upon transfer or sent to the long-term care Ombudsman. c) Resident #107 Review of Resident #107's medical records showed the resident was transferred to the hospital on [DATE] after falling and hitting her head. The resident remained in the hospital until 08/31/21. Resident #107 did not have capacity. During an interview on 11/17/21 at 10:21 AM, Employee #166 stated no written notice of discharge was provided to Resident #107's representative. Additionally, the ombudsman was not notified of Resident #107's transfer to the hospital. No further information was provided through the completion of the survey. .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . e) Resident #43 During an interview, on 11/15/21 at 12:32 PM , Resident #43 reported being admitted to the facility over the last several months, having a history of depression, and that the consulting psychiatrist had recently given a new order for a different medication. Resident #43 reported tearfullly, I am so depressed all the time. This is not how I thought I would end my life. They are things that I don't know what's happening. I have a collection of willow tree angels. I would like to know where they are and what's going to happen to them. I worry about my burial arrangements. I don't know where all my clothes are. This is what I have to deal with. A record review was completed on 11/16/21 at 9:00 AM. Resident #43's care plan did not address depression. There was evidence Resident #43 had been linked to the facility's consulting psychiatrist. On 11/16/21 at 12:37 PM, Social Worker #180 reported having knowledge of Resident #43 struggling with depression prior to her admission to the facility on [DATE]. Social Worker #180 reported Resident #43 likes to write / journal about her feelings. When asked if Resident #43 was linked to a psychologist/psychiatrist, Social Worker #180 reported, I'm not sure. Social Worker #180 acknowledged the facility had failed to implement a comprehensive, person-centerd care plan with measurable goals and objectives related to Resident #43's depression. d) Resident #69 Review of Resident #69's medical records showed an order written on 04/18/17 for six (6) ounces of nutritional supplement if 50% or less of the meal or snack was consumed. The order stated the amount of supplement given was to be charted. The type of nutritional supplement was not specified. Review of Resident #69's comprehensive care plan revealed the approach created on 07/29/21 to Provide diet and supplements as ordered. Review of Resident #69's consumption records for the previous 30 days revealed the resident had consumed 50% or less of dinner for the following dates: - 10/27/21: 26-50% of meal taken - 11/04/21: refusal of meal - 11/05/21: 26-50% of meal taken - 11/06/21: 26-50% of meal taken - 11/11/21: 26-50% of meal taken - 11/12/21: refusal of meal Resident #69's medical records did not document that the resident had been offered or had consumed a supplement on those dates. During an interview on 11/17/21 at 9:17 AM, the Director of Nursing (DON) was informed Resident #69's care plan approach to provide supplements as ordered was not followed. The DON had no additional information regarding the matter. No further information was provided through the completion of the survey. Based on record review and interview, the facility failed to develop and/or implement person-centered comprehensive care plans for six of 30 residents reviewed during the long term care survey process. Nutritional needs were not addressed for Resident's #46, #71, and #69. Catheter care was not addressed for Resident #64. Behavioral/emotional needs were not addressed for Resident #43. Resident identifiers: #46, #64, #71, #69, and #43. Facility census: 115. Findings included: a) Resident #46 Review of the current physician's orders found orders dated 01/22/21: --Soft diet with puree fruits and vegetables, thin liquids, staff supervision at meals; no Jello mixed with fruit. --Patient to use red built up handle for silverware and soup bowl; scoop plate and two handled cup with lid for meals. Review of the current care plan with the Director of Nursing (DON) on 11/18/21 at 7:53 AM found the care plan did not include any mention of the above orders related to meal service. b) Resident #64 During an interview with the Resident at 1:42 PM on 11/15/21, the Resident said she had a super pubic catheter which she had for about 10 years. She said, I had this before I came to the facility. The Resident was admitted to the facility on [DATE]. Review of the physician's orders found several orders for care of the catheter: --05/21/21, Change supra pubic catheter every 6 weeks. --09/22/21, 22 french/5cc supra pubic catheter: irrigate with 60 cc normal saline as needed if catheter loses patency or becomes clogged; may be changed as needed if catheter becomes dislodged or loses patency --08/06/21 Monitor output each shift --08/09/21 Provide catheter care each shift --09/10/21 Bedside drainage bag to be changed every 2 weeks or if bag leaks or breaks The Resident's current care plan was reviewed with the unit manager Registered Nurse (RN) #67 on 11/17/21 at 10:59 AM. The only mention of a catheter in the care plan was contained in the following problem: --(Name of Resident) is at risk for impaired skin integrity and urinary tract infections/dehydration due to impaired mobility, bowel incontinence and status post catheter tubing. Any current pressure ulcers located on episodic care plan located in nurses note. There were no interventions for care of the catheter. RN #67 confirmed the care plan did not include any treatment or care of the catheter. RN #67 said, I don't understand why it's not on here, I thought it had it's own category but I can't find it. On 11/18/21 at 7:55 AM, the Director of Nursing (DON) said the care plan had been fixed to include catheter care. c) Resident #71 Review of a paper copy of the Resident's weight record, located in the Resident's chart, found the Resident weighted 148 pounds on 05/03/21. On 11/12/21, the most recent weight, was 127 pounds. This represents a 14.19 % weight loss in 6 months. Review of the current care plan found a Problem, updated on 10/21/21: --Nutritional risk related to significant weight loss. The goal associated with the problem was: --Will achieve adequate nutrition status as evidenced by maintaining stable weight, no signs or symptoms of malnutrition by next review. Interventions included: --Consult (Name of physician) as needed for adjustments of dentures --Invite to activities that promote additional intake of food and fluids --Monitor consumption. Offer supplement if less than 50% of meal consumed. --Monitor weight pre protocol or as ordered and record. Notify registered dietician of significant weight changes pre dietary recommendations 5% in one month 7.5 % in three months 10% in six months follow up with recommendations to doctor. --Obtain labs as ordered the notify doctor of results --Provide diet and supplements as ordered, offer substitutes and alternatives at meals and frequent snacks. On 11/17/21 at 7:22 AM, the Unit Manager, Registered Nurse (RN) #67 confirmed the the care plan failed to address the Resident's current diet order for pureed diet with ground meat/extra sauce or gravy, no straws and staff assist for PO (by mouth) intake. On 11/18/21 at 9:17 AM, the care plan was reviewed with the Dietary Manager who said he attends the care plan meetings but he doesn't write the care plan. .

. Based on observation, resident review, and staff interview, the facility failed to follow physician's orders for six (6) of 30 residents reviewed during the long-term care survey process. Resident identifiers: #107, #69, #85, #83, #46, #71. Facility census: 115. Findings included: a) Resident #107 Review of Resident #107's medical record showed an order written on 11/02/21 for six (6) ounces of nutritional supplement if 50% or less of the meal or snack was consumed. The order stated the amount of supplement given was to be charted. The type of nutritional supplement was not specified. Review of Resident #107's consumption records since 11/02/21 showed the resident had consumed 50% or less for dinner on the following dates: - 11/03/21: 26-50% of meal taken - 11/04/21: refusal of meal - 11/05/21: refusal of meal - 11/07/21: 26-50% of meal taken - 11/08/21: 26-50% of meal taken - 11/09/21: 26-50% of meal taken - 11/11/21: 26-50% of meal taken - 11/15/21: 26-50% of meal taken On 11/05/21 at 6:29 PM, Resident #107 was documented as taking 120 milliliters of a supplement. On 11/09/21 at 8:36 PM, the supplement was documented as not taken. For the remaining dates, Resident #107's medical record did not document the resident had been offered or had consumed a supplement on those dates. During an interview on 11/17/21 at 9:22 AM, the Director of Nursing (DON) was informed Resident #107's physician's order to provide supplements as ordered was not followed. The DON had no additional information regarding the matter. No further information was provided through the completion of the survey. b) Resident #69 Review of Resident #69's medical record showed an order written on 04/18/17 for six (6) ounces of nutritional supplement if 50% or less of the meal or snack was consumed. The order stated the amount of supplement given was to be charted. The type of nutritional supplement was not specified. Review of Resident #69's consumption records for the previous 30 days revealed the resident had consumed 50% or less of dinner for the following dates: - 10/27/21: 26-50% of meal taken - 11/04/21: refusal of meal - 11/05/21: 26-50% of meal taken - 11/06/21: 26-50% of meal taken - 11/11/21: 26-50% of meal taken - 11/12/21: refusal of meal Resident #69's medical records did not document the resident had been offered or had consumed a supplement on those dates. During an interview on 11/17/21 at 9:17 AM, the Director of Nursing (DON) was informed Resident #69's physician's order to provide supplements as ordered was not followed. The DON had no additional information regarding the matter. No further information was provided through the completion of the survey. c) Resident #85 Review of Resident #85's medical record showed an order written on 07/26/21 for six (6) ounces of nutritional supplement if 50% or less of the meal or snack was consumed. The order stated the amount of supplement given was to be charted. The type of nutritional supplement was not specified. Review of Resident #85's consumption records for the previous 30 days showed the resident had consumed 50% or less for the following meals on the following dates: - 10/18/21, dinner: 1-25% of meal taken - 10/19/21, lunch: 1-25% of meal taken - 10/19/21, dinner: refusal of meal - 10/20/21, breakfast: 1-25% of meal taken - 10/20/21, dinner: 26-50% of meal taken - 10/22/21, breakfast: refusal of meal - 10/23/21, breakfast: 1-25% of meal taken - 10/24/21, dinner: 26-50% of meal taken - 11/01/21, dinner: 26-50% of meal taken - 11/02/21, breakfast: 1-25% of meal taken - 11/02/21, lunch: refusal of meal - 11/02/21, dinner: 1-25% of meal taken - 11/03/21, breakfast: 26-50% of meal taken - 11/04/21, breakfast: refusal of meal - 11/04/21, lunch: refusal of meal - 11/04/21, dinner: refusal of meal - 11/05/21, breakfast: 26-50% of meal taken - 11/05/21, dinner: 1-25% of meal taken - 11/06/21, dinner: refusal of meal - 11/07/21, breakfast: refusal of meal - 11/07/21, lunch: 26-50% of meal taken - 11/07/21, dinner: 26-50% of meal taken - 11/08/21, breakfast: refusal of meal - 11/08/21, lunch: 26-50% of meal taken - 11/08/21, dinner: refusal of meal - 11/09/21, lunch: 26-50% of meal taken - 11/09/21, dinner: refusal of meal - 11/11/21, breakfast: refusal of meal - 11/11/21, lunch: refusal of meal - 11/11/21, dinner: refusal of meal - 11/12/21, breakfast: 26-50% of meal taken - 11/13/21, breakfast: refusal of meal - 11/14/21, lunch: refusal of meal On the following dates and times, a supplement was documented as not taken: - 10/19/21 at 3:01 PM - 10/22/21 at 3:06 PM - 11/01/21 at 9:57 PM - 11/02/21 at 3:05 PM - 11/03/21 at 1:21 PM - 11/04/21 at 1:37 PM and 1:42 PM - 11/05/21 at 6:29 PM - 11/06/21 at 8:31 PM - 11/09/21 at 8:36 PM - 11/12/21 at 2:42 PM - 11/13/21 at 8:39 AM - 11/14/21 at 1:15 PM On 11/05/21 at 1:57 AM, Resident #85 was documented as taking 76-100% of a supplement. For the remaining dates, Resident #85's medical record did not document the resident had been offered or had consumed a supplement on those dates. During an interview on 11/17/21 at 9:13 AM, the Director of Nursing (DON) was informed Resident #85's physician's order to provide supplements as ordered was not followed. The DON had no additional information regarding the matter. No further information was provided through the completion of the survey. d) Resident #83 Review of the current physician's orders found an order dated 01/14/19, to obtain a Complete blood count, comprehensive metabolic panel, glycohemoglobin, lipid profile, obtain hemoglobin A1C, comprehensive metabolic panel, lipid panel, liver function tests, uric acid every 3 months (February, May, August, and November) On 11/18/21 at 7:52, the Director of Nursing (DON) confirmed the tests were not completed in August 2021 as ordered. She said the tests were completed in September 2021. .

. Based on observation, medical record review and staff Interview, the facility failed to ensure that facility was free from accident hazards in which it had control. One (1) medication cart was left unlocked and unattended and fall hazards due to extension cords left through-out the 300 hall, and no call system in place for a resident. This had the potential to effect more than a limited number of residents including. Resident identifier: #39. Facility census: 116. Findings included: a) Enchanted Garden Medication Cart An observation on 11/16/21 at 1:27 PM found the medication cart unlocked and unattended allowing access to medications by residents, visitors, and unauthorized persons. An interview with Registered Nurse RN #67 11/16/21 at 1:46 PM verified the Enchanted Garden medication cart was unlocked. RN #67 confirmed medication carts should be locked when unattended. RN #67 locked the cart at this time. b) 300-Hall On 11/17/21 at 1:03 PM an observation on the 300-hall found extension cords placed in the hallways lying on the floor and plugged in to all the outlets. An Interview on 11/17/21 at 1:05 PM with the Director of Nursing (DON) verified the cords laying on the floor is a fall/accident hazard. The DON stated that they were placed there to prepare for power outage on the 11/18/21 at 5:00 AM. The DON collected all the extension cords, at this time. On 11/17/21 at 1:25 PM during an interview with Maintenance Supervisor, he stated that the extension cords should not have left in the hall. He also stated that the maintenance department had to check to make sure the generator would hold all the electric needs and that cords would be long enough to reach all needs prior to the scheduled power outage. On 11/18/21 at 9:15 AM, the findings were discussed with the Administrator. No other information was provided prior to the end of survey on 11/18/21 at 12:30 PM. c) Resident #39 An observation on 11/15/21 at 2:00 PM found Resident #39 lying in bed without a call light in reach. This failure would make Resident #39 unable to call for help or assistance. On 11/15/21 at 2:15 PM with Registered Nurse (RN) #20 verified, Resident #39's call light was not in reach of resident and stated residents should always have their call system in reach. RN #20 placed the call light in reach at this time. On 11/18/21 at 9:15 AM, the findings were discussed with the Administrator. No other information was provided prior to the end of survey on 11/18/21 at 12:30 PM. b.) Resident #105 An observation on 11/15/21 at 01:42 PM, revealed no operable call system was available in the bathroom for Resident #105. An interview, with Employee #325, on 11/15/21 at 01:51 PM, confirmed there was no functioning call system in Resident #105's bathroom and verified Resident #105 did go in the bathroom and could access a call system if available. An interview with RN # 67, on 11/15/21 at 01:56 PM, verified there should be a functioning call system in the residents bathroom and there was no functioning call light for Resident #105 to activate in case assistance was needed while in the bathroom. A review of the resident centered care plan, dated 11/10/21, for Resident #105, showed the resident was at risk for falls and noted the resident was to use the call light as a fall prevention measure. c.) Resident #72 An observation, on 11/16/21 at 02;23 PM, revealed a tube of Calmoseptine cream on the shelf by the resident's sink. An interview, with RN #38, verified the Calmoseptine cream was on the shelf in the Resident #72's room and there was no order for the cream. Additionally RN #38 verified there was no order for Resident # 72 to have the medication at the bedside An interview with RN #67, on 11/16/21 at 02:50 PM, verified there was no order for Resident #72 to have Calmoseptine cream and since any cream was not applied by the resident , the cream should not have been there in the room.

. Based on observation, record review and staff interview the facility failed to have food items labeled and dated correctly, unclean equipment in the kitchen, one pantry on enchanted garden refrigerator with spillage and temperature logs in the kitchen were incomplete. This failed practice had the potential to affect a limited amount of residents who receive nutrients from the kitchen and pantry. Facility Census 115. Findings included; a) Kitchen and Pantry On 11/15/21 at 11:56 AM initial tour with Certified Dietary Manager (CDM) #168 found the following items in the reach in refrigerator with no label and/or date: --40 ice tea glasses with no label or date --one (1) bag of french fries open with no date --one (1) bag of carrots open no dates --one (1) bag of Brussels sprouts open with no date. --one (1) onion stored in small bag with no label and date. --mixer stand had debris around rim as well as the back of mixer stand CDM removed items found and discarded and also addressed to cook #73 needed to clean mixer stand. CDM agreed all issued found should have not been like that. On 11/15/21 at 11:56 AM initial tour with Certified Dietary Manager (CDM) #168 found the following items in the walk in refrigerator with no label and/or date: --one (1) chocolate cool whip open and with no date --1/2 of a cucumber wrapped in plastic with no date --one (1) bag of cheddar cheese open with no date CDM removed items found and discarded and agreed all items found should have not been there. On 11/15/21 at 11:56 AM initial tour with Certified Dietary Manager (CDM) #168 found the following items in the walk in freezer with no label and/or date: --one (1) bag of chicken patties open with no date --one (1) bag of chicken tenders open with no date CDM removed items found and discarded and agreed all items found should have not been there. On 11/15/21 at 12:40 PM initial tour with Certified Dietary Manager (CDM) #168 found the following items in the Enchanted Garden Pantry with no label and/or date: --Spillage from top shelf running to second shelf tray of a dark substance CDM agreed and asked dietary aide present to clean up when able. On 11/16/21 at 8:05 AM did observations and cook #73 was present CDM was unavailable. --Can opener on preparation table was pulled and had debris packed on blade. [NAME] # 73 agreed it was dirty and put in sink and stated, that is the dietary aides table. --observed temperature log for all refrigerators and freezers in the kitchen. There were several dates missing: 11/02/21, 11/03/21, 11/04/21, 110/5/21, 11/06/21, 11/07/21, 11/08/21, 11/11/21, 11/12/21, 11/14/21 and 11/15/21. Cook #73 agreed they had missing dates that were not completed and stated, the kitchen has been working short so things are not able to be done. .

. Based on observation, policy review, medical record review and staff interview, the facility failed to establish and maintain an infection prevention program to help prevent the development and transmission of communicable diseases and infections including Covid-19 in regard to, precaution signage and laundry services. This failed practice had the potential to affect more than a limited number of residents in the facility. Resident identifier: #263. Facility census: 115. Findings Included: a) Resident #263 On 11/15/21 at 12:37 AM, found no precaution signs on Resident #263's door. Medical record review on 11/16/21 at 10:38 AM, revealed, Resident #263 was in Covid isolation, Respiratory Droplet Precautions related to being new admission. During an interview on 11/16/21 at 10:41 AM, with the Nurse Aide (NA) revealed, Resident #263, was in modified droplet Precautions. On 11/16/21 at 10:48 AM, Registered Nurse (RN) #27 confirmed, there was no precautionary signage on Resident #263's door. RN #27 placed a sign for respiratory droplet isolation sign in Resident #263's door. The respiratory sign directed staff and visitors the instructions on personal protective equipment to don prior to entry. On 11/18/21 at 9:15 AM, the findings were discussed with the Administrator. No other information was provided prior to the end of survey on 11/18/21 at 12:30 PM. b) Laundry Room On 11/17/21 at 10:08 AM, inspection was made of the laundry room with Laundry Worker #202. In the clean section of the laundry room, where laundry was removed from the dryers and folded, was a table. On the table were uncovered cups containing beverages and uncovered donut holes. [NAME] bar wrappers were also on the table. This table was located to the right of the last dryer but was not where laundry was sorted and folded. Laundry worker #202 stated she was unaware that she should not be eating or drinking in the clean area of the laundry room. No further information was provided through the completion of the survey. .

. Based on record review and interview, the facility failed to ensure the Drug Regimen Review Policy addressed the time frame in which the physician must respond to the pharmacist's recommendations. This failed practice had the potential to affect all residents residing in the facility. Facility census: 115. Findings included: a) Drug Regimen Review Policy The facility's policy titled Drug Regimen Review, with no implementation date given, was reviewed. The policy did not address the time frame in which the physician must respond to the pharmacist's recommendations. During an interview on at 11/17/21 at 12:07 PM, the Assistant Administrator was informed the facility's Drug Regimen Review Policy did not give a time frame in which the physician must respond to the pharmacist's recommendations. The Assistant Administrator stated the policy would be revised to include this. No further information was provided through the completion of the survey. .