Does PETERSON REHABILITATION AND HEALTHCARE have any serious inspection findings?

Yes, PETERSON REHABILITATION AND HEALTHCARE has 3 Immediate Jeopardy citations on record, which represent the most serious type of deficiency. The facility has 68 total deficiencies from recent inspections.

What are the staffing levels at PETERSON REHABILITATION AND HEALTHCARE?

PETERSON REHABILITATION AND HEALTHCARE has a two-star staffing rating from CMS with 0.67 RN hours per resident per day. This rating is based on registered nurse (RN), licensed practical nurse (LPN), and nurse aide staffing hours.

Where is PETERSON REHABILITATION AND HEALTHCARE located?

PETERSON REHABILITATION AND HEALTHCARE is located in WHEELING, WV. It is a Medicare and Medicaid certified skilled nursing facility.

How many beds does PETERSON REHABILITATION AND HEALTHCARE have?

PETERSON REHABILITATION AND HEALTHCARE has 150 certified beds.

Who owns PETERSON REHABILITATION AND HEALTHCARE?

PETERSON REHABILITATION AND HEALTHCARE is a for profit - limited liability company facility and operates independently (not part of a chain).

PETERSON REHABILITATION AND HEALTHCARE

Q: What is PETERSON REHABILITATION AND HEALTHCARE's CMS rating?

PETERSON REHABILITATION AND HEALTHCARE has a two-star overall rating from CMS (Centers for Medicare & Medicaid Services), based on health inspections, staffing levels, and quality measures.

Q: Do nurses at PETERSON REHABILITATION AND HEALTHCARE stick around?

PETERSON REHABILITATION AND HEALTHCARE has average staff turnover at 53%, which is typical for the nursing home industry.

Q: Was PETERSON REHABILITATION AND HEALTHCARE ever fined?

Yes, PETERSON REHABILITATION AND HEALTHCARE has been fined $147,234 by federal regulators. Fines are issued for serious violations of Medicare and Medicaid requirements.

Q: Is PETERSON REHABILITATION AND HEALTHCARE on any federal watch list?

No, PETERSON REHABILITATION AND HEALTHCARE is not on any federal watch list. It is not designated as a Special Focus Facility or SFF Candidate by CMS.

20 HOMESTEAD AVENUE, WHEELING, WV 26003 · (304) 234-0500

For profit - Limited Liability company 150 Beds Independent Data: November 2025 3 Immediate Jeopardy citations

Trust Grade

0/100

#81 of 122 in WV

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PETERSON REHABILITATION AND HEALTHCARE nursing home in WHEELING, WV

Last Inspection: February 2025

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

Overview

Peterson Rehabilitation and Healthcare has received a Trust Grade of F, indicating poor performance and significant concerns about resident safety and care. It ranks #81 out of 122 facilities in West Virginia, placing it in the bottom half, and is the least favorable option in Ohio County. The situation appears to be worsening, as the number of issues identified at the facility increased from 6 in 2024 to 14 in 2025. Staffing is rated at 2 out of 5 stars, with a turnover rate of 53%, which is around the state average, indicating potential instability among caregivers. Notably, the facility has accumulated $147,234 in fines-higher than 92% of other facilities in West Virginia-suggesting ongoing compliance problems. Specific incidents include a serious failure to protect a resident from sexual abuse, which has been classified as an immediate jeopardy situation; a case where a resident was physically restrained after displaying aggressive behavior; and another incident where a resident suffered a burn from hot coffee due to inadequate safety measures. These findings highlight both critical safety risks and troubling care practices at the facility, making it essential for families to carefully consider these factors when researching care options.

Trust Score: F
In West Virginia: #81/122
Safety Record: High Risk
Inspections: Getting Worse
Staff Stability: 53% turnover. Above average. Higher turnover means staff may not know residents' routines.
Penalties: $147,234 in fines. Lower than most West Virginia facilities. Relatively clean record.
Skilled Nurses: Each resident gets 40 minutes of Registered Nurse (RN) attention daily — about average for West Virginia. RNs are the most trained staff who monitor for health changes.
Violations: 68 deficiencies on record. Higher than average. Multiple issues found across inspections.

★★☆☆☆

2.0

Overall Rating

★★☆☆☆

2.0

Staff Levels

★★★★☆

4.0

Care Quality

★★☆☆☆

2.0

Inspection Score

↔

Stable

2024: 6 issues

2025: 14 issues

The Good

4-Star Quality Measures · Strong clinical quality outcomes
Full Sprinkler Coverage · Fire safety systems throughout facility
No fines on record

Facility shows strength in quality measures, fire safety.

The Bad

2-Star Overall Rating

Below West Virginia average (2.7)

Below average - review inspection findings carefully

Staff Turnover: 53%

Near West Virginia avg (46%)

Higher turnover may affect care consistency

Federal Fines: $147,234

Well above median ($33,413)

Significant penalties indicating serious issues

The Ugly 68 deficiencies on record

3 life-threatening 1 actual harm

Feb 2025 14 deficiencies

CONCERN (D)

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

Deficiency F0558 (Tag F0558)

Could have caused harm · This affected 1 resident

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. Based on observation, record review, and interview the Facility failed to reasonably accommodate the needs of Resident #86 by ensuring the call light was in reach. This was a random opportunity for discovery. Facility census: 132. Findings included: a) Resident #86 a) On 02/12/25 at 1:10 PM the resident was observed sitting in wheelchair in her room watching television. She stated that she would like to go to bed and that she was hurting from sitting in the wheelchair. When asked if she could reach her call light, she attempted to and replied no. Her call light was behind her, wrapped around her bedrail. I rang the call light on the opposite side of the room and Nurses Aide (NA) #61 entered the room and acknowledge that resident did not have her call light. She handed call light to her and stated You don't have your light, here you go. NA #61 told her that she would get someone to help and be right back to assist her. She promptly returned with NA #135 and they assisted the resident with her needs using the hoyer lift.

CONCERN (D)

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

PASARR Coordination (Tag F0644)

Could have caused harm · This affected 1 resident

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. Based on record review and staff interview, the facility failed to have residents Pre-admission Screening and Record Review (PASSAR) reflect a new diagnosis after admission. This is true for one of (1) of six (6) residents reviewed for the care area of PAS-R during the long term care survey process. Resident Identifier: Resident #13. Facility Census 132. Findings included: a) Resident #13 A record review completed on 02/12/25 at 9:14 PM revealed Resident #13's most recent PASSAR dated 04/05/24 included the following: -Section III. MI/MR Assessment, Question 30. Current Diagnosis (check all that apply), was marked a. None. Question 47. The individual has a primary diagnosis of: was marked dementia b) Review of resident's diagnoses list revealed residents primary diagnosis was unspecified psychosis not due to substance or known physiological condition on 02/20/24. She was also given a diagnosis of hallucinations, unspecified on 02/20/24. c) During an interview with Social Worker #147 on 02/12/25 at 2:24 PM, they acknowledged Resident # 13 did not have a PASSAR that reflected her current diagnosis of psychosis or hallucinations.

CONCERN (D)

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

Deficiency F0645 (Tag F0645)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure the resident's Pre-admission Screening (PAS) reflected pre-admission diagnoses. This was true for two (2) out of six (6) residents reviewed for the category of PASARR (Pre-admission Screening and Record Review, during the Long-Term Care Survey Process. Resident identifiers: #125 and #67. Facility census: 132. Findings included: a) Resident #125 A medical record review, completed on 02/11/25 at 9:07 AM, revealed Resident #125 had been admitted to the facility on [DATE] with the following diagnoses: -Bipolar -Major Depression Disorder A PAS, completed on 01/28/25, marked NONE under Section III Question 30 entitled, Current Diagnosis (Check all that apply). Additionally, Section V Question 40 entitled, Major Mental Illness (MI) or Suspected MI was also marked NONE. During an interview on 02/12/25 at 2:24 PM, the Director of Social Services reported that resident's Bipolar and Major Depression Disorder diagnoses had not been captured on the 01/28/25 PAS and a new one had not been completed. b) A review of Resident #67's medical record on 02/12/25 at 9:20 PM revealed the resident PASSAR dated 12/06/22 included the following: Section III. MI/MR Assessment, Question 30. Current Diagnosis (check all that apply), was marked m. Major Depression. A review of Resident #67's diagnosis list on 02/12/25 at 9:22 PM revealed Resident #67 diagnosis on admission his date of 12/02/21 included bipolar disorder. During an interview on 02/12/25 at 2:26 pm with Social Worker (SW) #147, she acknowledged that resident had a diagnosis of bipolar upon admission and there had been no new PASSAR completed to reflect this upon after admission to this facility.

CONCERN (D)

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

Comprehensive Care Plan (Tag F0656)

Could have caused harm · This affected 1 resident

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. Based on medical record review and interview, the facility failed to ensure each resident had a person-centered comprehensive care plan developed and implemented to meet his or her preferences and goals, and address the resident's medical, physical, mental and psychosocial need regarding schizoaffective disorder. This practice affected one (1) of (28) resident's care plans reviewed. Resident identifier: #27. Facility census: 132. Findings included: a) Resident #27 On 02/12/25 a review of Resident #27's) medical records revealed a diagnosis of schizoaffective disorder on admission. A review of the current care plan showed there was no care plan addressing schizoaffective disorder. During an interview on 02/13/25 at 1:55 PM the Director of Nursing (DON) confirmed there was no schizoaffective disorder care plan for Resident #27.

CONCERN (D)

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

Deficiency F0657 (Tag F0657)

Could have caused harm · This affected 1 resident

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Based on record review and staff interview, the facility failed to revise the care plan regarding an appropriate diagnosis for Resident #128's urinary catheter, antipsychotic medication and behavior monitoring for Resident #90; and the discontinuation of a feeding tube for Resident #86. This was true for three (3) of 32 sampled residents reviewed during the survey process. Resident Identifier: #128, #90 and #86. Facility Census: 132. Findings Include: a) Resident #128 On 02/11/25 at 3:21 PM, a record review was completed for Resident #128. The review found the care plan listed the resident's need for a urinary catheter was personal preference. However, further review of the record found urinary retention as the correct diagnosis for the urinary catheter. On 02/12/25 at 2:22 PM, the Director of Nursing (DON) confirmed the diagnosis for the urinary catheter on the care plan was incorrect. The DON stated, I don't know why that was on the care plan .the reason was urinary retention. b) Resident #90 On 02/12/25 at 8:30 PM, a record review was completed for Resident #90. The review of the care plan found focus areas of antipsychotic medication and behaviors listed. However, on further review the resident was not prescribed an antipsychotic medication nor was he having any type of behaviors. An interview was held with the DON on 02/13/25 at 10:31 AM. The DON stated, he is not taking antipsychotic medication or having behaviors anymore .the care plan should have been updated. c) Resident #86 - Peg tube On 02/12/25 at 11:30 AM, a review of Resident #86's records revealed theresident's care plan addresses peg tube care. Page 7 of the care plan, under the focus category At risk for alteration in skin integrity related to impaired mobility. Interventions for that focus/goal included treatment to peg tube site per orders. Resident #86's current order and diagnosis list did not reveal the resident currently had a peg tube. Per review of discontinued orders it was revealed resident's orders for peg tube was discontinued on 05/18/23. On 02/12/25 at approximately 2:47 PM during an interview with DON and Administrator they both acknowledged the resident did not currently have a peg tube. When asked if peg tube care was listed in her care plan, the Administrator reviewed care plan and acknowledged the care plan stated treatment to peg tube site per orders.

CONCERN (D)

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

Quality of Care (Tag F0684)

Could have caused harm · This affected 1 resident

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. Based on record review and staff interview, the facility failed to follow physician's orders regarding medication administration, behavior monitoring, pain score, side effects of a antipsychotic, and supplement. This was true of two (2) of five (5) residents reviewed under the care area of unnecessary medications. Resident Identifiers: #13 and #58. Facility Census: 132. Findings Include: a) Resident #13 On 02/13/25 at 12:24 PM, a record review was completed for Resident #13. The review found blanks on the 02/2025 Medication Administration Record (MAR). The following is the list of the missed behavior and side effect monitoring: --02/04/25 physically abusive behavior --02/04/25 antianxiety medication side effect tracking --02/04/25 antipsychotic medication side effect tracking --02/04/25 socially inappropriate or disruptive behavior --02/04/25 verbally abuse behavior On 02/13/24 at approximately 2:30 PM, the DON confirmed the missing documentation on 02/04/25. b) Resident #58 On 02/13/25 at 1:00 PM, a record review was completed for Resident #58. The review found blanks on the 09/2024 MAR. The following is the list of the missed medications, behaviors, side effect monitoring, and pain score: --09/21/24 Atorvastatin 40mg (milligram) --09/21/24 Famotidine 20mg --09/21/24 Melatonin 5mg --09/21/24 Metformin 500mg --09/21/24 Seroquel 50mg --09/21/24 Tylenol Extra Strength 500mg-2 tablets --09/21/24 Behavior-refusal of care --09/21/24 Depression/Depressive Behaviors --09/21/24 Insomnia/Sleepless Behaviors --09/21/24 Pain score --09/21/24 Antidepressant side effect tracking --09/21/24 Antipsychotics side effect tracking --09/21/24 Socially inappropriate or disruptive behavior --09/21/24 Wandering/elopement behavior --09/21/24 2.0 Supplement On 02/13/24 at approximately 2:30 PM, the DON confirmed the missing documentation on 09/21/24.

CONCERN (D)

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

Deficiency F0761 (Tag F0761)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, record review and staff interview, the facility failed to date insulin upon opening for Resident #3 and dispose of expired insulin for Resident #18. These were random opportunities for discovery. Resident Identifiers: #3 and #18. Facility Census: 132. Findings Include: a) Medication Cart 800 wing On [DATE] at 1:00 PM, a tour of the medication cart on the 800 wing was completed. The tour found Resident #3's insulin glargine not dated upon opening and Resident #18's Novolog insulin expired on [DATE] after 28 days from opening. Registered Nurse (RN) #119 confirmed the insulin glargine was not dated upon opening and the Novolog insulin was expired. b) Facility policy On [DATE] at 2:30 PM, a review of the facility policy was completed. The facility policy, entitled Medication Labeling and Storage, under the section entitled Medication Labeling section 5 states, Multi-dose vials that have been opened or accessed are dated and discarded within 28 days . On [DATE] at 3:30 PM, the Director of Nursing (DON) was notified and confirmed the insulin should be dated upon opening and discarded after 28 days.

CONCERN (D)

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

Infection Control (Tag F0880)

Could have caused harm · This affected 1 resident

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. Based on observation, and staff interview, the facility failed to maintain an appropriate infection control program for foley catheter care. This was a random opportunity for discovery. Resident Identifier: 85. Facility Census: 132. Findings Include: a) Resident #85 On 02/10/25 at 12:46 PM, an observation of Resident #85's urinary catheter drainage bag touched the floor. On 02/10/25 at 12:48 PM, Nurse Aide (NA) #163 confirmed the drainage bag was touching the floor. NA #163 stated, let me raise the bed .it shouldn't be touching the floor. On 02/10/25 at approximately 2:00 PM, the Director of Nursing (DON) was notified. The DON confirmed the urinary catheter drainage bag should not be touching the floor.

CONCERN (E)

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

Deficiency F0577 (Tag F0577)

Could have caused harm · This affected multiple residents

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Based on results of State inspection, The facility failed to ensure the most recent survey results were located in prominent areas and readily accessible to residents and public. This deficient practice had the potential to effect more than a limited number of residents. Facility census: 132 Findings include: a) During the resident council meeting on 02/10/25 at 11:30 AM, Resident Council President , (Resident #1), stated she knew there were survey results available for the residents to see but was not sure where they were recently located. Resident #19, #40, and # 64 were also in attendance and stated they did not know survey results were available to them nor where they were located. Based on record review of Section C of the most recent MDS record Residents #1, #19, # 40, and #64 had capacity and were cognitively intact. c) During an interview with theAdministrator, on 2/11/24 at 12:25 PM, she verified the facility failed to post notice of the availability of the results of the most recent survey in prominent areas in the facility and make accessible to all residents.

CONCERN (E)

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

Grievances (Tag F0585)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, observation and staff interview the facility failed to ensure the grievance forms were within reach for each resident to enable to file grievance anonymously if they so choose. This was a random opportunity for discovery and was true for Resident #40. Facility Census: 132. Findings Include: a) Resident #40 Upon entrance to the facility on [DATE] an observation found the grievance forms were up too high for residents who could not stand up. If a resident is confined to the wheelchair they are unable to obtain a grievance form without asking staff or others to hand them the form. On 02/11/25 at 11:45 am Resident #40 indicated they were not able to reach the grievance forms nor the box provided to place the grievance forms without standing up from the wheelchair. On 02/11/25 at 11:50 AM, during and interview with Social Worker #147 it was confirmed the resident was unable to reach the forms or the box. She stated, residents could come to my office and ask for a form but resident's would not be able to file it anonymously if they could not stand up.

CONCERN (E)

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

Accident Prevention (Tag F0689)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . The facility failed to provide an environment that was free from accident hazards over which it had control. This was a random opportunity for discovery. Water temperatures were found to be above 120 degrees Fahrenheit (F). This deficient practice had the potential to negatively effect more than a limited number of residents. Facility census: 132. Findings included: a) State Operations Manual Appendix PP Review of the State Operations Manual Appendix PP found in the interpretive guidelines for F689 the following concern regarding water temperatures: - Water temperature of 124 degrees Fahrenheit will cause a 3rd degree burn in 3 minutes. - Water temperature of 120 degrees Fahrenheit will cause a 3rd degree burn in 5 minutes. - Burns can occur even at water temperatures below those identified, depending on an individual's condition and the length of exposure. -Third-degree burns penetrate the entire thickness of the skin and permanently destroy tissue. These present as loss of skin layers, often painless (pain may be caused by patches of first- and second-degree burns surrounding third-degree burns), and dry, leathery skin. Skin may appear charred or have patches that appear white, brown, or black. b) On 02/09/25 at 1:13 PM, the water temperature of the sink in room [ROOM NUMBER] was tested by surveyors feeling very hot. Surveyors requested the water temperatures be tested via thermometer. Maintenance Supervisor #73 tested the water temperature was tested by inserting the stem of the thermometer into the stream of running water, so that the sensor was fully immersed. A water temperature of 126 degrees Fahrenheit was reached. c) Water Temperatures in Shower Rooms Date and Time - Shower room wing 1 had a water temperature of 126 degrees Fahrenheit. - Shower room wing 2 had a water temperature of 121.6 degrees Fahrenheit. - Shower room wing 7 had a water temperature of 122.5 degrees Fahrenheit. d) During an interview with Maintenance Supervisor #73, on 02/09/25 at 1:21 PM, He stated the water temperatures were tested on ce every week. He said the temperatures averaged around 113 degrees Fahrenheit. e) Number of Residents that go to the shower rooms by wings: Wing 1 - 20 of 20 Wing 2 - 16 of 18 Wing 7 - 20 of 21 f) During an interview, on 02/09/25 at 3:10 PM, the Nursing Home Administrator confirmed that the maintenance director would ensure all water temperatures would be 110 degrees Fahrenheit or below.

CONCERN (E) 📢 Someone Reported This

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

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

Deficiency F0804 (Tag F0804)

Could have caused harm · This affected multiple residents

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Based on observation, staff interview, and food tray temperatures the facility failed to serve food to residents that was at an appetizing temperature. This failed practice was true for one (1) of two (2) wings tested for food tray temperatures throughout the Long-Term Care Survey Process. Facility census: 132. Findings included: a) Wing 1 Lunch Time Meal Observation During an observation on 02/12/25 at 12:53 PM, it was noted that a food truck was brought out of the kitchen with all resident lunch trays for residents on the 100 Wing. Staff members immediately began to deliver the trays to the residents' rooms. At 1:03 PM, when four (4) trays were left on the food truck, the Surveyor requested that CNA #135 select one tray that would be served last. CNA #135 selected Resident #45's tray and stated that she was actually getting ready to go out to eat with her family member and would not need her lunch tray. Registered Nurse (RN) #62 was asked to call the kitchen and ask them to come to the wing in order to temp the last tray on the food cart. On 02/12/25 at 1:07 PM, Dietary Aide #300 tested the temperature of Resident #45's lunch tray with the following results: -Hamburger: 116.5 degrees Fahrenheit (F) -Carrots: 112.2 degrees F -Ham: 104.0 degrees F Dietary Aide #300 agreed the food temperatures obtained were not considered to be the appropriate desired temperature for the point of delivery to the residents. Dietary Aide #300 stated temperatures should be 120 degrees F or above for all hot food.

CONCERN (E)

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

Food Safety (Tag F0812)

Could have caused harm · This affected multiple residents

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. Based on observation, staff interview, and equipment manual review the facility failed to keep the ice machine in safe operating condition. This had the potential to affect all Residents who get their nutrition from the kitchen, and residents who attend food related activities. Facility Census: 132. Findings Included: a) Ice Machines On 02/13/25 at 12:40 PM a tour with the Maintenance Director found the ice machines located in the Kitchen area had a drainpipe running on the floor to a drain. Nutrition rooms on units one (1) and three (3) had no required air gap on the ice machine drains. The drainpipes were touching the drains. Continued tour found unit one (1), five (5) and six (6) had no required filter on the ice machines. On 02/13/25 throughout the tour, the Maintenance Director confirmed the drainpipes should not be touching the floor or drain and all the ice machines should have a filter.

CONCERN (E)

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

Medical Records (Tag F0842)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review and staff interview, the facility failed to provide an accurate and complete medical record for seven (7) of 32 residents. Resident identifiers: #3, #17, #280, #128, #123, #71 and #75. Facility Census: 132. Findings Include: a) Resident #3 On [DATE] at 9:18 AM, a record review was completed for Resident #3. The review found the [NAME] Virginia (WV) Physicians Orders for Scope of Treatment (POST) was incomplete. The resident's signature under section E was not dated. On [DATE] at 2:21 PM, the Director of Nursing was notified and confirmed the resident's signature was not dated. b) Resident #17 On [DATE] at 9:30 AM, a record review was completed for Resident #17. The review found the WV POST form under section B had both selective treatments and comfort-focused treatments selected. The directions under section B specify pick one (1). On [DATE] at 2:21 PM, the DON was notified and confirmed both choices were selected and only one (1) should have been selected. c) Resident #280 On [DATE] at 10:30 AM, a record review was completed for Resident #280. The review found a verbal/telephone consent was obtained form the Medical Power of Attorney (MPOA) on [DATE]. The guidance states to receive the MPOA's signature in a reasonable amount of time. On [DATE] at 2:21 PM, the DON was notified and confirmed the MPOA's signature should have been obtained. d) Resident #128 On [DATE] at 1:00 PM, a record review was completed for Resident #128. The review found the transfer form was completed on [DATE] at 8:00 AM but was dated for [DATE] at 12:30 PM. On [DATE] at 2:21 PM, the DON was notified and confirmed the date on the transfer form was incorrect. e) Resident #71 A record review, completed on [DATE] at 10:50 AM, revealed a POST form with the following details: -CPR -Full Treatment -No Artificial Means of Nutrition The POST form was signed by Resident #71 but was not dated. During an interview on [DATE] at 02:19 PM, the DON confirmed the POST had not be dated by resident and could not be considered legally valid. f) Resident #123 A record review, completed on [DATE] at 11:00 AM, revealed a POST form with the following details: -CPR -Full Treatment -Provide Feeding through New or Existing Surgically-Placed Tubes The POST form was signed by Resident #123 but was not dated. During an interview on [DATE] at 2:18 PM, the DON confirmed the PAS had not be dated by resident and could not be considered legally valid. g) Resident #75 A record review of dialysis care revealed Resident #75's Physician orders for no blood draws / injections / blood pressures from right vascath arm. A medical record review found documentation of blood pressures being obtained in the right arm. During an interview on [DATE] at about 9:10 AM Resident #75 stated, he would not allow anyone to take blood pressures from his right arm. He stated, he protects his right arm.

May 2024 6 deficiencies 3 IJ (1 affecting multiple)

CRITICAL (J) 📢 Someone Reported This

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

Immediate Jeopardy (IJ) - the most serious Medicare violation

Deficiency F0605 (Tag F0605)

Someone could have died · This affected 1 resident

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Based on record review and interview the facility failed to keep Resident #38 free from a chemical restraint imposed for purposes of discipline when an antipsychotic medication was given without a physician order. The deficient practice put all one (1) resident that exhibit behaviors currently residing in the facility at risk for serious injury, serious harm, serious impairment, or death. Resident identifier: #38. Facility Census: 135. Findings included: a) Resident #38 During a complaint survey a review of Resident #38's nursing progress notes found: Nursing note dated 05/5/24 4:35 AM Came onto wing at 2:20, patient (pt) came out screaming and chasing the staff down the hallway because they wanted a regular diet, was told to go back to their room, patient went into the room and laid down on the bed. Patient was held down and given 5mg/1ml IM shot of haldol. pt came back out and charged at staff again. pt charged at nurses station and fell into soiled room door. pt tried to get up and attack nurses again but wasn't able to get up. pt scooted into their room. pt came back out, charged at the nurses desk again. pt was trying to grab this nurse, this nurse held his hands and tried to get him off me. supervisor helped him back off of this nurse and he fell on the floor and laid there as the cops and the ambulance came to take him to the hospital. During a confidential interview (CI) #1, on 05/22/24 with an individual present on the day noted, the nurse administering the IM injection, was unable to readily report the dose given. CI #1 stated Licensed Practical Nurse (LPN )#1 discarded the Haldol bottle, and she provided medication from a zip lock bag. Continued record review of Resident #38's Physicians orders found there was no active order for Haldol on 05/05/24. The facility was notified of the Immediate Jeopardy (IJ) at 3:10 PM on 05/22/24. The facility submitted their first abatement plan of correction (POC) at 5:44 PM on 05/22/24. The abatement POC was accepted by the state agency at 6:00 PM on 05/22/24. After observation of the implementation of the abatement POC, the IJ was abated at 11:40 AM on 05/23/24. The IJ started on 05/22/25 and ended on 05/23/24. The facility's approved abatement POC consisted of the following: Correction action for area of concern- On 05/22/24 at 3:21 PM one on one education for licensed nursing staff present and via phone call for staff not present was provided related to the facility medication administration policy, the six rights of medication administration, and not administering a medication without an order was initiated by the Director of Education for all 39 licensed nurses. The education consisted of the right patient, the right drug, the right time, right dose, right route, and right documentation. It also consisted of verifying the order prior to administering the medication. A plan for any staff member not educated to not work until education was completed and implemented. On 05/22/24 at 3:25 PM the Facility Quality Assessment and Assurance Committee ADHOC meeting was held by phone with the Facility Medical Director, Administrator, and Director of Nursing regarding incident administering a medication without an order to Resident #38 which occurred on 05/05/24 and what corrective action measures were being taken. On 05/22/24 from 3:35 PM to 5:00 PM an audit of PRN (as needed) medications given for the last seven days for all 136 residents were performed by RN Unit Manager #1 and the DON. The audit will ensure that any PRN medications that were given had a reason and the effectiveness of the medication was documented. This report was then audited against the nursing documentation for the last seven days to ensure that no PRN medication was given without an order. Any discrepancies found were corrected and if needed provider notified and new orders obtained if given. On 05/22/24 at 3:45 P.M. the Six Rights of Medication Administration signs were made and laminated and then secured to the seven medication carts in the facility as a visual reminder to the licensed nursing staff. On 05/22/24 from 4:00 P.M. to 5:00 P.M. an audit of the medication carts were conducted by RN Unit Manager #2, RN Wound Nurse, and the ADON to ensure that any discontinued PRN medication were not on the carts. If any were found they were removed and disposed of according to policy. Beginning 05/23/24, during the morning Interdisciplinary team (IDT) meeting the facility will review the PRN medication administration report from the previous day and review the 24-hour report to ensure that no PRN medications were given without an order. The facility will run a report of discontinued medications and ensure that the medications have been removed from the medication carts. The facility identifies the deficient practice occurred related to a medication being administered without an order, as the medication was a PRN. order that had previously been in place but had ended on 04/29/24 and not pulled from the medication cart. Beginning 05/23/24 the Director of Nursing or her designee will conduct an audit of 10 residents using the Unnecessary Drug Review audit to ensure that no residents are receiving medications without an order. The audit will be completed twice a week for four weeks and then as determined necessary. Findings will be referred to the Quality Assurance and Performance Improvement Committee for ongoing compliance. Beginning 05/23/24 the Director of Education or her designee will conduct an audit of 10 employees using the Medication Administration Audit tool to ensure that the licensed nursing staff are following the six rights of medication administration. The audit will be completed twice a week for four weeks and then as determined necessary. Findings will be referred to the Quality Assurance and Performance Improvement Committee. During an interview, with LPN #1 on 05/21/24 at 9:24 AM via phone, she stated, resident was so aggressive he was chasing staff down the hall multiple times. She stated, she administered an intermuscular Haldol 5ml per 1 ML in Resident #38's arm. She stated, she did try to administer the injection in the back of his arm, but it was administered in the middle of his arm due to him swinging his arms. She stated that five (5) staff members were present at this time. During an Interview on 05/22/24 at 1:48 PM, Nurse Practitioner #211 confirmed, she did not authorize an order for Haldol 5ml per 1 ML until 05/06/24 after he returned from the emergency room. During an Interview on 05/22/24 about 2:10 PM the director of Nursing verified Resident #38 did not have an active Haldol order when he was administered the drug.

CRITICAL (J) 📢 Someone Reported This

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

Immediate Jeopardy (IJ) - the most serious Medicare violation

Accident Prevention (Tag F0689)

Someone could have died · This affected 1 resident

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. Based on observation and staff interview the facility failed to ensure the residents environment over which it had control was free from accident hazards related to Resident # 27 received a burn after spilling reheated hot coffee on herself. The deficient practice put all residents that drink coffee currently residing in the facility at risk for serious injury, serious harm, serious impairment, or death. Resident identifiers: #27. Facility census: 135. Findings included: a) Hot Liquids Review of facility documentation during a Facility reported Incident investigation (FRI) showed a reportable dated 10/30/23. The incident occurred on 10/30/23 when Resident # 27 sustained a burn injury to the right side of her abdomen after spilling coffee on herself that had been reheated. Continued review revealed a physician treatment order for Silvadene External Cream to be applied to the right side of the abdomen topically every day for burn. A care plan dated 04/23/20 with a revision date of 09/13/22 review found: A focus area for potential safety concerns and injury from hot liquids. The goal was to Minimize risk for injury from hot liquids. Interventions included: Encourage resident to be out of bed and in sitting position for consumption of hot liquids. Initiated 04/23/20. Temp of liquids not to exceed 180 degrees. Initiated 07/06/21. Subsequent review of the 10/30/23 statement from Nurse Aide #202 found: Resident #27 requested her coffee to be re-heated with most meals. Resident #27 was in bed. The coffee was in regular coffee cup with no lid or straw. The five (5) day follow up found Incident reported as failure to follow plan of care resulting in injury, the whole house education completed on hot liquid safety and observation audits to be completed of staff reheating foods/liquids to ensure instructions are followed, temperature of item is checked and verified temperature is within range and properly logged. Review of in- serviced/educated on Safety of Hot Liquids date 10/30/23 found only NA #202 was educated. During an interview with Staff Development #27 it was revealed that Resident #27 had at least two (2) burns from hot coffee at different times. Also, she confirmed that only one staff member was educated after the 10/30/23 burn on Resident #27. Interviews on 05/21/24 at12:10 PM with Registered Nurse #120, Helping Hands #74 and Licensed Practical Nurse #58 revealed they were unaware of the facility policy/ procedure for reheating food and liquids. The facility was notified of the Immediate Jeopardy (IJ) at 4:37 PM on 05/21/24. The facility submitted their first abatement plan of correction (POC) at 5:41 PM on 05/21/24. The abatement POC was accepted by the state agency at 6:12 PM on 05/21/24. After observation of the implementation of the abatement POC, the IJ was abated at 1:00 PM on 05/22/24. The IJ started on 05/21/25 and ended on 05/22/24. The facility's approved abatement POC consisted of the following: Correction action for area of concern- On 05/21/24 at 4:53 P.M. one on one education for staff present and via phone call for staff not present was provided related to the facility Safety of Hot Liquids policy and that if food needs to be reheated, it will be discarded and the kitchen will send up new as well as after-hours things can be reheated in one central location and temperatures are to be taken and recorded and no higher than 140 degrees was initiated by the Director of Education for all 175 employees. A plan for any staff member not educated to not work until education is completed and implemented. On 05/21/24 from 4:55 P.M. to 6:00 PM Hot liquid risk screening tool were completed by RN Unit Manager #1 and RN Unit Manager #2 on all residents and care plans updated as needed to reflect the assessment. On 05/21/24 at 5:00 P.M. Maintenance Man #1 removed microwaves from the unit pantries. One microwave will be kept in the conference room area in the event that something needs to be heated after hours. A sign will be placed there to instruct staff how to heat food and beverages, including taking the temperature and recording. The liquids are to be no hotter than 140 degrees. On 05/21/24 at 5:05 P.M. the Facility Quality Assessment and Assurance Committee ADHOC meeting was held by phone with the Facility Medical Director, Administrator, and Director of Nursing regarding incident of Accident Hazard involving Resident #27 which occurred on 04/06/23 and again on 10/30/23 and what corrective action measures were being taken. On 05/21/24 at 5:30 P.M. the physician was notified, and orders received for Occupational Therapy evaluation. Beginning 05/22/24, during the morning Interdisciplinary team (IDT) meeting the facility will discuss if any new injuries have occurred related to hot liquids through reviewing the risk as well as reviewing the 24-hour report. Any new injuries from hot liquids will be investigated and new interventions in place to prevent future episodes. The facility identifies the deficient practice occurred related to a staff member not following the resident's plan of care and adhering to the facility policy as it relates to hot liquids. Beginning 05/22/24 the Administrator or her designee will forward any new reportable allegations to the Chief Operating Officer to review to ensure that the facility conducts a thorough investigation with accurate conclusions. Beginning 05/22/24 the Director of Nursing or her designee will conduct an audit of 10 residents using the Resident Skin Assessment tool. The audit will be completed twice a week for four weeks and then as determined necessary. Findings will be referred to the Quality Assurance and Performance Improvement Committee for ongoing compliance. Beginning 05/22/24 the Director of Education or her designee will conduct an audit of 10 employees using the Staff Questionnaire as it relates to how to reheat liquids and by demonstration. The audit will be completed twice a week for four weeks and then as determined necessary. Findings will be referred to the Quality Assurance and Performance Improvement Committee for ongoing compliance.

CRITICAL (K) 📢 Someone Reported This

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

Immediate Jeopardy (IJ) - the most serious Medicare violation

Free from Abuse/Neglect (Tag F0600)

Someone could have died · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review and staff interview, the facility failed to protect Resident #39's right to be free from sexual abuse. This was true for one (1) out of five (5) resident-to-resident altercations reviewed during the complaint process. Facility census: 135. Resident identifiers: #39 and #137. The facility's failure to follow their abuse policy and recognize the incident as an occurrence of resident-to-resident sexual abuse placed an unlimited number of residents currently residing in the facility at risk for possible abuse. The state agency determined this was an immediate jeopardy (IJ) situation. a) An electronic medical review, completed on 05/21/24 at 9:45 AM, revealed the following details: -RN Unit Manager #28 documented in a nursing note, dated 02/14/24 at 9:04 AM, At 0150 [1:50] this AM, Staff entered resident's room and observed Resident [#137] on top of roommate [Resident #39] naked, making humping motion, and attempting to remove roommates [roommate's] gown and incontinence brief. -RN Unit Manager #28 documented in nursing note, dated 02/14/24 at 6:59 AM, Aide alarmed this nurse about resident being sexually inappropriate with resident in room. The note also indicated written statements by aides would be given to supervisor on duty. -The only written statement on file was from Nurse Aide (NA) #6 who reported NA #210 requested help in the resident room. NA #6 stated she saw Resident #137 was completely nude and was trying to rip Resident #39's brief off. She also documented she changed Resident #39's bed sheets because Resident #137 had peed on his top sheet. -Review of Resident #137's care plan reflected the facility did not address inappropriate sexual behaviors. -Review of Resident #39's care plan reflected the facility did not address possible trauma from the experience. A record review was completed on 05/21/24 at 9:22 AM. The facility noted the date and time of the incident as happening on 02/14/24 at 1:50 AM. The facility provided the following description of the incident: Resident #137 was observed being sexually inappropriate with roommate (Resident #39). Residents were separated. Resident #39 was moved to a different wing. The facility's five (5) follow-up report outlined the following investigative details: -Resident #137 [the perpetrator] was an [AGE] year-old male who was admitted to the facility on [DATE] with a diagnosis of Dementia, Paranoid Personality Disorder, Hallucinations, Depression, and anxiety disorder. He had a Brief Interview for Mental Status (BIMS) score of 09 which is indicative of moderate cognitive impairment. -Resident #39 [the victim] was a [AGE] year-old male who was admitted to the facility on [DATE] with a diagnosis of Alzheimer's Disease, Dementia, and Depression. He had a BIMS of 01 which is indicative of severe cognitive impairment. -It was reported on 02/14/24 at approximately 2:00 AM a staff member noticed movement in the residents' room. Upon entering the room, the staff member found Resident #137 on top of Resident #39 and appeared to be trying to have sex with him. Resident #39 was dressed in a hospital gown and had an adult brief on. The staff immediately told Resident #137 to get off of him and that it was inappropriate. Staff assisted Resident #137 in getting dressed and removed him from the room to the nurses' station where he could be monitored. -Resident #39 was assessed, and no injuries were found. He showed no signs of emotional distress. -Upon completion of the investigation, the facility did not substantiate abuse occurred because of the incident due to Resident #137 did not have the capacity for intent. Interview with Social Worker -During an interview, completed on 05/21/24 at 10:58 AM, Social Worker #59 when asked to describe sexual abuse described it as, Anything that is uninvited. When asked if he had ever been trained to use the reasonable person concept when investigating complaints, Social Worker #59 stated he had not. By definition, a reasonable person concept would involve a case where a resident was unable to speak for themselves. The investigative team should assess how most people would react to the situation in question. Additionally, Social Worker #59 agreed there could be situations of abuse that do not result in an observable physical injury, or the psychosocial effects of abuse may not be immediately apparent. The social worker agreed that Resident #39 had a BIMS of 01 which would make it unlikely he would be able to speak about how the incident affected him. A resident with such severe cognitive impairment cannot usually recall what has occurred, or may not express outward signs of physical harm, pain, or mental anguish. Social Worker #59 agreed that neither physical marks on the body nor the ability to respond and/or verbalize was needed to conclude that sexual abuse/assault had occurred. During an interview, at approximately 11:20 AM on 05/21/24, the Administrator stated the facility did not substantiate resident-to-resident sexual abuse occurred as a result of the incident due to the fact Resident #137 did not have the capacity for intent. When explaining if there was an instance where a resident did not wish to engage in sexual activity with another resident that the facility must respond to it as an alleged violation of sexual abuse, the DON questioned how the facility would know if it was unwanted since they had no way of knowing Resident #39's sexual preference prior to his cognitive decline. The Surveyor explained that the expectation was if the resident did not have capacity to consent to sexual activity, the facility should always respond to it as an alleged violation of sexual abuse. Using a reasonable person concept, it could be assumed that a nude person climbing on top of you in the middle of the night, humping you, and attempting to remove your clothing would be considered sexually inappropriate and would reasonably cause anyone to have psychosocial harm. The Administrator and DON confirmed that neither resident's care plan had been updated to reflect the need to monitor Resident #137 more closely or to offer Resident #39 any trauma services. The resident-to-resident sexual abuse occurred on 02/14/24 at 1:50 AM. The facility was notified of the IJ on 05/21/24 at 12:10 PM. The State Office approved the facility's Plan of Correction (POC) at 5:54 PM on 05/21/24. After observation, staff interview, review of facility documentation, and record review determining the implementation of the POC, the IJ was abated at 1:00 PM on 05/22/24. The IJ started on 2/14/24 at 1:50 AM and ended on 05/22/24 at 1:00 PM. The facility's approved abatement POC consisted of the following: On 05/21/24 at 1:45 P.M. one on one education for staff present and via phone call for staff not present was provided related to the facility abuse policy, which included what abuse was and reporting requirements, including sexual and verbal abuse was initiated by the Director of Education for all 175 employees. The education consisted of the different types of abuse, whether it is physical and what this entails (hitting, slapping, punching, pinching, etc.), sexual and what that entails (unwanted physical touch, groping of private areas of the body, attempted intercourse, unwanted advances), emotional/verbal (making fun, degrading jokes, putting someone down, derogatory comments, yelling, cursing). A plan for any staff member not educated to not work until education was completed and implemented. On 05/21/24 from 1:45 P.M. to 3:30 P.M. interviews were completed by Management staff comprised of the Social Work, Social Service Designee, Business Office Manager, Assistant Business Office Manager, Human Resource Director, and the Admissions Director for 48 residents who have capacity using the Resident Ause Questionnaire with questions consisting of: How are you doing today?, How is your care?, Do you feel safe here?, Have you ever felt threatened by another resident or uncomfortable?, Do you have any issues with staff here?, Have staff ever made you feel afraid? No new concerns were identified by the facility following these interviews. On 05/21/24 from 1:45 P.M. to 3:15 P.M. skin inspections were performed by RN Unit Manager #1, RN Unit Manager #1, RN Skin Nurse, and ADON for 87 residents who do not have capacity. No abnormalities were found by the staff completing the inspections. On 05/21/24 at 2:03 P.M. the Chief Operating Officer for [NAME] Rehabilitation and Healthcare Center re-educated the Administrator and Director of Nursing on the facility abuse policy, including reporting and substantiating allegations of abuse regardless of capacity of the residents involved. On 05/21/24 at 2:40 P.M. the Facility Quality Assessment and Assurance Committee ADHOC meeting was held by phone with the Facility Medical Director, Administrator, and Director of Nursing regarding incident of abuse involving Resident #39 and Resident #137 which occurred on 02/12/24 and what corrective action measures were being taken. On 05/21/24 at 2:25 P.M. to 3:10 P.M. the Registered Nurse Assessment Coordinator #1 and Registered Nurse Assessment Coordinator #2 completed an audit of resident care plans and identified those who exhibited possible inappropriate sexual behaviors. These were reviewed and updated to ensure that appropriate interventions are in place. Beginning 05/22/24, during the morning Interdisciplinary team (IDT) meeting the facility will discuss if any new allegations or concerns of abuse have been brought to anyone staff members' attention as well as reviewing the 24-hour report. The facility will ensure any/all allegations will be thoroughly investigated, and actions will be taken to ensure the facility is following the abuse policy. The facility identifies the deficient practice occurred related to a failure to identify the potential psychosocial harm from the occurrence and the failure to identify the incident as sexual abuse regardless of capacity. Beginning 05/22/24 the Administrator or her designee will forward any new reportable allegations to the Chief Operating Officer to review to ensure that the facility conducts a thorough investigation with accurate conclusions. Beginning 05/22/24 the Director of Nursing or her designee will conduct an audit of 10 residents using the Resident Abuse Interview Tool and skin assessment. The audit will be completed twice a week for four weeks and then as determined necessary. Findings will be referred to the Quality Assurance and Performance Improvement Committee for ongoing compliance. Beginning 05/22/24 the Director of Education or her designee will conduct an audit of 10 employees using the Staff Abuse Questionnaire. The audit will be completed twice a week for four weeks and then as determined necessary. Findings will be referred to the Quality Assurance and Performance Improvement Committee for ongoing compliance. Review of the facility's Abuse/Neglect policy revealed the following details regarding the definition of sexual abuse: -Sexual abuse was defined as, but was not limited to, non-consensual sexual harassment, sexual coercion, contact, or sexual assault. -Anytime the facility has reason to suspect that a resident may not have the capacity to consent to sexual activity, the facility must take steps to ensure that the resident is protected from abuse.

SERIOUS (G) 📢 Someone Reported This

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

Actual Harm - a resident was hurt due to facility failures

Comprehensive Care Plan (Tag F0656)

A resident was harmed · This affected 1 resident

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. Based on record review, and staff interview, the facility failed to ensure one (1) of three (3) residents had a person-centered comprehensive care plan implemented to meet his/her other preferences and goals, and address the resident's medical, physical, mental, and psychosocial needs. Failure to implement Resident #72's care plan resulted in her sustaining a burn to her abdomen which required physician intervention. Resident #72 sustained actual harm due to the facility's failure to implement her care plan. Resident identifiers: #27. Facility census: 135. Findings included: a) Resident #27 Review of facility documentation during a Facility Reported Incident (FRI) investigation showed a reportable dated 10/30/23. The incident occurred on 10/30/23 when Resident #27 sustained a burn injury to the right side of her abdomen after spilling coffee on herself that had been reheated. Continued review revealed a Physician treatment order for Silvadene External Cream to be applied to the right side of the abdomen topically every day for burn. A care plan review found a care plan focus area initiated on 09/23/22 and revised on which included a potential for safety concerns and injury from hot liquids. A care plan goal initiated on 04/23/20 and revised on 09/13/22 included Minimize risk for injury from hot liquids. Interventions included: Encourage resident to be out of bed and in sitting position for consumption of hot liquids. Temp of liquids not to exceed 180 degrees. Initiated 07/06/21. Subsequent review of the 10/30/23 statement from Nurse Aide #202 found: Resident #27 requested her coffee to be re-heated with most meals. Resident #27 was in bed. Coffee was in a regular coffee cup with no lid or straw. The five (5) day follow up found incident reported as failure to follow plan of care resulting in injury, the whole house education completed on hot liquid safety and observation audits to be completed of staff reheating foods/liquids to ensure instructions are followed, temperature of item is checked and verified temperature is within range and properly logged. During an interview with Staff Development #27 it was revealed, Resident #27 had at least two (2) burns from hot coffee at different times. Also, she confirmed the care plan was not followed during the 10/30/23 incident that contributed to Resident #27 getting burned.

CONCERN (D) 📢 Someone Reported This

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

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

Report Alleged Abuse (Tag F0609)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review and staff interview, the facility failed to ensure all alleged violations involving abuse were reported in a timely fashion to all appropriate state agencies. This was true for one (1) out of five (5) resident-to-resident altercations reviewed during the complaint process. Facility census: 135. Resident identifiers: #39 and #137. Findings include: a) The Facility's Abuse/Neglect Policy Review of the facility's Abuse/Neglect policy revealed the following reporting requirements: -All alleged violations of abuse are to be reported by the facility to the SA (State Agency) and Adult Protective Services (APS). b) Alleged Resident-to-Resident Sexual Abuse An electronic medical review, completed on 05/21/24 at 9:45 AM, revealed the following details: -RN Unit Manager #28 documented in a nursing note, dated 02/14/24 at 9:04 AM, At 0150 [1:50] this AM, Staff entered resident's room and observed Resident [#137] on top of roommate [Resident #39] naked, making humping motion, and attempting to remove roommates [roommate's] gown and incontinence brief. -RN Unit Manager #28 documented in nursing note, dated 02/14/24 at 6:59 AM, Aide alarmed this nurse about resident being sexually inappropriate with resident in room. The note also indicated written statements by aides would be given to supervisor on duty. -The only written statement on file was from CNA #6 who reported CNA #210 requested help in the resident room. CNA #6 stated she saw Resident #137 was completely nude and was trying to rip Resident #39's brief off. She also documented she changed Resident #39's bed sheets because Resident #137 had peed on his top sheet. c) Facility Investigation and Reporting A record review was completed on 05/21/24 at 9:22 AM. The facility noted the date and time of the incident as happening on 02/14/24 at 1:50 AM. The facility provided the following description of the incident: Resident #137 was observed being sexually inappropriate with roommate (Resident #39). Residents were separated. Resident #39 was moved to a different wing. This incident was reported to Adult Protective Services (APS) and the Long-Term Care Ombudsman. There was no report made to the State Agency (Office of Health Facility Licensure and Certification.) d) Interview with Administrator During an interview, at approximately 11:30 AM on 05/21/24, the Administrator stated it was an oversight that the Office of Health Facility Licensure and Certification did not receive an immediate fax reporting of the allegations of resident-to-resident sexual abuse on 02/14/24.

CONCERN (D) 📢 Someone Reported This

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

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

Deficiency F0657 (Tag F0657)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to revise residents care plans after an occurrence of resident-to-resident sexual abuse. This was a random opportunity for discovery throughout the complaint survey process. Resident identifiers: #137 and #39. Facility census: 135 Findings included: a) Resident #137 An electronic medical review, completed on 05/21/24 at 9:45 AM, revealed the following details regarding Resident #137. -RN Unit Manager #28 documented in a nursing note, dated 02/14/24 at 9:04 AM, At 0150 [1:50] this AM, Staff entered resident's room and observed Resident [#137] on top of roommate [Resident #39] naked, making humping motion, and attempting to remove roommates [roommate's] gown and incontinence brief. -RN Unit Manager #28 documented in a nursing note, dated 02/14/24 at 6:59 AM, Aide alarmed this nurse about resident being sexually inappropriate with resident in room. -A written statement from Nurse Aide (NA) #6 stated NA #210 requested help in the resident room. NA #6 stated she saw Resident #137 completely nude and was trying to rip Resident #39's brief off. She also documented she changed Resident #39's bed sheets because Resident #137 had peed on his top sheet. -Review of Resident #137's care plan reflected the facility did not address inappropriate sexual behaviors. b) Resident #139 Review of Resident #39's care plan reflected the facility did not address possible trauma from the experience. Interview with Administrator and Director of Nursing (DON) During an interview, at approximately 11:20 AM on 05/21/24, the Administrator and DON confirmed that neither resident's care plan had been updated to reflect the need to monitor Resident #137 more closely due to his inappropriate sexual behaviors or to offer Resident #39 any trauma services.

Oct 2023 1 deficiency

CONCERN (D) 📢 Someone Reported This

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

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

Safe Environment (Tag F0584)

Could have caused harm · This affected 1 resident

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. Based on observations and staff interviews, the facility failed to ensure hallway temperatures were set at least 71 degrees Fahrenheit (F). This was a random observation. Facility census: 133. Findings included: a) On 10/16/23 at 4:30 PM, a tour of the Second floor found wall thermostats temperatures set at 59 to 69 degrees Fahrenheit (F). Charge Nurse #7 on Unit 800 confirmed the thermostat was set on 69 F and that it was cold. Residents were observed in their rooms covered with two (2) blankets. The Maintenance Director (MD) #99 was called and confirmed temperatures were set to low and all of the thermostats would be checked and adjustments made. On 10/19/23 at 10:15 AM, during an interview with the Director of Nursing (DON), the DON was informed of issues with the temperatures on all units on second floor. The DON stated they had a contract to service ceiling air conditioning units. At 10:25 AM on this same day during a discussion with MD #99 it was mentioned that the thermostat on the 800 Hall was set below 71 degrees and the ceiling vents were covered in gray dust. MD #99 stated that Housekeeping was responsible for cleaning the vents daily and Maintenance was responsible for cleaning filters and take care of any leaks. In addition, MD #99 stated that next year the ceiling units would be replaced.

Aug 2023 3 deficiencies

CONCERN (D) 📢 Someone Reported This

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

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

Free from Abuse/Neglect (Tag F0600)

Could have caused harm · This affected 1 resident

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. Based on facility record review, medical record review and staff interview, staff neglected to provide incontinence care to Residents #73 and #48. This is true for two (2) of two (2) residents reviewed for neglect related to incontinence care. Resident identifiers: #73 and #48. Facility census: 132. Findings included: a) Resident (R) #73 Review of the medical record on 08/22/23 revealed R#73's diagnoses include dementia with out behaviors, a psychotic disorder with delusion, anxiety, and falls. The annual Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 05/17/23 noted R #73 is frequently incontinent of urine, always incontinent of bowel, and requires extensive assistance with transfers, bed mobility, toileting and hygiene. The progress notes include the following documentation: --7/29/23 at 11:24 PM R#73 observed sliding on his buttocks across the floor. Assessment noted no injuries or pain. R#73 was assisted to his wheel chair and brought to the nurse's station. Record reviewed, continue plan of care. Staff to monitor more often in the evenings. written by Nurse Unit Manager #83. --07/29/23 at 11:44 PM R#73 in his wheel chair close to nursing station due to him not staying in bed. Will continue to monitor. written by Licensed Practical Nurse (LPN) #185. --07/30/23 7:00 AM LPN #186 documented she notified the Charge Nurse about patient being up in chair when shift began, he was washed up, changed and placed in bed. --07/30/23 10:49 AM R#73 was up in chair when day shift started, very drowsy. R#73 was washed and changed and sleeping most of the morning. Written by LPN #186. The Nurse Aide toilet use documentation form is blank for the night shift (11:00 PM - 7:00 AM) on 07/29/23. The behavioral documentation on the electronic Medication Administration Record (MAR) was coded as 0 for night shift on 07/29/23, indicating R#73 did not demonstrate refusal of care during toileting and assistance with activities of daily living (ADL) care. The MAR was also coded as 0 for night shift on 07/29/23 for insomnia/sleepless behaviors indicating no disruption in his sleep pattern. Review of the facility's reportables dated 07/30/23 revealed R#73 was found at the beginning of day shift saturated in urine, asleep in his chair. A witness statement written by Nurse Aide (NA) #11 states R#73 was incontinent of urine around 10:30 PM on 07/29/23. NA #11 changed the resident and placed him in bed. R#73 refused to go to bed, got back in his wheelchair and proceeded to wander the halls. NA #11 stated she was moved to Wing five (5) at 2:00 AM and not aware she was supposed to float and cover the first four (4) rooms on Wing Seven (7). NA #11 reported she did not go back to Wing Seven after 2:00 AM on 07/30/23 and did not provide any further care to R#73 during her shift. During an interview on 08/23/23 at 12:15 PM, the Director of Nursing (DON) acknowledged the nurse supervisor neglected to ensure all residents including R#73 and R#48 were assigned a care giver and provided incontinence care during the night shift of 07/29/23. The DON confirmed the medical record lacks evidence #73 was toileted on the night shift of 07/29/23. In addition, there is no evidence indicating staff assessed R#73 during the night of 07/29/23. b) Resident (R) #48 Review of the medical record on 08/22/23 found R#48's diagnoses include dementia with behaviors, congested heart failure, cognitive communication deficit, and obstructive uropathy. The quarterly MDS with an ARD of 06/11/23, notes he has a urinary catheter and is always incontinent of bowel. He requires extensive assistance for bed mobility, transfers, toileting, hygiene and dressing. The computerized Nurse Aide documentation for catheter care for night shift (11:00 PM - 7:00 AM) on 07/29/23 was blank, indicating no evidence catheter care was provided during the night shift. The bowel movement and continence record notes the last bowel movement was on 07/26/23 at 12:15 PM. The behavioral documentation on the electronic MAR was marked as NA for anxiety, restlessness, irritable fearful behaviors and marked as 0 for physically abusive behaviors for the night shift on 07/29/23, indicating no behaviors were demonstrated. The progress note written by LPN #186 on 07/30/23 at 7:08 AM, notes R#48 was found at the beginning of day shift, up in his chair, with dried stool in brief. Review of the facility's reportables dated 07/30/23 revealed R#48 was found at the beginning of day shift left in his chair with improper incontinence care. The witness statement written by NA #163 states she found R#48 in his room at 7:00 AM very agitated yelling for help. Staff assisted him to bed and found dried stool on the front and back of his perineum. Staff cleaned and dressed the resident and reported their findings to the unit nurse and the supervisor. NA #11 stated she was moved to Wing 5 at 2:00 AM and not aware she was supposed to float and cover the first four (4) rooms Wing 7. NA #11 reported she did not go back to Wing 7 after 2:00 AM on 07/30/23 and did not provide any further care to any residents on the 700 hall. During an interview on 08/23/23 at 12:15 PM, the DON acknowledged the nurse supervisor neglected to ensure all residents including R#73 and R#48 were assigned a care giver and provided incontinence care during the night shift of 07/29/23. The DON confirmed the records lack evidence R#48 received urinary catheter care on the night shift of 07/29/23 and was found on the morning of 07/30/23 with dried stool in his brief and on his body.

CONCERN (D) 📢 Someone Reported This

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

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

Quality of Care (Tag F0684)

Could have caused harm · This affected 1 resident

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. Based on facility record review, medical record review and staff interview, the facility failed to ensure incontinence care is provided to residents in according with professional standards of care. This is true for two (2) of four (4) residents reviewed for incontinence care. Resident identifiers: R#73 and R#48. Facility census: 132. Findings included: a) Resident (R) #73 Review of the medical record on 08/22/23 revealed R#73's diagnoses include dementia with out behaviors, a psychotic disorder with delusion, anxiety, and falls. The annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/17/23 noted R #73 is frequently incontinent of urine, always incontinent of bowel, and requires extensive assistance with transfers, bed mobility, toileting and hygiene. The progress notes include the following documentation: --7/29/23 at 11:24 PM R#73 observed sliding on his buttocks across the floor. Assessment noted no injuries or pain. R#73 was assisted to his wheel chair and brought to the nurse's station. Record reviewed, continue plan of care. Staff to monitor more often in the evenings. written by Nurse Unit Manager #83. --07/29/23 at 11:44 PM R#73 in his wheel chair close to nursing station due to him not staying in bed. Will continue to monitor. written by Licensed Practical Nurse (LPN) #185. --07/30/23 at 7:00 AM LPN #186 documented she notified the charge nurse about patient being up in chair when shift began, he was washed up, changed and placed in bed. --07/30/23 at 10:49 AM R#73 was up in chair when day shift started, very drowsy. R#73 was washed and changed and sleeping most of the morning. Written by LPN #186 The Nurse Aide toilet use documentation form is blank for the night shift (11:00 PM - 7:00 AM) on 07/29/23. The behavioral documentation on the electronic medication administration record (MAR) is coded as 0 for night shift on 07/29/23, indicating R#73 did not demonstrate refusal of care during toileting and assistance with activities of daily living (ADL) care. The MAR is also coded as 0 for night shift on 07/29/23 for insomnia/sleepless behaviors indicating no disruption in his sleep pattern. Review of the facility's reportables dated 07/30/23 revealed R#73 was found at the beginning of day shift saturated in urine, asleep in his chair. A witness statement written by Nurse Aide (NA) #11 states R#73 was incontinent of urine around 10:30 PM on 07/29/23. NA #11 changed the resident and placed him in bed. R#73 refused to go to bed, got back in his wheelchair and proceeded to wander the halls. NA #11 stated she was moved to wing five at 2:00 AM and not aware she was supposed to float and cover the first four rooms on wing seven. NA #11 reported she did not go back to wing seven after 2:00 AM on 07/30/23 and did not provide any further care to R#73 during her shift. During an interview on 08/23/23 at 12:15 PM, the Director of Nursing (DON) acknowledged the nurse supervisor failed to document staffing assignments and assure all residents including R#73 and R#48 were cared for and received incontinence care during the night shift of 07/29/23. The DON confirmed the records lack evidence R#73 was toileted on the night shift of 07/29/23. In addition, there is no evidence indicating staff assessed R#73 during the night of 07/29/23. The DON confirmed there is no evidence indicating R#48's behaviors prevented staff from providing care during the night of 07/29/23. b) Resident (R) #48 Review of the medical record on 08/22/23 found R#48's diagnoses include dementia with behaviors, congested heart failure, cognitive communication deficit, and obstructive uropathy. The quarterly MDS with an ARD of 06/11/23, noted he has a urinary catheter and was always incontinent of bowel. He requires extensive assist of two (2) for bed mobility, transfers, toileting, hygiene and dressing. The computerized Nurse Aide documentation for catheter care for night shift (11:00 PM - 7:00 AM) on 07/29/23 was blank, indicating no catheter care was provided during the night shift. The bowel movement and continence record noted the last bowel movement was on 07/26/23 at 12:15 PM. The behavioral documentation on the electronic MAR is marked as NA for anxiety, restlessness, irritable fearful behaviors and marked as 0 for physically abusive behaviors for the night shift on 07/29/23, indicating no behaviors were demonstrated. The progress note written by LPN #186 on 07/30/23 at 7:08 AM, notes R#48 was found at the beginning of day shift, up in his chair, with dried stool in brief. Review of the facility's reportables dated 07/30/23 revealed R#48 was found at the beginning of day shift in his chair with improper incontinence care. The witness statement written by NA #163 stated she found R#48 in his room at 7:00 AM very agitated yelling for help. Staff assisted him to bed and found dried stool on the front and back of his perineum. Staff cleaned and dressed the resident and reported their findings to the Unit Nurse and the Supervisor. NA #11 stated she was moved to Wing 5 at 2:00 AM and was not aware she was supposed to float and cover the first four (4) rooms on Wing 7. NA #11 reported she did not go back to Wing 7 after 2:00 AM on 07/30/23 and did not provide any further care to any residents on the 700 hall including R#48. During an interview on 08/23/23 at 12:15 PM, the DON acknowledged the Nurse Supervisor failed to document staffing assignments and ensure all residents including R#73 and R#48 were cared for and received incontinence care during the night shift of 07/29/23. The DON confirmed the records lack evidence R#48 received urinary catheter care on the night shift of 07/29/23. The DON confirmed R#48 was found on the morning of 07/30/23 with dried stool in his brief and on his body. The DON confirmed there is no evidence indicating R#48's behaviors inhibited staff from providing care and the last bowel movement documented was on 07/29/23.

CONCERN (F) 📢 Someone Reported This

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

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

Deficiency F0725 (Tag F0725)

Could have caused harm · This affected most or all residents

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. Based on facility record review, medical record review and staff interview, the facility failed to ensure there is sufficient qualified staff available at all times to meet the needs of the residents. The nursing supervisor failed to deploy staff in a manner to ensure all residents were assigned a care giver. This practice has the potential to affect more than a limited number of residents. Resident identifiers: #73 and #48. Facility census: 132. Findings included: a) Staff Postings The staff posting dated 07/29/23 lists two (2) Registered Nurses (RN), two (2) Licensed Practical Nurses (LPNs) and six (6) Nurse Aides (NAs) for the 11:00 PM to 7:00 AM shift to care for 135 residents on seven (7) halls. b) Reportable Allegations The facility's reportable allegations dated 07/30/23 identify concerns related to care not being provided to R#73 and R#48 during the night shift (11:00 PM - 7:00 AM) on 07/29/23. Investigation by the facility includes a witness statement written by NA #11. NA #11 reported she was moved to Wing Five (5) at 2:00 AM and was not aware she was supposed to float and cover the first four (4) rooms on Wing Seven (7). NA #11 reported she did not go back to Wing Seven after 2:00 AM on 07/30/23 and did not provide any further care to any residents on the 700 hall including R#73 or R#48 during her shift. c) Resident (R) #73 Review of the medical record on 08/22/23 revealed R#73's diagnoses include dementia with out behaviors, a psychotic disorder with delusion, anxiety, and falls. The annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/17/23 noted R #73 was frequently incontinent of urine, always incontinent of bowel, and requires extensive assistance with transfers, bed mobility, toileting and hygiene. The progress notes include the following documentation: --7/29/23 at 11:24 PM R#73 observed sliding on his buttocks across the floor. The assessment noted no injuries or pain. R#73 was assisted to his wheel chair and brought to the nurse's station. Record reviewed, continue plan of care. Staff to monitor more often in the evenings. written by Nurse Unit Manager #83. --07/29/23 at 11:44 PM R#73 in his wheel chair close to nursing station due to him not staying in bed. Will continue to monitor. Written by LPN #185. --07/30/23 at 7:00 AM LPN #186 documented she notified the Charge Nurse about patient being up in chair when shift began, he was washed up, changed and placed in bed. --07/30/23 at 10:49 AM R#73 was up in chair when day shift started, very drowsy. R#73 was washed and changed and sleeping most of the morning. Written by LPN #186 The NA toilet use documentation form is blank for the night shift (11:00 PM - 7:00 AM) of 07/29/23. d) Resident (R) #48 A review of the medical record on 08/22/23 found R#48's diagnoses include dementia with behaviors, congested heart failure, cognitive communication deficit, and obstructive uropathy. The quarterly MDS assessment with an ARD of 06/11/23, notes he has a urinary catheter and is always incontinent of bowel. He requires extensive assist of two (2) for bed mobility, transfers, toileting, hygiene and dressing. The computerized NA documentation for catheter care for night shift (11:00 PM - 7:00 AM) on 07/29/23 was blank, indicating no catheter care was provided during the night shift. The bowel movement and continence record notes the last bowel movement was on 07/26/23 at 12:15 PM. The progress note written by LPN #186 on 07/30/23 at 7:08 AM, notes R#48 was found at the beginning of day shift, up in his chair, with dried stool in brief. e) Staff interview During an interview on 08/23/23 at 12:15 PM, the Director of Nursing (DON) confirmed staffing on the 11:00 PM to 7:00 AM shift on 07/29/23 consisted of two (2) RNs, two (2) LPNs and six (6) NAs for 135 residents on seven (7) different halls. The DON acknowledged the Nurse Supervisor failed to document staffing assignments and assure all residents including R#73 and R#48 were cared for and received incontinence care during the night shift of 07/29/23.

Jun 2023 18 deficiencies

CONCERN (D)

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

Resident Rights (Tag F0550)

Could have caused harm · This affected 1 resident

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. Based on observation and staff interview, the facility failed to ensure meal trays were delivered in a manner to protect and promote resident dignity by failing to serve roommates a meal tray at the same time. This was based on two (2) random opportunities for discovery and had the potential to affect a limited number of residents. Resident identifiers: #115 and #55. Facility census: 138. Findings included: a) Resident #115 An observation, on 06/05/23 at 12:45 PM, found Resident #115's roommate was being fed by LPN #186. Resident #115 was in the room and had not been served lunch. Resident #115 sat and watched as the roommate ate. After watching the roommate eat for 14 minutes, Resident #115 rummaged in her bedside table and pulled out cookies to eat. During an interview, on 06/05/23 at 1:05 PM, Licensed Practical Nurse (LPN) #186 confirmed she had just finished feeding Resident #115's roommate and that Resident #115 had still not yet been served lunch. The LPN #186 explained it was facility protocol to feed those residents who required assistance with their meals prior to the tray carts hitting the floor for delivery of meals for independent diners. LPN #186 also confirmed Resident #115 had resorted to eating cookies since she did not have her lunch tray. LPN #186 acknowledged it was facility policy to serve residents in the same room at the same time and this was always a practice observed when serving independent diners when the tray cart hit the floor. She went on to say it was not something she had ever thought about when assisting residents who required assistance with their meals. Resident #115 did not receive her meal tray until 1:17 PM which was 32 minutes after the resident's roommate had been served and was eating. b) Resident #55 During an observation of meal services on 06/05/23 at 12:52 PM, it was revealed that Resident #55's roommate received his tray. During the observation at 1:14 PM Resident #55 received his tray. Resident #55's roommate had completed his tray. An interview at 1:15 PM with LPN #179 stated that the roommate has an appointment, so he got his tray early. She also stated that Resident #55 should have received his tray when his roommate got his. .

CONCERN (D)

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

Notification of Changes (Tag F0580)

Could have caused harm · This affected 1 resident

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. Based on family interview, record review, and staff interview, the facility failed to notify a resident's Medical Power of Attorney (MPOA) regarding a change in condition. This was true for one (1) of 35 sample residents reviewed during the Long-Term Care Survey Process. Resident #39 had testing ordered on 06/02/23 and the MPOA was not informed of the appointment. Resident identifier: #39. Facility census: 138. Findings included: a) Resident #39 During a family interview with the MPOA on 06/05/23 at 12:11 PM, the MPOA reported she had not been informed of the barium swallow testing until just before the interview occurred. The test was ordered on 06/02/23 and the staff informed her of the upcoming scheduled barium swallow study on 06/05/23. A review of the medical record revealed an order had been written on 06/02/23 for a barium swallow study on 06/27/23 at 8:30 AM for Resident #39. In an interview with the Director of Nursing (DON) on 06/07/23 at 10:18 AM, the DON verified the MPOA had not been notified timely regarding the order for the barium swallow study.

CONCERN (D)

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

Deficiency F0582 (Tag F0582)

Could have caused harm · This affected 1 resident

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. Based on medical record review and staff interview, the facility failed to provide a resident with a Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNF ABN). This is true for one (1) of three (3) residents reviewed for beneficiary notification. Resident identifier: #4. Facility census: 138. Findings included: a) Resident #4 Review of the medical record on 06/06/23 revealed Resident #4 received a Notice of Medicare Non-Coverage (NOMNC) on 12/14/22 indicating her coverage of Part A Medicare service would end on 12/19/22. The record lacked information indicating Resident #4 received a SNF ABN with the NOMNC . During an interview on 06/06/23 at 9:06 AM, Social Services (SS) #110 acknowledged the SNF ABN was not given to Resident #4 and should have been given since she elected to reside in the facility.

CONCERN (D)

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

Grievances (Tag F0585)

Could have caused harm · This affected 1 resident

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. Based on interviews with a resident's Medical Power of Attorney (MPOA), staff interview and record review, the facility failed to make prompt efforts to resolve a grievance and to keep the resident notified of progress toward resolution. This was true for one (1) of three (3) reviewed during the Long-Term Care Survey Process (LTCSP). Resident identifier: #17. Facility census: 138. Findings included: On 06/05/23 at 11:14 AM during an interview with Resident #17's MPOA stated that the facility lost her prescription eyeglasses, and they have never replaced them. A record review of the Grievance log found on 03/11/23 Resident #17's glasses was reported missing. Continued review revealed an appointment was made for 4/17/23. A subsequent review found Resident #17 did not go to this appointment. No further action was taken by the facility. On 06/06/23 at 11:29 PM the Social Worker (SW) verified a rescheduled appointment was not made until surveyor intervention. .

CONCERN (D)

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

Comprehensive Care Plan (Tag F0656)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, observation, and staff interview, the facility failed to implement the care plan and ensure emergency equipment was at the bedside and readily available for a resident with a tracheostomy. In addition, care plans were not developed for a resident admitted with a urinary catheter and a resident diagnosed with Post Traumatic Stress Disorder (PTSD). This was true for three (3) of 35 residents reviewed for care plans. Resident identifiers: #107, #123, #131. Facility census: 138. Findings included: a) Resident #107 Review of the medical record on 06/07/23 revealed Resident #107 had a tracheostomy and was at risk for respiratory impairment and dislodgement of his trachea because of a large stoma and history of mucous plugs. The care plan with a revision date of 05/18/23, noted to keep an ambu bag in the room at all times. Random observations on 06/06/23 revealed an emergency ambu bag was not visible and readily available in Resident #107's room. On 06/07/23 at 10:40 AM an observation with Licensed Practical Nurse (LPN) #72 confirmed there was no ambu bag in R#107's room. During an interview on 06/07/23 at 10:45 AM Corporate Nurse #201 and the Director of Nursing (DON) confirmed R#107's care plan states an ambu bag should always be in the room and available b) Resident #123 Review of the medical record on 06/07/23 revealed Resident #123 was admitted to the facility on [DATE] with a urinary catheter to assist with wound healing. The admission Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 05/09/23, is coded yes in section H0100 confirming R#123's indwelling urinary catheter. The care plan with a revision date of 06/05/23 was silent for Resident#123's indwelling urinary catheter. On 06/07/23 at 9:30 AM, LPN #40 reported Resident#123 had a urinary catheter because of multiple wounds. At 9:35 AM on 06/07/23, Corporate Nurse #201 confirmed a care plan was not developed for Resident#123's urinary catheter. c) Resident #131 A review of the medical record on 06/05/23 revealed a comprehensive person-centered care plan had not been developed for PTSD for Resident #131. The MDS assessment with an ARD of 05/15/23 for Section I: Diagnoses, indicated Resident #131 had a diagnosis of PTSD. In an interview with the Director of Nursing (DON) on 06/07/23 at 10:02 AM, verified the care plan had not been developed for PTSD for Resident #131.

CONCERN (D)

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

Deficiency F0657 (Tag F0657)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review and staff interview, the facility failed to update the care plan to reflect a change in code status. This is true for one (1) of 18 residents reviewed for code status. Resident identifier: #95. Facility census: 138. Findings included: a) Resident #95 Review of the medical record on [DATE] revealed Resident #95 was readmitted to the facility on [DATE]. The [NAME] Virginia Physician Order for Scope of Treatment (POST) form signed and dated [DATE], states no cardiac pulmonary resuscitation (CPR). Utilize comfort focused treatments. The care plan initiated [DATE] notes Resident #95's advanced directives as a full code indicating CPR will be performed. The care plan was not updated when the residents POST form was completed. On [DATE] at 10:35 AM, the Director of Nursing (DON) reviewed Resident #95's POST form and confirmed the care plan was not updated to reflect the resident's change in code status.

CONCERN (D)

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

Deficiency F0685 (Tag F0685)

Could have caused harm · This affected 1 resident

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. Based on observation, resident interview, staff interview, and record review, the facility failed to ensure proper treatment related to vision impairment for one (1) of one (1) residents reviewed in the care area of communication/sensory. Resident identifier: #17. Facility census: 138. Findings included: On 06/05/23 at 11:14 AM during an interview with Resident #17's Medical Power of Attorney stated that the facility lost her prescription eye glasses, and they have never replaced them. A record review of the Grievance log found on 03/11/23 Resident #17's glasses were reported missing. Continued review revealed an appointment was made for 4/17/23. Subsequently additional review found Resident #17 did not go to this appointment. No further action was taken by the facility. On 06/06/23 at 11:29 PM the Social Worker (SW) verified a rescheduled appointment wasn't made until surveyor intervention.

CONCERN (D)

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

Incontinence Care (Tag F0690)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review and staff interview, the facility failed to ensure a resident admitted with a urinary catheter had a written physician order with an appropriate indication for use and guidelines for monitoring and maintaining. This was true for one (1) of five (5) reviewed for urinary catheters. Resident identifier: #123. Facility census: 138. Findings included: a) Resident #123 Review of the medical record on 06/07/23 revealed Resident #123 was admitted to the facility on [DATE] with a urinary catheter to assist with wound healing. The admission minimum data set (MDS) assessment with an Assessment Reference Date (ARD) of 05/09/23, was coded yes in section H0100 confirming Resident #123's indwelling urinary catheter. The current physician orders lack any information related to Resident #123's indwelling urinary catheter. On 06/07/23 at 9:30 AM, Licensed Practical Nurse (LPN) #40 confirmed Resident#123 was admitted with a urinary catheter because of multiple wounds. LPN #40 reviewed the physician orders and agreed there were no orders for Resident#123's urinary catheter. LPN #40 immediately added an order for the urinary catheter.

CONCERN (D)

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

Respiratory Care (Tag F0695)

Could have caused harm · This affected 1 resident

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. Based on medical record review, observations, and staff interview, the facility failed to ensure emergency equipment was at the bedside and readily available for a resident with a tracheostomy. This is true for 1 of 2 reviewed for tracheostomy. Resident identifier: 107. Facility census: 138. Findings include: a) Resident #107 Review of the medical record on 06/07/23 revealed Resident#107 had a tracheostomy and was at risk for respiratory impairment and dislodgement of his trache because of a large stoma and history of mucous plugs. The physician orders dated 05/16/23 and the care plan with a revision date of 05/18/23, stated to keep emergency equipment including an ambu bag in the room at all times. Random observations on 06/06/23 revealed an emergency ambu bag was not visible and readily available in R#107's room. On 06/07/23 at 10:40 AM an observation with Licensed Practical Nurse (LPN) #72 confirmed there was no ambu bag in R#107's room. During an interview on 06/07/23 at 10:45 AM Corporate Nurse #201 and the Director of Nursing confirmed an ambu bag should be in Resident#107's room and available at all times.

CONCERN (D)

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

Deficiency F0698 (Tag F0698)

Could have caused harm · This affected 1 resident

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. Based on observation, record review and staff interviews, the facility failed to ensure one (1) of two (2) residents reviewed for the care area of dialysis during the Long-Term Care Survey Process (LTCSP), received such services consistent with physician's orders for care. Resident #103 did not have a dialysis emergency kit maintained at the bedside in accordance with physician's orders. Resident identifier: Resident #103. Census: 138. Findings included: a) Resident #103 A record review for Resident #103, showed current physician's orders for Dialysis Precautions which included maintaining an emergency kit at the bedside. In accordance with the physician's order, the emergency kit was to contain a tourniquet, sterile gauze, and gloves for the right arm in case of excessive uncontrolled bleeding from the arterio-venous shunt. An observation, on 06/06/23 at 10:25 AM, revealed no evidence of an emergency kit located in Resident #103's room. On 06/06/23 at 10:27 AM, Licensed Practical Nurse (LPN) #153, was requested to show the surveyor the dialysis emergency kit in the resident's room, however, LPN #153 could not locate the kit and verified the dialysis emergency kit was not in Resident 103's room as ordered by the physician. An additional interview, with Registered Nurse (RN) #95 and RN #55, on 06/06/23 at 10:36 AM, verified the dialysis emergency kit, ordered by the physician, was not present in the resident's room and should have been in case of a bleeding emergency.

CONCERN (D)

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

Medication Errors (Tag F0758)

Could have caused harm · This affected 1 resident

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Based on medical record review and staff interview the facility failed to follow a monthly medication regimen review (MRR) recommendation and attempt a gradual dose reduction of a psychotropic medication. This is true for one of five reviewed for unnecessary medications. Resident identifier: 95. Facility census: 138. Findings include: a) Resident (R) #95 Review of the medical record on 06/06/23 revealed a pharmacy recommendation dated 04/25/23 recommending an attempted gradual dose reduction (GDR) of Temazepam / Restoril (an hypnotic agent used to treat insomnia) 15 milligram (mg) every night. On 04/27/23, the nurse practitioner (NP) agreed and wrote to make the Temazepam as needed on the MRR form. The NP progress note dated 04/27/23 identified the gradual dose reduction and stated: .At this time noted patient takes Restoril (Temazepam) 15 mg at night for insomnia. At this time we will attempt a gradual dose reduction of the Restoril. At this time no reports of insomnia . The physician orders and the monthly medication administration record contain the original order dated 12/27/22, for Temazepam 15 mg at bedtime for insomnia. The medical record lacks information indicating a gradual dose reduction was attempted. During an interviews on 06/06/23 at 1:45 PM the Director of Nursing confirmed the recommended gradual dose reduction for Temazepam written on 04/25/23 was never implemented was currently being addressed by the NP.

CONCERN (D)

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

Deficiency F0761 (Tag F0761)

Could have caused harm · This affected 1 resident

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. Based on observation and staff interviews, the facility failed to ensure medications were not stored and administered to residents past the manufacturer's date of use. This failed practice was identified through a random opportunity for discovery and was found to be true during one (1) of four (4) medication cart reviews. An insulin vial, containing Humalog insulin, currently stored in the medication cart and being administered to a resident, was being administered past the manufacturer's guidelines for safe usage. Resident identifiers: Resident #79. Facility census: 138. Findings included: a) Resident #79 An observation, during the review of Wing one (1) medication cart, on 06/06/23 at 11:35 AM, revealed a vial of Humalog insulin, dated as opened on 05/08/23. An interview with Licensed Practical Nurse (LPN) #72, during the observation on 06/06/23 at 11:35 AM, verified the Humalog insulin had been opened 05/08/23 and was still in use. It was further stated the insulin would be good for 28 or 30 days. According to manufacturer's instruction, opened vials of Humalog of insulin were to be disposed of after 28 days of use. An additional interview, with LPN #72, on 06//06/23 at 12:00 PM, verified Resident #79 was given the Humalog insulin that was used past the 28-day discard date, and the insulin vial should have been discarded. LPN #72 stated Resident #79 had received five (5) units of the insulin this morning on 06/06/23. An interview, with the Director of Nursing (DON), on 06/06/23 at 1:05 PM, confirmed it was a Pharmacy standard of the facility, and in accordance with manufacturer's instruction for Humalog insulin to be discarded after 28 days of use and should not have been administered to the resident today. .

CONCERN (D)

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

Deficiency F0804 (Tag F0804)

Could have caused harm · This affected 1 resident

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. Based on Resident Council meeting interviews and staff interviews, the facility failed to serve food at a palatable temperature. During the last breakfast test tray on the 800 hallway, it was discovered Resident #55's food was not being served at an appetizing temperature. This had the potential to affect more than a limited number of residents. Resident identifier: #55. Facility census: 135. Findings included: a) Appetizing food temperatures During the breakfast test tray on the 800 hallway on 06/07/23 at 8:05 AM, it was discovered the temperature of the egg omelet was 120 degrees Fahrenheit. This temperature was obtained by Nurse Aide (NA) #171. She was able to locate a food thermometer in a room near the food cart. NA #171 reported the omelet should be near 135 degrees Fahrenheit. She then called the kitchen to obtain another breakfast tray. In an interview with the Certified Dietary Manager (CDM) on 06/07/23 at 8:13 AM, verified the egg omelet was not served at a palatable temperature. She also reported the temperature should be 135 degrees Fahrenheit.

CONCERN (D)

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

Deficiency F0806 (Tag F0806)

Could have caused harm · This affected 1 resident

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. Based on record review, resident interview, and staff interview, the facility failed to provide food that accommodated resident preferences. This was true for two (2) of 35 residents sampled in the Long-Term Care Survey Process. Resident identifiers: #1 and #46. Facility Census: 138. Findings included: a) Minutes of the 05/17/23 Resident Council Meeting On 06/05/12 at 6:23 PM, a review of the 05/17/23 Resident Council minutes revealed residents in attendance had requested the kitchen put gravy on meat and potatoes, asked that vegetables be put in bowls not on the plate to prevent bread from being soggy from the vegetable juices, and baked potatoes be served with more butter and sour cream. The documented departmental follow-up stated the Dietary Manager would meet with specific residents and update their tray cards to reflect their preferences. b) Resident Council meeting on 06/06/23 at 11:00 AM During a resident council meeting on 06/06/23 at 11:00 AM, Resident #1 and Resident #46 reported they had attended the 05/17/23 meeting and had requested gravy on their meat and potatoes. Both residents stated that the kitchen had failed to modify their tray cards and they were not receiving gravy on their meat or potatoes. c) Record Review A brief medical record review, completed on 06/06/23 at 1:07 PM revealed the following: -The Care Plans for Resident #1 and #46 stated the facility would honor resident food preferences. -The Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ard) of 05/03/23, reflected Resident #1 had a Brief Interview for Mental Status (BIMS) score of 15 which indicated Resident #1 was cognitively intact. -The Quarterly MDS, with an ARD date of 05/01/23, reflected Resident #46 had a BIMS score of 15 which indicated Resident #46 was cognitively intact. d) Interview with Dietary Manager During an interview on 06/07/23 at 8:46 AM, the Dietary Manager printed the tray cards for Resident #1 and Resident #46. The tray cards did not include each resident's preference to have gravy on the meat and potatoes. The Dietary Manager stated she had updated both tray cards to reflect the desire to have vegetables in bowls and to receive extra butter and sour cream for baked potatoes but failed to include each resident's desire to have gravy on their meat and potatoes. The Dietary Manager stated she would meet with each resident and update their tray cards promptly.

CONCERN (E)

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

Quality of Care (Tag F0684)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review and staff interview, the facility failed to follow a physician's order for the administration of an antibiotic. This was true for one (1) of three (3) residents reviewed for antibiotics. The facility failed to notify the physician when blood sugar levels were above 400 or when a blood sugar level was below 70. This was true for two (2) of three (3) residents reviewed for insulin. The facility failed to ensure the Physician Orders and the Physician Orders for Scope of Treatment (POST) form matched. This was true for two (2) of 18 residents reviewed for advance directives. Resident identifiers: #19, #44, #29, #95, #107. Facility census: 138. Findings included: a) Resident #19 A record review, completed on [DATE] at 2:48 PM, found a physician order for Bactrim DS Tablet 800-160 MG. The order directed, give one (1) tablet by mouth two (2) times a day for a urinary tract infection for seven (7) days. A review of the [DATE] Medication Administration Record (MAR) revealed Resident #19 began taking the antibiotic on [DATE] and the resident only received 13 of the 14 ordered doses: -[DATE] at 8:00 AM -[DATE] at 8:00 PM -[DATE] at 8:00 AM -[DATE] at 8:00 PM -[DATE] at 8:00 AM -[DATE] at 8:00 PM -[DATE] at 8:00 AM -[DATE] at 8:00 PM -[DATE] at 8:00 AM -[DATE] at 8:00 PM -[DATE] at 8:00 AM -[DATE] at 8:00 PM -[DATE] at 8:00 AM The Medication Administration Record (MAR) provided no evidence Resident #19 received her final dose of the antibiotic in the evening hours of [DATE]. Further record review revealed the medical record lacked evidence that the physician had been contacted about the missed dose. During an interview on [DATE] at 10:19 AM, the Director of Nursing (DON) reported Resident #18 had not finished the full 14 doses of the antibiotic and that the physician's order had not been followed correctly. b) Resident #44 A medical record review, completed on [DATE] at 2:00 PM, revealed a physician order stating finger stick blood glucose before meals and at bedtime for increased blood glucose notify Physician/Nurse Practitioner if less than 70 or greater than 400. The [DATE] Medication Administration Record (MAR) revealed: -On [DATE] at 4:30 PM Resident #44's blood sugar level was 472 -On [DATE] at 6:30 AM, Resident #44's blood sugar level was 450 The medical record reflected the Nurse Practitioner was not notified until [DATE] at 9:18 AM about the elevated blood sugar on [DATE]. Similarly, the physician was not notified until [DATE] at 12:59 PM about the elevated blood sugar on [DATE]. During an interview with the DON, on [DATE] at 2:45 PM, stated that the dates of the elevated blood sugar levels were weekends and the physician/nurse practitioner was contacted days later after the failure to do so was identified. The DON stated notification of the physician/nurse practitioner should have been done in real time without delay. c) Resident #29 During an interview on [DATE] at 12:30 PM, Resident #29 reported she takes insulin to manage her diabetes and stated, Sometimes my blood sugars can be off at times. A medical record review, completed on [DATE] at 8:03 PM, revealed a physician order stating resident's blood sugar level should be taken before meals every Tuesday and the physician/nurse practitioner should be notified if the blood sugar level was less than 70 or greater than 400. The [DATE] Medication Administration Record (MAR) revealed Resident #29's blood sugar level was 23 on [DATE] at 6:30 AM. There was no evidence in the medical record reflecting the physician/nurse practitioner was notified. During an interview with the DON, on [DATE] at 8:25 AM, she stated the facility was unable to produce evidence the physician/nurse practitioner was notified. d) Resident (R) #95 Review of the medical record on [DATE] revealed R#95 was readmitted to the facility on [DATE]. The current physician orders dated [DATE] noted the resident is to be a full code should she experience a cardiac arrest. The [NAME] Virginia Physician Order for Scope of Treatment (POST) form signed and dated [DATE], states no cardiac pulmonary resuscitation (CPR). Utilize comfort focused treatments. On [DATE] at 10:35 AM, the DON confirmed R#95's POST form does not match the current physician orders. e) R#107 Review of the medical record on [DATE] revealed a physician order dated [DATE] stating: only AED (Automated External Defibrillator). The POST form dated [DATE] states to perform CPR including mechanical ventilation, defibrillation and cardioversion administering full treatments to sustain life. During an interview on [DATE] at 2:43 PM Corporate Nurse #201 confirmed R#107's POST form and physician orders do not match.

CONCERN (E)

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

Staffing Information (Tag F0732)

Could have caused harm · This affected multiple residents

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. Based on observation and staff interview, the facility failed to ensure the daily nurse staffing was posted in a prominent place and readily accessible to residents on the second floor. This was a random opportunity for discovery. Facility Census: 138. Findings included: a) Posting of Nurse Staffing On 06/05/23 at 10:45 AM, a tour of the facility's second floor revealed nurse staffing was not posted. The second floor of the facility is home to the 500 wing, 600 wing, 700 wing, and 800 wing. During an interview on 06/05/23 at 11:40 AM, the Director of Nursing (DON) acknowledged that nurse staffing was not posted in a prominent place that would be readily accessible to residents on the second floor of the facility adding, It's always been that way since I've been here. I will address it now.

CONCERN (E)

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

Food Safety (Tag F0812)

Could have caused harm · This affected multiple residents

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. Based on observations and staff interviews, the facility failed to maintain the kitchen in a safe and sanitary manner in accordance with professional standards of practice. During the kitchen tour it was discovered a stove drip pan was heavily soiled with grease, eight (8) storage racks had a heavy dust build-up, the threshold to walk-in freezer was damaged. The floors to the walk-in freezer and reach-in coolers needed to be cleaned. Also, the ice machines located on each of the 8 hallways were not draining properly. These deficient practices had the potential to affect any resident receiving nourishment from the kitchen and ice from the eight (8) ice machines located in the Medical Storage Rooms. Facility census: 138. Findings included: a) Kitchen tour During the kitchen tour on 06/05/23 at 10:45 AM, it was discovered the drip pan for the main stove was heavily soiled from grease build-up. In the Dry Storage area there were eight (8) shelving units with all the bottom shelves crusted with dirt and dust. The walk-in freezer had a rusted threshold strip and both the walk-in freezer and reach-in cooler had floors that needed to be cleaned. In the interview during the tour, with the Certified Dietary Manager (CDM) on 06/05/23 at 10:49 AM, observed and verified the drip pans and the eight (8) racks all needed to be cleaned. The CDM also observed the damaged threshold strip and noted it needed to be replaced, she also agreed the floors to the walk-in freezer, walk-in cooler and the reach-in coolers all needed to be cleaned. b) Ice machines During a tour of the eight (8) Medical Storage rooms with the Director of Maintenance on 06/07/23 at 10:00 AM, it was discovered the ice machines for each of these rooms were not draining properly. The drainpipes were in close contact with the floor drain cap. There was no two (2) inch airgap between the drip lines and the floor drain cap to prevent backflow from siphonage or back pressure, which could cause the ice to become contaminated. In an interview with the Director of Maintenance (DOM) on 06/07/23 at 10:30 AM, the DOM verified all eight (8) ice machines were not draining properly and they did not have the correct airgap spacing from the floor drains.

CONCERN (F)

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

Medical Records (Tag F0842)

Could have caused harm · This affected most or all residents

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. Based on record review and staff interview, the facility failed to ensure complete and accurate medical records. Physician Orders for Scope of Treatment (POST) forms were incomplete and/or inaccurate for 17 of 18 records reviewed for accurate POST forms. Additionally, one (1) of 18 records reviewed had a missing POST form that was not part of the electronic medical record or the chart. Resident identifiers: #4, #19, #27, #29, #44, #87, #115, #119, #132, #28, #39, #71, #131, #90, #118, #246, #74, and #65. Facility census: 138. Findings included: a) Resident #4 Review of Resident #4's POST form showed that verbal consent was obtained from the resident's representative on 10/09/22. However, the resident representative's actual signature was never obtained. Additionally, the Nurse Practitioner's (NP) name was not printed, and the phone number was not provided. The 2021 POST form guidance titled, Using the POST Form: Guidance for Health Care Professionals states, The patient (or incapacitated patient's MPOA [medical power of attorney] representative or health care surrogate) must sign and date this section for the form to be legally valid. If the incapacitated patient's MPOA [medical power of attorney] representative or health care surrogate is unavailable at the time of form completion, this section can be signed by two witnesses for verbal confirmation of agreement from the patient's MPOA representative or health care surrogate. The form should be signed at the earliest available opportunity. The 2021 POST form guidance also states, The health care provider completing this form must print their name, sign, and date this section for the form to be legally valid. Failure to print their name or provide a license number may result in the WV e-Directive Registry being unable to verify the provider's information, thus preventing the form from being available through the Registry. Failure to provide a contact number may result in the inability to contact the provider regarding any errors in the form completion that need to be addressed. During an interview on 06/06/23 at 11:45 AM, Social Worker (SW) #3 acknowledged the facility had not followed up with Resident #4's legal representative to obtain an original signature, the nurse practitioner had failed to print their name and phone number, and the form was incomplete and not legally valid. b) Resident #19 Review of Resident #19's POST form showed that verbal consent was obtained from the resident's representative on 10/13/22. However, the resident representative's actual signature was never obtained. Additionally, the physician's name was not printed, the physician's phone number was not provided, and the physician's license number was missing. During an interview on 06/06/23 at 11:40 AM, SW #3 acknowledged the facility had not followed up with Resident #19's legal representative to obtain an original signature, the physician had failed to print their name, phone number, or license number and the form was incomplete and not legally valid. c) Resident #27 Review of Resident #27's POST form showed a POST form signed by the physician on 02/16/23. However, a signature had not been obtained from the resident/resident's legal representative. Additionally, the NP's name was not printed, the phone number was not provided, and the NP's license number was missing. During an interview on 06/06/23 at 11:45 AM, SW #3 acknowledged the facility had not obtained a signature from the resident/resident's legal representative, the NP had failed to print their name, phone number, or license number and the form was incomplete and not legally valid. d) Resident #29 Review of Resident #29's POST form showed a POST form signed by the NP on 02/16/23. The NP's name was not printed, the phone number was not provided, and the NP's license number was missing. During an interview on 06/06/23 at 11:47 AM, SW #3 acknowledged the NP had failed to print their name, phone number, or license number and the form was incomplete and not legally valid. e) Resident #44 Review of Resident #44's POST form showed a POST form signed by the NP on 10/10/22. The NP's name was not printed, and the phone number was not provided. During an interview on 06/06/23 at 11:43 AM, SW #3 acknowledged the NP had failed to print their name and phone number and the form was incomplete and not legally valid. f) Resident #87 Review of Resident #87's POST form showed that verbal consent was obtained from the resident's representative but was not dated. The resident representative's actual signature was never obtained. Additionally, the NP's name was not printed, the phone number was not provided, and the license number was missing. During an interview on 06/06/23 at 11:44 AM, SW #3 acknowledged the facility had not followed up with Resident #87's legal representative to obtain an original signature, the NP had failed to print their name, phone number, or license number and the form was incomplete and not legally valid. g) Resident #115 Review of Resident #115's POST form showed a POST form signed by the physician on 02/16/23. However, a signature had not been obtained from the resident/resident's legal representative. Additionally, the NP's name was not printed, the phone number was not provided, and the NP's license number was missing. During an interview on 06/06/23 at 11:41 AM, SW #3 acknowledged the facility had not obtained a signature from the resident/resident's legal representative, the NP had failed to print their name, phone number, or license number and the form was incomplete and not legally valid. h) Resident #119 Review of Resident #119's POST form showed a POST form signed by the NP on 02/16/23. The NP's name was not printed, their phone number was not provided, and the NP's license number was missing. During an interview on 06/06/23 at 11:46 AM, SW #3 acknowledged the NP had failed to print their name, phone number, or license number and the form was incomplete and not legally valid. i) Resident #132 Review of Resident #132's POST form showed a POST form signed by the NP on 03/23/23. However, a signature had not been obtained from the resident/resident's legal representative. Additionally, the NP's name was not printed, their phone number was not provided, and the NP's license number was missing. During an interview on 06/06/23 at 11:42 AM, SW #3 acknowledged the facility had not obtained a signature from the resident/resident's legal representative, the NP had failed to print their name, phone number, or license number and the form was incomplete and not legally valid. j) Resident #28 Review of Resident #28's medical record on 06/06/23 at 8:23 AM, showed it did not contain the Residents POST form. During an Interview on 06/07/23 at 9:16 AM, the Director of Nursing (DON) stated that they were unable to locate the POST form and verified it was not in Resident #28's medical record. k) Resident #39 During a medical record review on 06/06/23, it was discovered the POST for Resident #39 was incomplete. Verbal consent was provided by the Medical Power of Attorney (MPOA) on 03/01/23, but there was no required signature obtained by the MPOA. In an interview with the DON on 06/07/23 at 12:38 PM, verified the POST form was incomplete and had not been signed by the MPOA. l) Resident #71 During a medical record review on 06/06/23, it was discovered the POST form for Resident #71 was incomplete. The Health Care Provider who signed the POST did not provide a printed signature and contact phone number. In an interview with the DON on 06/07/23 at 12:38 PM, verified the POST did not have the physician's and or designee's printed signature or contact phone number. m) Resident #131 During a medical record review on 06/06/23, it was discovered the POST form for Resident #131 was incomplete. The POST had no signature, verbal consent or date from the resident representative. Also, there was no contact phone number for the physician or designee. In an interview with the DON on 06/07/23 at 12:38 PM, verified the POST form did not have a verbal consent or resident representative's signature, also there was no contact phone number for the physician or designee. n) Resident #90 During a medical record review on 06/06/23, it was discovered the POST form for Resident #90 was incomplete. The Health Care Provider who signed the POST form did not provide a printed signature and contact phone number. In an interview with the DON on 06/07/23 at 12:38 PM, verified the POST form did not have the physician's and or designee's printed signature or contact phone number. o) Resident# 118 During a medical record review on 06/06/23, it was discovered the POST form for Resident #118 had the wrong residents last name on the front page and the correct last name on the back of the form. Also, there was no printed signature or contact phone number for the physician or designee. p) Resident #246 During a medical record review on 06/06/23, it was discovered the POST form for Resident #246 was incomplete. The Health Care Provider who signed the POST form did not provide a printed signature and contact phone number. In an interview with the DON on 06/07/23 at 12:38 PM, verified the POST form did not have the physician's and or designee's printed signature or contact phone number. q) Resident# 74 During a medical record review on 06/06/23, it was discovered the POST form for Resident #74 was incomplete. The Health Care Provider who signed the POST form did not provide a printed signature and contact phone number. In an interview with the DON on 06/07/23 at 12:38 PM, verified the POST form did not have the physician's and or designee's printed signature or contact phone number. r) Resident# 65 During a medical record review on 06/06/23, it was discovered the POST form for Resident #65 was incomplete. The Health Care Provider who signed the POST form did not provide a printed signature and contact phone number. In an interview with the DON on 06/07/23 at 12:38 PM, verified the POST form did not have the physician's and or designee's printed signature or contact phone number.

Jan 2023 14 deficiencies

CONCERN (D) 📢 Someone Reported This

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

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

Deficiency F0551 (Tag F0551)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review and staff interview, the facility failed to identify a resident had a court-appointed legal guardian and failed to have a copy of the guardianship paperwork on file in the resident's medical record. This was true for one (1) of five (5) residents reviewed in the complaint survey process. Resident #152. Facility census: 144. Findings included: a) Resident #152 Resident #152 was admitted to the facility on [DATE]. The referral paperwork reflected resident had a court-appointed legal guardian and included the legal guardian's contact information. The facility's admission Record Face Sheet incorrectly identified the resident's family member as the Power of Attorney (POA). The facility did not have a copy of legal guardianship on file in the medical record. During an interview on 01/18/23 at 10:25 AM, the Administrator acknowledged the facility failed to identify Resident #152 had a court-appointed legal guardian and had not communicated with the legal guardian throughout resident's stay in the facility. .

CONCERN (D) 📢 Someone Reported This

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

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

Deficiency F0552 (Tag F0552)

Could have caused harm · This affected 1 resident

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. Based on record review and staff interview, the facility failed to ensure a resident's legal guardian was informed of treatment risks, benefits, options, and alternatives when the resident was admitted to the facility. This was true for one (1) of five (5) residents reviewed in the complaint survey process. Resident identifier: #152. Facility census: 144. Findings included: a) Resident #152 A medical record review, completed on 01/17/23 at 9:30 AM, revealed the admission paperwork had been reviewed only with Resident #152 and not with the resident's court-appointed legal guardian. During an interview on 01/18/23 at 10:25 AM, the Administrator acknowledged the facility failed to ensure the resident's legal guardian was included in the admission process. .

CONCERN (D) 📢 Someone Reported This

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

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

Deficiency F0553 (Tag F0553)

Could have caused harm · This affected 1 resident

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. Based on record review and staff interview, the facility failed to ensure a resident's legal guardian was afforded the opportunity to participate in the resident's care planning process and was not included in decisions / changes in resident's care and treatment. This was true for one (1) of five (5) residents reviewed in the complaint survey process. Resident identifier: #152. Facility census: 144. Findings included: a) Resident #152 A medical record review, completed on 01/17/23 at 9:30 AM, revealed Resident #152 had a court-appointed legal guardian. Further review revealed: --Section Q - Participation in Assessment and Goal Setting of the admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/24/22, stated that resident and family participated in the assessment. It also specifically answered NO to the Guardian participating in the assessment. --Nowhere in the medical record did it reflect the legal guardian had been invited to participate in the care planning process. During an interview on 01/18/23 at 10:25 AM, the Administrator acknowledged the facility failed to invite the court-appointed legal guardian to participate in Resident #152's care planning process. .

CONCERN (D) 📢 Someone Reported This

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

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

Deficiency F0561 (Tag F0561)

Could have caused harm · This affected 1 resident

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. Based on interviews and record review during a complaint survey, the facility failed to ensure the right to make choices about aspects of life that were important. Specifically, Resident #120 was not given showers per preference and the residents normal pattern. This was a random opportunity for discovery. Resident identifier: #120. Facility census: 144. Findings included: Resident #120. A record review, during a complaint investigation, found a Grievance Report, stating that Resident #120 did not receive care and services per preferences. Medical record review revealed, Resident #120's shower schedule is on Sunday, Tuesday, and Friday on night shift. The residents Medical Power of Attorney (MPOA) requested showers to be given at 5:30 AM on the scheduled shower days per the resident's normal pattern at home. A continued review of Resident #120's activities of daily living (ADL) documentation found: --12/02/22 at 11:31 PM- shower given. --12/05/22 at 12:56 AM- shower given. --12/06/22 at 11:50 PM- shower given. --12/09/22 at 12:49 PM- shower given. --12/14/22 at 12:33 AM- shower given. --12/19/22 at 12:00 AM- shower given. --12/20/22 at 11:38 PM- shower given. --12/24/22 at 12:24 AM- shower given. --12/25/22 at 11:48 PM- shower given. --12/27/22 at 11:15 PM- shower given. --12/31/22 at 2:20 AM- shower given. --01/02/23 at 12:31 AM- shower given. --01/04/23 at 1:55 AM- shower given. --01/07/23 at 2:20 AM- shower given. --01/11/23 at 1:00 AM- shower given. --01/14/23 at 2:18 AM-shower given. --01/15/23 at 11:40 PM-shower given. During an interview at 01/17/23 at 11:30 AM, the Administrator confirmed Resident #120 was not receiving showers per preference. No further information was provided prior to the end of the survey, 01/18/23 at 3:15 PM. b) Resident #55 The facility failed to follow up on a request made by the Resident and Surrogate for a transfer to another healthcare facility. According to a progress note by Social Worker #37 after a care plan meeting on 11/15/22, both the Resident and surrogate attended and requested a transfer referral to another healthcare facility. During an interview with Social Worker #37 on 01/17/23 at 11:00 AM, the SW #37 could not remember making such a referral nor provide any evidence that the referral had been made. According to the previous Social Worker progress notes, the resident has been requesting a transfer since 07/20/22. According to the Physician Capacity Statement dated 12/05/22 the Resident lacked capacity. He has an appointed Surrogate according to the Surrogate Decision Maker Designation signed by the Physician on 08/04/21. The above information was confirmed with the Administrator on 01/18/23 at 11:00 AM. .

CONCERN (D) 📢 Someone Reported This

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

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

Notification of Changes (Tag F0580)

Could have caused harm · This affected 1 resident

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. Based on record review, resident representative interview, and staff interview, the facility failed to ensure notification was made to the resident's legal representative when the resident was discharged from the facility. This was true for one (1) of five (5) residents reviewed. Resident Identifier: #152. Facility census: 144. Findings included: a) Resident #152 A medical record review, completed on 01/17/23 at 9:30 AM, revealed Resident #152 was discharged from the facility on 07/28/22. The record did not reflect the resident's court-appointed legal guardian was notified of the discharge. During an interview on 01/18/23 at 10:25 AM, the Administrator acknowledged the facility was unable to provide evidence Resident #152's court-appointed legal guardian was notified of the discharge. .

CONCERN (D) 📢 Someone Reported This

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

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

Grievances (Tag F0585)

Could have caused harm · This affected 1 resident

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. Based on staff interview, record review and policy review, the facility failed to make prompt efforts to resolve a grievance. This was a random opportunity for discovery. Resident identifier: #149. Facility census: 144. Findings Included: a) Resident #149 A record review, during a complaint investigation for abuse and neglect, found a Grievance Report, stating that Resident #149 reported she did not receive a shower all week. Continued review of the Grievance Report revealed the investigation for Resident #149 found the incident date 10/29/22 with the incident investigated on 11/10/22 due to the grievance form found/located on the Director of Nursing's (DON) desk. A medical record review revealed Resident #149 was not assisted offered a shower until 11/10/22. A subsequent record review for Resident #149 found no reportable to appropriate agencies for the allegation of neglect for the failure of the facility to provide goods and services. During an interview on 01/17/22 at 2:45 PM the Administrator, confirmed the grievance for Resident #149 was not investigated promptly. No further information was provided prior to the end of the survey, 01/18/23 at 3:15 PM. .

CONCERN (D) 📢 Someone Reported This

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

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

Report Alleged Abuse (Tag F0609)

Could have caused harm · This affected 1 resident

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. Based on record review, staff interview, and operation policy, the facility failed to report an alleged violation related to neglect or abuse, and report the results of all investigation to the proper authorities within prescribe time frames. This was a random opportunity for discovery. Resident identifiers: #72 and #149. Facility census: 144. Findings included: Record review of the facility's policy titled, Identifying Types of Abuse, showed: - Neglect is the failure of the facility, its employees, or service providers to provide goods and services to a resident that is necessary to avoid physical harm, pain, mental anguish, or emotional distress. - Neglect occurs when the facility, is aware of, or should have been aware of, goods and services that a resident requires but the facility failed to provide them, and this has a result in (or may result in) physical harm, pain, mental anguish or emotional distress. - Neglect may be a pattern of failures or may be the result of one or more failures involving one resident and one staff person. Record review of the facility's policy titled, Abuse Investigation and Reporting, showed: - All alleged violations involving abuse, neglect, exploration, or mistreatment, including injuries of an unknown source and misappropriation of property will be reported by the facility Administrator, or his/her designee the appropriate agencies. (Listed) a) Resident #72 A record review, during a complaint investigation for abuse and neglect, found a Grievance Report, stating that Resident #72 was waiting for incontinence care on 11/07/22 at approximately 12:30 PM and she was still waiting for incontinence care at 2:45 PM. Continued review of the Grievance Report revealed the investigation for Resident #72 found resident had a score of Brief Interview for Mental Status (BIMS) of 14. A BIMS score of 14 indicates that the resident is cognitively intact. Also, when she was asked to use the call bell, Resident #72 could not find the call bell. A subsequent record review found no reportable to appropriate agencies for the allegation of neglect for the failure of the facility to provide goods and services. During an interview on 01/17/22 at 2:15 PM, the Administrator confirmed the facility did not report the allegation of neglect to the appropriate agencies. b) Resident #149 A record review, during a complaint investigation for abuse and neglect, found a Grievance Report, stating that Resident #149 reported she did not receive a shower all week. Continued review of the Grievance Report revealed the investigation for Resident #149 found the incident date 10/29/22 with the incident investigated on 11/10/22 due to the grievance form found/located on the Director of Nursing's (DON) desk. A medical record review revealed Resident #149 was not assisted or offered a shower until 11/10/22. A subsequent record review for Resident #149 found no reportable to appropriate agencies for the allegation of neglect for the failure of the facility to provide goods and services. During an interview on 01/17/22 at 2:15 PM the Administrator confirmed the facility did not report the allegation of neglect to the appropriate agencies. No further information was provided prior to the end of the survey, 01/18/23 at 3:15 PM. .

CONCERN (D) 📢 Someone Reported This

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

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

Transfer Notice (Tag F0623)

Could have caused harm · This affected 1 resident

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. Based on medical record review and staff interview, the facility failed to provide evidence a resident's representative was provided a written Notice of Transfer/Discharge when a resident was discharged from the facility. This was true for one (1) of five (5) residents reviewed for discharges. Resident identifier: #152. Facility census: 144. Findings included: a) Resident #152 A medical record review, completed on 01/17/23 at 9:30 AM, revealed Resident #152 was discharged from the facility on 07/28/22. The record did not reflect the resident's court-appointed legal guardian was provided a written Notice of Transfer indicating the reason for transfer, the effective date of transfer, the location to which the resident was being transferred and a statement of the resident's appeal rights. During an interview on 01/18/23 at 10:25 AM, the Administrator acknowledged the facility was unable to provide evidence a written Notice of Transfer was provided. .

CONCERN (D) 📢 Someone Reported This

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

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

Deficiency F0655 (Tag F0655)

Could have caused harm · This affected 1 resident

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. Based on record review and staff interview, the facility failed to provide a resident's legal guardian with a summary of the baseline care plan that includes the initial goals for the resident, a summary of current medications and dietary instructions, and the services and treatments to be provided or arranged by the facility. This was true for one (1) of five (5) residents reviewed in the complaint survey process. Resident identifier: #152. Facility census: 144. Findings included: a) Resident #152 A medical record review, completed on 01/17/23 at 9:30 AM, revealed the facility had failed to Resident #152's court-appointed legal guardian a summary of the baseline care plan. During an interview, on 01/18/23 at 10:25 AM, the Administrator acknowledged the facility's error and agreed the legal guardian had not received any details regarding Resident #152's baseline care plan. .

CONCERN (D) 📢 Someone Reported This

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

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

Deficiency F0657 (Tag F0657)

Could have caused harm · This affected 1 resident

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. Based on record review and staff interview, the facility failed to invite the court-appointed legal guardian to participate in the comprehensive care plan process. The care plan goals did not show evidence of legal guardian input. This was true for one (1) of five (5) residents reviewed. Resident identifier: #152. Facility census: 144. Findings included: a) Resident #152 A medical record review, completed on 01/17/23 at 9:30 AM, revealed Resident #152 had a court-appointed legal guardian. Further review revealed: --Section Q - Participation in Assessment and Goal Setting of the admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) on 05/24/22, stated that the resident and family participated in the assessment. It also specifically answered NO to the Guardian participating in the assessment. --Resident #152's care plan incorrectly identified resident's brother as the Medical Power of Attorney (MPOA). --No evidence was found in the medical record reflected, the legal guardian had been invited to participate in the care planning process. During an interview on 01/18/23 at 10:25 AM, the Administrator acknowledged the facility failed to invite the court-appointed legal guardian to participate in Resident #152's care planning process. .

CONCERN (D) 📢 Someone Reported This

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

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

ADL Care (Tag F0677)

Could have caused harm · This affected 1 resident

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. Based on staff interview and medical record review, the facility failed to provide care and services in accordance with professional standards of practice regarding bathing and showers. This was a random opportunity for discovery. Resident identifiers: #149 and #150. Facility census: 144. Findings Included: a) Resident #149 A record review, during a complaint investigation for abuse and neglect, found a Grievance Report, stating that Resident #149 reported she did not receive a shower for a week. A continued review of the Grievance Report revealed the investigation for Resident #149 found the incident date 10/29/22 with the incident investigated on 11/10/22 due to the grievance form being found/located on the Director of Nursing's (DON) desk. A medical record review revealed Resident #149 was not assisted or offered a shower from 10/29/22 until 11/10/22. During an interview on 01/17/22 at 2:45 PM the Administrator, confirmed Resident #149 did not receive showers as scheduled. b) Resident #150 A record review, during a complaint investigation for abuse and neglect, found a Reportable, stating that Resident #150 reported Nurse Aide (NA) #21 made her uncomfortable and scolded her. Resident #150 stated that NA #21 said, I am telling you right now, I'm the only person here and I'm not giving you a shower when it is just me. NA #21 refused to give her a shower as scheduled on 11/04/22. A continued medical record review revealed Resident #150 did not receive a shower from 11/02/22 until 11/08/22. During an interview on 01/17/22 at 2:45 PM the Administrator, confirmed Resident #150 did not receive showers as scheduled. No further information was provided prior to the end of the survey, 01/18/23 at 3:15 PM. .

CONCERN (D) 📢 Someone Reported This

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

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

Deficiency F0805 (Tag F0805)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on review of medical records, observation, and staff interview, The facility failed to provide food in a form to meet individual needs. This was true for Resident #145 and #137, whom had orders for no bread and residents were given a Danish for breakfast on 01/18/23. Resident identifiers: #145 and #137. Facility Census: 145. Findings include: a) Resident #145 Review of Resident #145's medical records found he was admitted on [DATE] with diagnosis of dysphagia due to Parkinson's disease. Review of his diet order found an order for Mechanical soft, ground texture, thin regular consistency liquids. Kennedy cup. Gravy on all meats. No bread. Observation of breakfast, on 01/18/22 at 7:35 am, found resident was given a Danish. According to meal ticket the resident was to receive buttered wheat toast with removal of crust. Verified by Employee #149, Licensed Practical Nurse (LPN). She confirmed the resident should not have received a Danish which was formed and difficult to swallow. Nursing Home Administer (NHA) informed on 01/18/23 at 2:15 pm, of the resident was provided a Danish on his breakfast tray even though the meal ticket indicated he should have received buttered toast with crust removal. b) Resident #137 Review of Resident #137's medical records found she was admitted on [DATE]. Review of her diet order found an order for Mechanical soft, ground texture, thin regular consistency liquids. No bread. Observation of breakfast, on 01/18/22 at 8:35 am, found resident was given a Danish. According to meal ticket the resident was to receive buttered wheat toast with removal of crust. Verified by Employee #136, Nursing Assistant (NA). She confirmed the resident should not have received a Danish which was formed and difficult to swallow. Nursing Home Administer (NHA) informed on 01/18/23 at 2:15 pm, of the resident was provided a Danish on her breakfast tray even though the meal ticket indicated she should have received buttered toast with crust removal. .

CONCERN (E) 📢 Someone Reported This

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

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

Quality of Care (Tag F0684)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, record review, staff interview and resident interview the facility failed to provide the appropriate quality of care in the following care areas. They failed to provide professional standards of practice relating to enteral tube feedings and following procedure, failed to follow Physicians recommendations to treat and monitor a wound and failed to follow dietary orders. Resident Identifiers: #53, #105, #120, #93, #91, #21, #74, #50, #112, #29. Facility Census: 144 Findings Included: a) Tube feeding During the initial walk through on 1/16/23 at 11:30 AM it was observed that the tube feeding administration bags were not labeled with identifying information for three (3) Residents that had tube feeding being administered. These three (3) observations were confirmed with Licensed Practical Nurse (LPN) #123 on 1/16/23 at 11:40 AM. According to professional standards of practice and the facility procedure for Enteral Tube Feeding, Revision date November 2018, all supplies and formula are to be changed and dated every twenty-four (24) hours. In additional, the formula is to be labeled with the Residents name, name of the formula, rate of administration, date and time the formula was began and the nurses initials. This was confirmed with the Administrator on 1/18/23 at 11:25 AM. 1) Resident #53 Resident #53 had a current order for bolus tube feedings 2 Cal HN 1 can (237 milliliters (ml) five (5) times per day via Crustaceous endoscopies gastronomy Tube (PEG) via pump. The 5 (five) cans of 2 Cal HN are poured into the tube feeding bag and ran at 237 ml per hour for one (1) hour. The feedings are administered at midnight, 8 AM, 12 noon, 4 PM and 8PM. Once the 237 ml's are administered, the pump is placed on hold until the next feeding is due. Per staff interview on 1/17/23 at 2:10 PM with LPN #68, the feedings are administered via pump due to behaviors from the Resident increasing the risk of dislodging the PEG tube during administration if administered via syringe. There was no label on the tube feeding bag identifying the contents of the bag or the additional necessary information. 2) Resident #105 Resident #105 has a current order for Jevity 1.5 30 cc/hr continuously. There was no label on the tube feeding bag identifying the contents of the bag or the additional necessary information 3) Resident #120 Resident #120 had a current order for Jevity 1.5 40 cc/hr continuously. There was no label on the tube feeding bag identifying the contents of the bag or the additional necessary information b) Resident #93 During the initial walk through on 1/16/23 at 11:50 AM, it was observed that Resident #93 was lying in bed rubbing her left hip crying. She stated she had fallen recently and her left hip was hurting. She rated her pain a ten (10) out of ten (10) on the pain scale. I ask the Licensed Practical Nurse (LPN) #68 if the Resident had pain medication available. She did and the LPN stated she would assess the Resident. Medical record review shows that Resident #93 has two medications ordered for pain: 12/27/22 Acetaminophen Tablet 325 miligrams (mg) Give 2 tablet by mouth every 6 hours as needed for Pain. 12/27/22 Ultram Tablet 50 mg (tramadol HCL) give 1 tablet by mouth every 4 hours as needed for pain. Upon investigation, the Resident fell on 1/7/23. There appeared to be no injuries. However, when the resident complained of left hip pain on 1/8/23 and 1/10/23, an X-ray of the left hip was completed on 1/10/23. Review of the X-ray reported a negative report. No abnormalities. No new orders from the Physician. The Medication Administration Report (MAR) documents the Resident was administered acetaminophen as ordered for pain (level in parenthesis) on the following dates: 1/8/23 (7), 1/10/23 (6), 1/11/23 (9), 1/12/23 (8), 1/14/23 (5). On 1/16/23 (5) (survey date) the resident was administered Ultram as ordered. This was the first time she had been administered Ultram. During a staff interview with LPN #68 on 1/17/23 at 11:35 AM, she stated if I were assessing residents pain I would choose medication based on the pain level. For a pain level of five (5) or less I would probably give the Acetaminophen, six (6) or above I would give Ultram. The orders usually do not give specific perimeters as to which pain medication to administer. According to the facilities Policy for Administering Pain Medication dated October 2010, the Nurse is to Conduct a pain assessment as indicated. The initial assessment is comprehensive and should follow the facility pain assessment procedure Administer pain medications as ordered. These two (2) orders are incomplete as they do not indicate at which pain level to administer which medication. This was confirmed with the Administrator on 1/17/23 at 12:32 PM. d) Resident #21 Resident #21 was admitted to the facility on [DATE], diagnosis of cerebral vascular accident (CVA), oropharyngeal phase requiring the need for speech therapy. Speech therapist recommended precautions of mechanical soft diet with nectar thickened liquids. No straws and swallow precautions (general swallow techniques/precautions, no straws, bolus modifications and effortful swallowing) in place; order effective 12/29/22. Observation of breakfast meal, on 01/18/23 at 7:25 am, Resident #21, had straw in his milk carton. Verification by Employee #145, a Nursing Assistant (NA) upon review of diet card. Nursing Home Administer (NHA) informed on 01/18/23 at 2:15 pm, of the resident was provided straws on his breakfast tray even though the meal ticket indicated no straw. e) Resident #74 Resident #74 was admitted to the facility on [DATE], diagnosis of dysphagia following a nontraumatic subarachnoid hemorrhage, oropharyngeal phase requiring the need for speech therapy. Speech therapist recommended precautions of pureed texture diet with nectar thickened liquids. No straws; order effective 01/16/23. Observation of breakfast meal, on 01/18/23 at 7:40 am, Resident #74, had straw in her milk carton. Verification by Employee #149, Licensed Practical Nurse (LPN) upon review of diet card/order. Nursing Home Administer (NHA) informed on 01/18/23 at 2:15 pm, of the resident was provided straws on his breakfast tray even though the meal ticket indicated no straw. f) Resident #50 Resident #50 was admitted to the facility on [DATE], diagnosis of dysphagia, oropharyngeal phase requiring the need for speech therapy. Speech therapist recommended precautions of regular texture diet with thin/regular liquids. No straws; order effective 12/08/22. Observation of breakfast meal, on 01/18/23 at 8:20 am, Resident #50, had straw in his milk carton. Verification by Employee #124, Nursing Assistant (NA) upon review of diet card. Nursing Home Administer (NHA) informed on 01/18/23 at 2:15 pm, of the resident was provided straws on his breakfast tray even though the meal ticket indicated no straw. g) Resident #112 Resident #112 was admitted to the facility on [DATE]. Review of diet order revealed an order for regular texture, thin/regular consistency liquids. Double portions effective 05/09/22. Observation of lunch meal, on 01/18/23 at 1:10 am, Resident #112, found the resident did not have double portions . Verification by Employee #136, Nursing Assistant (NA) upon review of diet card. Nursing Home Administer (NHA) informed on 01/18/23 at 2:15 pm, of the resident was not provided double portions on his lunch tray even though the meal ticket indicated double portions. h) Resident #28 Resident #28 was admitted to the facility on [DATE]. Review of diet order revealed an order for pureed texture, thin/regular consistency liquids; calorie count each meal; effective 08/17/22. Observation of Resident #28's breakfast and lunch meal, on 01/18/23 at 7:40 am and 12:38 pm. Verification by the Nursing Home Administrator (NHA) on 01/18/23 concerning calorie count each meal. She stated, It should have been for three (3) days at admission. She confirmed it was still an active order. c) Resident (R) #91 On 01/17/23 at 11:00 AM, an observation during R #91's care with wound nurse (WN) #120, revealed a blackened left great toe with a necrotic appearance. WN #120 reported the toe always looks that way and noted they were not treating the toe at this time. Review of the medical record on 01/17/23, revealed R#91 was seen by a podiatrist on 01/04/23. The podiatry note states the physician applied betadine to R#91's gangrenous wound on the left great toe. The note further states: .It is imperative to monitor the left great toe for wet gangrene which should be treated as a medical emergency. Betadine applications will help keep the area clean and dry . The treatment record is silent for any daily treatments for R#91's left great toe. During an interview on 01/17/23 at 12:50 PM, the Director of Nursing (DON) reported she was unaware of any concern related to R#91's left great toe. The DON reviewed the medical record and confirmed daily assessments and treatments were not in place for R#91's left great toe. .

CONCERN (E) 📢 Someone Reported This

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

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

Deficiency F0810 (Tag F0810)

Could have caused harm · This affected multiple residents

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. Based on medical record review, observations, and staff interview, the facility failed to ensure resident whom required special eating equipment and utensils were provided the assistive devices to consume meals. Resident identifiers: #70, #57, #55 and #37. Facility Census: 145. Findings include: a) Resident #70 Review of Resident #70's medical records found a physician's order for scooped bowl at meals effective date 07/19/21. Observation on 01/18/23 at breakfast at 8:15 am and for lunch at 1:05 pm revealed the resident did not receive a scoop plate for either meal. It was verified both times by Employee #223, Nursing Assistant (NA). She also verified the meal ticket read: Adaptive equipment: Scoop bowls. Nursing Home Administer (NHA) informed on 01/18/23 at 2:15 pm, of the resident not receiving scooped bowls was not provided on her breakfast or lunch. b) Resident #57 Review of Resident #57's medical records found an order for a Kennedy cup. Observation on 01/18/23 at breakfast at 8:20 am revealed the resident did not receive a Kennedy cup for her breakfast meal. It was verified by Employee #124, Nursing Assistant (NA). She also verified the meal ticket read: Adaptive equipment: Kennedy cup. Nursing Home Administer (NHA) informed on 01/18/23 at 2:15 pm, of the resident not receiving a Kennedy cup for her breakfast meal. c) Resident #55 Review of Resident #55's medical records found a physician's order for provable cup and supervision during meals; effective date 04/25/22. Observation on 01/18/23 at lunch at 12:45 pm revealed the resident did not receive a provable cup for lunch was verified by Employee #225, Nursing Assistant (NA). She also verified the meal ticket read: Adaptive equipment: provable cup and supervision during meals. Nursing Home Administer (NHA) informed on 01/18/23 at 2:15 pm, of the resident not receiving a provale cup and supervision was not provided on his lunch. d) Resident #37 Review of Resident #37's medical records found an order for Patient to receive right angled utensils, scooped plate and Kennedy cup with straw with all meals; effective 06/21/21 . Observation on 01/18/23 at lunch at 12:40 pm revealed the resident did not receive a Kennedy cup or right angled utensils for her lunch meal. It was verified by Employee #124, Nursing Assistant (NA). She also verified the meal ticket read: Adaptive equipment: Kennedy cup, scooped late and right angled utensils. Nursing Home Administer (NHA) informed on 01/18/23 at 2:15 pm, of the resident not receiving a Kennedy cup and right angled utensils for her lunch meal. .

Feb 2022 12 deficiencies

CONCERN (D)

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

Resident Rights (Tag F0550)

Could have caused harm · This affected 1 resident

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. Based on observation, resident interview, and staff interview, the facility failed to ensure residents were treated with dignity and respect. A Resident had signage posted in the room that discussed treatment and care that was visible to anyone in the room and from the hallway. This was a random opportunity for discovery. Resident identifier: #133. Facility census: 145. Findings included: Record review of the facility's policy titled Quality of life-Dignity, revised on August 2009, showed signs indicating the resident's clinical status or care needs shall not be openly posted in the resident's room. a) Resident #133 An observation, on 02/14/22 at 11:25 AM, revealed a sign visible from hallway that stated, Fluid Restriction 711-2 see nurse. During an interview on 02/14/22 at 11:25 AM, Resident #133 stated there was no understanding why a fluid restriction was in place. An observation, on 02/16/22 at 11:45 AM, showed a sign visible from hallway that stated, Fluid Restriction 711-2 see nurse. During an interview on 02/16/22 at 11:46 AM, Resident #133 stated that when the Surveyor finds out about the fluid restriction an explanation why the restriction was in place would be appreciated. During an interview on 02/16/22 at 11:55 AM, Licensed Practical Nurse (LPN) #87, stated that there was no understanding of why Resident #133 was on fluid restriction but maybe edema I think. LPN #87 stated that the signs in the Resident's rooms are helpful to the new staff and those staff who do not always work on the floor and are familiar with the Residents. During an interview on 02/16/22 at 12:39 PM, the Administrator stated that signs posted about Residents care was a dignity issue and should not be posted where the sign would be visible to the hallway. .

CONCERN (D)

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

Deficiency F0578 (Tag F0578)

Could have caused harm · This affected 1 resident

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. Based on record review and staff interview, the facility failed to ensure one (1) of 36 residents reviewed during the long-term care survey process had advance directives completed as recognized by State Law. Resident #73's Selection of Health Care Surrogate (HCS) form failed to document the appointed HCS's telephone number and address, thereby providing no way to contact the appointed representative in an emergency. Resident identifier: #73. Facility census: 145. Findings included: a) Resident #73 A medical record review, completed on 02/15/22 at 1:56 PM, found Resident #73's attending physician had documented Resident #73 was unable to make medical decisions. Further, the attending physician had appointed a Health Care Surrogate (HCS) to make medical decisions on Resident #73's behalf. The Selection of Health Care Surrogate (HCS) form did not include the address and telephone number of the appointed HCS. During an interview, on 02/16/22 at 8:49 AM, Social Worker #20 confirmed the HCS form was not completed in its entirety. The Social Worker #20 agreed it gave no way for the HCS to be contacted in an emergency and reported the issue would be addressed. .

CONCERN (D)

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

Deficiency F0583 (Tag F0583)

Could have caused harm · This affected 1 resident

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. Based on observation, staff interview, and policy review, the facility failed to ensure the confidentiality and privacy of Resident #101's personal medical records. Resident #101's Medial Power of Attorney paperwork was filed on another resident's chart. This was a random opportunity for discovery. Resident identifier: #101. Facility census: 145. Findings included: a) Policy Review Review of the facility's Management and Protection of Protected Health Information policy revealed it was considered to be the responsibility of all personnel who have access to resident information to ensure that such information is managed and protected to prevent unauthorized release or disclosure. b) Resident #101 An observation on, 02/15/21 at 11:51 AM, revealed Resident #101's Medical Power of Attorney paperwork was erroneously filed on Resident #127's chart. On 02/16/22 at 8:13 AM, Licensed Practical Nurse (LPN) #84 verified Resident #101's Medical Power of Attorney paperwork was incorrectly filed on Resident #127's chart. LPN #84 stated, That's a big problem and confirmed Resident #101 did not reside on the unit but on another unit upstairs in the facility. .

CONCERN (D)

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

Deficiency F0625 (Tag F0625)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review and staff interview, the facility failed to provide evidence a bed hold notification was given to a resident or the resident's representative before being transferred to an acute care hospital. This had the potential to affect all residents being transferred. Resident identifier: Resident #73. Facility census: 145. Findings included: a) Resident #73 A medical record review was completed on 02/15/22 at 1:42 PM. Resident #73 was transferred/discharged to the hospital on [DATE]. There was no evidence the facility had provided the resident or resident's representatives a bed hold notification at the time of the transfer/discharge. In an interview on 02/17/22 at 1:13 PM, the Director of Nursing reported the facility had no evidence a detailed written bed hold notice had been provided to Resident #73 upon transfer/discharge to the hospital. .

CONCERN (D)

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

Deficiency F0642 (Tag F0642)

Could have caused harm · This affected 1 resident

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. Based on record review and staff interview, the facility failed to accurately assess/document a resident's medical diagnosis. This was true for one (1) resident reviewed. Resident identifier: #86 Facility census 145. Findings included: a) Resident #86 On 2/16/22 at 11:15 AM, review of residents most recent Medium Data Set (MDS) on 1/24/22 dementia diagnosis was not claimed.On 2/16/22 at 2:15 PM, interview with Registered Nurse Assessment Coordinator(RNAC) #58 how a new diagnosis would be captured RNAC #58 stated, usually when reviewing the orders and residents chart. This surveyor requested for section I and N to be printed to review, found dementia diagnosis not claimed on 1/24/22 most recent MDS. On 2/17/22 at 2:30 PM, interview with Director of Nursing (DON) when asking when diagnosis of dementia was given to resident # 86 and DON stated, on January 6th 2022 when Nurse Practitioner (NP) gave dementia diagnosis with start of new medication. .

CONCERN (D)

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

Deficiency F0657 (Tag F0657)

Could have caused harm · This affected 1 resident

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. The facility failed to ensure comprehensive care plans were revised in the area of visitor restrictions. This was a random opportunity for discovery. Resident Identifiers: #62, #7. Facility census: 145. Findings included: a) Revised Guidance from the Centers for Medicare and Medicaid Services (CMS) On 11/12/21 CMS issued revised guidance, QSO-20-39-NH, directing Visitation is now allowed for all residents at all times. b) Resident #62 A medical record review, completed on 02/21/22 at 5:00 PM, revealed Resident #62's care plan listed the following goal: Resident will not show any signs of depression/ anxiety or ill effects related to current center policy that limits visitation from outside family/ friends. The goal was initiated on 11/11/21 and revised on 11/16/21. c) Resident #7 A medical record review, completed on 02/21/22 at 5:45 PM, revealed Resident #7's care plan listed the following goal: Resident will not show any signs of depression/ anxiety or ill effects related to current center policy that limits visitation from outside family/ friends. This goal was initiated on 03/23/20 and revised on 0202/22. h) Interviews with the Infection Preventionist and the Director of Nursing (DON) During an interview, on 02/22/22 at 10:43 AM, the Infection Preventionist reported the facility was aware of the 11/12/21 CMS guidance which opened visitation to all visitors at all times. The Infection Preventionist reported the facility re-opened at that time and has remained open with no restrictions. When the above-mentioned care plan goals were reviewed with the Infection Preventionist, she was not certain why they had not been revised. The Director of Nursing (DON), during an interview on 02/22/22 at 11:00 AM, stated the care plans would be revised promptly and acknowledged the care plan goals were not consistent with the residents right to have unrestricted visitation. .

CONCERN (D)

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

ADL Care (Tag F0677)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, record review, and staff interview, the facility failed to ensure two (2) of three (3) residents reviewed for the care area of activities of daily living (ADL's) received the necessary care and services to maintain good grooming and personal hygiene. Resident #91 had unwanted facial hair. Resident #296 did not receive showers. Resident identifiers: #91 and #296. Facility census: 145. Findings included: a) Resident #91 During an interview on 02/14/22 at 12:17 PM, Resident #91 was observed with an abundant amount of facial hair on her chin. Certified Nursing Assistant (CNA) #137 confirmed the presence of the facial hair on Resident #74 and stated, We have to help her with shaving. She cannot do it independently. A brief medical record review, completed on 02/16/22 at 11:09 AM, revealed Resident #91 required one-person physical assist with personal hygiene which is defined as combing hair, brushing teeth, shaving, applying makeup, washing/drying face and hands. During a second interview on 02/16/22 at 12:30 PM, Resident #91's facial hair was still present. Resident #91 reported she gets a shower once a week. If CNA #137 showers me, I get shaven. The other CNAs do not. Further discussion revealed Resident #91 would not only like to be assisted with shaving with every shower but would like for assistance to be offered with shaving more than one time a week when she is given bed baths in her room. During an interview, on 02/16/22 at 12:45 PM, the Director of Nursing (DON) reported it would be her expectation that every CNA who assists Resident #91 with her shower would assist her with shaving. The DON stated staff would be re-educated regarding their role and assisting Resident #71 with shaving more than once a week would also be addressed. b) Resident #296 During an annual recertification with a simultaneous complaint investigation for Residents not being groomed adequately found Resident #296 on 02/17/22 did not get showers as scheduled. Medical record review revealed, Resident #296's shower schedule and preference were two (2) times weekly. A continued record review of Resident #296's Discharge 09/03/21 Minimum Data Set (MDS), section G (Functional Status) indicates total assistance with bathing and grooming. MDS Section E (Behaviors) also indicated Resident #296 does not reject care. Subsequent review of the care plan and [NAME] (an overview of resident care for nursing staff) revealed, Resident #296 is total dependent for bathing and extensive assist for personal hygiene. A continued review of Resident #1s ADL documentation found: Two (2) Shower documented given on 08/04/21and 08/11/21 from 07/22/21 through 09/03/21. On 02/17/22 at 11:04 PM the Director of Nursing (DON) verified Resident #296 did not receive showers as scheduled. .

CONCERN (D)

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

Accident Prevention (Tag F0689)

Could have caused harm · This affected 1 resident

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. Based on observation, record review, and staff interview, the facility failed to provide one (1) on one (1) supervision to a resident during meal time. This was a random opportunity for discovery. Resident identifier: #35. Facility census: #145. Findings included: a) Resident #35 An observation, on 02/15/22 at 2:00 PM, showed Resident #35 eating alone in the 700 hall day room. A review of Resident #35's medical record showed a physician order dated 07/26/21 that stated, 1 on 1 CONSTANT SUPERVISION for meals. An observation, on 02/16/22 at 1:10 PM, showed Resident #35 eating alone in the 700 hall day room. During an interview on 02/16/22 at 1:20 PM, Nurse Aide (NA) #163, stated that staff watch over Resident # 35 when eating but there were six (6) more residents on the 700 hall that needed assistance with feeding, so NA #163 just periodically checks on Resident #35 to make sure Resident #35 was not choking. NA #163 acknowledged the order that Resident #35 was a one (1) on one (1) during meals but stated just frequent checks was what usually occurred. During an interview on 02/16/22 at 3:00 PM, the Administrator stated that one (1) on one (1) constant supervision would be defined as staff sitting beside a resident at all times. .

CONCERN (D)

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

Deficiency F0692 (Tag F0692)

Could have caused harm · This affected 1 resident

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. Based on record review and staff interview, the facility failed to obtain weekly weights for a resident with a feeding tube. This was true for one (1) out of three (3) residents reviewed for Tube Feedings. Resident identifiers: #34. Facility census: 145. Findings included: a) Resident #34 A review of Resident #34's medical record showed a physician order dated 12/16/21 that stated, Weekly weights due to enteral feeding. Further review of Resident #34's medical record showed the Weights Summary page. The following weeks Resident #34 was not weighed per physician order: No weights obtained for the week of 12/19/21-12/25/2021 No weights obtained for the week of 01/23/22-01/29/22 During an interview on 02/16/22 at 12:40 PM, Administrator stated that the physician order that instructed the weekly weights for eternal feedings for Resident #34 was not followed. .

CONCERN (E)

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

Comprehensive Care Plan (Tag F0656)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review and staff interview, the facility care planned that their center policy limited visitation from outside family and friends to protect the well-being of their residents from COVID-19, despite the Centers for Medicare and Medicaid Services (CMS) guidance opening visitation to all residents, at all times. This was a random opportunity for discovery. Resident identifiers: #132, #101, and #5. Facility Census: 145. Findings included: a) Revised Guidance from CMS On 11/12/21 CMS issued revised guidance, QSO-20-39-NH, directing Visitation is now allowed for all residents at all times. b) Resident #132 A medical record review, completed on 02/21/22 at 3:00 PM, revealed Resident #132 was admitted to the facility on [DATE]. Resident #132's care plan listed the following goal: Resident will not show any signs of depression/ anxiety or ill effects related to current center policy that limits visitation from outside family/ friends. The goal was initiated on 11/23/21 and revised on 12/20/21. c) Resident #101 A medical record review, completed on 02/21/22 at 3:30 PM, revealed Resident #101 was admitted to the facility on [DATE]. Resident #101's care plan listed the following goal: Resident will not show any signs of depression/ anxiety or ill effects related to current center policy that limits visitation from outside family/ friends. The goal was initiated on 12/08/21 and revised on 12/28/21. d) Resident #5 A medical record review, completed on 02/21/22 at 4:00 PM, revealed Resident #5 was admitted to the facility on [DATE]. Resident #5's care plan listed the following goal: Resident will not show any signs of depression/ anxiety or ill effects related to current center policy that limits visitation from outside family/ friends. The goal was initiated on 01/20/22 and revised on 01/31/22. e) Interviews with the Infection Preventionist and the Director of Nursing (DON) During an interview, on 02/22/22 at 10:43 AM, the Infection Preventionist reported the facility was aware of the 11/12/21 CMS guidance which opened visitation to all visitors at all times. The Infection Preventionist reported the facility re-opened at that time and has remained open with no restrictions. When the above-mentioned care plan goals were reviewed with the Infection Preventionist, she was not certain why the mention of any limited visitation was made as it was not the case. The Director of Nursing (DON), during an interview on 02/22/22 at 11:00 AM, stated the care plans would be revised promptly and acknowledged the care plan goals were not consistent with the residents right to have unrestricted visitation. .

CONCERN (E)

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

Quality of Care (Tag F0684)

Could have caused harm · This affected multiple residents

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. c) Resident #108 A medical record review, completed on 02/16/22 at 7:33 PM, revealed Resident #108 experienced an unwitnessed fall on 07/25/21 at 10:18 AM. RN #61 documented, Call to room where patient sitting on buttocks on floor beside of bed. Patient stated she was asleep and woke up on floor. Assessed with no injuries. Transferred back to bed with PT [physical therapy]. Resident's Brief Interview for Mental Status (BIMS) score, on July 16, 2021, was determined to be a 09 indicating Resident #109 was cognitively impaired. During an interview on 02/17/22 at 2:14 PM, the DON stated neuro checks were not done following Resident #108's fall. The DON went on to acknowledge neuro checks should have been since it was an unwitnessed fall. d) Resident #91 On 02/17/22 at 2:08 PM, an electronic medical record review completed. There was an order for Resident #91 to receive insulin on a sliding scale. The term sliding scare refers to the progressive increase in doses, based on pre-defined blood glucose ranges. The physician order outlined the following: HumaLOG Solution 100 UNIT/ML (Insulin Lispro) subcutaneously before meals and at bedtime for Diabetes Mellitus II uncontrolled. Inject as per sliding scale, if 201 - 250 = 2 units 251 - 300 = 4 units 301 - 350 = 6 units 351 - 400 = 8 units 401 - 450 = 10 units 451 - 500 = 12 units Call MD/NP for blood sugar less than 70 or greater than 500. Review of the October 2021, November 2021 and December 2021 Medication Administration Records (MARs) revealed the following dates and times where nursing failed to obtain blood glucose levels, leaving the MAR completely blank: 10/02/21 6:30 AM 10/08/21 11:30 AM 10/14/21 6:30 AM 10/23/21 6:30 AM 10/31/21 6:30 AM 11/01/21 6:30 AM 11/08/21 6:30 AM 11/14/21 6:30 AM 11/16/21 6:30 AM 11/17/21 6:30 AM 11/18/21 6:30 AM 11/30/21 6:30 AM 12/01/21 6:30 AM 12/08/21 6:30 AM 12/10/21 6:30 AM During an interview on 02/22/22 at 11:08 AM, the DON reported nursing should have taken resident's blood glucose level, documented it, and followed the sliding fee guidance as to whether Resident #91 required insulin coverage or not. The DON stated the issue would be addressed. e) Resident #1 A record review revealed Resident #1's unwitnessed fall on 12/11/21 from her motorized wheelchair, she was observed on the floor. She was holding her self up and her head was under the sink. Continued review for Resident #1's Neurological Evaluation from the fall on 12/11/21 found they were not completed as ordered. During an interview on 02/22/22 at 11:30 PM with the Administrator, she acknowledged that Neurological Checks should have been completed per policy for resident #1's unwitnessed fall on 12/11/21. Based on record review, resident interview, and staff interview, the facility failed to perform Neuro checks after unwitnessed falls, failed to clarify a physician order related to insulin, and failed to follow a physician order. This was true for five (5) of 36 sampled residents. Resident identifiers: #1, #35, #91,#134 and #108. Facility census: 145. Findings included: Record review of the facility's policy titled Neurological Assessment, revised on October 2010, showed neurological assessments are indicated following an unwitnessed fall. a) Resident #134 During an interview on 02/15/22 at 10:14 AM, Resident #134 stated, I had my first fall yesterday and I hit my head. The staff were not in here when I fell out of my wheelchair. Review of Resident #134 medical record showed no neurological assessments initiated for fall unwitnessed fall on 02/14/22. During an interview on 02/16/22 at 2:54 PM, Director of Nursing (DON) stated that Resident # 134's fall on 02/14/22 was unwitnessed. During an interview on 02/16/22 at 3:20 PM, Licensed Practical Nurse (LPN) #84 stated that Resident # 134 had an unwitnessed fall on 02/14/22 but Neurochecks were not initiated because Resident #135 seemed alert and oriented after the fall. LPN #84 stated there was no documentation on the details of the fall because it was just not done but realized now documentation would have been beneficial. During an interview on 02/16/22 at 4:04 PM, DON stated that neurological evaluations should have been started on Resident # 134's unwitnessed fall. b) Resident #35 During an interview on 02/14/22 at 11:30 AM, Resident #35 stated that there was an issue with low blood sugar this morning. A review of Resident #35's medical record showed a physician order dated 02/01/22 that stated, HumaLOG Solution 100 UNIT/ML (Insulin Lispro(Human) Inject as per sliding scale: 170 - 219 = 1 unit; 220 - 269 = 2 units; 270 - 319 = 3 units; 320 - 419 = 4 units; 420 - 500 = 5 units, if greater than 420 give 6 units Further review of Resident #35's medical record review showed two (2) dates on February 2022 Medication Administration Record (MAR) when insulin was administered for blood sugars greater than 420. The dates included: 02/03/22- Blood sugar was 422 and 5 units of insulin was administered 02/14/22- Blood sugar was 425 and 5 units of insulin was administered During an interview on 02/17/22 at 10:30 AM, DON, stated that the order was contradictory when the blood sugar reached 420. DON stated that the order would need to be clarified. .

CONCERN (E)

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

Medical Records (Tag F0842)

Could have caused harm · This affected multiple residents

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. Based on record review, and staff interview, the facility failed to maintain a medical record for each resident which contained complete and accurately documented information. Treatments were not documented for Residents #98, #25, and #84. This was true for three (3) of four (4) residents reviewed under the pressure ulcer care area. Facility census: 145. Findings included: a) Resident #98 A record review revealed Resident #98 had physician's orders to receive a treatment to a sacral wound daily. A review of the Treatment Administration Record (TAR) showed treatments for 01/06/22, 01/07/22, 01/24/22 and 02/09/22 had not been documented as being provided. There was no evidence Resident #98 had refused the treatment or was out of the facility on these dates. b) Resident #84 A record review revealed Resident #84 had physician's orders for wound care to the upper thigh, right and left ischium and sacral area on day and evening shifts. A review of the TAR showed no evidence of documentation of treatments for 01/13/22, 01/14/22. 01/16/22. 01/20/22, 01/30/22, 02/08/22 and 02/12/22. Resident #84 also had physician's orders for treatment to the left heel. A review of the TAR showed no evidence of documentation of the treatment being provided for 02/12/22. c) Resident #25 A record review revealed Resident #25 had physician's orders for a wound treatment to the inner thigh and coccyx. A review of the TAR showed no evidence of documentation of treatments provided on 01/11/22 and 01/24/22. d) Staff interview An interview, on 02/15/22 at 1:05 PM, with the Director of Nursing (DON), confirmed there were blanks on the dates noted above on the TAR for Residents' #98, #84 and #25. The DON stated if the documentation was not there, it could not be determined if the treatments had been completed. The DON also added Resident #84 sometimes refused treatments, but it was the responsibility of the nurse to document if that happened and not to leave the treatment record blank. .

Understanding Severity Codes (click to expand)

Life-Threatening (Immediate Jeopardy)

J - Isolated K - Pattern L - Widespread

Actual Harm

G - Isolated H - Pattern I - Widespread

Potential for Harm

D - Isolated E - Pattern F - Widespread

No Harm (Minor)

A - Isolated B - Pattern C - Widespread

Questions to Ask on Your Visit

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

Our Honest Assessment

Strengths

• Licensed and certified facility. Meets minimum state requirements.

Concerns

• Multiple safety concerns identified: 3 life-threatening violation(s), 1 harm violation(s), $147,234 in fines. Review inspection reports carefully.
• 68 deficiencies on record, including 3 critical (life-threatening) violations. These warrant careful review before choosing this facility.
• $147,234 in fines. Extremely high, among the most fined facilities in West Virginia. Major compliance failures.
• Grade F (0/100). Below average facility with significant concerns.

Bottom line: This facility has 3 Immediate Jeopardy findings. Serious concerns require careful evaluation.

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About This Facility

What is Peterson Rehabilitation And Healthcare's CMS Rating?

CMS assigns PETERSON REHABILITATION AND HEALTHCARE an overall rating of 2 out of 5 stars, which is considered below average nationally. Within West Virginia, this rating places the facility higher than 0% of the state's 100 nursing homes. A rating at this level reflects concerns identified through health inspections, staffing assessments, or quality measures that families should carefully consider.

How is Peterson Rehabilitation And Healthcare Staffed?

CMS rates PETERSON REHABILITATION AND HEALTHCARE's staffing level at 2 out of 5 stars, which is below average compared to other nursing homes. Staff turnover is 53%, compared to the West Virginia average of 46%.

What Have Inspectors Found at Peterson Rehabilitation And Healthcare?

State health inspectors documented 68 deficiencies at PETERSON REHABILITATION AND HEALTHCARE during 2022 to 2025. These included: 3 Immediate Jeopardy (the most serious level, indicating potential for serious harm or death), 1 that caused actual resident harm, and 64 with potential for harm. Immediate Jeopardy findings are rare and represent the most serious regulatory concerns. They require immediate corrective action.

Who Owns and Operates Peterson Rehabilitation And Healthcare?

PETERSON REHABILITATION AND HEALTHCARE is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility operates independently rather than as part of a larger chain. With 150 certified beds and approximately 134 residents (about 89% occupancy), it is a mid-sized facility located in WHEELING, West Virginia.

How Does Peterson Rehabilitation And Healthcare Compare to Other West Virginia Nursing Homes?

Compared to the 100 nursing homes in West Virginia, PETERSON REHABILITATION AND HEALTHCARE's overall rating (2 stars) is below the state average of 2.7, staff turnover (53%) is near the state average of 46%, and health inspection rating (2 stars) is below the national benchmark.

What Should Families Ask When Visiting Peterson Rehabilitation And Healthcare?

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

Is Peterson Rehabilitation And Healthcare Safe?

Based on CMS inspection data, PETERSON REHABILITATION AND HEALTHCARE has documented safety concerns. Inspectors have issued 3 Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death). The facility has a 2-star overall rating and ranks #100 of 100 nursing homes in West Virginia. Families considering this facility should ask detailed questions about what corrective actions have been taken since these incidents.

Do Nurses at Peterson Rehabilitation And Healthcare Stick Around?

PETERSON REHABILITATION AND HEALTHCARE has a staff turnover rate of 53%, which is 7 percentage points above the West Virginia average of 46%. Moderate turnover is common in nursing homes, but families should still ask about staff tenure and how the facility maintains care continuity when employees leave.

Was Peterson Rehabilitation And Healthcare Ever Fined?

PETERSON REHABILITATION AND HEALTHCARE has been fined $147,234 across 4 penalty actions. This is 4.3x the West Virginia average of $34,551. Fines at this level are uncommon and typically indicate a pattern of serious deficiencies, repeated violations, or failure to correct problems promptly. CMS reserves penalties of this magnitude for facilities that pose significant, documented risk to resident health or safety. Families should request specific documentation of what issues led to these fines and what systemic changes have been implemented.

Is Peterson Rehabilitation And Healthcare on Any Federal Watch List?

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

Facility Details

Beds: 150
Avg. Residents: 134
Occupancy: 89.4%
Ownership: For profit - Limited Liability company
Chain: Independent
Medicare: Yes
Medicaid: Yes
Sprinklers: Yes

Trust Score Breakdown

Base Score: 50
2-Star Rating: +10
3 Immediate Jeopardy citations: -36
1 Actual Harm citation: -5
68 Deficiencies: -10
Fines ($147,234): -15
Final Score: 0/100

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Data: CMS Medicare Care Compare

Updated: November 2025

Facility ID: 515002