Every finding on record at Belmont Healthcare Center

Based on observation and staff interview, the facility failed to store, prepare, distribute and serve food in accordance with professional food safety standards. Additionally, the facility failed to follow proper sanitation practices for food preparation equipment. This practice had the potential to affect all residents. Facility census: 60.Findings include:a) Healthcare Services Group (HCSG) policy #28 titled Environment, states:All trash will be contained in a covered, leak proof containers that prevent cross contamination.b) HCSG Policy #30, titled Dispose of Garbage and Refuse, states: The Dining Services Director will ensure that appropriate lids are provided for all containers.On 04/27/26 at 11:06 AM this surveyor completed an initial walkthrough of the kitchen with the Director of Dining Services (DDS). There was no lid on the trash can beside the juice machine. The DDS verified this deficient practice and placed a lid on the container. There was also no lid on the trash can in the dish room. The DDS verified this deficient practice and stated, We do not have a lid for this trash can, but I think maintenance has ordered one.

Based on observation and staff interview, the facility failed to store, prepare, distribute and serve food in accordance with professional food safety standards. Additionally, the facility failed to follow proper sanitation practices for food preparation equipment. This practice had the potential to affect all residents. Facility census: 60.Findings include: a) Healthcare Services Group (HCSG) policy #28 titled Environment states: All food preparation areas, food service areas, and the dining areas will be maintained in a clean and sanitary condition.The Dining Services Director will ensure that all employees are knowledgeable in the proper procedures for cleaning and sanitizing all of the food service equipment and surfaces.The Dining Services Director will ensure that a routine cleaning schedule is in place for all the cooking equipment, food storage areas, and surfaces.b) HCSG policy #19 titled Food Storage: Cold Foods states:All Time/Temperature Control for Safety (TCS) foods, frozen and refrigerated, will be appropriately stored in accordance with guidelines of the FDA Food Code.All foods will be stored wrapped or in covered containers, labeled and dated, and arranged in a manner to prevent cross contamination.c) HCSG policy #27 titled Equipment states:All foodservice equipment will be clean, sanitary, and in proper working order.All equipment will be routinely cleaned and maintained in accordance with manufacturer's directions and training materials.All staff members will be properly trained in the cleaning and maintenance of all equipment.All food contact equipment will be cleaned and sanitized after every use.All non-food contact equipment will be clean and free of debris.d) HCSG policy #23 titled Manual Ware Washing (3-Compartment Sink) states:All cookware, dishware, and service ware not processed through the dish machine will be manually washed and sanitized.The Dining Services staff will be knowledgeable in proper techniques including:Before processing any dishware, service and/or cookware, it is best practice to set up the three compartment sink.Remember to check the water temperature and concentration of the sanitizer in the sink compartments.Water temperature must be maintained at 110 degrees Fahrenheit (F) in the wash sink.Chemical sanitizer testing and concentrations used according to manufacture's guidelines.Appropriate test strips will be utilized to measure the concentration of the sanitizer solution for the chemical being used.Results will be recorded on the Three-Compartment Sink Log.e) Initial walkthrough of the kitchen on 04/27/26 at 11:06 AM. The Director of Dining Services (DDS) accompanied this surveyor and verified the findings were true.The top of the juice machine was soiled with debris.There were crumbs in the toaster tray.There was one (1) opened outdated brownie mix with a use-by date of 04/18/26 in the dry storage room.Employee coats were hanging on the bread rack.There was no open or use-by date on one (1) case of bacon in the walk-in cooler.The meat slicer was covered and had old food debris on and around the blade.No water temperature or sanitizer concentration was recorded on the three-compartment sink log for breakfast today (04/27/26).There was one beverage in the pantry refrigerator that was not labeled or dated.The microwave in the pantry was soiled and needed cleaning.During dining observation on 04/27/26 at 12:15 PM the beverage carts for 200 and 400 halls had trash bins on the same shelf as the milk containers intended for residents. The surveyor asked the Assistant Director of Nursing (ADON) if this was allowed and she stated, I am not sure, this is usually how they are sent out.On 04/27/26 at 12:30 PM the ADON removed the trash bins from both beverage carts.On 04/28/26 at 12:11 PM this surveyor found an employee's coat hanging on the bread rack again. The DDS verified this, moved the coats to the proper area and told staff to please don't hang them there anymore.

Based on Resident Council, and staff interviews, the facility failed to provide residents with the right to send and receive mail on Saturdays. This has the potential to affect more than a limited number of residents. Residents identified: #55, #20, #10, #33, #50, #39, #22, #45, #24 and #30. Facility census: 60.Findings include: a) Resident Council During the Resident council meeting on 04/28/26 at 3:30 PM The residents stated that they do not receive their mail delivery on Saturdays. During an interview on 04/29/26 at 9:00 AM the Activity Director verified, The residents do not receive mail on Saturdays. On 04/29/26 at 9:25 AM the Administrator stated that the manager on duty will get the mail and deliver it to the residents from now on.

Based on a review of a facility reported incident (FRI) and staff interviews, the facility failed to use the investigation results to determine the appropriate action regarding sexual abuse. This was true for two (2) of five (5) residents reviewed for abuse during the Long-Term Survey Process. Resident identifiers: #56 and #67. Facility census: 60.a) Resident #67 A review of the facility reportables found a sexual abuse allegation, dated 03/17/26, which involved Resident #67 reporting, Someone tried to rape me last night. She reported she was lying in bed asleep when she felt Resident #32 pulling on her leg. Resident #67 reported she wasn't sure what the man was doing, but she thought he was going to try to rape her. Employee #78 reported she was charting when she heard Resident #67 yelling. She reported that she and another Certified Nurse Assistant (CNA) went to check on Resident #67, and Resident #32 was standing in Resident #67's room naked. Employee #78 reported that she asked Resident #67 if she was okay and Resident #67 said, Yes, just get his naked ass out of here. Employee #43 reported that when they went to Resident #67's room, Resident #32 was standing in the room with just a t-shirt on, no brief or pants. Resident #67 was examined by the Nurse Practitioner (NP). Resident #67 reported to her that a man came into my room and pulled me down in bed. The facility submitted a Five-Day Follow-Up report to the appropriate state agencies. Under the Completions of Investigation/Conclusion section, it read, Allegations of sexual abuse are not substantiated. The facility failed to recognize Resident #67's expression of anxiety over awakening to Resident #32 being in her room (uninvited), naked from the waist down, and pulling her down in bed. The facility failed to recognize that Resident #67 considers the facility to be her home, where she expects to remain safe, have privacy, and be treated with respect and dignity. Resident #67 trusted that the facility staff would address her concerns related to Resident #32 being in her room uninvited, naked from the waist down, and pulling her down in bed. Resident #56 remained vulnerable throughout the incident and the investigative process. During an interview conducted on 04/29/26 at approximately 10:35 AM, the Administrator verified that Resident #32 was found in Resident #67's room with no brief or pants on 03/17/26. The facility's position was that no physical harm was done to Resident #67, which is why the allegation of sexual abuse was not substantiated. The facility failed to adequately evaluate whether Resident #67 felt safe or take steps to alleviate the fear.: b) Resident #56 A review of the Reportables found a sexual abuse allegation on 02/04/26 -Resident #32 inappropriately touching Resident #56. On 02/04/26 at 2:00 PM, Nurse Aide #13 reported that she witnessed Resident #32's hands under Resident #56's blanket rubbing close to her private parts. Staff intervened and asked Resident #56 if Resident #32 had touched her private area, she stated yes. During an investigation conducted by the Social Worker and Administrator, Resident #56 was interviewed regarding an incident involving Resident #32. Resident #56 stated that Resident #32 rubbed her private area and expressed her belief that the contact was intentional. Additionally, Resident #56 was examined by her attending physician, to whom she also verbalized that Resident #32 had touched her private area. When seen by the Psychologist she voiced no recollection of the event. The facility failed to recognize Resident #56's expression of anxiety over Resident #32 placing his hand under the blanket and rubbing the resident in an unwelcome fashion. The facility failed to recognize Resident #56 considers the facility to be her home, where there is an expectation that she would remain safe, had privacy, and would be treated with respect and dignity. Resident #56 trusted that the facility staff would address her concerns related to Resident #32 touching her / caressing her under the blanket, which was unwanted. Resident #56 remained vulnerable throughout the incident and the investigative process. A quarterly Minimum Data Set (MDS) assessment, with an assessment reference date of 04/21/26, reflected that the resident had a Brief Interview for Mental Status (BIMS) score of 14, indicating that Resident #56 was cognitively intact. A physician determination of capacity indicated that the resident has capacity. The facility's Five-Day Follow-Up report, under the completion of investigation section, it read I am unable to substantiate sexual abuse due to an inconsistency in statements. During interviews conducted on 04/29/26 at approximately 10:30 AM, the Administrator verified that Resident #32 touched Resident #56 on 02/04/26. The facility's position is that the contact with the resident's private area was accidental, occurring while Resident #32 was rubbing her leg under the blanket. The facility failed to adequately evaluate whether Resident #56 felt safe and/or take steps to alleviate the fear. Resident #32 theoretically continues to have access to Resident #56 and/or other vulnerable residents.

Based on observation and interview the facility failed to ensure the resident environment was as free from accident hazards as possible. This was a random opportunity to discover a blender storage area and medication carts unlocked and unattended. Facility Census: 60.Findings included: a) Resident #47 CommuniCare policy titled Medication Administration states: Never leave medication unattended. Remain with resident until the medication is swallowed. Do not leave medication at bedside. On 04/27/26 at 2:55 PM this surveyor interviewed Resident #47 while he was lying in his bed. This surveyor noticed a medicine cup on the bedside table. Resident #47 stated it was milk of magnesia. On 04/27/26 at 3:08 PM the surveyor asked the Director of Nursing (DON) to enter Resident #47's room to ask him what the medicine was, and if it was allowed to be left unattended. He stated it is milk of magnesia, and I will asked the nurse if Resident #47 asked her to leave it. On 04/27/26 at 11:30 AM, An observation of an unlocked, unattended medication cart on the 400 Hall. The cart was in a place easily accessible allowing access to these medication by residents, unauthorized persons, or visitors. At this time the Director of Nursing verified and locked the cart. On 04/28/26 at 2:40 PM, a second observation of an unlocked, unattended medication cart on the 400 Hall. The cart was in a place easily accessible allowing access to these medications by residents, unauthorized persons, or visitors. At this time the Licenses Practical Nurse (LPN) # 57 verified the cart was left unlocked and unattended. She locked the cart. During a routine inspection of the activities area across from the Director of Nursing's (DON) office on 4/27/2026 at approximately 12:45 PM, staff discovered an unsecured blender stored under the sink. This appliance poses an accident hazard because the blender container itself is made of breakable glass and has sharp blades at the bottom. It was left in a lower cabinet, unlocked and accessible to anyone who uses the activities area. The DON confirmed that the blender should not have been stored under the sink when it was brought to his attention. In fact nothing was to be under the sink, especially something that can be dangerous. The DON removed the blender and had a lock installed on the cabinets.

Based on food tray temperatures, resident interviews and staff interviews, the facility failed to serve food that was attractive, palatable and at a safe and appetizing temperature to prevent foodborne illness. Residents identified: #47, #33, #42 and #9. Facility census: 60 On 4/28/26 12:00 PM it was noted that the kitchen staff were not taking and recording temperatures for items on the always available menu. Before the surveyor brought it to the Director of Dining Services' (DDS) attention, the beef patties, hotdogs and brown gravy lacked recorded temperatures prior to the start of the lunch meal service. The DDS acknowledged they had not been taking and recording these food items' temperatures and will educate the staff to start doing so as soon as possible. The DDS stated, The always available menu item temperatures are not being recorded. I will start educating staff today, and we will start recording the temperatures of all food items.

Based on observations, clinical record reviews, facility documentation, and staff interviews, it was determined that the facility failed to establish and maintain an infection prevention program to prevent the development and transmission of communicable diseases related to hand hygiene.This practice had the potential to affect more than an isolated number of residents. Facility census: 60. Findings included:a) Hall Meal PassAn observation on 04/27/26 12:20 PM revealed that the Resident's in rooms on the 400 hall, did not receive hand hygiene prior to or during the noon meal pass. During an observation of the meal pass on the 200 and 400 halls on April 28, 2026, at approximately 12:55 PM, staff placed hand wipes on the meal trays. However, staff did not assist residents with physical limitations in using the wipes, nor did they inform other residents that the wipes were available on their trays.During an interview,on 04/28/23 at 1:50 PM, Nurse Aide (NA) 49 was asked if residents on the 100 hall received hand washing or sanitizing prior to the lunch meal that day. She verified that hand hygiene was not provided.

The facility failed to maintain the confidentiality of resident records, as evidenced by leaving a medicine cart's computer screen unlocked with resident information on display. This failed practice has the potential to affect more than a limited number of residents. Facility census: 60. Findings include:a) On 04/29/26 at 12:37 PM, this surveyor noticed that the medicine cart labeled blue cart, had the computer screen on, displaying residents' personal information.At 12:38 PM on 04/29/26, this surveyor asked the Director of Nursing (DON) if the computer screen is allowed to be on with no employee around, and he stated nope and locked the computer screen.

Based on observation and resident interviews, the facility failed to assist dependent Residents with activities of daily living (ADL's) in accordance with their assessed needs for care. This was true for one (1) of three (3) residents reviewed for ADL care. Resident Identifier: #26. Facility census: 60. Findings Included:a) Resident # 26During an interview and observation conducted on 04/27/26 at 11:28 AM, the surveyor met with Resident #26, who had visible facial hair.The resident stated that her preference was to receive assistance with shaving; however, she noted that she does not always receive this help. During an Interview on 04/27/26 at 1:08 PM the Director of Nursing (DON) verified that Resident #26 had visible facial hair and that he would have staff assist her with getting shaved.

Based on observation and staff interviews, the facility failed to store, prepare, and serve food in a safe and sanitary manner by not removing dented cans from service. This was a random opportunity for discovery. This has the potential to affect more than a limited number of residents. Facility census: 60. Findings include: A) Dented cans At approximately 11:50 AM on 10/21/24, during a tour of the kitchen, three (3) dented cans were placed on the shelf alongside cans intended for service. Two (2) cans contained corn and one (1) can contained sliced peaches. At approximately 11:53 AM on 10/21/24, Culinary Aide (CA) #38, stated they were the cook for the day due to the Dietary Manager (DM) being out of the facility, and acknowledged the dents in the cans, and they should have been removed from the shelves with the other cans meant for service.

Based on observation and interview, the facility failed to maintain effective infection control practices in the laundry room. Additionally, facility staff failed to adhere to infection control policies and protocols while providing catheter care. Resident Identifier: #44. Facility Census: 60. Findings included: a) Laundry Room During an inspection of the laundry room with Executive Director (ED) #6 on 10/22/24, at approximately 3:55 PM, discarded mop heads with a brown substance on them, were observed in the laundry sink. Additionally, several towels with brown stains were observed on top of a bin near the sink. Multiple covered, empty bins, for storing soiled items were available and lined up against the opposite wall. ED #6 confirmed soiled items should not be in the sink, or on top of the bins. The presence of uncovered soiled items increases the risk of contamination for all items in the laundry room. b) Resident #44 Catheter care for Resident #44 was observed on 10/23/24 at approximately 1:12 PM. This surveyor had requested Licensed Practical Nurse (LPN) #9's presence during the procedure. LPN #9 introduced Nurse Aide (NA) #53, and stated catheter care would be performed by NA #53. Resident #44 was under Enhanced Barrier Precautions (EBP), and the sign outside the resident's room noted this. NA #53 entered Resident #44's room wearing gloves but did not don additional personal protective equipment (PPE) or perform hand hygiene before proceeding. She closed the room door and pulled a screen to provide privacy for the resident. NA #53 informed the resident she would be performing catheter care, and then proceeded to undo the resident's brief. Without changing her gloves or performing hand hygiene, NA #53 gathered her supplies and began the procedure. She used moistened soapy towels to clean the catheter from the meatus forward. As she continued, she discarded each used towel on the floor. After she finished cleaning the catheter, she re-fastened the resident's brief, collected the soiled towels from the floor, and placed them in a trash bag. Once the procedure was complete, NA #53 again failed to discard her gloves or perform hand hygiene. She then went on to empty the catheter bag, and measured the volume of urine, still without changing her gloves or performing hand hygiene. LPN #9 expressed her shock at NA #53's failure to adhere to infection prevention protocols. She confirmed NA #53 did not follow the facility's EBP policy, or infection control procedures. LPN #9 mentioned she would take a moment to speak with NA #53 and provide a 'teachable moment' as soon as she exited the resident's room. The facility's Director of Nursing (DON) was unavailable for an interview. However, ED #6 confirmed on 10/23/24, at approximately 5:16 PM, LPN #9 had informed her about NA #53's failure to follow infection control protocols during catheter care.

Based on record review and staff interview the facility failed to ensure professional standards of practice were followed in regards to completing neurological assessments following a fall. This was true for one (1) of 25 residents reviewed during the long term are survey process. Resident Identifier: Resident #13. Facility Census: 60. Findings included: a) Resident #13 A review of Resident #13's medical records found the resident suffered a fall on 07/08/24, 09/20/24, and 10/19/24. After each fall neurological assessments were indicated and initiated. However, these neurological assessments were not completed as required. During an interview with the Director of Nursing (DON) on 10/23/24 at 1:05 PM, she acknowledged the neurological assessments were incomplete after the falls dated 07/08/2024, 09/20/2024, and 10/19/2024 .

Based on record review and staff interview, the facility failed to maintain a correct capacity form for Resident #23 and failed to correctly document dates and times of neurochecks for Resident #13. Resident identifiers: #23 and #13. Census: 60 Findings included: a) Resident #23 A review of Resident #23's records on 10/21/24 at 7:18 PM revealed the following: Physician's Determination of Capacity Form dated 06/05/24 documented the resident did not have capacity to make his own medical decisions with duration being long term due to inability to process information and disorientation caused by a cerebral vascular accident. Physician's Determination of Capacity Form dated 8/30/24 expressed the resident had capacity to make his own medical decisions and was signed by only one physician. During an interview with the Administrator on 10/22/24 at 12:05 PM she acknowledged her understanding in order to restore capacity to a resident who has been deemed incapacitated you must have 2 (two) physician's signatures. She acknowledged, there was only one signature for Resident #23 to restore capacity but the physician had planned to re-evaluate as it was done in error and does not believe resident to have capacity to make his own medical decisions. She also acknowledge that resident's care plan had been updated to state that resident had capacity when it should not have been. b) Resident #13 A review of Resident #13's medical record found Resident #13's neurological assessments dated 09/09/24 had incorrect dates and signature times documented. On 10/23/24 at 1:05 PM, during an Interview with the Director of Nursing, #23, she acknowledged the signatures and dates in the documentation of the neuro checks for Resident #13's fall on 09/09/24 were incorrect. 50801

Based on observation and interview, the facility failed to ensure that residents had a means of contacting their caregivers through a call system that was accessible to them while in their bed, or other sleeping accommodations within their room. Resident Identifiers: #46 and #38. Facility Census: 60. Findings included: a) Resident #46 During an interview with Resident #46 on 10/21/24 at approximately 1:51 PM, the resident stated she needed to speak to a staff member. She looked around and was unable to locate her call light. Resident then stated, I'll wait for someone to come. Upon being notified the resident needed help, Licensed Practical Nurse (LPN) #51 arrived and confirmed the call light was on the floor below the resident's bed, and inaccessible to the resident. LPN #51 confirmed that the call light was out of the reach of the resident and stated, Well that is a problem! LPN #51 then retrieved the call light and placed it next to the resident, and attended to the resident's needs. b) Resident #38 An observation of Resident #38 on 10/21/24 at 1:45 pm, found the reisdents call light was not within the residents reach. An interview with Licensed Practical Nurse (LPN) #9, at 1:48 pm on 10/21/24, confirmed Resident # 38 was unable to reach his call light. 50801

b) Resident # 64 On 05/20/24 at 12:00 PM a record review of the facility reported incident dated 04/01/24 was performed. During the review, it was noted that on 04/01/24 at approximately 12:00 PM, Resident #64 was in the facility dining room. She requested to be taken back to her room stating she needed to have a bowel movement. Employee #56 reported she took Resident #64 down the hall to Employee #70. Employee #56 informed Employee #70 that Resident #64 wanted to be put in bed and placed on the bed pan to have a bowel movement. Employee #56 stated that Employee #70 stated she would, get her. Employee #56 reported that she also informed Employee #71 and that Employee #71 also stated she would get her. At approximately 1:30 PM, Employees #57 and #42 went into give Resident #64 a bath, at which time it was noted Resident #64 had the lift pad under her and was noted to have stool on her. Employees #57 and #71 reported to facility staff their findings. It was also noted during the review of the facility reported incident in the 5 (five) day, that the facility had substantiated the allegation of neglect for Resident #64. On 05/20/24 at 03:13 PM an interview with facility Social Worker (SW) was conducted. The SW acknowledged that the facility substantiated neglect in the investigation. Based on record review, observation, resident and staff interview, the facility failed to ensure that residents were free from physical abuse. Multiple incidents took place in which Resident #2 was physically abusive to other residents in the facility. The facility failed to take necessary action to prevent further abuse. This created an immediate jeopardy sitaution for more than an isolated number of residents. Resident identifiers: #1,# 2, #3,# 4, #57. Facility census: 65. Findings included: a) On 05/20/24 at approximately 11:30 AM, a record review was conducted of a facility reported incident dated 03/15/24. During review, it was determined Resident #2 was witnessed by facility staff hitting another resident in the face during an argument in the hallway. The Licensed Social Worker confirmed in the report that Resident #2 was trying to move Resident #3's wheelchair and an argument started. Two nurse aides witnessed Resident #2 strike Resident #3 in the face. The residents were then separated and redirected. Further record review revealed a facility reported incident dated 03/26/24. During review, it was determined Resident #2 got into an argument in the dining room with Resident #4. During the argument, Resident #2 swung her cane and hit Resident #4 in the stomach. The Licensed Social Worker confirmed the residents were separated, redirected, and a one-on-one talk was provided to the residents. A review of facility reported incident (FRI) dated 03/28/24 determined Resident #2 entered Resident #1's room between 9:30 PM and 10:00 PM. Resident #2 told Resident #1 she was going to, leave my house one way or another. Resident #2 then proceeded to place a blanket over Resident #1's face and attempted to smother her. Resident #2 then grabbed a towel, stating If that's not good enough, I 'll use this and placed a towel over Resident #1's face. Resident #1 was heard screaming by a Nurse Aide who came into the room to intervene. The Nurse Aide escorted Resident #2 out of the room. The Licensed Social Worker stated referrals were made for a psychiatric facility for Resident #2 and they were accepted. One on one supervision was put into place, and Resident #2 was care planned for behaviors. A facility reported incident dated 05/17/24 revealed Resident #2 slapped Resident #57. This incident was currently under investigation. On 05/20/24 at approximately 11:30 AM, a record review of orders for Resident #2 was conducted. During the review, it was noted Resident #2 had orders for one-on-one supervision beginning on 05/20/24 with a start time of 6:00 PM. One on one supervisions were ordered to take place between 12:00 PM and 8:00 PM. On 05/20/24 at approximately 11:45 AM, during a tour of the facility, two surveyors witnessed Resident #1 in her room with no one on one supervision. On 05/20/24 at approximately 11:53 AM, an interview was conducted with Resident #1 regarding the incident from 03/28/24. Resident #1 stated, She tried to kill me. She took a blanket and a towel and put it over my face and tried to smother me with it. If I didn't have this oxygen on, I would be dead. I fought and fought her for 10-15 minutes while she held the blanket and towel over my face. The only thing that kept me alive was this oxygen. She told me, I was gonna leave her house, one way or another, and I didn't know what she meant at first, but once she started, I knew she meant I was going to die. They were supposed to have her on one on one after that, but there was a new nurse here that no one told, and I looked up and she was taking the stop sign down off my door to try and come back in my room again. She went into another woman's room after she went in mine, while she was supposed to be on one on one and no one was with her. And that woman can't speak up for herself. It still makes me very upset. Resident #1 was asked if they were afraid, to which she stated, Very much so. I am very much afraid of her, I can't get up and move, I have to be lifted out of bed, so yes, I am very fearful that she will come back in here and do it again. Resident #1 was asked if she had voiced these concerns to facility staff, to which she stated, Yes, and they tell me they won't let her come in here. Resident #2 resides next door to Resident #1. Resident #1 stated, That makes me even more afraid that it will happen again. Every time she walks by my room she looks in here and says she needs to talk to me. Resident #1 stated she had trouble sleeping at night, knowing Resident #2 is in the room beside her. On 05/20/24 at approximately 12:30 PM a review of progress notes for Resident #2 from 01/27/24 through 05/20/24 revealed: 01/28/24 at 5:05 PM - Resident having more confusion noted this evening with sun downing. Easily agitated. Worried over her two small dogs and getting home to them. Redirected by staff with distractions. 01/29/24 at 6:06 PM- Resident (sp) became agitated around time of shift changed (sp). Resident was walking around facility going in and out of other residents rooms taking items that did not belong to her. Resident was shouting I am working with the FBI government and I am here to watch of of you. Resident was not able to be redirected at first. Several attempts were made to try and redirect resident with food, drink, comfort, distraction, walking. Resident was adamant that she did not want any of that, she was insistant(sp) that we all get out of her house. Resident then struck staff member in the face and stated get out of my way why can't you just leave me in here (in another residents room). That staff person walked out of the room to try and deescalate (sp) the situation. Nurse then was able to redirect resident out of the room and in to the hallway. Resident then grabbed the nurse by the arms and scratched stating get away from me. Resident then started walking down the hallway with a staff member following behind to ensure safetyof (sp) resident. At this point to keep staff and resdient(sp) safe a close eye was kept on resident at all times for duration of shift. Resident continued to have behaviors throughout the shift but was able to be redirected. 01/30/24 at 3:56 PM- This nurse spoke with resident MPOA (medical power of attorney) regarding recent behaviors to staff and sundowning. Discussed medication changes and POA in agreement. This nurse notified MPOA that resident roommate has voiced being scared of resident, MPOA agreed he is fine with room change if needed. 01/31/24 at 10:09 PM- Res was wandering into other reside4nts (sp) rooms yelling in the hallway at staff to get out of her house. Res is refusing to use her walker. Res smacked me across the face twice and tried biting me when I tried to redirect her away from pulling the fire alarm. I walked along side res in the halls and she was grabbing anything she could pick up and throwing it. Res would yell out anytime I asked her to not go into another res room. Multiple staff tried to redirect res. Res refused a snack & to sit in living room area by nurses station. Res was walked backed to her room per staff & laid back down. 02/01/24 at 10:32 AM- Resident upset wanting everyone out of her home walking down hallways yelling and throwing items. Resident hitting staff and attempted to pull fire alarm. Resident unable to be redirected. 02/01/24 at 5:24 PM- After supper meal resident wanders back from dining room location. She has sun downing behaviors. She is unable to locate her room and doesn't recognize her surroundings. She is very intrusive in and out of other resident's rooms and beds. She was drinking other patients water from pitcher that was then replaced. She becomes very verbally agitated. She took a swing towards staff trying to assist her to her own room. She curses at them very loudly. She upset roommate due to her cursing. She was relocated to lounge and given distractions with short success only. She yells I just want to get the hell out of her and go home! Offered to watch movie, NO, Magazines given as a distraction at this time. 02/05/24 at 6:27 AM- late entry for 2/4/24 at 1800 resident yelling and cussing at roommate, residents seperated(sp) and roommate stated she was afraid to stay in that room. Roommate stated that this resident has been throwing things at roommate and yelling at screaming at her, states the roommate stated she was going to hit her with her cane. On call nurse manager(sp) notified. Roommate moved to room [ROOM NUMBER] for the night. Roommates POA aware. 03/15/24 at 2:27 PM- LATE ENTRY- Resident observed attempting to propel another res. In her wheelchair, when co res asked her to stop, this res begun to yell and tell co res she owned the place, then they both begun to yell at each other then the both struck out at each other landing strikes to faces. Res were immediately separated and re-directed. No injuries noted to either resident. All parties made aware. 03/26/24 12:49 PM- IDT follow up Type of incident: resident on resident What was happening at the time: Resident was in dining room and started swinging her cane. Another resident asked her to stop. This resident started insisting her husband owned her place. The second resident argued with her. This resident supposedly hit second resident in stomach with cane. 03/28/24 10:48 PM- notification:resident attempted to smother another resident. Confused, escalating behaviors. 03/28/24 11:00 PM- Resident had incident this evening where she would ask staff who they were, how they got in her house, who hired them and what company they work for. Resident didn't 't understand she was in the nursing home she thought she was in her own home. Resident tookher(sp) quad cane and hit the med cart with it and then tried hitting this nurse. Staff member was able to talk to resident and get her to calm down. CNA was able to get resident back to her own room and lay down in bed. Spoke with telehealth provider [provider name] to obtain order to send resident out for evaluation. 03/29/24 at 12:00 AM- What was happening at the time: Resident had incident this evening where she would ask staff whoable(sp) to talk to resident and get her to calm down. CNA came to me later and reported that resident was in another residents room and tried to smother resident with a blanket and then with a towel. CNA was able to get resident back to her own room and lay down in bed. Spoke with telehealth provider [provider name] to obtain order to send resident out for evaluation. Root cause of incident: Dementia, impaired cognitive functioning, resident wanders aimlessly throughout the facility, resident believes she owns the facility and becomes irritated when residents and staff will not leave. 04/15/24 at 6:40 PM- the resident was observed by two aides smacking another resident in the mouth on blue hall. The resident seemed frustrated because of the other resident yelling out. Both of the resident (sp) were separated. The resident then went to her room. No injuries observed. No signs of pain. Md has been notified and a vm was left for poa. Orders are to place resident back on 1:1 supervision. No further changes at this time. 04/20/24 at 3:32 AM- Resident up/out of room, yelling at CNA, cursing. Aggressive behavior. Started to enter another residents room with this nurse intervening and redirecting back to room. Very irritable and anxious. Asking Where's Steve What the hell are you all doing in my house? Redirected, reassured resident. Assisted resident back to bed, offered food and fluids. Calmed. Currently lying quietly in bed with 1-1 supervision continued. 05/17/24 at 4:48 PM- Resident had altercation with another resident. Resident 's (sp) separated. MD, DON, Administrator notified. Order placed for 1:1 from 12p-8pm At approximately 12:50 PM on 05/21/24, a record review was conducted of Resident #2's care plan. The care plan focus for behaviors reads as follows: The resident has a behavior problem. Patient with sundowners. Patient believes at times that other residents are looking at her or in her home. Patient noted to hit staff and yelling out to get out of her house. Patient noted to go in other patient's rooms and drink out of other resident's water pitcher. Behaviors of throwing items and screaming at others. Resident to close her door and place furniture in front of the door to block anyone from coming in. Resident noted to have delusions, believing she owns the facility. Resident known to comment on the race of caregivers. It was discovered during review of the care plan that Resident #2 was not care planned for aggressive or abusive behaviors towards other residents in the facility, only staff, despite multiple incidents involving Resident #2 and other residents. On 05/20/24 at approximately 1:07 PM, an interview was conducted with the Licensed Social Worker (LSW) regarding the incident. The LSW stated the facility offered Resident #1 to move rooms or put a stop sign on the door. The LSW states there was not an attempt to move Resident #2 further away from Resident #1, nor were there conversations had with the Medical Power of Attorney for Resident #2 concerning a move. The LSW was asked if there had been follow up interviews conducted with Resident #1 since the incident and if the resident felt safe. The LSW stated., I have talked to her a few times. When asked about documentation concerning the follow up interviews with Resident #1, the LSW stated they could be found in Point Click Care (PCC). Upon review, the only note in PCC regarding a follow up for Resident #1 was on 03/29/24, the day after the incident occurred. The state agency (SA) determined these failures caused the victims of Resident #2's abuse to suffer physical and psychosocial harm. Due to the facility's failure to follow up with the victims of Resident #2's abuse, proper services were unable to be provided to the victims after an instance of abuse. This caused further psychosocial harm. Not only did these failures harm the victims of Resident #2's abuse, but it also placed them and at risk of serious harm/death. This was due to the facility's failure to put proper interventions in place to ensure Resident #2 would not abuse other residents in the future. This placed more than a limited number of residents in an Immediate Jeopardy (IJ) situation. The facility was first notified of the IJ at 3:40 PM on 05/20/24. The State Agency (SA) received the Plan of Correction (POC) at 5:49 PM on 05/20/24. The SA accepted the POC at 5:49 PM on 05/20/24. The abatement time was 10:46 AM on 5/21/24. The plan of correction included the following: Resident #2 is immediately placed back on 24 hours a day one-on-one supervision. Resident #2 is being moved away from Resident #1 effective 05/20/24. The center will issue a 30-day discharge immediately for Resident #2. Dr. (name) (psychologist) has been contacted to see Resident #2 this week for further evaluation. 1:1 education will be provided to staff that provide 1:1 services to residents. After the IJ was removed, a deficient practice remained at a scope and severity of D, due to incontinence care for Resident #64.

Based on record review and resident and staff interview, the facility failed to ensure the psychosocial wellbeing of a resident was met following a traumatic event, due to failing to follow up with Resident #1 to assess her psychosocial wellbeing and make necessary referrals for Resident #1 to maintain her psychosocial wellbeing. Multiple incidents took place in which Resident #2 was physically abusive to other residents in the facility. The facility failed to take necessary action to prevent further abuse. This created an immediate jeopardy situation. Resident identifiers: #1,and #2. Facility census: 65 Findings included: a) Resident #1 On 05/20/24 at approximately 11:30 am, a record review was conducted of a facility reported incident dated 03/28/24. During review it was determined Resident #2 entered Resident #1's room between 9:30 PM and 10:00 PM. Resident #2 told Resident #1 she was going to, leave my house one way or another. Resident #2 then proceeded to place a blanket over Resident #1's face and attempted to smother her. Resident #2 then grabbed a towel, stating, If that's not good enough, I'll use this and placed a towel over Resident #1's face as well. Resident #1 was heard screaming by a Nurse Aide who came into the room to intervene. The Nurse Aide escorted Resident #2 out of the room. The Licensed Social Worker stated referrals were made for a psychiatric facility for Resident #2 and they were accepted. One on one supervision was put into place, and Resident #2 was care planned for behaviors. The facility made an offer to Resident #1 to move to another room or to put a stop sign at her door. Resident #1 chose to stay in the room and put a stop sign up. On 05/20/24 at approximately 11:53 AM, an interview was conducted with Resident #1 regarding the incident from 03/28/24. Resident #1 stated She tried to kill me. She took a blanket and a towel and put it over my face and tried to smother me with it. If I didn't have this oxygen on, I would be dead. I fought and fought her for 10-15 minutes while she held the blanket and towel over my face. The only thing that kept me alive was this oxygen. She told me I was gonna leave her house, one way or another, and I didn't ' t know what she meant at first, but once she started, I knew she meant I was going to die. They were supposed to have her on one on one after that, but there was a new nurse here that no one told, and I looked up and she was taking the stop sign down off my door to try and come back in my room again. She went into another woman's room after she went in mine, while she was supposed to be on one on one and no one was with her, and that woman can't speak up for herself. It still makes me very upset. Resident #1 was asked if they were afraid, to which she stated Very much so. I am very much afraid of her, I can't get up and move, I have to be lifted out of bed, so yes, I am very fearful that she will come back in here and do it again. Resident #1 was asked if she had voiced these concerns to facility staff, to which she stated Yes, and they tell me they won't let her come in here. Resident #2 resided next door to Resident #1, which Resident #1 stated, That makes me even more afraid that it will happen again. Every time she walks by my room, she looks in here and says she needs to talk to me. At approximately 12:00 PM on 05/20/24, a record review was conducted of progress notes pertaining to the facility's response to the incident on 03/28/24. Progress notes are typed as written, with resident names replaced with identifiers: 03/29/24 at 12:57 PM- SW (Social Worker) spoke with resident regarding the incident that happened the previous night. Resident #1 admits the incident scared her. SW offered her the opportunity to switch rooms so her room would not be as close to Resident #2. Resident #1 declined the invitation. She said she likes her room and wants to stay there. SW offered to have a stop gate put up on her door to deter other residents from coming in her room. Resident #1 said she would like that. SW inquired how Resident #1 is feeling regarding the incident. Resident #1 said as of right now she isn't having any anxiety or fears related to the incident. SW encouraged her to call on her is (sp) she does or if she needs anything. There were no further progress notes or follow-up visits regarding the incident. On 05/20/24 at approximately 1:07 PM, an interview was conducted with the Licensed Social Worker (LSW) regarding the incident. The LSW stated the facility offered Resident #1 to move rooms or put a stop sign on the door. The LSW stated there was not an attempt to move Resident #2 farther away from Resident #1, nor were there conversations had with the Medical Power of Attorney for Resident #2 concerning a move. The LSW was asked if there had been follow up interviews conducted with Resident #1 since the incident and if the resident felt safe. The LSW stated, I have talked to her a few times. When asked about documentation concerning the follow up interviews with Resident #1, the LSW stated it could be found in Point Click Care (PCC). Upon review, the only note in PCC regarding a follow up for Resident #1 was on 03/29/24, the day after the incident occurred. The state agency (SA) determined these failures caused Resident #1 to suffer psychosocial harm. Due to the facility's failure to follow up with Resident #1, proper services were unable to be provided to the resident after an instance of abuse, causing further psychosocial harm. This placed the resident in an Immediate Jeopardy (IJ) situation. The facility was first notified of the IJ at 3:40 PM on 05/20/24. The SA received the Plan of Correction (POC) at 5:49 PM on 05/20/24. The SA accepted the POC at 5:49 PM on 05/20/24. The plan of correction stated: Resident #2 will be put on 1:1 supervision 24hr/d (day) effective immediately on 05/20/24. Resident #2 will be moved to another private room on the opposite hallway from Resident #1 on 05/20/24. Social Worker will visit Resident #1 on 05/20/24 to assess the resident's psychosocial well-being and continue to do so every morning 5d/week until the resident, Social Worker and psychologist deem a change in level of care is required. Psychologist (name) will visit Resident #1 this week and continue recommended scheduled follow up visits until the resident and psychologist deem a change in the level of care is required. Resident #2 will be issued a 30-day discharge notice on 05/20/24. 1:1 education will be provided to staff that provide 1:1 service to residents. After notification of the IJ the facility intervened, and the following progress notes were made by the social worker. 05/20/24 at 04:58 PM- SW spoke with resident after being informed that she has been feeling anxious and fearful regarding the incident that had happened between her and Resident #2. SW was not award(sp) that Resident #1 had been feeling anxious and fearful. Resident #1 said that she has been holding it inside because she doesn't like to complain. SW assured her that reporting her fear and anxiety is not complaining. Resident #1 said that she is very anxious and fearful and isn't able to sleep at night. She said that she has been sleeping during the day. SW asked Resident #1 if she would be interested in talking to the psychologist and taking medication for the anxiety. She said that she would. SW informed Resident #1 That Resident #2 was being moved and would no longer be her neighbor. Resident #1 expressed relief and said she hope(sp) that she will now be able to sleep at night. 05/21/24 at 08:02 AM- SW spoke with resident this morning to see how she is feeling. Resident #1 said that she slept better last night knowing Resident #2 was no longer next door to her. Resident #1 said she is feeling less fearful and stressed today. At approximately 10:13 AM on 05/21/24, a follow up interview was conducted with Resident #1 after the IJ was issued, and plan of correction accepted. Resident #1 was asked if anyone from the facility met with her regarding the incident. Resident #1 stated the Social Worker had been to her room and met with her and got everything situated. Resident #1 mentioned Resident #2 had been moved and stated, Thank you for looking into that, last night was the first time I have been able to sleep during the night in months. The IJ was abated on 05/21/24 at 10:46 AM.

Based on resident facility record review, medical record review, and staff interview, the facility failed to ensure that a resident's respiratory care was provided consistent with professional standards of practice. A resident's oxygen concentrator was set at a lower liter than ordered. This was a random opportunity for discover identified during a complaint survey. Resident identifier: #66. Facility census: 65. Findings included: a) Resident #66 On 05/20/24 at approximately 7:00 PM during a record review of the facility reported incident involving the allegation of neglect on 04/12/24 for Resident #66, it was identified that the daughter of Resident #66 found the resident lying flat in bed, lethargic and difficult to arouse. It further stated he was ordered 6L (six liters) of continuous oxygen but was only on 3L (three liters) and the facility had a 5L (5 liter) concentrator at his bedside and a 10L (ten liter) concentrator was required to supply the 6L as ordered. On 05/20/24 at approximately 7:30 PM during a record review of the facility investigation and supportive documentation, it was identified that the medical record from the discharging facility identified Resident #66 to be on 3L of oxygen but the orders received by the facility did not include an order for the oxygen. It was further identified that the Licensed Practical Nurse (LPN) #23 that had taken the report from the discharging facility, stated the 6L of oxygen was what she was told. LPN #23 stated the CNA's had prepared the room and the paramedics that brought Resident #66 had transferred him to the concentrator in the room. She stated she was not aware that he was not on a high enough level (Liter) of oxygen. A review of the Treatment Administration Record (TAR) from 03/05/24 through 03/31/24 identified that the Humidified oxygen at six (6) via NC (nasal canula) continuous every shift for hypoxia was being checked off by the nursing staff that the oxygen was set at 6L. During this time frame, and the oxygen saturation levels were documented to range between 93-98. In reviewing the April Medical Administration Record (MAR) the oxygen levels continued to range from 90-97. On 05/21/24 at approximately 3:00 PM, in reviewing the incident, the Administrator provided a written summarization of the investigation the facility completed. This summarization included a header for Corrective Actions stating- Neglect was substantiated because we failed to follow a doctor's order. The following corrective actions have been put in place: 1. All concentrators were immediately audited for accuracy of rate with no other issues identified. 2. Nursing Staff educated about the need to confirm the accuracy of oxygen orders and equipment upon admission. 3. Nursing management staff educated about the need to not only review resident chart/documentation upon admission but the need to inspect all equipment in use/needs. 4. Nursing management following new process to ensure correct equipment is present in residents' rooms upon admission. 5. The resident was educated about the risks and consequences of lowering the Head of Bed (HOB) with advanced COPD (chronic obstructive pulmonary disease) and care planned for this behavior. 6. Oxygen concentrators and their rates are monitored multiple times per week by the MDS (Minimum Data Set) nurse. On 05/21/24 at approximately 3:00 PM during this review with the Administrator the immediate concentrator audit referenced in the facility summarization was identified to have been completed, the education with the resident (and daughter) about the risks and consequences of lowering the Head of Bed (HOB) with advanced COPD and the care planned behavior was identified to have been completed. The ongoing monitoring of the oxygen concentrators was also identified. Further review of the education that was provided during an in-service training dated 04/17/24 with the Program Title/Content stating- Nurse is to clarify correct level of O2 (oxygen) requirement upon getting report and ensure order is correct. Nurse is set up O2 concentrator in room, apply to resident. Checking correct level set on concentrator/tank. CNA's (Certified Nursing Assistants) are never to adjust O2 (oxygen) levels. The following staff members were identified to have not completed the educations as required: * Licensed Practical Nurse (LPN) #45 * Certified Nursing Assistant (CNA) #72 * Certified Nursing Assistant (CNA) #32 * Certified Nursing Assistant (CNA) #25 On 05/21/24 at approximately 3:05 PM, during the interview with the Administrator she agreed the education had not been completed.

Based on record review and staff interview the facility failed to implement written Quality Assurance and Performance Improvement (QAPI) polices and procedures for data collection and monitoring including adverse event monitoring. This failed practice was true for 6 (six) of 6 (six) investigations reviewed. Resident identifiers: Resident #64, #66. Facility census: 65. Findings included: a) Resident #64 On 05/20/24 at approximately 08:37 PM, a review of the facility policy, [NAME] Virginia Abuse, Neglect and Misappropriation Policy was performed noting the following text on page 19: All investigations of abuse, neglect and misappropriation will be reviewed by the QAPI committee. The committee will determine if the investigation is complete and if the action taken has resolved the issue or if a performance improvement plan is needed. On 05/21/24 at approximately 12:00 PM, a review of the facility policy, QAPI (Quality Assurance Performance Improvement) Plan was performed noting the following text on page 5 (five). ii. The facility will track, investigate and monitor adverse events that must be investigated every time they occur, and action plans will be implemented to prevent recurrence. On 05/21/24 at approximately 01:07 PM, the DON provided a single sheet of paper containing occurrence no. 1188387 and note ID #3866090. On 5/21/24 at 01:33 PM an interview conducted with the Administrator. The Administrator was usable to provide documentation that the policy and procedure from facility policies West Virginia Abuse, Neglect and Misappropriation and facility policy QAPI (Quality Assurance Performance Improvement) Plan had occurred during the facility QAPI meetings. stating We didn't do an AD HOC on Resident #64. Are you asking me if we look at every incident to make sure everything is in it that it says in that policy? No I don't. We don't make a note. We talk about it. Facility Administrator acknowledged that she does not review all incidents/reportables to make sure they are following the policy and procedure including the process for the investigation to ensure all required documentation is present. Facility Administrator also acknowledged there is no QAPI meeting documentation related to reviewing them. b) Resident #66 On 05/21/24 at approximately 03:10 PM during an interview with the Administrator, of the statements that was gathered by the Social Worker (SW) for the facility reported incident occurring on 04/12/24 and involving Resident #66. The statements gathered were referenced to the facility policy and procedure for the Abuse, Neglect, and Misappropriation process identified on page 13; Statements will be obtained from staff related to the incident, including victim, person reporting incident, accused perpetrator and witness.; The statement(s) will be made in writing, signed, and dated at the time it is written. 1. Supervisors may write the statement for a person giving a statement about the incident to them and the person giving the statement must sign and date it, or a third party may witness the statements. On 05/21/24 at approximately 03:15 PM the statements gathered by the SW identified the following discrepancies and were reviewed with the Administrator; * Licensed Practical Nurse (LPN) #79 completed a had written witness statement on 04/12/24 (date of event), this statement was signed and dated at the time it was given. Below the statement, an additional statement is identified to have been dated 04/15/24 by the Social Worker (SW) #13 for LPN #79 statement. This statement was not signed and dated by LPN #79. No third party witness signature was identified. * LPN #79 typed an additional witness statement. No signature or date was identified for LPN #79. * Certified Nursing Assistant (CNA) #25 completed a hand written witness statement on 04/12/24 (date of event), this statement was signed and dated at the time it was given. Below the statement, an additional statement is identified to have been obtained by SW #13 for CNA #25. This statement was not signed or dated by CNA #25. No third party witness signature was identified. * SW #13 completed a phone interview with LPN #23, This statement was not signed or dated by LPN #23. No third party witness signature was identified. * SW #13 completed a phone interview with CNA #80, This statement was not signed or dated by CNA #80. No third party witness signature was identified. * SW #13 completed a phone interview with CNA #69, This statement was not signed or dated by CNA #69. No third party witness signature was identified. On 5/21/24 at 01:33 PM an interview conducted with the Administrator. The Administrator was usable to provide documentation that the policy and procedure from facility policies West Virginia Abuse, Neglect and Misappropriation and facility policy QAPI (Quality Assurance Performance Improvement) Plan had occurred during the facility QAPI meetings. stating We didn't do an AD HOC on Resident #64. Are you asking me if we look at every incident to make sure everything is in it that it says in that policy? No I don't. We don't make a note. We talk about it. Facility Administrator acknowledged that she does not review all incidents/reportables to make sure they are following the policy and procedure including the process for the investigation to ensure all required documentation is present. Facility Administrator also acknowledged there is no QAPI meeting documentation related to reviewing them. During this interview with the Administrator on 05/21/24 at approximately 03:15 PM, the Administrator agreed that the signatures and dates were not obtained for the witness statements as required. She further agreed that she does not review all incidents/reportable's to make sure they are following the policy and procedure for a complete and thorough investigation.

a) Resident #64 On 05/20/24 at 11:30 AM a review of the facility reported incident dated 04/01/24 was performed. It was noted that on 04/01/24 at approximately 12:00 PM, Resident #64 was in the facility dining room, she requested to be taken back to her room stating she needed to have a bowel movement. Employee #56 reports that she took Resident #64 down the hall to Employee #70. Employee #56 informed Employee #70 that Resident #64 wanted to be put in bed and placed on the bed pan to have a bowel movement. Employee #56 states that Employee #70 stated she would get her. Employee #56 reports that she also informed Employee #71 and that Employee #71 also stated she would get her. At approximately 01:30 PM, Employees #57 and #42 went into give Resident #64 a bath, at which time it was noted Resident #64 had the lift pad under her and was noted to have stool on her. Employees #57 and #71 reported to facility staff their findings at this time and an investigation was initiated. It was noted that 6 (six) employees were named in the investigation. Statements were present for 3 (three) employees, Employees #57, #65 and #71. Including the 3 (three) statements present there was noted to be a single sheet of paper with 5 (five) paragraphs. The paragraphs began with the sentence, Social Worker (SW) interviewed. Of these 5 (five) paragraphs it was noted that 3 (three) employees, Employees #70, #65 and #71 and 2 (two) Resident's, Resident #64 and #8 were listed to have been interviewed by the SW. The paper was dated 04/01/24 and was signed by the SW. These interviews were noted to lack how the statement was obtained, the employee and resident signatures, and the date and time each was obtained. On 05/20/24 at 03:13 PM An interview with the SW was conducted. During the interview, the SW acknowledged that the single sheet of paper containing the 5 (five) paragraphs were interviews she conducted with the named employees and residents. The SW also acknowledged she was unsure how the statements were obtained stating, They were possibly phone interviews, perhaps I spoke with them in person, I don't know. When asked who Resident #64's assigned CNA was on 04/01/24 at the time the incident occurred, the SW replied, I am not sure who was assigned, I assume it was Employee #71. The SW acknowledged that she did not interview other resident's on this assignment or have skin checks performed on them. The SW also acknowledged that the facility substantiated neglect in the investigation. The SW was then asked to provide the assignment sheet from that date and time. On 05/20/24 at 4:15 PM the assignment sheet for the incident was provided by the SW. After review of assignment sheet for 04/01/24, it was noted that Employee #25 was Resident #64's assigned CNA. The SW acknowledged that Employee #71 was not Resident #64's assigned CNA at the time of the incident. When asked for the statement obtained from Employee #25, the SW acknowledged that she had not obtained a statement from Employee #25. On 05/20/24 at approximately 08:37 PM, a review of the facility policy, [NAME] Virginia Abuse, Neglect and Misappropriation Policy was performed and the following text on page 13: Statements will be obtained from staff related to the incident, including victim, person reporting incident, accused perpetrator and witnesses. The statements will be made in writing, signed, and dated at the time it is written. Supervisors may write the statement for a person giving a statement about the incident to them and the person giving the statement must sign and date, or a third party may witness the statements. On 5/21/24 at 10:45 AM an interview was conducted with the Administrator and Director of Nursing (DON). The facilities Regional [NAME] President (RVP) was also present for the interview. The Administrator was asked to review the investigation packet. The Administrator confirmed there was not a statement from Employee #25, who was Resident #64's assigned CNA at the time of the incident. The Administrator was presented the single sheet containing multiple statements signed only by the SW, not by the individuals from whom the statements were obtained. The Administrator stated, This is a copy of the SW's statement, not individual statements obtained from the employees and resident's involved. The Surveyor then explained to the Administrator that the SW acknowledged on 05/20/24 that this was individual statements she obtained from the employees and residents listed. The RVP then asked if the SW could be brought into the room to participate The SW then entered the interview. The SW confirmed these were statements she obtained from the staff and resident's listed, not her statement. The SW also confirmed she had not obtained a statement from Employee #25. The Administrator then acknowledged each individual employee and resident should have signed and the way the SW wrote them was not in compliance with their policy. Based on record review and staff interview the facility failed to implement written policies and procedures that ensured investigations into allegations of abuse and neglect were thoroughly investigated. This failed practice was true for 1 (one) of 6 (six) investigations reviewed. Resident identifiers: #64. Facility census: 64. Findings included:

a) Resident #64 On 05/20/24 at 11:30 AM a review of the FRI complaint and investigation was performed. It was noted that on 04/01/24 at approximately 12:00 PM, Resident #64 was in the facility dining room, she requested to be taken back to her room stating she needed to have a bowel movement. Employee #56 reported she took Resident #64 down the hall to Employee #70. Employee #56 informed Employee #70 that Resident #64 wanted to be put in bed and placed on the bed pan to have a bowel movement. Employee #56 stated that Employee #70 said she would get her. Employee #56 reports that she also informed Employee #71 that Employee #70 also stated she would get her. At approximately 1:30 PM, Employees #57 and #42 went into give Resident #64 a bath, at which time it was noted Resident #64 had the lift pad under her and was noted to have stool on her. Employees #57 and #71 reported to facility staff their findings at this time and an investigation was initiated. 6 (six) employees were named in the investigation. Statements were present for 3 (three) employees, Employees #57, #65 and #71. Including the 3 (three) statements present there was noted to be a single sheet of paper with 5 (five) paragraphs. The paragraphs began with the sentence, Social Worker (SW) interviewed. Of these 5 (five) paragraphs it was noted that 3 (three) employees, Employees #70, #65 and #71 and 2 (two) Resident's, Resident #64 and #8 were listed to have been interviewed by the SW. The paper was dated 04/01/24 and was signed by the SW. These interviews were noted to lack how the statement was obtained, the employee and resident signatures, and the date and time each was obtained. On 05/20/24 at 03:13 PM An interview with the SW was conducted. During the interview, the SW acknowledged that the single sheet of paper containing the 5 (five) paragraphs were interviews she conducted with the named employees and residents. The SW also acknowledged she was unsure how the statements were obtained stating, They were possibly phone interviews, perhaps I spoke with them in person, I don't know. When asked who Resident #64's assigned CNA was on 04/01/24 at the time the incident occurred, the SW replied, I am not sure who was assigned, I assume it was Employee #71. The SW acknowledged that she did not interview other resident's on this assignment or have skin checks performed on them. The SW also acknowledged that the facility substantiated neglect in the investigation. The SW was then asked to provide the assignment sheet from that date and time. On 05/20/24 at 04:15 PM the assignment sheet for the incident was provided by the SW. After review of assignment sheet for 04/01/24, it was noted that Employee #25 was Resident #64's assigned CNA. The SW acknowledged that Employee #71 was not Resident #64's assigned CNA at the time of the incident. When asked for the statement obtained from Employee #25, the SW acknowledged that she had not obtained a statement from Employee #25. On 05/20/24 at approximately 08:37 PM, a review of the facility policy, [NAME] Virginia Abuse, Neglect and Misappropriation Policy was performed noting the following text on page 13: d. Statements will be obtained from staff related to the incident, including victim, person reporting incident, accused perpetrator and witnesses The statements will be made in writing, signed, and dated at the time it is written. Supervisors may write the statement for a person giving a statement about the incident to them and the person giving the statement must sign and date, or a third party may witness the statements. On 5/21/24 at 10:45 AM an interview was conducted with the Administrator and Director of Nursing (DON), the facilities Regional [NAME] President (RVP) was also present for the interview. The Administrator was asked to review the investigation packet. The Administrator confirmed there was not a statement from Employee #25, who was the Resident #64's assigned CNA at the time of the incident. The Administrator was presented the single sheet containing multiple statements signed only by the SW, not by the individuals from whom the statements were obtained. The Administrator stated, This is a copy of the SW's statement, not individual statements obtained from the employees and resident's involved. The surveyor then explained to the Administrator that the SW acknowledged on 05/20/24 this was individual statements that she obtained from the employees and residents listed. The RVP then asked if the SW could be brought into the room to participate in the interview. The SW then entered the interview. The SW confirmed these were statements she obtained from the staff and resident's listed. The SW also confirmed she had not obtained a statement from Employee #25. The Administrator then acknowledged each individual employee and resident should have signed and that they way the SW wrote them was not in compliance with their policy. Based on record review, staff interview and the facility policy and procedure, the facility failed to provide evidence that all alleged violations were thoroughly investigated and that corrective action was taken. Witness statements and staff education was not thoroughly completed. This was true for one (1) of five (5) facility reported incidents reviewed during the complaint survey. Resident identifier: #64. Census: 65.

Based on observation, resident interview, medical record review, and staff interview, the facility failed, for one (1) of thirteen (13) sampled residents, to ensure care and services were provided to ensure the highest practical well being possible. Resident #29 exhibited verbal and non-verbal indicators of pain on multiple occasions during the survey event, and staff did not intervene to reduce her pain and discomfort until after surveyor intervention. Facility census: 65. Findings include: a) Resident #29 Multiple observations, from 10/20/09 through 10/22/09, revealed that every time Resident #29 was up in the chair for over twenty (20) minutes, she began to both exhibit verbal and non-verbal signs of pain. On 10/20/09 at 10:15 a.m., she was yelling. In response to her yelling, the survey team observed this resident, who was noted to be guarding, crying, and moving her left hip outward, lifting her buttocks from the chair seat. When asked if her hip hurt, she replied, "Yes." Staff, when immediately informed of the situation, laid her down in the bed. At 11:35 a.m., she was observed to be resting in bed, with no guarding, crying, or movement of her hip. On 10/21/09 at 4:30 p.m., again she was up in the chair and heard yelling out in pain. The survey team entered the room and observed the resident was exhibiting guarding and moving her hip and leg. Both lower extremities were observed to be not supported on the foot rests (they were dangling in front), and her hips were noted to have slid out from the chair. Staff was immediately informed of the situation and repositioned her in the chair. Following repositioning, the resident no longer yelled out and, when asked, indicated she was more comfortable. On 10/22/09 at 9:00 a.m., observation again found her up in the chair and yelling. Upon entering the room, she related, "I am wore out." Staff was immediately informed and assisted her to lay down. Shortly thereafter, she was observed to be resting comfortably. Interview with Employee #6, on 10/21/09 at 10:00 a.m., revealed she thought physical therapy had evaluated her for a new chair and one (1) had been ordered last week to aid in her comfort. At this time, copy of the purchase order / invoice was requested. Staff took several hours to produce the requested information. In the meantime, the administrator (Employee #77), when interviewed, related he was not aware of a new chair being ordered for Resident #29, as staff had not obtained any billing information from him; he did, however, relate that in a meeting, they had talked about ordering a new chair. Review of Resident #29's medical record found no physical therapy notes or other evidence the resident had been evaluated for a new chair. On the afternoon of 10/22/09, staff produced a purchase order / invoice for a new chair for Resident #29; the document was dated 10/22/09. The facility failed to provide prompt interventions to promote comfort and/or alleviate Resident #29's pain. .