Every finding on record at E.A. Hawse Healthcare Center

Based on record review, observation and staff interview, the facility failed to provide a complete and accurate medical record for a resident in the areas of [NAME] Virginia POST Form, care plan, and PASSR. This is true for Resident's #4, #6, #9 and #17. Facility Census 54. Findings included: a) Resident #4 A record review completed on [DATE] of Resident #4's WV POST revealed the following: Section A. Cardiopulmonary Resuscitation Orders. Follow these orders if the patient has no pulse and is not breathing. Resident checked Yes CPR: Attempt Resuscitation, including mechanical ventilation. defibrillation and cardioversion. (Requires choosing Full Treatments in section B) Section B read as follows: Initial treatment orders. Follow these orders if the patient has a pulse and is breathing. Option not checked by the resident was Full Treatments (required if CPR is chosen in section A). Goal: Attempt to sustain life by all medically effective means. Option checked was second option Selective treatments. Goal: Attempt to restore function while avoiding intensive care and resuscitation efforts ventilator, defibrillator and cardioversion.) An interview with Regional Director #74 was conducted on [DATE] at 2:06 PM who acknowledged the discrepancy in the form completion for Resident #4. b) Resident #6 A review of Resident #6's admission paperwork on [DATE] at approximately 1:00 PM, revealed the PASARR dated [DATE] contained incorrect information. In section thirty (30), part M, Major Depression was not selected or listed in the Other area. However, in section forty (40), part A, Major Depression is listed and reviewed. Section thirty (30) shows all active diagnoses (mental) a resident may have and section forty (40) shows what diagnoses the provider is using for the level II screening process. The diagnosis used on this form must also be listed in the patient's active diagnosis area of their charts. Further review of Resident #6's current active diagnoses shows Major Depression is not listed. There is only Depression, Unspecified listed. Copied from charting: F32.A DEPRESSION, UNSPECIFIED N/A, not an acceptable Primary Diagnosis During a follow up interview with the DON on [DATE] at approximately 3:50 PM, they confirmed the records were inaccurate and will ensure they are corrected. c) Resident #17 Resident #17, a male, was admitted to the facility on [DATE]. A care plan was initiated for the resident on [DATE]. The care plan was reviewed with the resident and his daughter on [DATE]. Page one (1) of the care plan has an entry for another person. The entry read (name) wishes to be discharged to home. Resident #17's first name is not (name). This error was reviewed with the MDS RN #5 on [DATE] at 9:10 AM. MDS RN stated, I will fix this. A revision was made and the corrected care plan was presented on [DATE]. d) Resident #9 Record review determined that on [DATE] this resident lacked the capacity to make their own medical decisions. A review of the resident's care plan: (First Name of Resident) has a DNR code Status withability to make health care decisions.Date Initiated: [DATE]Revision on: [DATE] This discrepancy was reviewed with MDS RN #5 on [DATE] at 11:25 AM. The MDS RN stated she would correct this immediately. The resident's Care Plan was corrected prior to survey exit.

Based upon observation, resident interviews, staff interviews and record review. the facility failed to maintain an effect pest control program for flies. This failed practice had the potential to affect many residents in the facility. Facility census: 54. Findings included: a) On 06/08/26, during the initial walk through of the facility and resident rooms, the following rooms had flies present: #A01#A03#A11#A12#A15#B04#B06#B10 The residents in these rooms complained about the flies bothering them. Additionally during the course of the survey, flies were observed in the B Hallway and Administration Conference Room. This finding was discussed with the Nursing Home Administrator (NHA) on 06/08/26 at 2:40 PM. The NHA stated the whole area around the nursing home has problems with flies because of the large chicken and turkey processing plants in the area. NHA immediately called their pest control contract agency and asked them to come. A follow-up conversation on 06/10/2026 at 11:43 AM with the NHA asked about the outcome of the call with the pest control company. She stated their first available date to come was 06/16/26, and she had requested to be put on the first available list if they had a cancellation. A review of the pest control records on 06/10/26 at noon found: -Monthly pest control treatments are done by Orkin. Last report dated 05/14/26, included Interior Flylight replacement and replacement of glue boards in fly lights.

Based on observation, record review and staff interview, the facility failed to ensure a resident's comprehensive care plan was revised upon change in physician's orders in regards to a perimeter mattress. This is true for Resident #5. Facility Census: 54. Findings included: a) Reviewed the following documents on 06/10/26: Care plan for Resident #5, page 1. Focus-Resident #5 is at risk for falls r/t pain, limited physical functioning, requires assist with transferring. He has a history of falling at home. Resident also is non-compliant with assistance for transfers. He is observed to independently transfer and ambulate. Date Initiated: 02/07/2026 Revision on: 05/27/2026 Interventions included- Perimeter mattress to aide in identifying the edge of the bed. Date Initiated: 11/25/2025 Revision on: 01/14/2026 Review of physician orders for Resident #5 revealed no orders for perimeter mattress on 06/10/26. b) An interview with Resident #5 on 06/10/26 10:00 AM was conducted. Resident pointed out bruises on his arm and stated he depends on others to help him use his walker to walk up and down the hall. He stated he wears his shoes and or grippy socks and admitted having a history of falling. He was observed in his bed with no perimeter mattress. On 06/10/26 during an interview with Regional Director #74 who reported that Resident #5 was in a perimeter mattress prior to being sent out to the hospital with and injury and returned with a back brace. Per their policy, the facility will not replace perimeter mattress until approval is given from his provider. Resident went out on 05/24/26 and returned on 05/26/26. There were no orders for a perimeter mattress during this time but his care plan was not revised. She reported this intervention was meant to be removed from his care plan at that time.

Based on record review and staff interview, the facility failed to inform the resident or their representative in advance of treatment risks and benefits, options, and alternatives for an anti-depressant medication prior to the administration of the medication. This failed practice did not allow the resident to be provided an informed choice. Resident identifier: #31. Facility census: 54.Findings included:a) Resident #31Resident #31 was admitted to the facility on [DATE].The resident had the following diagnoses pertaining to mental illness:-DEPRESSION, UNSPECIFIED, 08/16/2024, Admission-ANXIETY DISORDER, 08/16/2024, Admission-MAJOR DEPRESSIVE DISORDER, RECURRENT, MILD, 01/29/2026 During Stay-UNSPECIFIED DEMENTIA, UNSPECIFIED SEVERITY, WITHOUT BEHAVIORAL DISTURBANCE, PSYCHOTIC DISTURBANCE, MOOD DISTURBANCE, AND ANXIETY, 08/16/2024, AdmissionFor these diagnoses, the resident had the following orders:-Mirtazapine Oral Tablet 7.5 MG (Mirtazapine)Give 1 tablet by mouth one time a day for appetite stimulantPharmacy Active 04/22/2026 A review of the electronic health record was done and surveyor was unable to locate informed consent for (Mitrazapine) Remeron. This was then requested from facility. On 06/09/26 at approximately 12:30 PM, Corporate RN #74 stated they were having difficulty locating this consent. Resident had been on Remeron since 2024, with a Gradual Dose Reduction (GDR) completed in April 2026. On 06/09/26 at 4:30 PM, when surveyor asked about the consent again, and whether it had been located, the Corporate RN #74 stated she could not locate it.

Based on record review and staff interview, the facility failed to have a Registered Nurse (RN) on duty for 8 hours per day for seven days a week on 01/01/26. This failed practice had the opportunity to lead to residents not receiving the care and treatment only an RN can provide, and could affect multiple residents. Facility census: 54.Findings included: a) Record Review On 06/10/2026, the surveyor requested posted nurse staffing sheets as well as time detail for hours worked from a report from the facility's time keeping system for twenty dates. These dates included: 02/22/25 thru 03/01/2506/22/25 thru 06/28/2512/31/2501/01/2602/14/2602/15/2605/31/2606/01/26 These records were reviewed for eight (8) hours of RN hours worked per day, plus calculations made to determine if the facility met the 2.25 hours per patient day minimum. It was determined the facility did not have eight (8) hours of RN staffing on 01/01/26. b) Staff interview During an interview with the Nursing Home Administrator (NHA) on 06/10/2026 at 3:19 PM, the NHA indicated an RN worked 1.25 hours and got sick. They replaced the RN with an LPN.

Based on record review and staff interviews, the facility failed to ensure Resident #18's environment remained as free of accident hazards as possible; and that each resident received adequate supervision and assistance devices to prevent accidents. Resident #18 had a care plan for nonskid footwear which were not in place at the time of a fall. The Central Supply closet which contained harmful chemicals was not secured by a locking door. Resident identfieir: #18. Facility census: 54. Findings included: Resident #18 a) Record review of nursing progress notes dated [DATE] revealed Resident #18 was found on the floor with a head injury and complaining of right leg pain. It was noted that Resident #18's feet were bare during assessment after the fall. On [DATE] at 3:15PM, During an interview with the Director of Nursing and the Assistant Director of Nursing They both confirmed resident #18 did not have nonskid footwear on at the time of her fall. Resident #18's Care Plan, dated back to [DATE], revealed the resident was to have nonskid/footwear. A nursing note dated [DATE] 2:40 PM revealed: Called to resident's room by staff member, upon entering room, resident was observed to be laying on the floor on her right side between her bed and the wall, a pool of bright red blood was on the floor behind resident's head, pressure dressing was held in place to the right side of resident's head, during this time resident was only verbal stating My right leg when asked if it hurt she moaned, blanket placed between leg and floor and resident appeared to feel some comfort with this measure per her bodylanguage - pupils were reacted to light - foley catheter was patent and intact with clear yellow urine present, resident's feet were observed to be bare, Physical Therapy had been in room minutes before the fall - paramedics were notified by another staff member. When paramedics arrived, taking charge of situation, paramedics lifted resident off floor, performing a log roll blanket carry, and placed on stretcher, Resident was taken to (name of hospital). - POA (name) notified via phone call of incident 39043 b) Central Supply Closet On [DATE] at 11:40 AM, the central supply closet in the resident hallway A opened when this surveyor turned the door handle. The door had a keypad on it. This surveyor entered the room to look around. The Director of Nursing (DON) entered the central supply closet. She stated she had entered the keypad code to open the closet door. This surveyor showed the DON that the door opened without the keypad code being entered. The DON confirmed this and stated she did not know how long this had been occurring. She stated she would immediately notify maintenance. The supply closet was noted to contain the potentially hazardous substances: - DermaRite's GelRite Instant Gel Hand Sanitizer, which contained the following warnings on the bottle, Avoid contact with eyes. In case of contact, flush thoroughly with water and In case of accidental ingestion contact a physician or poison control center right away. - Dermarite's Dermaklenz wound cleanser, which contained the following warning on the bottle, For external use only. Avoid eye contact. - Bacitracin first aid antibiotic ointment, which contained the following warning on the box, If swallowed get medical help or contact poison control center right away. - Good Sense Diphenhydramine ointment, which contained the following warnings on the box, If swallowed get medical help or contact poison control center right away and Avoid contact with the eyes. - Hibiclens antimicrobial skin cleanser, which contained the following warning on the box, Keep out of eyes, ears, and mouth. May cause serious and permanent eye injury if permitted to enter and remain in the eye or may cause deafness when instilled in the middle ear through perforated eardrums. On [DATE] at 3:00 PM, the Administrator stated the keypad battery had died and had been replaced. No further information was provided through the completion of the survey. The facility failed to provides an environment that is free from accident hazards over which the facility has control

The facility failed to serve food in a safe sanitary manner in regards to hand washing after coughing and touching soiled items and storing medical ice packs in the freezer in the residents pantry. This has the potential to affect all resident that gets their nutrition form the kitchen. Facility census: 54. Findings Included: a) Resident Pantry During the tour on 11/11/24 at 12:20 PM to the Resident pantry found multiple medical Ice packs stored in resident freezer. An interview 11/11/24 at 12:20 PM with the Dietary Manager confirmed the medical ice packs should not be stored with resident food. b) Kitchen An observation on the second tour to the kitchen 11/13/24 at 12:35 PM found the [NAME] #46 testing holding temperatures, she coughed and stepped away to the office area, she then opened the trash with her hands, returned to tray line and started to continue temperature testing without washing her hands until surveyor intervention. [NAME] #46 verified she should have washed her hands prior to returning to steam table, she stated that she forgot. During an interview 11/13/24 at 1:18 PM with the Dietary Manager confirmed the cook #46 should have washed her hands prior to returning to work.

Based on record review, and staff interview, the facility failed to provide activities of daily living (ADL's) to maintain good personal hygiene for dependent residents. This is true for 0ne (1) of three (3) residents reviewed for ADL care. Resident Identifiers: #20, #17, #33, #23, #16 and #34. Facility census: 54. Findings included: a) Resident #17 During an annual recertification with a simultaneous complaint investigation for Residents not being groomed adequately found Resident #17 on 11/11/24 not get his showers per schedule. Medical record review revealed, Resident #17's shower schedule and preference are two (2) times weekly. A continued review of Resident #17s ADL documentation found: No documentation for showers given. On 11/12/24 at 1:11 PM the Director of Nursing (DON) verified the facility could not provide documentation for Resident #17's showers. b) Resident #20 During an observation 11/11/24 at about 1:54 PM Resident #20 appeared to be unkept, with oily hair and facial hair. Medical record review revealed, Resident #20's shower schedule and preference are two (2) times weekly. A continued review of Resident #20s ADL documentation found: No documentation for showers given. On 11/12/24 at 1:11 PM the Director of Nursing (DON) verified the facility could not provide documentation for Resident #20's showers. 43340 c) Resident #23 A record review, completed on 11/12/24 at 12:02 PM, revealed Resident #23 had one (1) shower (on 11/08/24) over the last 30 days. On 11/12/24 at 1:11 PM, the DON verified the facility was unable to produce evidence that showers were provided to residents on a consistent basis within the last 30 days. d) Resident #33 A record review, completed on 11/12/24 at 12:15 PM, revealed that Resident #33 had two (2) showers (on 11/02/24 and 11/08/24) over the last 30 days. On 11/12/24 at 1:11 PM, the DON verified the facility was unable to produce evidence that showers were provided to residents on a consistent basis within the last 30 days.

Based on observation, interviews, and record review, the facility failed to notify the physician, and obtain orders for the care of the indwelling catheter, for a newly admitted resident. Resident identifier: #257. Facility Census: 54. Findings: a) Resident #257 Record review on 11/12/24, at approximately 2:15 PM revealed that the resident had been admitted to the facility on [DATE]. Further record review revealed that there was neither a physician's order for an in-dwelling catheter, nor any orders for catheter care. A review of the facility matrix, provided to the surveyors, showed no evidence that Resident #257 had an indwelling catheter. On 11/12/24, at approximately 3:00 PM, further investigation revealed that the resident's baseline care plan did not indicate any awareness of the resident's in-dwelling catheter. Additionally, the plan failed to address the risks associated with catheter-related urinary tract infections (CAUTI) and did not implement any protocols for the care of the in-dwelling catheter. During an interview with the Minimum Data Set (MDS) Registered Nurse (RN) #8, who was responsible for the Care Plans, on 11/12/24 at approximately 11:14 AM, MDS RN #8 confirmed that the care plan did not address the resident's catheter. MDS RN #8 stated that she receives the information on each resident during a meeting with other clinical staff, she further stated that there had been no mention of an in-dwelling catheter for Resident #257. The Director of Nursing (DON), during an interview on 11/12/24, at approximately 1:35 PM, confirmed that the staff were aware that the resident had an indwelling catheter. However, the resident's care plan had not been updated, and no physician's orders had been obtained for the care of the catheter. During an interview with the Regional Director of Clinical Operations (RDCO) #104 on 11/13/24 at approximately 9:45 AM, RDCO stated that the physician had prescribed orders for the removal of the in-dwelling catheter. Follow-up observation of the resident at approximately 9:50 AM revealed that the catheter had been removed.

Based on record review and staff interview, the facility failed to obtain laboratory services to meet the needs of its residents. This deficient practice had the potential to affect one (1) of five (5) residents reviewed for the care area of unnecessary medications. Resident identifier: #15. Facility census: 54. Findings included: a) Resident #15 Review of Resident #15's medical records showed a physician's order written on10/19/24 for laboratory testing consisting of Prothrombin Time/International Normalized Ratio (PT/INR) to be performed on 10/19/24. Resident #15 was receiving the medication Coumadin (warfarin) to prevent blood clots. PT/INR testing helps to determine effective Coumadin dosing. No PT/INR laboratory testing results for 10/19/24 were found in the resident's medical record. A physician's order was written on 10/23/24 for PT/INR every week for four (4) weeks, then monthly. The first INR was to be obtained on Wednesday 10/23/24 and then the laboratory testing was to be performed on Thursdays on night shift. A lab results report for a PT/INR specimen received 10/24/24 stated the testing could not performed because the specimen tube received was underfilled. A lab results report for a PT/INR specimen received 10/25/24 stated the testing could not be performed because the specimen was not received at room temperature. On 10/26/24, a PT/INR specimen was received by the laboratory. The test was performed on 10/27/24. A nursing note written on 10/28/2024 at 4:30 PM stated, [Physician] notified of resident's current PT/INR Values - No new orders received. On 11/12/24 at 3:11 PM, the Regional Director of Clinical Operations confirmed results for PT/INR testing were not available for 10/19/24. She stated blood had been drawn for laboratory testing and sent to the laboratory, but she didn't know what happened to the specimen after that. The Regional Director of Clinical Operations also confirmed PT/INR testing could not be performed on 10/24/24 and 10/25/24 because the specimens were incorrect. On 11/13/24 at 11:40 AM, the Director of Nursing stated laboratory testing specimens were obtained by facility nursing staff and sent to the laboratory via courier.

Based on record review and staff interview, the facility failed to ensure an admission assessment was completed with an antipsychotic and residents reviewed during the long-term care survey process had a Physician Orders for Scope of Treatment (POST) form completed per directions specified by the [NAME] Virginia Center for End-of-Life Care in conjunction with the [NAME] Virginia Health Care Decisions Act (16-30-1). The POST forms were unsigned by the Resident or Medical Power of Attorney (MPOA). Resident identifiers: Resident #31and #15. Facility census: 54. Findings Included: a) Resident #31 Record review on 11/11/24 at 2:55 PM found, a POST Form patient information and section F health care provider on Resident #31's chart was completed with the Physicians Full name, Licenses number and phone number. The POST was dated 06/14/24. 11/13/24 09:18 AM 104 Corp nurse verified no physician full name During an interview on 11/13/24 at 9:18 AM with the Corporate Nurse #104, she confirmed Resident #31's POST form was incomplete without a physician's information. 39043 b) Resident #15 Review of Resident #15's physician's orders showed the resident was ordered the medications Seroquel (quetiapine), an antipsychotic medication, and Reglan (metoclopramide) on 10/16/24. Resident #15's discharge instructions from the hospital on 10/16/24 included instructions to continue the medications Seroquel (quetiapine), which is an antipsychotic medication, and Reglan (metoclopramide), a medication for nausea. A side-effect of antipsychotic medications and the medication Reglan is a movement disorder called tardive dyskinesia (TD). Abnormal Involuntary Movement Scale (AIMS) assessments can be performed to assess the presence or worsening of TD. On 11/12/24 at 2:00 PM, the Regional Director of Clinical Operations stated the facility did not have a policy regarding Abnormal Involuntary Movement Scale (AIMS) assessments. She stated AIMS assessments are performed on admission for residents receiving antipsychotic medications and then every six (6) months following admission. Resident #15's Nursing Admission Evaluation dated 10/16/24 answered No to the question regarding whether the resident was receiving an antipsychotic and/or Reglan medication. On 11/13/24 at 10:13 AM, the Regional Director of Clinical Operations confirmed Resident #15's Nursing Admission Evaluation was incorrect. She stated a Yes response to the question would have triggered an Abnormal Involuntary Movement Scale (AIMS) assessment.

Based on record review and staff interview, the facility failed to provide a resident with a discharge summary that was completed by all departments and failed to ensure it included follow-up dates and times for medical appointments. This was true for one (1) of two (2) residents reviewed under the discharged pathway. Resident identifier: #56. Facility census: 54. Findings included: a) Resident #56 A record review, completed on 11/12/24 at 8:56 PM, revealed the following details: -Resident #56 was admitted to the facility on [DATE]. -Resident went home with his significant other on 09/23/24. -Resident was cognitively intact -Resident was able to complete tasks independently. -An After Visit Summary from the hospital, dated 09/20/24, listed a follow-up neurosurgery appointment in two (2) weeks. -A facility discharge report, dated 09/23/24, reflected that the Nursing section was completed. However the Social Services section, Dietary Manager section, and the Activity Director section were left blank and incomplete. -The facility discharge report also incorrectly indicated that Resident #56 did not have any follow-up appointments. During an interview on 11/13/24 at 11:00 AM, the Director of Nursing acknowledged form was incomplete and inaccurate.

Based on observation, interview, and record review, the facility failed to revise and update the care plan based on the changing preferences and needs of the resident. Resident identifier: #16. Facility Census: 54. Findings: a) Resident #16 During a brief interview on 11/11/24 at approximately 12:09 PM, resident #16 stated that she was unable to move her left sided extremities. Resident's Medical Power of Attorney (MPOA), who was present in the room, explained that resident had recently been diagnosed with a malignant neoplasm of the right temporal lobe, and stated that resident had lost the use of her left side. Resident's bedside table was observed on the left side of the bed with the resident's eyeglasses, and a cup of water on it. Resident wanted some water, and upon being asked whether she could reach the water, the resident stated that she could not, because her left arm did not work. Resident's MPOA then retrieved the cup of water and offered it to the resident. Observation on 11/12/24 at 9:28 AM again revealed the bedside table with resident's water and eyeglasses on the left side of the bed. A review of Resident #16's care plan revealed a note that stated: Place call light to resident's right side Date Initiated: 10/23/2024 Revision on: 11/01/2024 During an interview with the Minimum Data Set (MDS) Registered Nurse (RN) #8, on 11/12/24 at approximately 11:14 AM, she stated that the resident had been care planned for left sided paralysis. An interview with RN #1 on 11/12/24 at approximately 12:15 PM confirmed that the bedside table should be on the resident's right side. She stated that she would make sure that the table was positioned at the resident's right side. However, observation on 11/13/24 at approximately 9:08 AM revealed that the bedside table had been pushed away from the right side of the bed, to make space for fall pads that had been placed on the floor. When this was brought to the attention of Licensed Practical Nurse (LPN) #95, LPN stated that it would be taken care of.

Based on record review and interview, facility failed to develop a baseline care plan that addressed the risks associated with catheter-related urinary tract infections (CAUTI) and did not implement any protocols for the care of the in-dwelling catheter. Additionally, the facility failed to notify the physician, and obtain orders for the care of the indwelling catheter for a newly admitted resident This was a random opportunity for discovery. Resident Identifier: Resident #257. Facility Census: 54. Findings included: a) Resident #257 During an interview with Resident #257 on 11/11/24 at approximately 2:30 PM, resident was observed to have an in-dwelling catheter. The resident stated that the catheter had been inserted at the hospital. Record review on 11/12/24 at approximately 2:15 PM revealed that the resident had been admitted to the facility on [DATE]. Further record review revealed neither a physician's order for an in-dwelling catheter, nor any orders for catheter care. A review of the facility matrix provided to the surveyors showed no evidence that Resident #257 had an indwelling catheter. On 11/12/24, at approximately 3:00 PM, further investigation revealed that the resident's baseline care plan did not indicate any awareness of the resident's in-dwelling catheter. Additionally, the plan failed to address the risks associated with catheter-related urinary tract infections (CAUTI) and did not implement any protocols for the care of the in-dwelling catheter. During an interview with the Minimum Data Set (MDS) Registered Nurse (RN) #8, who was responsible for the Care Plans, on 11/12/24 at approximately 11:14 AM, MDS RN #8 confirmed that the care plan did not address the resident's catheter. MDS RN #8 stated that she received information on each resident during a meeting with other clinical staff. She further stated that there had been no mention of an in-dwelling catheter for Resident #257. During an interview with the Director of Nursing (DON) on 11/12/24 at approximately 1:35 PM, DON confirmed that the resident's care plan had not been updated, and no physician's orders had been obtained for the care of the catheter. During an interview with the Regional Director of Clinical Operations (RDCO) #104 on 11/13/24 at approximately 9:45 AM, RDCO stated that the physician had prescribed orders for the removal of the in-dwelling catheter. Follow-up observation of the resident at approximately 9:50 AM revealed that the catheter had been removed.

Based on resident interview, record review, and staff interview, the facility failed to promote self-determination and honor resident preferences regarding bathing/showers. This was true for two (2) out of five (5) residents reviewed under choices. Resident identifiers: #23 and #33. Facility census: 54. Findings included: a) Resident #23 During an interview, on 11/12/24 at 12:15 PM, Resident #23 reported she had not had a bath in a week. She also stated she had asked a half a dozen people not to have her shower day on Tuesday because she does not like to attend church services with her hair wet. The resident stated, I must not have asked the right people because they keep doing it. Resident #23 went on to state, I frequently do not accept a shower on Tuesdays because of my preference to not have wet hair when going to church but despite telling each CNA about my preference to have a different shower day, it has never been changed. A record review completed on 11/12/24 at 1:08 PM, confirmed resident's refusals for Tuesday's showers. In addition Section C of the Quarterly MDS, dated [DATE], reflected a Brief Interview for Mental Status (BIMS) score of 13, indicating that resident was cognitively intact. A Physician Determination of Capacity, dated 11/05/23, reflected resident had capacity to make medical decisions. During an interview, on 11/12/24 at 1:15 PM, the Director of Nursing (DON) stated she was not told about resident's request to have a different shower day. The Regional Director of Clinical Operations #104 stated a resident should not need to request a change in shower schedule with six (6) different staff and that the facility should and would the honor the resident's request for a different shower day. b) Resident #33 During an interview on 11/12/24 at 2:30 PM, Resident #23 stated she has dandruff/itchy scalp and she has requested over and over again that the CNAs assisting with her shower actually scrub her scalp but they all just get her hair wet, add the shampoo, and then immediately rinse her hair. Resident reported she tries to demonstrate how she would like to have her hair scrubbed but it is difficult for her to do so because of her limited range of motion. Resident stated she has never had a nurse speak to her about her request nor has there ever been an order for dandruff shampoo. During an interview on 11/12/24 at 2:38 PM, the DON reported that the CNAs should report any resident concerns to the nurse on duty and the nurse should follow-up with the physician for any new orders. The DON stated she would check in to the possibility of dandruff shampoo being ordered and re-educate staff about adhering to a resident's preference.

Based on observation, and interview, the facility failed to ensure that residents were treated with dignity and respect, as demonstrated by leaving urinary catheter bags uncovered. This was a random opportunity for discovery during the Long-Term Care Survey Process. Resident identifiers #47 and #257. Facility census: 54. Findings included: a) Resident #47 On 11/12/24 at approximately 11:50 AM, Resident #47 was observed wheeling her chair down the corridor with her uncovered catheter bag and tubing resting in her lap. During an interview with Registered Nurse (RN) #1 at approximately 11:55 AM on 11/12/24, the RN confirmed that the catheter bag should not be placed in the resident's lap and should have been covered. The RN instructed a Nursing Assistant (NA) to find a cover for the resident's catheter bag or to place a blanket over the resident's lap immediately. The RN also confirmed that Resident #47 requires a two-person lift and cannot get into her chair without assistance. A review of Resident #47's care plan revealed the following: This resident is unable to do the following tasks d/t medical reasons: SIT TO LYING, LYING TO SITTING, SIT TO STAND. Date Initiated: 07/31/202 This resident is unable to do the following tasks d/t medical reasons: TRANSFERS: Assist X2 with mechanical lift. Date Initiated: 04/22/2024 b) Resident #257 During an interview with Resident #257 on 11/11/24, at approximately 2:30 PM, it was noted that the resident's catheter bag was uncovered and dangling off the foot of the bed. A follow-up observation on 11/12/24, at approximately 1:00 PM revealed Resident #257's catheter bag remained uncovered and was still dangling off the foot of the bed. At approximately 1:15 PM on 11/12/24, RN #1 confirmed that the catheter bag needed to be covered. The RN called out and instructed a NA to cover the bag.

Based on observation and staff interview, the facility failed to respect resident dignity. Four (4) residents requiring assistance with dressing were noted to have on non-skid socks that had the residents names either on the top or on the side of the sock. This practice was not inconspicuous and could readily be seen by any visitor. This was a random opportunity for discovery. Resident identifiers: #8, #13, #44, and #41. Facility Census: 47. Findings included: a) Resident #8 Observation, on 01/23/23 at 9:30 AM, found Resident #8 sitting in the hallway by the nurses station wearing non-skid socks with her name visible on the top of the left sock. A brief record review, completed on 01/23/23 at 9:45 AM, found Resident #8 required staff assistance with dressing. A second observation on 01/23/23 at 10:25 AM, Activity Assistant #14 was asked if she would agree Resident #8's name was visible on her left sock. Activity Assistant #14 glanced at Resident #8 and merely stated, Yeah. b) Resident #13 Observation, on 01/24/23 at 1:20 PM, found Resident #13 walking down the hallway wearing non-skid socks with her name visible on the top of the socks. A brief record review, completed on 01/24/23 at 1:26 PM, found Resident #8 required staff assistance with dressing. A second observation on 01/24/23 at 1:34 AM, with Social Worker #39 found Resident #13 walking in the lobby wearing non-skid socks with her name visible. Social Worker #39 identified this as a dignity issue. c) Resident #44 Observation on 01/24/23 at 1:22 PM, found Resident #44 sitting in her wheelchair in the lobby wearing non-skid socks with her name visible on the side of the socks. A brief record review, completed on 01/24/23 at 1:28 PM, found Resident #44 required staff assistance with dressing. A second observation on 01/24/23 at 1:36 AM, with Social Worker #39 found Resident #44 sitting in the lobby in her wheelchair wearing non-skid socks with her name visible. Social Worker #39 identified this as a dignity issue and asked resident's permission to reposition sock. d) Resident #41 Observation on 01/24/23 at 1:24 PM, found Resident #41 propelling herself down the hallway with her name visible on the top of her non-skid socks. A brief record review, completed on 01/24/23 at 1:30 PM, found Resident #41 required staff assistance with dressing. A second observation on 01/24/23 1:38 AM, with Social Worker #39 found Resident #41 sitting in the hallway by the nurses station in her wheelchair wearing non-skid socks with her name visible. Social Worker #39 identified this as a dignity issue and asked resident's permission to reposition sock.

Based on observation, review of facility documentation, and staff interview, the facility failed to ensure drugs and biologicals, used in the facility, were stored, and administered in accordance with current accepted professional practices. This was true for medications stored in one (1) of two (2) medication carts and one (1) of one (1) medication storage rooms inspected. The facility failed to ensure medications were dated when opened and put in to use, failed to ensure medications being stored for use after the manufacturer's use by date, were discarded and not administered to residents and failed to ensure medications were stored at the proper manufacturer's temperature requirement. This deficient practice was identified during a random opportunity for discovery and had the potential to affect more than a limited number of residents. Facility census: 47 Findings included: a. Policy Review A review of the Policy : Lifetree Pharmacy Policy: Storage of Medications, revision date 09/01/20, showed medications and biologicals were to be stored safely and properly following manufacturer's recommendations. Under Temperature,, Section B. , noted medications requiring storage at room temperature were to be kept at temperatures ranging from 59 degrees Fahrenheit (F) to 77 degrees F. Under Temperature, Section C., noted medications requiring refrigeration were to be kept in a refrigerator at temperatures between 36 degrees F and 46 degrees F. Refrigerators were to have an appropriate thermometer to allow temperature monitoring. Under Expiration Dating (Beyond Use Dating), Section C, noted certain medication or package types , once opened , required an opened date and an expiration date, which may be shorter than the manufacturer's expiration date , due to the usable life after opening. Under Expiration Dating (Beyond Use Dating), E. and F., showed no expired medication would be administered to a resident with all expired medications removed from the active supply and destroyed in accordance with facility policy, regardless of amount remaining. b) Medication Cart A Inspection An inspection of Medication Cart A, on 01/24/23 at 08:46 AM, showed the following: 1) A stock bottle of Tylenol 325 milligrams (mg) not dated when opened and being used for resident medication administration. An interview, on 01/24/23 at 08:46 AM, with Licensed Practical Nurse (LPN) #3, revealed staff were to date all over the counter medications when opened. LPN #3 verified the Tylenol 325 mg was opened, with no date noted and being administered to residents. 2) Lantus insulin, dated as opened on 12/03/23, and Novolog insulin, dated as opened on 12/03/22. During the Medication Cart A inspection, conducted 01/24/23 at 08:46 AM, LPN #3 verified the insulins were currently in use. According to Manufacturer's directions, for both Lantus and Novolog, the medications are to discarded after 28 days of when the insulin was opened. b) Medication Room inspection An observation of the actual temperature readings , on 01/24/23 at 08:56 AM , revealed the outside temperature gauge to read 47.4 degrees F with the inside thermometer reading 48/50 degrees F. The temperature readings were verified with LPN #3. On 01/24/23 at 08:56 AM, LPN #3 verified the following medications and the specific storage instructions for each: - Two (2) vials of Levemir insulin, with manufacturer's storage instructions of do not freeze. The fill date of the vials were 12/14/22 and 10/21/22. - Four (4) vials of Novolog insulin, with manufacturer's storage instructions of do not freeze. The fill date of the vials were 1/2/23 , 12/13/22 , 12/8/22 and 12/12/22. -One (1) vial of Lantus insulin, with manufacturer's storage instructions of do not freeze. The fill date of the insulin was 1/2/23. -One (1) Lantus pen, with manufacturer's storage instructions of do not freeze. The fill date of the insulin was 10/05/22. On 01/24/23 at 09:03 AM , the refrigerator contents check continued in which Registered Nurse (RN) #90 verified the following medications and the the specific storage instructions for each: - Tuberculin Purified Protein Derivative (PPD ) vaccine with manufacturer's direction for the vaccine to be stored at a temperature range 35-46 degrees and do not freeze. RN #90 verified the fill date to be 11/15/22. - Fluvac, with a with a manufacturer's direction for the medication to be stored at 36-46 degrees F and do not freeze. RN #90 verified the fill date of 10/13/22. -Hydrocortisone suppositories, with a with a manufacturer's direction to store at 68-77 degrees F. RN #90 verified the fill date of 11/21/22 and stated further, the refrigerator temperatures were too cold for this medication to be stored there. A review of the temperature logs for 11/2022, 12/2022 at 01/2023 revealed the following : A review of 11/2022 temperature logs provided by the facility, showed fourteen (14) days in which the documented refrigerator temperatures were 32 degrees F or lower. The dates included: 11/05/22, 11/06/22, 11/10/22, 11/14/22 through 11/17/22, 11/24/22 through 11/30/22. A review of the 12/2022 temperature logs provided by the facilty , showed three (3) days in which the documented refrigerator temperatures were 32 degrees F or lower. The dates included 12/01/22, 12/17/22 and 12/19/22. a review of the 01/2023 temperature logs provided by the facilty , showed fourteen (14) days in which the documented refrigerator temperatures were 32 degrees F or lower. The dates included 01/2/23 through 01/06/23, 01/10/23 through 01/14/23 and 01/16/23 through 01/18/23. An interview, with RN #90, on 01/24/23 at 09:14 AM, verified the medications, in the medication room refrigerator noted above, should not have been stored at a freezing temperature and confirmed the several dates of when the storage was at 32 degrees F. RN #90 further stated, the temperature of 32 degrees F would have been too cold for storage. An interview, with the Administrator, on 01/25/23 at 08:15 AM , revealed the facility was not unsure if the thermometer had been working correctly but confined medications were not to be stored outside the range of the manufacturer's direction. During the interview, the Administrator confirmed staff were to date stock medications when opened and put into use. An additional interview, with the Administrator, on 01/25/23 at 08:45 AM stated nurses were to date the vial or pen, when the insulin was opened and it was each nurse's responsibility to ensure the insulin was not used past the manufacturer's date. On 01/25/23 at 09:44 AM, the Administrator provided documentation of the insulin type and expiration date. A review of the document and further interview with the Administrator, verified Lantus and Novolog insulin in a vial or pen , should have been discarded after 28 days of use.

Based on observation and staff interview, the facility failed to ensure the and privacy of Resident #27 during a treatment. This was a random opportunity for discovery. Resident identifier: #27. Facility census: 47. Findings included: a) Resident #27 Observation, on 01/24/23 at 11:40 AM, identified Resident #27's door was open. RN #20 had pulled the first privacy curtain between Resident #27 and his roommate but failed to pull the second privacy curtain by the foot of resident's bed to ensure resident privacy during treatment. During an interview on 01/25/23 at 8:25 AM, the Administrator reported all nursing staff have been trained to pull both privacy curtains to ensure resident privacy.

Based on observation and staff interview, the facility failed to provide a safe, clean, comfortable, and homelike environment. The facility failed to ensure resident rooms were in good repair. These were random opportunities for discovery. Room identifiers: B09A and B05A. Facility census: 47. Findings included: a) Room B09A Observation, on 01/23/23 at 9:to AM, found the wall had multiple scrapes / gouges spanning the an area of approximately 18 inches. Additionally, the area behind the bed had scrapes / gouges spanning an area of approximately 28 inches. During a second observation, on 01/25/23 at 8:37 AM, Social Worker #39 reported the scrapes / gouges were not homelike and needed to be repaired. The social worker also stated, This definitely should have been addressed and repaired. I will see that it gets done. b) Room B05A Observation on 01/23/23 at 9:55 AM, found the wall had two white rectangular patched areas both approximately four (4) inches long and twelve (12) inches long. During an second observation, on 01/25/23 at 8:40 AM, Social Worker #39 reported it appeared the maintenance department had forgotten to finish the repair by sanding and painting over the patch work. The social worker stated it was not homelike and she would be sure to address the concern.

Based on record review, staff interview, and review of the facility's policy for therapy screening, the facility failed to ensure a resident with a decline in functional range of motion received timely care and services to prevent further declines. This resulted in actual harm to the resident due to loss of functional range or motion. The resident was assessed as having declines in functional range of motion on two (2) consecutive assessments with no measures implemented in an attempt to prevent further decline. This was evident for one (1) of five (5) sampled residents reviewed for the care area of range of motion. Resident identifier: #10. Facility census: 56. Findings include: a) Resident #10 Review of the Minimum Data Set (MDS) assessment, with an assessment reference date (ARD) of 01/08/12, revealed the resident had no functional impairment of the upper extremities and impairment on only one (1) side of the lower extremities. The MDS, with an ARD of 04/01/12, indicated there had been no decline in the resident's baseline since the prior assessment. The resident continued to have no functional impairment of the upper extremities and impairment of one (1) side of the lower extremities. Record review also revealed the resident received Physical Therapy (PT) from 02/24/12 through 04/04/12. Review of the MDS, with an ARD of 07/01/12, found the resident had experienced a decline in her functional ROM to include impairment of both upper extremities and of one (1) side of the lower extremities. Record review found no interventions to the resident's care plan to address this decline. The MDS, with an ARD of 09/30/12, revealed the resident had experienced further decline in functional ROM to include impairment of both upper extremities and both lower extremities. Record review found no new interventions to address this decline. Further review of the resident's care plan found no new interventions had been established to address the resident's decline in functional ROM abilities that had been identified on the 07/01/12 and 09/30/12 MDS assessments. In an interview, on 10/23/12 at 8:30 a.m., the Rehabilitation Services Manager, Employee #74, stated "I did not know" referring to the decline in the resident's functional ROM abilities. The Multidisciplinary Therapy Screen Policy, received from the Administrator on 10/23/12, at approximately 9:30 a.m., revealed the process of obtaining quarterly physical therapy referrals required a physician order. Record review found no physician's order for screening after the discontinuation of physical therapy services for this resident on 04/04/12, despite the resident's decline after therapy services ended. .

Based on resident interview, staff interview, and medical record review, the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. The facility failed to provide effective pain relief, resulting in actual harm due to ineffective pain management, for one (1) of three (3) Stage 2 residents reviewed for the care area of pain. Resident identifier: #4. Facility census: 56. Findings include: a) Resident #4 During an interview with Resident #4, on 10/16/12 at 9:23 a.m., he stated he had pain in his legs all of the time and medication did not help. On 10/17/12 at 2:30 p.m., a follow up interview was conducted at which time Resident #4 stated his pain was in his legs. He rated his pain as a ten (10) on a zero (0) to ten (10) pain scale, with zero (0) being no pain and ten (10) being the highest pain level. He stated his pain affected his ability to perform activities of his choice and affected his sleep. An interview with Employee #28, a Unit Charge Nurse/Licensed Practical Nurse (LPN) was conducted on 10/17/12 at 12:45 p.m. She stated Resident #4 received a scheduled Tylenol every evening and had an "as needed" (PRN) Tylenol order as well, although the resident had not received the PRN Tylenol since last month (09/20/12). She was unable to produce evidence of any follow up evaluations for Resident #4 regarding the effectiveness of his scheduled pain medication. When asked if the resident was assessed for pain, she stated the registered nurses performed pain assessments on residents at weekly intervals, but it was unrelated to the administration of pain medication. This situation was discussed with the Director of Nursing (DON) on 10/17/12 at 3:00 p.m. She was unable to produce any additional information regarding assessment and reassessment of Resident #4's pain and his response to the medication for pain. On 10/17/12, a record review was performed. Resident #4 had [DIAGNOSES REDACTED]. Since 10/26/11, he had received Tylenol 650 milligrams (mg) orally every evening at 9:00 p.m. for "joint stiffness/pain." There was a numeric value next to each Tylenol administration stating "Pain." On 10/13/12 this value was a four (4). Employee #4, a Unit Charge Nurse/Licensed Practical Nurse (LPN), clarified this value on 10/23/12 at 12:45 p.m. by explaining it was a pain assessment performed by the afternoon shift nurse at some point during the shift, it had no relationship to the administration of the 9:00 p.m. Tylenol or its effectiveness. Resident #4 also had a physician's orders [REDACTED]. This had first been ordered on [DATE]. There was no evidence of assessments of Resident #4's pain prior to or after the administration of the muscle rub. Since 10/26/11, there was no evidence any other pain medications had been tried, other than Tylenol or the Muscle Rub. The current care plan, last reviewed on 09/20/12, had a goal of, " ... will state relief in pain within 1 hour of receiving pain medication." An intervention associated with this goal was, "Document patient's response to pain and medications or therapeutics aimed at abolishing or relieving pain". In addition, an intervention stated, "Notify physician if interventions are unsuccessful or if current complaint is a significant change from patient' s past experience of pain". There was no evidence the care plan was followed, no evidence of a follow up to determine if pain management was effective, and no evidence the physician was notified of progress or lack of progress to ensure Resident #4 achieved his highest possible level of well-being through effective pain management. .