Every finding on record at Elizabeth Care Center

Based on record review and staff interview, the facility failed to complete a performance review of nurse aides at least once every 12 months. This was true for one (1) of five (5) nurse aides reviewed for the care area of sufficent and competent nurse staffing. This deficient practice had the potential to affect more than a limited number of residents. Facility census: 35. Findings included:a) Nurse Aide #56 Review of Nurse Aide #56's personnel file showed a performance review was conducted on 11/14/24. On at 03/25/2026 at 1:05 PM, the Office Coordinator confirmed Nurse Aide #56 continued to work in the facility as a per diem employee. The Office Coordinator also confirmed the nurse aide's last performance review was on 11/14/24. The Office Coordinator stated Nurse Aide #56 had required some time off work. When she returned, the office software changed her hire date, causing her yearly performance review to be missed. No further information was provided through the completion of the survey.

Based on observation and staff interview, the facility failed to ensure staffing information was posted in a prominent place readily accessible to residents, staff and visitors. This failed practice had the ability to affect more than a limited amount of residents and/or visitors to the facility. Facility Census 35. Findings Included: a) Daily Staff Posting On 03/24/2026 at 10:35 AM, the daily staffing post at the nurse's desk was observed to be dated for 03/23/26. b) Interview with Administrator On 03/24/26 at 10:45 AM, interview with Administrator who reported the Director of Nursing had the staffing sheet in her hand this morning and she was unsure what might have occurred. She returned around 10:55 AM and reported the staff posting had been placed behind yesterday's posting and has now been corrected. She also stated the nurse's station is the only place in the facility in which daily staffing is posted.

Based on record review, observation, and staff interviews, the facility failed to store and prepare food in accordance with professional standards for food safety. There were foods not labeled and dated in the freezer and pantry refrigerator, there were missing temperatures for the kitchen equipment, outdated food in the refrigerator, dented cans, and kitchen utensils that needed cleaned. This deficient practice had the potential to affect all residents receiving nutrition from the kitchen. Census: 35. Findings Included: A policy titled, Food Preparation and Service, states the temperatures of foods held in steam tables are monitored throughout the meal by food and nutrition services. A policy titled, Refrigerators and Freezers, states Food Service Supervisors or designated employees will check and record refrigerator and freezer temperatures daily with first opening and at closing in the evening. It also states, all food shall be appropriately dated to ensure proper rotation by expiration dates. Received dates (dates of delivery) will be marked on cases and on individual items removed from cases for storage. Use by dates will be completed with expiration dates on all prepared food in refrigerators. Expiration dates on unopened food will be observed and use by dates indicated once food is opened. A policy titled, Sanitization, states for fixed equipment or utensils that do not fit in the dishwashing machine, washing shall consist of the following steps: equipment will be disassembled as necessary to allow access of the detergent/solution to all parts and removable components will be scraped to remove food particle accumulation and washed according to manual or dishwashing procedures. Another policy titled, Food Receiving and Storage, states all foods stored in the refrigerator or freezer will be covered, labeled, and dated (use by date) and all foods belonging to residents must be labeled with the resident's name and the use by date. a) Kitchen Tour During the initial kitchen tour, on 03/23/26 at 11:45AM, the following issues were identified:-there were missing temperatures on the food temperature log. None of the temperatures for meals served on 03/01/26 and 03/02/26 were logged.-the curly fries in the freezer were in a ziploc bag with no label or date.-there were two (2) dented cans, one of spaghetti sauce and the other a cheddar cheese sauce, on the shelf to be used.-the can opener had leftover food on the cutting edge.-the refrigerator and freezer temperatures for 03/02/26 were missing on the temperature logs -the dishwasher and three (3) compartment sink temperatures were missing from the temperature logs for 03/01/26 and 03/02/26.-there was a jar of outdated pickle relish in the refrigerator dated best by 03/19/26. All of these findings were confirmed by Dietary Services Director at 12:00 PM on 03/23/26. b) Tour of Pantry A tour of the pantry, at 8:45 AM on 03/24/26, revealed a bag of grapes with no label of resident's name or a received or use by date. This was confirmed by Certified Nursing Assistant #34 at 8:45 AM. c) Second Kitchen Tour On 03/24/26 at 3:00 PM, a second tour of the kitchen was conducted. The following findings were identified:-the knife rack had dust layered on top and the inside of the knife rack was full of crumbs.-Wet nesting (the practice of placing recently washed items together restricting air flow which can lead to bacterial growth) was identified in the drying rack with several wet cups stacked on top of each other. These findings were confirmed by Dietary Services Director on 03/24/26 at 3:15 PM.

Based on documentation review, resident interview, and staff interview, the facility failed to allow residents the right to file a grievance anonymously without having to ask for assistance from staff. This was true for five (5) of five (5) residents interviewed for for grievances. Resident identifiers: #15, #20, #24, #6, and #27. Facility Census: 35 Findings Included: Review of the facility policy titled, Grievances/Complaints, revealed that grievances and/or complaints may be submitted orally, or in writing, and may be filed anonymously. a) Resident Council Meeting During a Resident Council meeting, held on 03/24/26 at 2:30 PM, residents reported they did not know how to file their own grievance. If they had a complaint they would talk to staff, who would file the complaint and generally resolve the issue. They were not aware of any way to file a complaint anonymously. The Resident Council members agreed they had to go through a nurse or administrative staff directly. They denied having access to any forms or knowledge of any other manner in which to anonymously file a grievance within the facility. The following residents were in attendance and agreement: Resident's #15, #20, #24, #6, and #27. b) Interview with the Administrator During an interview on 03/24/26 at 3:38 PM, the Administrator acknowledged there was no anonymous grievance procedure within the building. She reported the facility had never had any anonymous grievances. She later stated there is a 1-800 number posted on the wall in which she did not know where the complaints went to and that the Ombudsman information was posted for grievances.

Based on resident interview, observation, and staff interview, the facility failed to ensure resident dignity during dining. The facility failed to ensure tablemates in the dining room received their meal trays at the same time. This was a random opportunity for discovery. Resident Identifiers: #3, #16 and #5. Facility Census: 35. Findings included: a) Resident Rights Review of the facility's documentation on Resident Rights revealed that employees shall treat all residents with kindness, respect, and dignity. b) Lunch Dining Observation During a dining observation, on 03/24/2026 at 12:05 PM, it was noted that Resident #16, Resident #5, and Resident #3 were all sitting together at a table. Two (2) of the three (3) residents sitting at that table were served: Resident #16 and Resident #5. Then four (4) more tables were served before Resident #3 received her meal. Resident #3 let the nursing staff know she was hungry and still waiting for her food at 12:13 PM. The nursing staff informed the cook that they needed Resident #3's meal tray. During an interview at 12:14 PM, [NAME] #63 was asked why Resident #3 was not served at the same time as the other residents at her table. [NAME] #63 replied, It was on me. I did not realize she was sitting there.

Based on documentation review, resident interview, observation, and staff interview, the facility failed to ensure one (1) of two (2) residents received the assistance needed with activities of daily living. Resident #6 did not receive the assistance needed to maintain personal grooming according to her preferences. Resident identifier: #6. Facility census: 35.Findings included:Review of the facility policy titled Activities of Daily Living (ADLs) revealed, residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). The policy further stated residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene. Hygiene was described as bathing, dressing, grooming, and/or oral care. a) Resident #6 During an interview on 03/23/26 at 1:38 PM, Resident #6 stated that the only concern she had was she had facial hair located on her chin that the staff used to shave for her, but they have not done it lately, and she would be tickled if someone would take care of it for her. Surveyor did observe many hairs growing from her chin. During an interview, on 03/23/26 at approximately 3:40 PM, the Administrator acknowledged Resident #6 had unwanted facial hair and she stated, I will take care of it. On 03/24/2026 at 11:00 AM, Resident #6 reported she was happy that the nursing staff shaved her chin for her.

Based on observation, record review, and staff interview, the facility failed to ensure residents had appropriate assistive devices for eating and drinking. Resident #12 did not have a Kennedy cup (a lightweight open handle cup used to prevent spills) at bedside. Resident #14 had a suction divided plate that was set inside of the plate cover and therefore unable to suction to the table. This was true for one (1) of one (1) residents sampled for nutrition and one (1) of twelve (12) residents sampled for dining during the Long-Term Care Survey Process. Resident Identifiers: #12, #14 Census: 35. Findings included: A policy titled, Food and Nutrition Services, states nursing staff will ensure that assistive devices are available to residents as needed. a) Resident #12 Review of the electronic medical record revealed: -An order, dated 02/25/26, that read, Devices: Kennedy cup. -Resident #12's care plan had a Kennedy cup listed as an intervention with the focus of Nutrition: [Resident #12] is at risk for alteration in nutritional status [related to] R/T cognitive deficits, moderate protein calorie malnutrition (MNA) 02/05/26, [history] HX vitamin D deficiency, mechanically altered diet, therapeutic diet, low BMI (body mass index), HX nausea. -Section GG of the annual minimum data set (MDS), with an assessment reference date of 02/26/26, showed resident had an impairment in one upper extremity requiring partial assistance with eating and drinking. Resident #12 was observed lying in bed, at 11:00 AM on 03/24/26, with a regular cup and a straw on the bedside table. Certified Nursing Assistant #34 confirmed resident did not have a Kennedy cup in her room at 11:17 AM. b) Resident #14 A brief record review revealed Resident #14 had an order for a suction divided plate with meals. During dining observation, on 03/24/2026 at 12:04 PM, Resident #14 did receive the suction divided plate, but it was not suctioned to the table. It was suctioned to the plate base, and the plate base could still move around the table. At 12:18 PM, Certified Nursing Assistant (CNA) #34 did take the suction divided plate out of the base and suctioned it to the table. Surveyor asked Resident #14 if that was better? She said,Yes. CNA #34 was asked if it should have been suctioned to the table when Resident #14 was served. She replied, As far as I know, it should have been.

Based on record review and staff interview, the facility failed to ensure complete and accurate medical records for Resident #13 and Resident #4. This was true for one (1) of three (3) residents sampled for beneficiary notification and one (1) of five (5) residents sampled for unnecessary medications during the Long-Term Care survey process. Resident identifiers: #13, #4. Facility Census: 35.a) Resident #13 During a record review, it was noted the Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNF-ABN) form was missing a check in the boxes under the options category. These options explain how the resident or Power of Attorney (POA) want the facility to bill Medicare for their continued stay after Medicare A stops paying.It was confirmed by Business Office Manager, at approximately 12:00 PM on 03/24/26, the boxes were not checked and should have been. b) Resident #4 During a record review, the Psychotropic Medication Informed Consent form was missing a check in the boxes labeled statement of consent. The following are the options provided that were not marked:-I do desire the use of the medication(s) listed above and do consent to their use. I understand that once the target symptom or behavior is controlled, the dose should be gradually decreased to the lowest possible dosage and frequency, or discontinued unless contraindicated by physician.-I have been informed of non-pharmacological interventions that have been attempted.-I have received education regarding this medication, including side effects and Black Box Warnings.-I do consent to the use of medication interventions but only on a temporary basis for treatment of life-threatening medical symptoms only.-I do not desire, nor consent to, the use of this medication intervention on a regular or temporary basis. I realize the risks of not taking this medication may result in uncontrolled symptoms or behaviors which may make it difficult for the nursing staff to appropriately provide care. During an interview with the Director of Nursing, on 03/24/26 at approximately 3:30 PM, it was confirmed none of the boxes were checked.

Based on observation and staff interview, the facility failed to maintain adequate, appetizing temperatures for breakfast foods served in resident rooms. This was a random opportunity for discovery in the Long Term Care Survey process. Resident identifiers: Resident #09, Resident #26. Facility census: 32. Findings included: a) Facility On 09/24/24 at 2:00 PM, a resident council meeting was held. During the meeting, Resident #26 stated Breakfast delivered to our rooms are cold. It just doesn't taste right. At that time, Resident #9 stated, Yes, sometimes our breakfast is cold when they bring it. I don't say anything about it though. They bring me something else if I ask them too. On 09/25/24 at 7:20 AM, an observation was made of breakfast trays being delivered resident rooms. The last tray was taken from the food cart at 7:36 AM and the temperature of the food being served was taken. The following are the temperatures obtained by Dietary Staff #12: Scrambled eggs: 103.5 degrees Fahrenheit (F) Pancakes: 93.8 degrees F Oatmeal: 143 degrees F At that time, Dietary Staff #12 acknowledged the scrambled eggs and pancakes were not within the recommended temperature range of 120 degrees at point of service.

Based on record review and staff interview, the facility failed to ensure all required members of the Quality Assurance and Performance Improvement Committee (QAPI) attend a quarterly meeting as required. Facility Census: 62. Findings Included: a) On 09/25/14 at 11:57 AM record review indicates the facility Quality Assurance Committee meets every second (2nd) Tuesday of each month. The following individuals are listed as individuals that attend: Medical Director Consultant Pharmacists Director of Nursing (DON) Administrator Social Service Director Therapy Director Activities Director Dietary Manager Minimum Data Set (MDS) Nurse Nursing House Supervisor (Infection Preventionist) IP Nursing Unit Manager Business Office Manager Human Resources Director Review of the QAPI meeting sign in sheets for four (4) quarters starting in September 2023, the following information was obtained: March, April, May 2024 - All required members were not present at any meeting this quarter. March, there was no IP present April, there was no Medical Director or IP present May, there was no IP or Administrator present June, July, August 2024 - All required members were not present at any meeting this quarter. June, there was no IP, no DON and no Medical Director present. July, there was no IP, no DON and no Medical Director present. August, there was no IP present. On 09/25/24 at 1:33 PM the Director of Nursing and the Administrator confirmed there were missing required personnel for two (2) of the four (4) quarterly meetings.

Based on record review and staff interview, the facility failed to ensure advanced directives were implemented for Resident #133. This was true for one (1) of three (3) residents reviewed during the survey. This will be cited as past non-compliance because the facility identified what had happened and took immediate steps to correct the failure to ensure it does not reoccur. All components of the plan of correction were completed prior to this survey beginning. This did occur, and was substantiated by the facility as occurring. Resident #133 had completed a Physician Order for Scope of Treatment (POST) form, indicating her wishes to be a full code therefore this will be cited as past non-compliance. Facility census: 32. Resident identifiers: Resident #133. Findings included: a) Facility On [DATE] at 02:25 PM, a record review was completed for Resident #133 which revealed the following progress notes, (typed as written): [DATE] 22:00 Health Status Note Note Text: Resident resting in bed with O2 (oxygen) in place at 2L/nc; HOB elevated 30 degrees; she told CNA that she was having some trouble breathing, and felt nauseated; CNA alerted this nurse, and placed pulse ox on; this nurse checked resident at 22:15 and found her not breathing, no pulse, pupils fixed and nonreactive, extremities cold to touch, torso rigid; color yellow, pale; sternal rub, shaking resident, calling her name were ineffective; monitored VS x 5 min with no signs of life; NOC and Administrator notified; call to family who requested to come in to see resident; call to Provider at 2300 who gave order to not attempt CPR and pronounce resident deceased . [DATE] 23:20 COMMUNICATION Note Text: Call to family to let them know of resident passing; (granddaughter) very upset and gave phone to husband; family requesting to come in to see resident; stated they would be here in ,d+[DATE] min; family arrived at MN; this nurse relayed sequence of events and interventions by staff; (granddaughter) voiced understanding; family expressed wishes for [NAME] Funeral Home and wants to wait until they arrive; family boxed up some personal items (pictures, glasses, hearing aids, jewelry), and stated they would probably donate some items to this facility; awaiting Funeral Home arrival. Further review of Resident #133's medical record revealed Resident #133 had completed a POST which indicated her wishes for Cardiopulmonary Resuscitation (CPR), including mechanical ventilation, defibrillation and cardioversion with full treatments and a time limited trail of 14 days of medically assisted nutrition but no surgically placed tubes. In addition, Resident #133's physician's orders and care plans were reviewed which revealed the following: Physician's order: Full Code- Full interventions. Medically assisted nitration for a limited trail of 14 days but no surgically placed tubes. Active [DATE] Care plan: Focus: West Virginia (WV) Advanced Directives: full code, full treatments. Provide medically assisted nutrition time limited trail of 14 days but no surgically placed tubes. Goal: Wishes will be honored through next review. Interventions: Full Code. Review advanced directives with resident/family yearly and as needed. On [DATE] at 03:15 PM, a review of the facility reportable incident (FRI) was completed. The review of this FRI, dated [DATE], revealed that Resident #133 was observed to be nonresponsive upon staff entering Resident #133's room. Resident #133 was noted to be cold to touch, rigid, with yellow pale skin tone. Resident #133 was noted to have a full code status in the medical record. Resident #133's physician was notified of Resident #133's status including above findings and the order was given to not begin CPR due to signs of death. The investigation started immediately on [DATE]. A statement was obtained from all staff on duty the night of [DATE] which included the following statements: b) Nurse Aide (NA) #46 NA #46 stated that at 10:00 PM, NA #46 went to change Resident #133. Resident #133 voiced having trouble breathing. NA #46 states she elevated the position of Resident #133's head of bed, Resident #133 voiced being nauseous. NA #46 states she went and told RN #53 what Resident #133 had voiced. NA #46 stated that she got the vital pole and put the pulse oximetry on Resident #133 noting an oxygen saturation of 94%. NA #46 told Resident #133 she was going to leave the pulse oximetry on Resident #133 for a few minutes and come back to check on her. NA #46 reports at 10:15 PM, when NA #46 re-entered Resident #133's room that RN #53 was in there at this time with Resident #133's medications. NA #46 stated that she told RN #53 was not breathing and voiced that Resident #133's skin color appeared to be yellowish-pale color. NA #46 states RN #53 began sternal rubs and Resident #133 was cold to touch. NA #46 states she continued to check for a pulse with no pulse found. c) RN #53 RN #53 stated that on [DATE] around 10:00 PM, Resident #133 had been resting in bed with oxygen in place at two (2) liters per minute via nasal cannula with the head of bed elevated to 30 degrees. RN #53 stated Resident #133 had expressed to NA #46 that she was having some trouble breathing and felt nauseated. RN # 53 stated NA #46 alerted her and that NA #46 had placed the pulse oximeter on Resident #133 RN #53 stated that she checked Resident #133 at 10:15 PM and found Resident #133 not breathing, no pulse, pupils fixed and non-reactive, extremities cold to touch, torso rigid, color yellow and pale. RN # 53 stated she began sternal rubs, shaking Resident #133, calling Resident #133's name, which was ineffective. RN #53 stated Resident #133's vital signs were monitored for five (5) minutes with no signs of life. RN #53 stated she attempted to call the nurse on call and administrator with no answer initially. RN #53 stated she called Resident #133's family who requested to come in and see Resident #133. RN #53 also stated she made a call to Resident #133's physician, who gave orders to not attempt CPR and pronounced Resident #133 deceased . On [DATE] the Administrator had an additional conversation with RN #53, in which RN #53 stated that when asked why she did not initiate CPR, RN #53 stated that she didn't know why. RN #53 further stated that she was in the mode of pronouncing death and not thinking about CPR. RN #53 stated that was why she was observing for five (5) minutes for signs of life. RN #53 stated because of her assessment, she thought that Resident #133 was gone. When the Administrator asked RN #53 if she thought those observations represented irreversible signs of death, RN #53 stated yes she did. RN #53 stated that she was just trying to do the right thing. On [DATE] the five (5) day follow up investigation was submitted which stated RN #53 was suspended pending investigation and later terminated as a result of the investigation with the allegation having been substantiated. On [DATE] at approximately 9:30 AM, the Administrator provided a copy of the facility plan of action which indicated the following: On [DATE] all staff on duty to be educated on Full Code Protocol and Responding to resident change in condition which was followed by 100% compliance with education of all staff. On [DATE] all staff were re-educated on Full Code Protocol, Responding to resident change in condition, visual aid for clinical algorithm for unresponsive resident and irreversible signs of death with 100% compliance with education of all staff. In addition, a post test of education is scheduled within one (1) month and six (6) months. This education was added to the orientation process for all newly hired employees also. Two (2) ADHOC (impromptu) Quality Assurance and Performance Improvement meetings were conducted to evaluate the occurrence and review actions, a root cause analysis was performed with the above action plans developed. On [DATE] at approximately 10:00 AM, a review of the staff education was completed in addition to the QAPI meetings. All staff signatures were obtained and were verified via the staff roster. On [DATE] at approximately 10:30 AM, an interview was conducted with the facility Administrator who confirmed the incident which involved Resident #133 did happen as reported.

Based on observation and staff interview, the facility failed to ensure the resident's medical record was accurate and complete. Resident #25's dental assessments were incorrect. Resident #27's post form did not have the correct date. Resident identifiers: #25 and #27. Facility census: 32. Findings included: a) Resident #25 Observation of the resident on 12/05/22 at 11:43 AM, found the resident had several likely broken and decayed teeth. The most recent full Minimum Data Set (MDS) a significant change MDS, with an assessment reference date (ARD) of 06/17/22 found the MDS coded the resident as having obvious broken or decayed teeth. On 12/06/22 at 8:35 AM, the Clinical Nurse Consultant (CNC) #13 reviewed the last three (3) dental status assessments in the resident's medical record, dated 09/05/22, 10/25/22 and 11/15/22, and agreed the assessments did not indicate the resident had any dental issues. 45174 b) Resident #27 During a medical record review on 12/05/22 at 3:04 PM, Resident # 27's Physician Orders for Scope of Treatment (POST) form was reviewed. On the POST form section E, Signature: Patient or Patient Representative signature date was her date of birth not the date of signature. During a interview on 12/06/22 10:26 AM the Social Worker acknowledged on Resident # 27's POST form, Resident signature date was her date of birth not the date it was signed.

Based on record review and staff interview, the facility failed to ensure a safe and effective transition of care for one (1) of two (2) residents reviewed for the care area of hospitalization during the long term care survey process. There was no documentation the following information was sent with Resident #24 when transferred to the hospital: the reason for the transfer, contact information of the practioner responsible for care, resident representative contact information, advance directive information, diagnosis, medications (including when last received) comprehensive care plan goals, any treatment or devices, most recent labs, other diagnostic tests, and recent immunizations, recent vital signs, etc. Resident identifier: #25. Facility census: 32. Findings included: a) Resident #25 Record review found the following nursing note: 10/23/2022 11:10 Health Status Note Note Text: Resident not at baseline this am. responsive to verbal stimuli will not answer staff question fixed gaze. weak grasps, pupil's small resident would not open eyes enough to see reaction. Resident lethargic Respiration labored and shallow VS (vital signs) bp (blood pressure) 164/80, temp 99.7, hr 68, O2 97%, Resp (respirations) 26. Doctor in new order for resident to be sent to ED (emergency department) for evaluation. POA (power of attorney) agreeable with order. On 12/06/22 at 10:15 AM, the Clinical Nurse Consultant (CNC) said the facility nurse is to complete an E-interact transfer form to send with the resident when transferred to the hospital. The CNC confirmed she was unable to find any evidence the form was completed; therefore, there was no evidence of what information, if any, was communicated to the hospital at the time of transfer.

Based on record review and staff interview, the facility failed to provide a copy of the bed-hold policy to two (2) of two (2) residents and or the responsible party when the residents were admitted to the hospital. This was true for two (2) of two (2) residents reviewed for the care area of hospitalization during the long term care survey process. Resident identifiers: #25 and #35. Facility census: 32. Findings included: a) Resident #25 Record review found the following nursing note: 10/23/2022 11:10 Health Status Note Note Text: Resident not at baseline this am. responsive to verbal stimuli will not answer staff question fixed gaze. weak grasps, pupil's small resident would not open eyes enough to see reaction. Resident lethargic Respiration labored and shallow VS (vital signs) bp (blood pressure) 164/80, temp 99.7, hr 68, O2 97%, Resp (respirations) 26. Doctor in new order for resident to be sent to ED (emergency department) for evaluation. POA (power of attorney) agreeable with order. On 12/06/22 at 1:49 PM, the Clinical Nurse Consultant (CNC) #13 verified she was unable to find evidence a copy of the bed hold policy was sent with the resident or responsible party at the time of transfer or within 24 hours of the emergency transfer. b) Resident #35 Record review found the resident was transferred to the hospital on 9/21/2022 at 9:55 AM, Change of Condition Note Text: Resident coughed up dark red sputum. Is having increase SOB O2 89% @3l via NC (nasal cannula.) adventitious lung sounds noted throughout lung fields with diminished sounds in left lower lobe. Doctor notified and order resident to be sent to ED for evaluation. POA (power of attorney) notified and agreeable with transfer. On 12/06/22 at 2:50 PM, the Clinical Nurse Consultant (CNC) #13 and the Social worker (SW) verified they were unable to find evidence a copy of the bed hold policy was sent with the resident or responsible party at the time of transfer or within 24 hours of the emergency transfer.

Based on record review and staff interview, the facility failed to ensure two (2) of five (5) residents receiving psychotropic medications received a gradual dose reduction (GDR) or had documentation by the physician a GDR was clinically contraindicated. Resident identifiers, #8, #19. Facility census 32. Findings included: a) Resident #8 On 12/06/22 at 09:54 AM, based on documentation, a Gradual Dose Reduction (GDR) recommendation was completed by Pharmacist on 08/08/22 for multiple antipsychotic medications. The GDR listed two medications, olanzapine 2.5mg qhs and quetiapine 12.5mg qhs. The Physician signed the GDR form on 08/29/22 agreeing with the recommendation, discontinuing only the olanzapine. The physician failed to provide any clinical contraindications for the quetiapine to be continued at current level. Resident #8 continued to receive quetiapine from 08/29/22 until present with no documentation the medication continued to be required. On 12/06/22 at 11:54 AM, the Clinical Nurse Consultant #13 acknowledged the physician failed to address the pharmacist recommendation for a GDR for quetiapine. On 12/07/22 at 9:43 AM, Director Of Nursing (DON) #1 reviewed the pharmacists recommendations. The DON confirmed the physician failed to address all medications recommended by the pharmacist for a GDR. She said she would work with pharmacist and physician to assure all medications are addressed going forward. b) Resident #19 Record review on 12/06/22 at 8:53 AM, found a Gradual Dose Reduction (GDR) recommendation was completed by the pharmacist on 09/14/22 for multiple antipsychotic medications. The GDR listed three (3) separate medications, Aripiprazole 5mg daily, Lorazepam 0.5mg / 1 mg daily and Sertraline 50mg daily. The physician signed the GDR form on 09/27/22 agreeing with the recommendation, decreasing Lorazepam to 0.5mg two times per day. The Physician ordered that Ativan be decreased to 0.5mg BID. The physician failed to provide the clinical rational for continuing Sertraline at the current levels. Resident #19 continued to receive Sertraline from 09/27/22 until present. On 12/06/22 at 11:54 AM, the Clinical Nurse Consultant #13 reviewed the recommendations of the pharmacist and acknowledged not all the recommendations were addressed. On 12/07/22 at 9:43 AM, Director Of Nursing (DON) #1 confirmed not all recommendations made by the pharmacist were addressed. The DON said she would work with pharmacist and physician to assure all medications are addressed going forward.

Based on record review and staff interview, the facility failed to ensure the physician addressed each recommendation made by the pharmacist for a gradual dose reduction (GDR) for medications for two (2) of five (5) residents reviewed for unnecessary medications during the long - term care survey. Resident identifiers: #8 and #19. Facility census: 32. Findings Included: a) Resident #8 On 12/06/22 at 09:54 AM, based on documentation, a Gradual Dose Reduction (GDR) recommendation was completed by Pharmacist on 08/08/22 for multiple antipsychotic medications. The GDR listed two medications, olanzapine 2.5mg qhs and quetiapine 12.5mg qhs. The Physician signed the GDR form on 08/29/22 agreeing with the recommendation, discontinuing only the olanzapine. The physician failed to provide any clinical contraindications for the quetiapine to be continued at current level. On 12/06/22 at 11:54 AM, the Clinical Nurse Consultant #13 acknowledged the physician failed to address the pharmacist recommendation for a GDR for quetiapine. On 12/07/22 at 9:43 AM, Director Of Nursing (DON) #1 reviewed the pharmacists recommendations. The DON confirmed not all medications were addressed, and said she would work with pharmacist and physician to assure all medications are addressed going forward. b) Resident #19 Record review on 12/06/22 at 8:53 AM, found a Gradual Dose Reduction (GDR) recommendation was completed by the pharmacist on 09/14/22 for multiple antipsychotic medications. The GDR listed three (3) separate medications, Aripiprazole 5mg daily, Lorazepam 0.5mg / 1 mg daily and Sertraline 50mg daily. The physician signed the GDR form on 09/27/22 agreeing with the recommendation, decreasing Lorazepam to 0.5mg two times per day. The Physician ordered that Ativan be decreased to 0.5mg BID. The physician failed to provide the clinical rational for continuing Sertraline at the current levels. On 12/06/22 at 11:54 AM, the Clinical Nurse Consultant #13 reviewed the recommendations of the pharmacist and acknowledged not all the recommendations were addressed. On 12/07/22 at 9:43 AM, Director Of Nursing (DON) #1 confirmed not all recommendations were addressed. The DON said she would work with pharmacist and physician to assure all medications are addressed going forward.

Based on observation, record review, and staff interview, the facility failed to ensure the oxygen concentrator was set on the physician ordered flow rate. Resident #5. Facility census: 32. Findings included: a) Resident #5 Observation on 12/05/22 at 12:33 PM, found the oxygen concentrator flow rate was set at 3 liters per minute. Licensed Practical Nurse (LPN) #21 confirmed the physician's order directed the flow rate to be set at 2 liters per minute. LPN #21 said she would correct the problem. Review of the medical record found an order, dated 12/28/21, Oxygen at 2L (liters) via nasal cannula. On 12/06/22 at 2:01 PM, the Clinical Nurse Consultant (CNC) #13 was advised of the above observation. No further information was provided.

Based on medical record review, resident interview and staff interview the facility failed to ensure the residents had the right to participate and must be given the opportunity to participate in development, review and revision of his/her care plan. This was true for one (1) of thirteen (13) reviewed for care plans during the Long-Term Care Survey Process. Resident Identifiers: Resident #30. Facility Census: 32. Findings Included: a) Resident #30 During an interview on 12/05/22 at 12:03 PM, Resident # 30 stated I am not invited and have never attended a care planning meeting. During a review on 12/06/22, Resident # 30 medical record revealed a Care plan note dated 10/26/2022 Typed as written Resident #30's name was discussed in care plan meeting today. R/P (responsible party) was invited but did not attend. During an interview on 12/06/22 at 9:11 AM the Social Worker stated I send a letter to the representatives inviting them to the care plan meeting. If the Resident does not have capacity we still invite the resident to the meetings or go to their rooms. Her sister attends the meetings by phone. Resident #30 has attended some of her care plans meetings. During an interview on 12/06/22 at 9:16 AM, the SW stated my progress note did not reflect she was invited or attended the care plan meeting on 10/26/22.

Based on observation, medical record review, resident interview and staff interview the facility failed to develop and implement a comprehensive person-centered care plan with communication devices such as hearing aid. This is true for one (1) of thirteen (13) resident care plans reviewed during the Long-Term Care Survey (LTCSP). Resident # 20. Facility Census: 32 Findings Included: a) Resident #20 During an interview on 12/05/22 at 2:40 PM Resident # 20 stated I have a hearing aid in one ear and the other hearing aid is broken. During an observation on 12/05/22 at 2:40 PM Resident # 20 had a hearing aid in the right ear only. Further review of the medical record revealed Resident # 20 care plan with an initiation date of 08/11/22. The care plan contained the following: Focus: Communication deficit related to difficulty being understood Goal: Basic needs will be met through review date. Inventions: -ask questions requiring yes or no -observe for non-verbal communication -use short phrases when communicating with resident. Allow ample response time. There was no evidence of a hearing aid intervention in Resident # 20's care plan. During an interview on 12/06/22 at 10:55 AM the Minimum Data Set (MDS) Registered Nurse (RN) #20 acknowledged the care plan with an initiated date of 08/11/22 was incorrect and did not reflect a hearing aid intervention.

Based on observation, medical record review, resident interview and staff interview, the facility failed to accurately complete a Minimum Data Set (MDS) assessments for two (2) of thirteen (13) residents reviewed during the Long-Term Care Survey (LTCSP). The MDS's for Resident #20 did not accurately reflect the use of hearing aides and Resident #34 MDS did not accurately reflect the prognosis of end of life of less than six (6) months. Resident identifier: #20 and #34. Facility Census: 32 Findings Included: a) Resident #20 During an interview on 12/05/22 at 2:40 PM Resident # 20 stated I have a hearing aid in one ear and the other hearing aid is broken. During an observation on 12/05/22 at 2:40 PM Resident # 20 had a hearing aid in the right ear only. Review of the quarterly MDS's on 12/06/22 with Assessment Reference Dates (ARD) of 09/02/22 discovered the following: Section B, titled Hearing, Speech and Vision, Section B0300 Hearing Aid was coded as: zero (0) for no hearing aid. During an interview on 12/06/22 at 10:22 AM, the Social Worker (SW) #30 stated I did not know Resident # 20 had a broken hearing aid. During an interview on 12/06/22 at 10:36 AM, the SW stated I spoke to Resident #20's representative. They keep one at home in case this one breaks. They will not bring it; they are afraid it will get misplaced. I know no one had mentioned broken hearing aides. During an interview on 12/06/22 at 10:55 AM the MDS Register Nurse (RN) #20 acknowledged the quarterly MDS with ARD of 09/02/22 Section B hearing aid was coded incorrectly. b) Resident #34 Review of the quarterly MDSs on 12/06/22 with (ARD) of 10/20/22 discovered the following: Section J, titled Health Conditions, Section J1400 Prognosis was coded as: zero (0) for life expectancy of less than 6 months. During a review on 12/06/22 Resident # 20's medical record revealed a physician note dated 09/27/22 stated .typed as written He has palliative care. Cancer pain. During a review on 12/06/22, Resident # 20's medical record revealed a Social Services note dated 1019/22: He has a Dx of Ca to his liver, abdomen and colon. He is prescribed Tylenol PRN and Oxycodone Q6hrs for pain. Lately his pain has increased. He continues to feed himself and is still able to propel himself up the hallway to activities or around the block. Resident's name is pleasant and cooperative with staff. No changes in POST (DNR with selective treatments) Hospice was offered but denied this review. Family realizes that the time will come that Hospice may be needed.