Every finding on record at Lindside Healthcare Center

Based upon observation, record review, and staff interview, the facility failed to post nurse staffing information in a prominent location, readily available for review to the public. Additionally, the facility failed to maintain current information pertaining to actual hours worked by registered nurses, licensed practical nurses or nurse aides. Census: 53Findings included: a) Observation Upon initial entrance to the facility on [DATE] at approximately 10:00 AM, the Surveyor looked for the posted nurse staffing information in the lobby, front living room area, and main entrance area where many other signs were posted. The nurse staffing data was not found. The nurse staffing data was only located after asking the Nursing Home Administrator where it was located. The nurse staffing sheet was posted in the hallway near the nursing station. b) Record Review Posted nurse staffing data was reviewed for the following dates:-07/03/25-07/04/25-07/05/25-07/06/25-07/07/25-07/08/25-07/09/25-10/30/25-10/31/25-11/01/25-11/02/25-12/23/25-12/24/25-12/25/25-01/10/26-01/11/26-01/12/26-02/17/26-02/18/26 There were no changes marked to any of the typed data on the 19 posted nurse staffing sheets, thus indicating this was not a fluid document with changes being made to staffing as they occur. On 11/02/25, the posted nurse staffing data did not report any Registered Nurse (RN) hours worked.Upon discussing this finding with the Nursing Home Administrator (NHA) on 03/10/26 at 3:45 PM, the NHA stated she was pretty sure there was a nurse manager on duty that day, and stated we are very careful to ensure we have RN coverage. She stated she would check further and get back with me. On 03/11/26, the NHA presented a punch detail sheet from the facility's time and attendance system where there was an RN on duty on 11/02/25 from midnight until 8:45 AM. This created a discrepancy from the posted nurse staffing sheet, which stated zero (0) hours worked by RN. On 07/06/25, the Hours Per Patient Day (HPPD) was calculated to be 2.15 based upon the total hours worked and the census on the posted nurse staffing data. This finding was reviewed with the NHA on 03/10/26 at 3:45 PM. The NHA stated on 03/11/26 at 9:20 AM, she felt the numbers were wrong on the posted staffing sheet and stated she would pull staff punch time detail reports for the staff who worked. A recalculation of HPPD was performed based upon timecard punches of nursing staff who worked that day. The HPPD was then calculated to be 2.27 based upon a census of 58 and total hours worked of 131.75. This discrepancy meant the total hours worked was inaccurately reported on the posted nurse staffing sheet for 07/06/25. This finding was reviewed again with the NHA on 03/11/26 at approximately 1:15 PM. The NHA nodded her head in agreement when advised a deficiency would be cited for F732.

Based on record review and staff interview, the facility failed to develop a care plan with measurable goals and interventions to address the care and treatment for a resident with dementia. This failed practice was found true for (1) one of (5) five residents reviewed for dementia care during the Long-Term Care Survey Process. Resident identifier #7. Facility census: 53. Findings included: a) Resident #7 A record review, completed on 03/10/26 at 12:30 PM, revealed a diagnosis of dementia for Resident #7, dated 10/20/22. Further review of Resident #7's care plan revealed no dementia care plan with measurable goals and interventions developed. During an interview on 03/10/26 at 2:56, the interim Minimum Data Set Registered Nurse (MDSRN) stated, The doctor did give him that diagnosis; we just missed it. We did not develop a care plan for his dementia.

Based on record review and staff interviews, the facility failed to ensure an accurate and complete medical record. This failed practice was found to be true for (2) two of (5) five residents reviewed under the care area of unnecessary medications during the Long-Term Care Survey Process. Resident identifiers: #43 and #3. Facility Census: 53. Findings included: a) Resident #43 A record review, completed on 03/09/26 at 2:27 PM, revealed an allergy for Resident #43 to the medication Loxitane. Further review of Resident #43's current medications revealed that he has been prescribed Loxitane since his admission in November of 2018. The admission history and physical (H&P), dated 09/24/18, shows Loxitane was taken off as an allergy, however it was still listed as an allergy in his medical record. During an interview on 03/10/26 at approximately 1:30 PM, the Director of Nursing (DON) confirmed that Resident #43 is not allergic to Loxitane and has been on it since admission. The DON further confirmed that listing Loxitane as an allergy was incorrect. b) Resident #3 On 03/09/26 at 3:00 PM, a record review was completed for Resident #3. The review found Resident #3 had a physician's order for Tamsulosin (Flomax) 0.4mg one (1) capsule by mouth at bedtime for BPH (benign prostatic hyperplasia). The review found the diagnosis of BPH was incorrect due to the resident being a female. On 03/10/26 at 8:45 AM, the Administrator confirmed the diagnosis for the medication for Resident #3 was incorrect.

Based on record review and staff interview, the facility failed to obtain informed consent for a psychotropic medication for Resident #4. This was true for one (1) of five (5) residents reviewed under the care area of unnecessary medications. Resident Identifier: #4. Facility Census: 53.Findings Included: a) Resident #4 On 03/10/26 at 1:23 PM, a record review was completed for Resident #4. The review found a physician's order, dated 02/24/26, for Zoloft 25 mg one (1) tablet by mouth one (1) time a day for depression. Upon further review, a signed informed consent was not found for the medication in the medical record. On 03/10/2026 at 2:45 PM, the Director of Nursing (DON) confirmed the informed consent was not obtained for Zoloft.

Based on resident interviews, observation, and staff interview, the facility failed to ensure the full contact information for the Office of Health Facilities Licensure and Certification (OHFLAC) was posted for the residents. This was a random opportunity for discovery during the required resident council meeting during the Long-Term Care Survey Process. Census: 53. Findings included:During the Resident council meeting which began at 2:05 PM and ended at 2:38 PM on 03/10/26, residents stated they did not have the number for OHFLAC and did not know how to call and complain. When the meeting ended, the State Surveyor checked the posters with important contact information that were posted in the front hallway. The OHFLAC address was listed but not the phone number. During an interview on 03/10/26 at 3:29 PM, the Director of Social Services confirmed that the number was not posted.

Based on record review and staff interview, the facility failed to ensure advance directives were correct and in accordance with Resident #44's wishes. This was true for one (1) of 19 residents reviewed for accurate advance directives throughout the Long-Term Care Survey Process. Resident Identifier: #44. Census: 53.Findings included: In the facility's policy titled [NAME] Virginia Code Status, Section IV Conflict Resolution directed, In the event there is a conflict between the orders on a resident's POST [Physician Orders for Scope of Treatment] form and his/her advance directive, then the conflict will be resolved as below considering: ii. whether the resident initialed the authorization box in section D on the POST form which allows a new form to be completed for a deterioration in the resident's condition.The POST form, dated and signed by Resident #44 on 12/19/23, did not have the authorization box marked and was marked as a full code.The POST form, dated 11/26/25, was marked Do Not Resuscitate (DNR) and signed by the Resident's Medical Power of Attorney (MPOA).In an interview with the Director of Social Services, at 11:32am on 03/10/26, it was confirmed that the 11/26/25 POST form was incorrect.

Based upon observation, resident interview, and staff interview, the facility failed to ensure a safe, clean, comfortable homelike environment. This was found to be true for one (1) of 24 residents reviewed during the Long-Term Care Survey Process. Resident identifier: #13. Facility census: 53. Findings included: a) Resident #13 During an initial interview with Resident #13, on 03/09/26 at 11:10 AM, the resident was sitting in her recliner. The recliner was approximately 3 - 4 feet away from the wall. The surveyor observed an area of approximately one (1) square foot on the wall behind the recliner which had been patched with a white substance. Surveyor asked the resident how long the wall had been missing paint in that area. Resident stated it had probably been at least two months. At approximately 11:28 AM on 03/09/26, the surveyor asked the Nursing Home Administrator (NHA) to accompany her to the resident's room. The unpainted area on the wall was pointed out. The NHA stated yes, that was where we patched in preparation for painting. A few minutes later while walking back down the hall, she stated the maintenance person who was doing all of their painting had gone back to school and was now working in the facility as a CNA.

Based on record review and interview, the facility failed to ensure accuracy of Minimum Data Set (MDS) in regard to immunizations. This was true for one (1) of one (1) residents reviewed for respiratory care throughout the Long-Term Care Survey Process. Resident identifier: #10. Census: 53.Findings included: Review of the MDS, Section O showed Resident #10 was not up-to-date with the Covid 19 vaccination. Review of the immunization record showed Resident #10 had last Moderna Covid 19 vaccination on 10/20/25. During an interview on 03/10/26 at 2:55 PM, Clinical Manager RN #71 confirmed that Moderna is a one-dose vaccine and Resident #10 was up-to-date for 2025-2026. It was also confirmed that the MDS was coded incorrectly.

Based on record review and staff interviews, the facility failed to ensure quality of care for residents. This failed practice was found true for one (1) of (4) four residents reviewed under the care area of accidents and one (1) of five (5) residents reviewed under the unnecessary medications pathway throughout the Long-Term Care Survey Process. Resident identifiers: #4 and Resident #7. Facility Census: 53. Findings included: a) Resident #34 A conversation with the Director of Nursing (DON), on 03/10/26 at 1:15 PM, revealed Resident #34 had a physician order to use the Omnicycle six days a week for restorative therapy. Record review revealed Resident #34 used the Omnicycle on the following dates:-02/13/26-02/14/26-02/16/26-02/18/26-02/19/26-02/23/26-02/24/26-02/25/26-02/27/26-03/04/26-03/06/26-03/07/26-03/09/26 Resident refused on the following dates:-02/20/26-02/21/26 It was observed N/A was marked on the following dates:-03/03/26-03/05/26-03/02/26-02/26/26-02/17/26-02/12/26-02/11/26 In speaking with the DON, the column N/A could mean a number of things; however, the fact is the resident did not participate in the exercise for that day. The DON stated, They know not to use that column. b) Resident #7 On 03/10/26 at 2:00 PM, a record review was completed for Resident #7. The review found a physician's order, dated 09/11/21, to obtain a valproic acid level every 6 (six) months. The review, also, found a valproic acid level dated 05/29/25. There were no other valproic acid levels found after this date. The valproic acid level should have been collected on 11/29/25. On 03/10/26 at 3:58 PM, the Director of Nursing (DON) confirmed the laboratory test was not obtained as ordered by the physician.

Based upon resident interview, observation, and staff interview, the facility failed to ensure a safe environment to prevent a tripping hazard. This was found to be true for one (1) of 24 residents reviewed during the Long-Term Care Survey Process. Resident identifier: #13. Facility census: 53. Findings included: a) Resident #13 During an initial interview with the resident on 03/09/2026 at 11:10 AM, she asked if the State Agency (SA) would look at the floor going into the bathroom. The resident stated, I am afraid I will trip on it. She further stated she had reported it several times, and maintenance had fixed it once, but it did not stay. The surveyor opened the door to the bathroom and observed the transition strip on the flooring in the doorway was bent upward and the wooden floor beneath it was bent downward creating a gap. This gap created a potential tripping hazard. At approximately 11:28 AM, the SA asked the Nursing Home Administrator (NHA) to accompany the SA to the resident's room. The surveyor pointed out the gap in the threshold in the resident's bathroom. The NHA stated she would have maintenance get that fixed.

Based on record review and staff interview, the facility failed to offer Pneumococcal vaccinations to aid in the prevention of Pneumonia. This failed practice was found true for (2) two of (5) five residents reviewed for vaccinations during the Long-Term Care Survey Process. Resident identifiers: Resident #15 and Resident #4. Facility Census 53.Findings included: a) Resident #15A record review, completed on 03/11/26 at 9:43 AM, revealed that Resident #15 lacked documentation showing the pneumococcal vaccination was offered.During an interview on 03/11/26 at 10:05 AM, the Infection Preventionist (IP) stated, He had the vaccinations before he came here. She presented a document from a local pharmacy indicating he had all vaccinations except the pneumococcal vaccination. The State Agency (SA) pointed out to the IP that the document did not indicate the pneumococcal vaccination had been given. The IP stated, I guess he refused it.Further record review revealed no declination in the medical record for the pneumococcal vaccination, and a Physician's Determination of Capacity indicating that Resident #15 lacked capacity to make medical decisions. At approximately 10:25 AM on 03/11/26, the Director of Nursing brought the SA a signed declination for the pneumococcal vaccination with the current date date of 03/11/26 signed by the incapacitated resident.During an interview on 03/11/26 at 10:26 PM the IP agreed that Resident #15 had not been offered the pneumococcal vaccination after the SA pointed out that the declination had today's date and was signed by Resident #15, who lacked the capacity to make medical decisions.b) Resident #4A record review, completed on 03/11/26 at 10:45 AM, revealed that Resident #4's pneumococcal vaccination was marked as not eligible.During an interview on 03/11/26 at 10:50 AM, the IP stated, She is not eligible because she is not 60.Further record review on 03/11/26 at 11:00 AM, revealed that Resident #4 is currently [AGE] years old.A review on 03/11/26 at 11:10 AM, of the policy titled Resident Pneumococcal Vaccines, read as follows:It is the policy of this facility to provide resident-centered care that meets the psychosocial, physical and emotional needs and concerns of the residents. The purpose of this policy is to educate staff and notify residents and responsible parties in an effort to reduce the severity and episodes of certain types of pneumonia. The CDC recommends that individuals age [AGE] years and older and adults 10 through [AGE] years old with certain medical conditions or risk factors be vaccinated against pneumococcal pneumonia, and in particular, those who also have chronic lung diseases such as COPD, those who smoke cigarettes, those who have diabetes and other conditions that may lower their resistance to infection.During an interview on 03/11/26 at 11:30 PM, the IP confirmed that the age on the policy is 50 and that Resident #4 had not been offered the pneumococcal vaccination.

Based on document review and staff interview, the facility failed to provide written documentation upon discharge on the right to appeal and provide contact information to the Ombudsman and local State Agency. This was true for 3 of 3 residents reviewed (Residents #61, #62, and #63). Facility census 58. Review of the discharge documentation on 02/10/26 during the hours of 10:15 a.m. through 11:15 a.m. for Residents #61, #62, and #63 revealed no readily available documentation that included any written information on the resident's right to appeal discharge with contact information to the local Ombudsman or State Agency. An interview on 02/10/26 at 11:40 a.m. with the facility's Director of Nursing (DON) verified these findings. These findings were also acknowledged by the facility's Administrator at the exit conference on 02/10/26 at approximately 12:30 p.m.

Based on record review, resident, and staff interview. The facility failed to ensure that a resident received the treatment and care in accordance with professional standards of practice in regard to monitoring pain levels. This was true for three (3) of five (5) residents reviewed for pain during the Long-Term Survey Process. Resident Identifier: #26, #29, and #157. Facility census: 54. Findings included: a) Resident #29 Medical record review revealed Resident #29 had a broken hip. The resident had a physician orders for pain management. The oder was for Acetaminophen Oral Tablet (Acetaminophen). Give 500 mg by mouth every six (6) hours as needed for pain. The order stated, Do not exceed 3000mg total dose in a 24-hour period from any medication with a state date 08/02/24. A continued review of Medication Administration Record (MAR) revealed: --08/13/24 at 8:06 AM pain level 8 - Acetaminophen 500 mg tablet given. --08/14/24 at 7:09 AM pain level 8 - Acetaminophen 500 mg tablet given. An interview on 08/21/24 at 5:12 PM with Assistant Director of Nursing (DON), she confirmed Resident #29's Pain medication did not have perameters, and she was not receiving pain medication per nursing standards. b) Resident #26 During an interview on 08/19/24 at 2:42 PM Resident #29 stated that he has a good bit of pain. Medical record review revealed Resident #26's physician orders for pain management: --Acetaminophen Oral Tablet (Acetaminophen), Give 2 tablet by mouth every 8 hours as needed for pain with a start date 02/28/24. --Oxycodone HCl Oral Tablet 5 MG (Oxycodone HCl) *Controlled Drug* Give 1 tablet by mouth every 6 hours as needed for pain, with a start date 06/29/24. Continued review found no parameters were on the pain management orders. A continued review of Medication Administration Record (MAR) revealed: --06/03/24 at 7:28 AM pain level 3- Oxycodone HCL tablet given. --06/03/24 at 3:37 PM pain level 3 - Oxycodone HCL tablet given. --06/08/24 at 7:25 AM pain level 3 - Oxycodone HCL tablet given. --06/08/24 at 8:27 PM pain level 3 - Oxycodone HCL tablet given. --06/09/24 at 7:33 AM pain level 3 - Oxycodone HCL tablet given. --06/13/24 at 8:15 PM pain level 3 - Oxycodone HCL tablet given. --06/17/24 at 7:20 AM pain level 3 - Oxycodone HCL tablet given. --06/18/24 at 7:12 AM pain level 3 - Oxycodone HCL tablet given. --06/22/24 at 7:40 AM pain level 3 - Oxycodone HCL tablet given. --07/06/24 at 7:35 AM pain level 3 - Oxycodone HCL tablet given. --07/06/24 at 8:19 PM pain level 3 - Oxycodone HCL tablet given. --07/07/24 at 7:27 AM pain level 3 - Oxycodone HCL tablet given. --07/13/24 at 7:26 AM pain level 4 - Oxycodone HCL tablet given. --07/14/24 at 7:39 PM pain level 3 - Oxycodone HCL tablet given. --07/22/24 at 6:46 AM pain level 4 - Oxycodone HCL tablet given. --07/23/24 at 6:47 AM pain level 4 - Oxycodone HCL tablet given. --08/13/24 at 8:06 AM pain level 2 - Oxycodone HCL tablet given. --08/14/24 at 7:09 AM pain level 4 - Oxycodone HCL tablet given. Subsequent review revealed no acetaminophen tablets were given from 06/01/24 through 08/21/24. Also, no milligram was noted on the ordered acetaminophen. An interview on 08/21/24 at 3:21 PM with Assistant Director of Nursing (DON), she confirmed Resident #26's pain medication did not have perameters, and he was not receiving pain medication per nursing standards. 43340 c) Resident #157 During an interview on 08/19/24 at 3:21 PM, Resident #157 stated he received PRN (as needed) oxycodone for pain management. A record review was completed on 08/20/24 at 8:51 PM. Resident #157 was admitted to the facility on [DATE]. A review of the August 2024 Medication Administration Record (MAR) revealed the following order: Oxycodone Hcl Oral Tablet 5 MG. Give 1 tablet by mouth every 4 hours as needed for pain. Additionally, the August MAR revealed the following dates and times Resident #157 was given oxycodone one (1) time for pain rated at 0 and eight (8) times for mild pain rated between 1-2: -08/05/24 at 9:15 PM for a Pain Level of 2 -08/07/24 at 10:25 PM for a Pain Level of 1 -08/08/24 at 5:40 AM for a Pain Level of 0 -08/09/24 at 2:05 PM for a Pain Level of 2 -08/10/24 at 00:59 AM for a Pain Level of 2 -08/12/24 at 4:35 PM for a Pain Level of 2 -08/13/24 at 00:30 AM for a Pain Level of 2 -08/14/24 at 8:46 PM for a Pain Level of 1 -08/18/24 at 10:45 AM for a Pain Level of 2 Subsequently, the numeric pain rating scale (NPRS) was reviewed. It is a 0-10 scale that is often used by clinicians to assess pain intensity in clinical settings. On the scale, 0 means no pain and 10 means the worst pain imaginable. The NPRS can be administered verbally or graphically, and patients can complete it themselves. The NPRS is often categorized into the following ranges: No pain: 0 Mild pain: 1-3 Moderate pain: 4-6 Severe pain: 7-10 During an interview, on 08/21/24 at 3:02 PM, the ADON was asked how a nurse would know it was OK to administer the ordered oxycodone for pain. She responded the resident would be asked to rank their pain. The ADON was then asked if any pain level was reported, would the oxycodone be ordered. The ADON stated that oxycodone is typically utilized for more severe pain. When the above-mentioned dates where oxycodone was administered for a pain between 0 - 3 were reviewed with the ADON, she reported the nurses should have called the physician to question if he wanted to prescribe a different medication for a lesser level of pain.

Based on medical record review and staff interview, the facility failed to provide evidence a resident/resident's representative was provided a written Notice of Transfer for an acute hospital transfer. The facility also failed to provide evidence that a copy of the Notice of Transfer was sent to the Ombudsman. This was true for three (3) out of four (4) hospital transfers reviewed during the long-term care process. This had the potential to affect all residents being transferred or discharged . Resident identifiers: #20, #38, and #29. Facility census: 54. Findings included: a) Resident #29 Medical Record review on 08/21/24 revealed resident #29 was discharged to the hospital on 08/13/24. Subsequent review of Resident #29's medical record showed it did not contain documentation that the Notice of Transfer or Discharge was provided to the Resident Representative, or the Ombudsman was notified of the discharges on 08/13/24. On 08/21/24 at 5:58 PM during an interview the Administrator verified, there was no evidence that the Notice of Transfer or Discharge was completed and provided to the Resident's Representative for the discharges on 08/13/24. The Administrator also confirmed the Ombudsman was not notified of the discharges on 08/02/24. b) Resident #20 A medical record review was completed on 08/21/24 at 9:14 AM. The record review revealed Resident #20 was transferred to the hospital on 02/16/24. The record did not reflect the resident/resident's representative was provided a Notice of Transfer. During an interview with the Administrator on 08/21/24 at approximately 4:40 PM, the Administrator reported the correct Notice of Transfer/Discharge was not provided to resident upon transfer. c) Resident #38 A medical record review was completed on 08/21/24 at 9:53 AM. The record review revealed Resident #38 was transferred to the hospital on 11/16/23. The record did not reflect the resident/resident's representative was provided a Notice of Transfer, nor did the record reflect the Notice of Transfer was sent to the Ombudsman. During an interview with the Administrator on 08/21/24 at approximately 4:40 PM, the Administrator reported the correct Notice of Transfer / Discharge was not provided to resident upon transfer. 43340

Based on record review and staff interview the facility failed to thoroughly investigate thoroughly investigate 2 (two) instances of resident-to-resident sexual abuse and one instance of resident-to-resident physical abuse by failing to obtain statements from staff who were working at the time of the incidents, furthermore the facility failed to assess and interview like residents of the facility. This failed practice was true for 3 (three) of 5 (five) residents reviewed for abuse. Resident identifiers: #30, #54, #1 and #39. Facility Census: 54. Findings included: a) Resident #30 On 08/21/24 at approximately 10:00 AM, a review of the Facility Reported Incident (FRI) dated 07/26/24 was conducted revealing that on the morning of 07/26/24 at 10:30 AM, Licensed Practical Nurse (LPN) #82 witnessed Resident #207 pat Resident #30's mid section through his clothing. Further review of this investigation revealed 3 (three) statements which are typed as written and read as follows: Statement from LPN #82: I witnessed Resident #207 touching Resident #30 on his genital area outside his pants. I immediately removed Resident #207 from Resident #30. Administrator walking down hall during incident. She made Social Worker (SW) aware. Statement from Resident #30: I don't remember that. Statement from Resident #207: I did not do that. Further review of this investigation revealed there were no statements obtained from other staff working and that no other resident's were assessed or interviewed. In addition, a review of the policy and procedure entitled, [NAME] Virginia Abuse, Neglect and Misappropriation was conducted revealing that when conducting an investigation of abuse, the facility will obtain statements from staff related to the incident, including victim, person reporting incident, accused perpetrator and witnesses. On 08/21/24 at 12:00 PM, an interview was conducted with the facility SW. At this time, the SW acknowledged that she had not interviewed and obtained statements from other staff working 07/26/24, nor had other residents who may have had contact with Resident #207. In addition, the SW acknowledged she had not followed the policy and procedure. b) Resident #54 On 08/20/24 at 09:05 AM, a review of the Facility Reported Incident (FRI) dated 07/17/24, for Resident #54 was conducted revealing that on the night of 07/17/24 at 11:30 PM, Resident #54 was seen in the activity room with Resident #39 by Licensed Practical Nurse (LPN) #98. Resident #39 was massaging Resident #54's neck. LPN #98 asked Resident #39 to stop. Resident #54 was crying and said Resident #39 had asked to touch her all day on the butt and thigh. On 08/21/24 at approximately 10:00 AM, review of this investigation revealed 3 (three) statements which are typed as written and read as follows: Statement from LPN #98: Nurse saw Resident #39 rubbing Resident #54's shoulders. Resident #39 redirected to his room. Resident #39 went to his room and to bed. Resident #54 stated Resident #39 tried to touch her earlier in the day. Statement from Resident #54 (which was obtained by a face to face interview with Resident #54 and written by facility Social Worker (SW)): Resident #54 stated that man was rubbing my shoulders. My mom told me that a man should never touch me unless it's my doctor. When asked if it happened any other time, Resident #54 stated that Resident #39 patted her leg twice while sitting on couch watching TV. Resident #53 stated she went to bingo and Resident #39 asked her is she was a kid or retarded. Statement from Resident #39 (which was obtained by a face to face interview with Resident #39 and written by facility SW): I was trying to console that lady, she was crying. Resident #39 acknowledged he probably shouldn't touch people without permission. Further review of this investigation revealed there were no statements obtained from other staff working and that no other resident's were assessed or interviewed. In addition, a review of the policy and procedure entitled, [NAME] Virginia Abuse, Neglect and Misappropriation was conducted revealing that when conducting an investigation of abuse, the facility will obtain statements from staff related to the incident, including victim, person reporting incident, accused perpetrator and witnesses. On 08/21/24 at 12:00 PM, an interview was conducted with the facility SW. At this time, the SW acknowledged that she had not interviewed and obtained statements from other staff working the night of 07/17/24, nor had other residents who may have had contact with Resident #39. In addition, the SW acknowledged the allegation Resident #54 made that Resident #39 asked to touch her all day on the butt was not addressed in the investigation and she had not followed the policy and procedure. 50801 c) Resident #1 On 08/21/24 at approximately 10:00 AM, a review of the Facility Reported Incident (FRI) dated 10/20/2024 was conducted revealing that on the evening of 10/20/2024 at 18:15 PM, Licensed Practical Nurse (LPN) #85 's written report of the allegation which is typed as written and reads as folllows: Resident #1 was hit resident by Resident #301 on the left side of the face multiple times and on the back of the head. DON made aware. Resident # 301 was sent to hosipital for evaluation. On 08/21/24 at approximately 10:00 AM, review of this investigation revealed 2 (two) statements dated 10/21/23, which are typed as written and read as follows: Resident #1: That woman hit me. That woman mean. Resident # 20: That woman hit him. I saw it Further review of this investigation revealed there were no statements obtained from other staff working and that no other resident's were assessed or interviewed. On 08/21/2024 at 11:42 AM, an interview was conducted with the Director of Social Services. At this time, she acknowledged that she had not interviewed and obtained statements from other staff working the night of 10/20/24, nor had she interviewed other residents who may have had contact with Resident #301. A review of the policy and procedure entitled, [NAME] Virginia Abuse, Neglect and Misappropriation was conducted revealing that when conducting an investigation of abuse, the facility will obtain statements from staff related to the incident, including victim, person reporting incident, accused perpetrator and witnesses.

Based on record review and staff interview the facility failed to implement the facility Policy and Procedure entitled, [NAME] Virginia Abuse, Neglect and Misappropriation by failing to thoroughly investigate incidents of abuse between residents. The facility failed to obtain statements from staff who were working at the time of the incident. Furthermore, the facility failed to assess and interview like residents of the facility. This failed practice was true for three (three) of 5 (five) residents reviewed for abuse. Resident identifiers: #30, #54, and #1. Facility census: 54. Findings included: a) Resident #30 On 08/21/24 at approximately 10:00 AM, a review of the Facility Reported Incident (FRI) dated 07/26/24 was conducted revealing that on the morning of 07/26/24 at 10:30 AM. Licensed Practical Nurse (LPN) #82 witnessed Resident #207 pat Resident #30's mid section through his clothing. Further review of this investigation revealed 3 (three) statements which are typed as written and read as follows: Statement from LPN #82: I witnessed Resident #207 touching Resident #30 on his genital area outside his pants. I immediately removed Resident #207 from Resident #30. Administrator walking down hall during incident. She made Social Worker (SW) aware. Statement from Resident #30: I don't remember that. Statement from Resident #207: I did not do that. Further review of this investigation revealed there were no statements obtained from other staff working and that no other resident's were assessed or interviewed. In addition, a review of the policy and procedure entitled, [NAME] Virginia Abuse, Neglect and Misappropriation was conducted revealing that when conducting an investigation of abuse, the facility will obtain statements from staff related to the incident, including victim, person reporting incident, accused perpetrator and witnesses. On 08/21/24 at 12:00 PM, an interview was conducted with the facility SW. At this time, the SW acknowledged that she had not interviewed and obtained statements from other staff working on 07/26/24, nor had other residents who may have had contact with Resident #207 been interviewed or assessed. In addition, the SW acknowledged she had not followed the policy and procedure. b) Resident #54 On 08/20/24 at 09:05 AM, a review of the Facility Reported Incident (FRI) dated 07/17/24, for Resident #54 was conducted revealing that on the night of 07/17/24 at 11:30 PM, Resident #54 was seen in the activity room with Resident #39 by Licensed Practical Nurse (LPN) #98. Resident #39 was massaging Resident #54's neck. LPN #98 asked Resident #39 to stop. Resident #54 was crying and said Resident #39 had asked to touch her all day on the butt and thigh. On 08/21/24 at approximately 10:00 AM, review of this investigation revealed 3 (three) statements which are typed as written and read as follows: Statement from LPN #98: Nurse saw Resident #39 rubbing Resident #54's shoulders. Resident #39 redirected to his room. Resident #39 went to his room and to bed. Resident #54 stated Resident #39 tried to touch her earlier in the day. Statement from Resident #54 (which was obtained by a face to face interview with Resident #54 and written by facility Social Worker (SW)): Resident #54 stated, that man was rubbing my shoulders. My mom told me that a man should never touch me unless it's my doctor. When asked if it happened any other time, Resident #54 stated that Resident #39 patted her leg twice while sitting on couch watching TV. Resident #53 stated she went to bingo and Resident #39 asked her is she was a kid or retarded. Statement from Resident #39 (which was obtained by a face to face interview with Resident #39 and written by facility SW): I was trying to console that lady, she was crying. Resident #39 acknowledged he probably shouldn't touch people without permission. Further review of this investigation revealed there were no statements obtained from other staff working and that no other resident's were assessed or interviewed. In addition, a review of the policy and procedure entitled, [NAME] Virginia Abuse, Neglect and Misappropriation was conducted revealing that when conducting an investigation of abuse, the facility will obtain statements from staff related to the incident, including victim, person reporting incident, accused perpetrator and witnesses. On 08/21/24 at 12:00 PM, an interview was conducted with the facility SW. At this time, the SW acknowledged that she had not interviewed and obtained statements from other staff working the night of 07/17/24, nor had other residents who may have had contact with Resident #39 been interviewed and assessed. In addition, the SW acknowledged the allegation Resident #54 made that Resident #39 asked to touch her all day on the butt was not addressed in the investigation and she had not followed the policy and procedure. c) Resident #1 On 08/21/24 at approximately 10:00 AM, a review of the Facility Reported Incident (FRI) dated 10/20/2024 was conducted revealing that on the evening of 10/20/2024 at 18:15 PM, Licensed Practical Nurse (LPN) #85 's written report of the allegation which is typed as written and reads as folllows: Resident #1 was hit resident by Resident #301 on the left side of the face multiple times and on the back of the head. DON made aware. Resident # 301 was sent to hosipital for evaluation. On 08/21/24 at approximately 10:00 AM, review of this investigation revealed 2 (two) statements dated 10/21/23, which are typed as written and read as follows: Resident #1: That woman hit me. That woman mean. Resident # 20: That woman hit him. I saw it Further review of this investigation revealed there were no statements obtained from other staff working and that no other resident's were assessed or interviewed. On 08/21/2024 at 11:42 AM, an interview was conducted with the Director of Social Services. At this time, she acknowledged that she had not interviewed and obtained statements from other staff working the night of 10/20/24, nor had she interviewed other residents who may have had contact with Resident #301. A review of the policy and procedure entitled, [NAME] Virginia Abuse, Neglect and Misappropriation was conducted revealing that when conducting an investigation of abuse, the facility will obtain statements from staff related to the incident, including victim, person reporting incident, accused perpetrator and witnesses.

Based on medical review and staff interview, the facility failed to provide the resident/resident representative notice of the bed hold policy when Resident #29 was transferred to a local hospital. This was true for one (1) of three (3) residents reviewed for transfers. Resident identifier: #29. Facility census: 54. Findings included: a) Resident #29 Medical Record review on 08/21/24 revealed Resident #29 was discharged to the hospital on 08/13/24. Continued review of Resident #29's medical record showed it did not contain documentation that the resident or the resident's representative received a copy of the bed hold policy at the time of transfer. In addition, there was no documentation in the medical record of contacting the resident / resident representative regarding the bed hold policy. In an interview with the Administrator on 08/21/24 at 5:58 PM, the Administrator confirmed there was no documentation regarding staff notifying the resident/resident representative of the bed hold policy for the hospital transfer on 08/13/24.

Based on resident interview, staff interview and record review, the facility failed to ensure the right to make choices about aspects of life that is important to one (1) of three (3) residents reviewed for choices. Specifically, Resident #35 was not given showers when requested or the choice. Resident identifiers: #19, and #35. Facility census: 54. Findings included: a) Resident #35 During an interview with Resident #35 on 08/19/24 at 2:44 PM, she stated she never received her shower when she prefered. Resident #35 continued to say that she would like to have showers at least every other day. Medical record review revealed, Resident #35's shower schedule was on Saturday, Sunday, Monday, Wednesday, and Thursday on day shift. A review of the 06/07/24 Quarterly Minimum Data Set (MDS), found the resident's brief interview for mental status was fifteen (15). A continued review of Resident #35s ADL documentation found; she was not receiving showers as scheduled. On 08/21/24 at 3:37 PM during an Interview with Assistant Director of Nursing (ADON) stated that they have been working with staff and trying to get resident showers when they prefer. She verified Resident #35 was not getting her showers as scheduled. b) Resident #19 During an interview with, Resident #19 on 08/19/24 at 2:28 PM, the resident stated she had been accustomed to taking a shower every day throughout her life. However, since she had been at the long-term care facility, her shower schedule had been limited to Mondays and Wednesdays. She mentioned that this restriction was due to the shower rooms being reserved for men on Tuesdays and Fridays. The resident expressed her preference for daily showers, and stated that if it were possible, she would prefer to have a shower every day. She went on to state, I know that Tuesdays and Fridays are set aside for men, but I don't understand why I can't get a shower on the other days of the week. Resident's Medical Power of Attorney (MPOA), who was also present during the interview. The MPOA said Resident #19 was meticulous about her cleanliness. She revealed that she had voiced her concerns, about the showers, to the nursing staff on two previous occasions. Document review on 08/19/24 at 2:44 PM of Resident #19's Annual Minimum Data Set (MDS) assessments revealed just one (1) assessment for Section F - Preferences for Routine & Activities on 11/21/23. Resident's answer to the question How important is it to you to choose between a tub bath, shower, bed bath, or sponge bath? Her response had been very Important. A review of the shower logs revealed that Resident #19 had received approximately three (3) showers a week. Showers were recorded for the following days during the month of July 2024: 07/13/24 (Saturday) 07/15/24 (Monday) 07/17/24 (Wednesday) 07/20/24 (Saturday) 07/22/24 (Monday) 07/24/24 (Wednesday) 07/27/24 (Saturday) 07/28/24 (Sunday) 07/29/24 (Monday) 07/31/24 (Wednesday) Document review further revealed that, for the month of August 2024, she had received showers on: 8/01/24 (Thursday) 08/03/24 (Saturday) 08/05/24 (Monday) 08/07/24 (Wednesday) 08/10/24 (Saturday) 08/12/24 (Monday) 08/15/24 (Thursday) 08/17/24 (Saturday) 08/19/24 (Monday) At 2:56 PM on 08/19/24, during an interview with Nursing Assistants (NA) #36 and #90 they stated that they always tried to accommodate residents' requests. However, due to having only one shower room, staffing constraints, and a high number of residents scheduled for showers, they confirmed that it was not always possible for them to do so. During an interview, on 08/22/24 at approximately 3:30 PM, with the Executive Director (ED) #29, she revealed a shower schedule dated 08/21/24. Showers were scheduled for Resident #19 on Sundays, Mondays, Wednesdays, Thursdays, and Saturdays.

Based on record review and staff interview the facility failed to notify the representative/family of an acute hospitalization . This was true for two (2) out of three (3) residents reviewed for the care area of hospitalization during the Long-Term Care Survey process. Resident identifier: Resident #20. Facility census 54. Findings included: a) Resident #20 A record review, completed, on 08/20/24 at 7:09 PM, revealed Resident #20 had capacity to make his own medical decisions. Record review also revealed Resident #20 was transferred to the hospital on 02/16/24. A Nurses Note, dated 02/16/2023 at 10:41 PM, noted that Resident #20 had informed the nurse he was not feeling well and that he just wanted to go to the hospital. The physician was notified and new orders were received to send resident to the emergency room for evaluation. There was no evidence resident's daughter was notified. Section E. Key Contacts of the eInteract Transfer form, dated 02/16/24, listed resident as his own Resident Representative. There was no evidence resident's daughter / representative / next of kin / emergency contact was notified of transfer. During an interview, on 08/21/24 at 4:02 PM, the Assistant Director of Nursing (ADON) reported the facility could not produce evidence Resident #20's daughter/ representative / emergency contact was notified. The ADON acknowledged that even though resident was mentally competent, his designated resident representative or family, as appropriate, should have been notified of significant changes in the resident's health status because the resident may not have been able to notify them personally, especially in the case of sudden illness.

Based on record review and staff interview the facility failed to timely report allegations of suspected abuse between residents timely within the 2 (two) hour window to the appropriate State Agency. This failed practice was true for 2 (two) of 5 (five) residents reviewed for abuse. Resident Identifiers: Resident #39, Resident #01 and Resident #207. Facility Census: 54. Findings include: a) Resident #39 On 08/21/24 at approximately 10:00 AM, a review of the Facility Reported Incident (FRI) dated 06/18/24 was conducted revealing that on the morning of 06/13/24 during the afternoon Licensed Practical Nurse (LPN) #71 reported that Resident #207 appeared to be touching the private are of Resident #39. LPN #71 stated she immediately separated the residents and re-directed each of them. During the review of this FRI, it was noted the allegation type selected was sexual abuse, which according to the reporting requirements of the Office of Health Facility Licensure and Certification Long Term Care Nursing Home Program must be reported to the appropriate state agency within 2 hours of occurrence. This allegation of sexual abuse was noted to occur on 06/13/24, however it was not reported until 06/18/24, which is outside of the reporting requirements referenced above. In addition, facility Policy and Procedure entitled, [NAME] Virginia Abuse, Neglect and Misappropriation was reviewed, revealing that if the events that cause an allegation involve abuse and/or serious bodily injury, the self-report must be made immediately, but not later than 2 hours after the allegation is made. On 08/21/24 at approximately 01:30 PM, an interview was conducted with the Administrator at which time she acknowledged the facility failed to follow the reporting requirements set forth by Office of Health Facility Licensure and Certification Long Term Care Nursing Home Program , in addition to the facility Policy and Procedure entitled, [NAME] Virginia Abuse, Neglect and Misappropriation . 50801 b) Resident #1 On 08/21/24 at approximately 10:00 AM, a review of the Facility Reported Incident (FRI) dated 10/20/2024 was conducted revealing that on the evening of 10/20/2024 at 6:15 PM, Licensed Practical Nurse (LPN) #85's documented that Resident #1 was hit on the left side of the face multiple times by Resident #301. TheFaxed record of Adult Protective Services Mandated Reporting Form was not sent until 10:28 PM to The Office Of Health Facilities Certification And Licensure The Faxed Record of Adult Protective Services Mandated Reporting Form was not sent until 10:37 PM to Adult Protective Services, On 08/21/2024 at 11:42 AM, in an interview with The Director of Social Services, she confirmed the resident to resident abuse occurred and it was not reported in the 2 hour window for reporting.