Every finding on record at Majestic Care of Beckley

Based upon record review and staff interview, the facility failed to implement and carry out the comprehensive care plan. This was found to be true for three (3) of twenty residents reviewed during the long term care survey process. Resident identifiers: #2, #16, #34, Facility census: 48a) Resident #2 Record review of physician orders revealed an order for Basaglar 100 unit/mL KwikPen insulin, to inject 10 units subcutaneously once daily for diabetes mellitus baseline coverage, with instructions to hold the medication if the resident's blood glucose reading was below 80 mg/dL (milligrams per deciliter) Review of the resident's comprehensive care plan failed to reveal interventions or parameters addressing the physician's order to hold insulin when blood glucose levels were below 80 mg/dL. Further review of the Medication Administration Record (MAR) indicated that on 01/22/26, Basaglar insulin was administered when the resident's blood glucose level was 77 mg/dL, which was below the ordered parameter to hold the medication. During an interview on 03/03/26 at 2:30 PM, the Assistant Director of Nursing (ADON), RN #67, confirmed that the resident's care plan did not include interventions reflecting the physician's parameters for insulin administration and acknowledged the insulin was administered despite the blood glucose reading being below 80 mg/dL. b) Resident #34 Resident #34's care plan reads as follows: Dycem to recliner. Date initiated 02/17/2026. An observation at 2:23PM on 03/03/26 confirmed Resident #34 did not have dycem in his recliner as was written in resident's care plan. This was confirmed in resident's room by Nurse #39 at 2:23PM on the same day. This was also confirmed that this was on Resident #34's care plan with Nurse #67 at 2:35PM on 03/03/26.

Based upon observation, record review and staff interviews, the facility failed to follow physician orders to ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices. This related to insulin administration and diet orders. This was found to be true for two (2) of two (2) residents reviewed during the long term care process. Resident identifiers: #2, and #15. Facility census: 48 a) Resident #15 A review of the resident's Dietary Order revealed the following: Regular diet, Regular texture, Thin consistency no salt packet, food in bowls, double protein portions all meals. 2 Peanut butter and jelly sandwiches to lunch and dinner trays.Diet Active 12/02/2025 An observation was made of the resident during lunch meal service on 03/03/26. The resident did not have any peanut butter and jelly sandwiches on his lunch tray. The Surveyor spoke with resident and asked him if he was missing his peanut butter and jelly sandwich. Resident nodded his head yes and pointed to tray as if to indicate there were none on his tray. An interview with RN #67 was held on 03/03/26 at 12:32 PM in the dining room to ask if he was supposed to have two peanut butter and jelly sandwiches on his tray. She responded, Let me go check his orders. She arrived back two minutes later with two peanut butter and jelly sandwiches in her hands and asked resident if he wanted her to open the plastic Ziplock bag containing the sandwich. He nodded his head affirmatively. He proceeded to eat the sandwich when handed to him. A second observation was made of Resident #15 during lunch meal service on 03/04/26 at 12:25 PM. Surveyor observed resident's tray as soon as it was placed in front of him. There were no peanut butter and jelly sandwiches on his lunch tray. b) Resident #2 Record review revealed a physician order for Basaglar 100 unit/mL KwikPen insulin to inject 10 units subcutaneously once daily for diabetes mellitus baseline coverage, with instructions to hold the medication if the resident's blood glucose reading was below 80 mg/dL. Review of the Medication Administration Record (MAR) indicated that on 01/22/26, Basaglar insulin was administered when the resident's blood glucose reading was 77 mg/dL, which was below the ordered parameter to hold the medication. During an interview on 03/03/26 at 2:30 PM, the Assistant Director of Nursing (ADON), RN #67, confirmed that the insulin was administered when the blood glucose level was below the physician-ordered parameter and acknowledged this was not in accordance with the physician's order.

Based on record review and staff interview, the facility failed to increase/prevent decrease in range of motion/mobility for one (1) of three (3) residents. Resident identifier: 16. Facility census: 48. Findings included: a) Resident # 16 Medical record review revealed the resident had diagnoses of contracture of foot and ankle. In interview with Regional [NAME] president (RVP) of Operations on 03/03/26 at 10:45 AM, it was discussed the facility failed to provide services to Resident #16 with treatment to increase mobility or prevent further decrease in range of motion with foot and ankle. According to RVP Resident #16 has never been screened or evaluated for Physical Therapy (PT). A review of the medical record revealed the restorative exercise log. This was the only evidence of any type of therapy being provided to the resident. The restorative exercise log review showed that range of motion with the resident's foot and ankle was not addressed. The restorative exercise log revealed the exercises done with the resident consisted of upper extremity active assisted range of motion exercises, wheelchair push-ups, and lower extremity sitting exercises. None of these exercises dealt with the contracture of the foot and ankle. Care plan review revealed the resident had a contracture to bilateral ankles and indicated therapy would screen, evaluate and treat the resident per physician orders. The record review and staff interview revealed therapy had not screened, evaluated or treated this resident.

Based on record review and staff interview, the facility failed to ensure the resident's Pre-admission Screening (PAS) reflected pre-admission diagnoses. This was true for two (2) out of eight (8) residents reviewed for the category of PASRR (Pre-admission Screening and Record Review, during the Long-Term Care Survey Process. Resident identifiers: #12 and #36. Facility Census: 48a) Resident #12 A review on 03/03/26 revealed that this resident's admission diagnoses (dated 06/19/13) included Schizoaffective Disorder, Bipolar Disorder, Major Depressive Disorder, Generalized Anxiety Disorder, Schizophrenia, and Epilepsy. Although the resident has current medication orders for these conditions, a review of the PASRR dated 10/10/24 shows that Schizophrenia and Epilepsy (seizures) were omitted from Section III (Current Diagnosis) and Section V (Major Mental Illness). While the current Care Plan identified focus areas for cognitive impairment, mood alterations, and seizure risks, the PASRR remains incomplete. During an interview on 03/04/26, the Administrator, Assistant Director of Nursing, and Regional Resource Administrator agreed that the PASSR must be resubmitted to include all medical diagnoses. b) Resident #36 admitted on [DATE], this resident's diagnoses included Unspecified Dementia with Anxiety, Schizophrenia, Impulse Disorder, Unspecified Convulsions, and Other Seizures. However, the PASARR updated on 08/28/24 failed to capture Seizure Disorder under Question 30, despite the resident having a diagnosis of seizures at admission. While the Minimum Data Set (MDS) Section I was consistent with the electronic health record, the PASARR did not accurately reflect the seizure diagnosis. These findings were reviewed with the Nursing Home Administrator and [NAME] President on 03/04/26, and no further information was provided prior to the survey exit.

Based on observation and interview, the facility failed to promote dignity while dining by ensuring residents at the same table were served lunch at the same time. This was a random opportunity for discovery during the long-term care survey process. Resident identifier: #27 Census: 48The following observations were made in the C wing dining room: On 03/02/26, four (4) residents were seated at the long table. Two residents received their meals at 12:25 PM, while Resident #27 was served at 12:38 PM. These times were confirmed during an interview with Nurse #19 at 12:38 PM. On 03/03/26, two (2) residents were seated at a table when state surveyors arrived at 12:15 PM. One resident was served at 12:32 PM, and Resident #27 was served at 12:40 PM. This information was confirmed in an interview with the DON at 12:40 PM.

Based on observation and interview, the facility failed to ensure Resident #34 received assistive device to prevent accidents by not having dycem in resident's recliner. This was true of one (1) of two (2) residents sampled. Resident identifier: #34. Facility census: 48. a) Resident #34 An observation at 2:23 PM on 03/03/26 confirmed Resident #34 did not have dycem in his recliner as was written in resident's care plan to help prevent falls. This was confirmed in resident's room by Nurse #39 at 2:23 PM on the same day.

Based on observation, interview, and record review, the facility failed to ensure Resident #4 was provided a slow-sip cup to decrease risk for swallowing and choking problems. This was a random opportunity for discovery during the long-term care survey process. Resident identifier: #4. Census: 48a) Resident #4 At 12:30PM on 03/02/26 in the dining room on C wing, Resident #4 had a slow-sip cup listed on the meal ticket. However, Resident #4 was only given two (2) cartons of milk with straws and no cups. An interview with Nurse #19, who was in the dining room at the time, confirmed resident should have a slow-sip cup. Speech Language Pathologist (SLP) #116 came in to assist resident with his meal, and the surveyor asked if she was working on resident not using a slow-sip cup. She stated she was not and that the resident should have it. The care plan read as follows: [Resident #4] presents with potential for nutritional risk related to history of swallowing and choking problems (edentulous), mechanically altered diet, ease of chewing and swallowing. An intervention listed: slow-sip cup.

Based on observation, record review, and staff interview, the facility failed to ensure each resident was free from physical restraints. Resident #48 was physically restrained by the facility, causing psychosocial harm. This was true for one (1) of one (1) residents reviewed for physical restraints during the long term care survey process. Resident identifier: #48. Facility census: 51. Findings included: a) Resident #48 At approximately 12:00 PM on 08/12/24, during review of the resident matrix (resident census and conditions of residents) provided by the facility, it was determined the facility had Resident #48 marked as being in physical restraints. Upon review of Resident #48's record, it was determined the resident was in a geri chair with a hard lap tray across it, preventing the resident from standing. The order for the restraint reads as follows: When OOB (Out of Bed): GERICHAIR BILAT HIPSTERS & LAP TRAY FOR SAFETY. CHECK RES (Resident) Q30 MIN (Every 30 minutes) FOR PROPER POSITIONING OF RES & LAP TRAY Q2 HOURS & PRN FOR EXERCISE, REST, TOILETING & HYGIENE NEEDS. At approximately 1:30 PM on 08/12/24, an interview was conducted with Licensed Practical Nurse (LPN) #103 regarding the geri chair and lap tray for Resident #48. LPN #103, regarding the lap tray, stated, I've been here since he first got here. When he got here he would walk around all the time, but he had some falls so they put him in the chair and put the tray on it so he couldn't get up and walk. LPN #103 was asked if Resident #48 was able to release the lap tray from the chair on command, in the event of an emergency, to which she stated No, he can't release it. But he can probably yell out if he needs help (Multiple attempts were made to communicate with Resident #48 during the survey process, however, Resident #48 never spoke, nor yelled during the survey). At this time, Resident #48 was observed trying to stand up out of the geri chair, but was unable to due to the lap tray. Resident #48's right leg started to bounce up and down, anxiously, when he was unsuccessful in standing. Seconds later, Resident #48 attempted to stand again, which was unsuccessful. After a second unsuccessful attempt at standing up, Resident #48's right leg bounced up and down harder, and at a faster pace. This continued for approximately 30 seconds and Resident #48 fell asleep in the chair. During further record review at approximately 3:00 PM on 08/12/24, it was noted the facility entered the following note, completed by the Director of Nursing (DON) into Resident #48's record on 7/30/24: Assessment completed regarding continuing the need for lap tray. After assessing resident we will continue to utilize the lap tray due to increase in fall risk in the past. Resident did have a decline in health in [DATE] and the lap tray was discontinued on 12/6/23. The resident began walking again without assistance and having increased falls. It was decided we would re-order a soft lap buddy on 1/4/24. Resident still continued to walk and have increased falls. The lap tray was re-ordered on 1/8/24. Resident has had the following orders in the past due to increased falls. Low bed, removing mattress from the low bed with another mat beside (as resident tends to get out of bed and crawl on the floors,) helmet, hipsters, soft lap buddy. Nothing has been successful. The order will continue for the lap tray and to release q2h prn for periods of rest, activies [sic], hygeine [sic], brief changes, or to lay down in bed. MPOA is aware of the lap [NAME] [sic] and in agreement for continued use. The Pre-restraint assessment completed by the facility, attached to the progress note, revealed the facility did not assess Resident #48 for the use of a wheelchair, walker, chair alarm, cane, or many other forms of restraint alternatives, before putting him into a geri chair with a lap tray, as evidenced by the section titled Restraint Alternatives on the assessment. The options given are low bed, wheelchair, cushion, chair alarm, wedges, non-slip grip socks, walker, pillow, cane, other. Marked with an X in the section are low bed, non-slip grip socks, and other. The final section of the pre-restraint assessment titled Results have the following options: None, chemical restraint, physical restraint. The box reading None is marked with an X while chemical restraint and physical restraint are not marked. A call was placed to the wife of Resident #48, who is the Medical Power of Attorney (MPOA), to determine whether she was aware of the use of the lap tray, due to the note stating the MPOA was aware of the lap buddy, and not the lap tray, however, the call was not successful. Despite the note dated 7/30/24 stating the resident required the geri chair and lap tray as a restraint for safety due to increased falls, a preliminary viewing of the incident report provided by the facility, from December 2023, through August 2024, the resident had five (5) incidents from 12/15/23 through 7/16/24, one of which was a result of a shower chair breaking as the resident was on the way to be bathed. Of the remaining four, it was unclear which ones, if any, the resident was ambulating before falling, as all the incidents were noted as unwitnessed. At approximately 9:15 AM on 08/13/24, this surveyor entered the dining room on unit 3-C of the facility, where Resident #48 was parked in the geri chair. Resident #48 was noted to be in the geri chair, with the lap tray down, and his pants were visibly soiled/wet in the groin area. At approximately 9:21 AM, Resident #48 attempted to stand up from the geri chair but was unable to due to the lap tray. At this time, Resident #48's right leg began to bounce up and down, anxiously. The resident attempted to stand again, unsuccessfully, at which time his right leg began to bounce up and down at a faster pace. Resident #48 attempted to stand a third time and was unsuccessful, at which time his leg bounced up and down faster. At this time, Resident #48 attempted to stand up from the geri chair a fourth time, again, unsuccessfully. At this time, the resident's right leg was bouncing, furiously, up and down, along with his left hand. The resident seemed visibly agitated and anxious at this time. The resident eventually calmed down after approximately five (5) minutes and fell asleep in his chair. At approximately 9:37 AM, Nurse Aide (NA) #8 entered the dining room and began speaking with another resident was falling asleep in his wheelchair. NA #8 asked the resident if he wanted to go back to his room to go to sleep, at which time she took the resident back to his room. NA #8 did not interact with Resident #48, nor check on him for proper positioning of himself or the lap tray, nor did she notice he was visibly soiled. NA #8 entered the dining room again at approximately 9:40 AM and removed a clothing protector from breakfast from a female resident, then removed the resident from the dining room. NA #8 did not interact with Resident #48 at this time, nor did she notice he was visibly soiled. At approximately 9:46 AM, NA #8 escorted a new resident into the dining room and placed them at the table to the direct right of Resident #48. At this time, there was no interaction with Resident #48 to check positioning of him, the lap tray, or to notice he was visibly soiled. At approximately 9:47 AM, NA #57 entered the dining room with another new resident, placed the at the table next to Resident #48. NA #57 did not notice Resident #48 was soiled, nor did they check for proper positioning of the resident or lap tray. At approximately 9:49 AM, Recreation Specialist (RS) #69, entered the dining room to escort residents to an activity taking place at the time. As RS #69 approached Resident #48, she stated Oh, he's wet, at which point, she backed away from Resident #48, gathered other residents, and left the dining room. RS #69 did not ask Resident #48 if he needed assistance, nor did she check to see if the lap tray, or Resident #48, was properly positioned. At approximately 9:51 AM, NA #8 entered the dining room again. NA #8 walked over to a resident sitting beside Resident #48, spoke with resident, turned around, used the hand sanitizer dispenser, and left the dining room. NA #8 did not check on Resident #48, despite him being visibly soiled, for proper positioning of him or the lap tray. At approximately 10:06 AM, Resident #48 attempted to stand up from the geri chair, however, he was unsuccessful due to the lap tray. At this time, the resident started bouncing his legs up and down, anxiously. The resident attempted to reposition himself in the geri chair at this time. Resident's legs now are bouncing faster and harder. Resident #48 attempted to stand out of the chair one more time, unsuccessfully. At this time, the resident's legs were bouncing faster. At approximately 10:15 AM, NA #57 entered the dining room and asked two other residents if they wanted to go to the social and listen to some music. The residents stated they did, at which time, she escorted them past Resident #48, out the door and to the activity room. NA #57 did not check on Resident #48 during this trip to the dining room, leaving him still, visibly soiled, and the positioning of him and the lap tray in question. At this time, Resident #48 remained the only resident in the dining room. At approximately 10:21 AM, NA #8 and NA #57 entered the dining room. NA #8 stated He's wet. NAs began to escort resident out of the dining room, at which point, this surveyor asked them if RS #69 had come to inform them Resident #48 was soiled after she left the dining room at approximately 9:49 AM. Both NAs stated no. At approximately 10:30 AM, NA #8 and #57 were observed brining Resident #48 out into the hallway from his room, standing him up out of the chair, and assisting him with walking approximately 15 to 20 feet before sitting him back in the chair. Resident #48 was observed in the chair the rest of the day. Review of the facility's policy on physical restraints states the opportunity for motion and exercise is provided for a period of not less than ten (10) minutes during each two (2) hours in which restraints are employed. Resident #48 was exercised for approximately 30 to 40 seconds. At approximately 10:45 AM on 08/13/24, the Administrator of the facility was notified of Resident #48 being visibly soiled at approximately 9:15 AM, RS #69 entering the dining room and stating Oh, he's wet and leaving, without alerting staff, resulting in Resident #48 not being changed until approximately 10:21 AM. The administrator asked how long the resident was sitting in the dining room soiled. This surveyor stated, From about 9:15 AM until about 10:21 AM when the aides came to get him. However, he was already wet, so he may have been way for a longer period of time. At this time, the administrator stated the facility would report and investigate the claim of neglect. The facility completed its investigation and substantiated the allegation of neglect due to RS #69 stating she forgot to notify anyone of Resident #48's needs. At approximately 10:00 AM on 08/14/24, Resident #48 was observed attempting to stand up from his geri chair. The attempt was unsuccessful and the resident began to bounce his left leg up and down at a fast pace. The resident seemed anxious and agitated. At approximately 10:02 AM, Resident #48 attempted to rise out of the geri chair for a second time. Unsuccessful, the resident started to bounce his leg at a faster pace. The resident seemed more agitated and anxious. At approximately 10:04 AM, Resident #48 attempted, again, to stand from the geri chair. The resident was unsuccessful and seemed to become more agitated and anxious, bouncing his leg up and down ferociously. The resident eventually stopped trying to get up and began to stare off. A reasonable person standard was applied to this situation because Resident #48 is not able to verbalize how not being able to stand was making him feel. However, he was showing outward signs of agitation as evidenced by his leg bouncing up and down and it becoming faster after each attempt to stand up. A reasonable person would feel agitation and frustration if restrained and not able to stand and walk freely Further record review revealed Resident #48 has orders for a weighted blanket while in bed and a concave mattress, due to increased falls from bed. At approximately 12:00 PM on 08/14/24, an interview was conducted with the DON, in which she was asked to supply incident reports pertaining to the falls suffered by Resident #48 and how they led to him being physically restrained in the geri chair. The DON stated the resident had a number of falls and the facility was concerned about his safety. The DON was asked if the facility ever considered less restrictive measures before they restrained Resident #48 in the geri chair, such as a wheelchair. The DON stated We didn't believe a wheelchair was appropriate for him, so no, I don't believe we did evaluate him for one, but I would have to check to make sure. The DON stated she did not believe the resident could propel a wheelchair now, stating He probably could have before, but not now. Review of the Minimum Data Set (MDS) Assessments For Resident #48 revealed the following: For the MDS dated [DATE], Section G0300 reveals the resident was Steady at all times while walking. The resident was independently walking distances of ten (10) feet on uneven surfaces and with picking up objects. The MDS showed the resident required partial to moderate assistance, or supervision for Activities of Daily Living (ADLs) The MDS also revealed the resident received no restorative services at this time. The MDS indicated the resident exhibited wandering behaviors every day. After the initial order for the physical restraint on 06/16/24, the MDS dated [DATE] revealed the resident remained independent with the same tasks as in the MDS in May 2023. The MDS states the resident exhibits wandering behaviors daily. In a significant change MDS, dated [DATE], the resident was not noted to have any impairment of lower or upper extremity. However, walking was no longer attempted, due to a medical or safety concern, and the resident was now totally dependent for all ADLs. The resident still, according to the MDS, exhibited wandering behavior daily. Each MDS was submitted following the significant change in August 2023, up to and including the annual MDS dated [DATE], now shows the resident completely dependent for all ADLs, walking not being attempted due to a medical or safety concerning, and exhibiting wandering behavior daily, despite being restrained in the geri chair with a lap tray. At approximately 1:00 PM on 08/14/24, an interview was conducted the the MDS Coordinator and the DON. The MDS coordinator was asked about the resident exhibiting wandering behavior daily if he was in the chair. The MDS Coordinator stated When they release him from the chair he will stand up and walk. He will stand up and walk if he isn't watched. The DON was asked if the resident was able to walk if he would be able to propel a wheelchair on his own, despite her saying she did not feel he could in an earlier interview. The DON stated Some days he can walk and some days he can't. We thought he would slide out of a wheelchair if we put him in one. The DON and MDS Coordinator both stated Resident #48 was able to ambulate independently up until the point of being ordered the geri chair with the lap tray. The DON confirmed at this time the facility did not assess Resident #48 for a wheelchair due to them believing he would slide out of it. Review of the Treatment Administration Record (TAR) for Resident #48 reveals the following order: When OOB (Out of Bed): GERICHAIR BILAT HIPSTERS & LAP TRAY FOR SAFETY. CHECK RES (Resident) Q30 MIN (Every 30 minutes) FOR PROPER POSITIONING OF RES & LAP TRAY Q2 HOURS & PRN FOR EXERCISE, REST, TOILETING & HYGIENE NEEDS. Upon review of the TAR for May, June, July, and August 2024, there are no initials or signatures on the TAR to indicate the resident was ever released from the restraint every two hours. At approximately 2:19 PM on 08/14/24, the DON stated the facility did not have a signed consent from Resident #48's MPOA for the use of the restraint. The DON was asked about the progress note dated 7/30/24, in which it states the MPOA is aware of the use of the lap buddy and agrees with its usage, and if the MPOA knows of the lap buddy or the more restrictive lap tray. The DON states the MPOA is aware of the lap tray but is unable to provide any documentation to support. The DON states the MPOA is hard to get a hold of by phone and has never visited the resident since he came to the facility, and is unable to provide any proof of consent, other than the note stating the MPOA is aware. The DON was then asked about the TAR, and being unable to verify the resident was released from the restraints as ordered. The DON stated That is just on there as an FYI, no one signs off on it. There are nurses notes stating he was released from the restraints. When asked how the facility verifies the resident was released from the restraints every two hours, since no one signs off on the TAR, the DON stated I don't guess I really have a way, other than the nurses notes are in there. At this time, the DON and this surveyor reviewed the nurses notes in the system from May through August 2024. This review revealed no notes mentioning the resident was released from the restraints every two hours as required. When asked if she would confirm there were no signatures or nursing notes to indicate the resident was removed from the restraints, the DON stated I confirm there's nothing there but I don't agree with it. The DON supplied the incident reports pertaining to falls for Resident #48 from April of 2023 through August 2024. Upon review of an incident report dated 07/10/24, it was noted a bruise was observed by NA #8 while changing the resident. The bruise was noted to be on the left leg of the resident and to be the same height and size as the armrest on the geri chair. The incident reports revealed the following: 04/19/23- Presumed fall. Resident lying in floor with table overturned. 04/27/23- Resident lying on bathroom/shower floor resting his head on his hands. No injuries or redness. Resident stated he didn't fall. 04/30/23- Resident ambulating in hallway, and fell on his left arm and slid down wall to floor. Brief noted around resident's knees. Brief fell to resident's knees, may have contributed to fall. 05/06/23- Resident fell on left shoulder and hip while turning in front of a door. 06/13/23- Resident observed in floor of dining room with another resident's wheelchair flipped forward. 06/15/23- Resident found by NA, head pointing downward in the floor. Legs and feet pointing upward draped across dining room chair. Lap tray was ordered on 06/16/23. The DON stated in the interview the resident used to be in the military and would crawl underneath his roommates bed, thinking he was working on it, and that's how staff would sometimes find him. The exact number of falls of the resident falling while ambulating compared to the resident rolling out of bed are unknown.

Based on observation and staff interview, the facility failed to ensure the food was stored in accordance with professional standards for food service safety. This was identified during the long term care survey and had the potential to affect more than a limited number of residents. Identifiers: Walk-in refrigerator, Refrigerator #1, Walk-in freezer. Facility census: 51. Findings Included: a) Walk-in refrigerator During a tour of the kitchen on [DATE] at 10:37 AM the walk-in refrigerator the following food storage issues were identified: * [NAME] peppers that had began to rot and the outside was watery and softened with white mold. * Watermelon that had began to rot and the outside was watery and softened. * Tomato's that had began to rot and the outside was watery and softened with white mold. * Busted egg in open carton. * Lettuce opened but not dated that had began to rot and the lettuce was watery and softened with a brownish color. * Butter that was not dated. * Open pack of cheese not dated. * Blue pack of raisins not dated. During an interview with the Hospital Supportive Services Supervisor (HSSS) on [DATE] at approximately 10:41 AM she agreed, the items appeared to be rotten and molding. The HSSS disposed of these items at this time. The HSSS also agreed that the items not dated should have been dated and disposed of these items also. b) Reach in refrigerator. During a tour of the kitchen on [DATE] at approximately 10:43 AM the following food storage issues were identified in the walk-in refrigerator: * Parmesan cheese dated [DATE] - [DATE]. * Jell-O not dated. * One (1) bag of sliced ham [DATE] - [DATE]. * Two (2) bags of sliced ham [DATE] - [DATE] * Two (2) packs of opened cheese not dated During an interview with the Hospital Supportive Services Supervisor (HSSS) on [DATE] at approximately 10:51 AM she agreed that the items dated for [DATE]- [DATE] and the items dated [DATE]/24 - [DATE] had expired and should have already been discarded. The HSSS did dispose of the items at this time. The HSSS also agreed that the items not dated should have been dated and disposed of these items also. c) Walk in freezer. During a tour of the kitchen on [DATE] at approximately 10:53 AM the walk-in freezer contained the following food storage issues: * Three (3) cod fillets five (5) pound boxes not dated. During an interview with the Hospital Supportive Services Supervisor (HSSS) on [DATE] at approximately 10:59 AM she agreed that the items not dated should have been dated. The HSSS disposed of the items at this time.

Based on observation and staff interview the facility failed to maintain an effective infection control program to prevent spread of disease and infections by not properly identifying Enhanced Barrier Precaution (EBP) isolation rooms. This was a random opportunity of discovery. Resident Identifiers: #26, #45 and #307. Facility Census: #51 Findings Included: a) Resident #26 On 08/13/24 at 11:15 AM observation found Enhanced Barrier Precaution (EBP) isolation personal protective equipment (PPE) (provided in caddies on the door) on resident room doors that had no identifying isolation sign. The Infection Prevention Nurse #34 provided a list of residents that are in EBP. The list provided identified eighteen (18) residents that should be in EBP. While comparing the list to the room doors, it was found that three (3) of the rooms were not in compliance with the facility policy which states Signs are to be posted on the door outside the resident room indicating the type of precautions and PPE required . and . PPE is available outside the resident rooms . This information is necessary for staff know what PPE is required during care so as to not spread germs throughout the facility. Resident #26 (room B331A) is required to be in EBP due to Methicillin-resistant Staphylococcus Aureus (MRSA). There was no identifying isolation sign nor was there any personal protective equipment available outside the room. On 08/23/24 at 12:05 PM this was confirmed with the Infection Control Nurse #34 who agreed the appropriate signs nor the PPE were available as required. b) Resident #45 On 08/13/24 at 11:15 AM observation found EBP isolation PPE (provided in caddies on the door) on resident room doors that had no identifying isolation sign. The Infection Prevention Nurse #34 provided a list of residents that are in EBP. The list provided identified eighteen (18) residents that should be in EBP. While comparing the list to the room doors, it was found that three (3) of the rooms were not in compliance with the facility policy which states Signs are to be posted on the door outside the resident room indicating the type of precautions and PPE required . and . PPE is available outside the resident rooms . This information is necessary for staff know what PPE is required during care so as to now spread germs throughout the facility. Resident #45 (room C304A) is required to be in EBP due to Methicillin-resistant Staphylococcus Aureus (MRSA). There was no identifying isolation sign on the door to the room. On 08/23/24 at 12:05 PM this was confirmed with the Infection Control Nurse #34 who agreed the appropriate sign was not posted as required. c) Resident #307 On 08/13/24 at 11:15 AM observation found EBP isolation PPE (provided in caddies on the door) on resident room doors that had no identifying isolation sign. The Infection Prevention Nurse #34 provided a list of residents that are in EBP. The list provided identified eighteen (18) residents that should be in EBP. While comparing the list to the room doors, it was found that three (3) of the rooms were not in compliance with the facility policy which states Signs are to be posted on the door outside the resident room indicating the type of precautions and PPE required . and . PPE is available outside the resident rooms . This information is necessary for staff know what PPE is required during care so as to now spread germs throughout the facility. Resident #307 (room B326A) is required to be in EBP due to Vancomycin-resistant Enterococcus (VRE). There was an inappropriate identifying sign on the door stating the resident was in contact isolation while it should read as EBP. On 08/23/24 at 12:05 PM this was confirmed with the Infection Control Nurse #34 who agreed the appropriate sign were not posted as required.

Based on record review and staff interview the facility failed to ensure residents did not receive a second purified protein derivative test (PPD) when it was not warranted. This is true for five (5) of eight (8) residents reviewed for immunizations during the survey. Resident Identifiers: #1, #4, #10, #26 and #31 Facility Census: #51 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. Findings Include: a) Resident #1 On 08/13/24 record review shows Resident #1 received a purified protein derivative test (PPD) 04/09/24. The PPD skin test is a method used to diagnose silent (latent) tuberculosis (TB) infection. According to the facility reported incident, after receiving this test, Nurse Manager (NM) #58 discovered that the resident had already received a PPD on 03/05/24. On 08/14/24 at 2:50 PM during an interview with NM #58 she stated the administering documentation is usually put in the CareVue charting system the facility uses. She had checked for documentation and it was not present. She then checked in a box that is a to do box where she would have had any previous immunizations that needed to be input in the CareVue system, There were none present for this resident. She continued to put the order in the system for the PPD to be administered to the resident. The following day she found documentation that the resident had indeed received a PPD on 03/05/24. She immediately called the physician and the pharmacist. The pharmacist informed her the resident would not be harmed by this. He also instructed her it could read as a false positive and not to read the results which involves watching the forearm where it was administered for a red swelling spot. The physician gave orders to watch for a localized rash. The resident was observed for 72 hours with no adverse reaction. All responsible parties were notified. The facility performed a house wide audit of all immunizations for system documentation. They provided education to all nursing staff. They have changed their process as to ensure this does not occur again. Rather than place documentation in a box, the nurse staff hand delivers the documentation to the Registered Nurse to enter into the system, as the Licensed Practical Nurse staff can not document under immunizations in the system. This was confirmed on 08/14/24 at 4:00 PM with the Director of Nursing. b) Resident #4 On 08/13/24 record review shows Resident #4 received a purified protein derivative test (PPD) 04/09/24. The PPD skin test is a method used to diagnose silent (latent) tuberculosis (TB) infection. According to the facility reported incident, after receiving this test, Nurse Manager (NM) #58 discovered that the resident had already received a PPD on 03/05/24. On 08/14/24 at 2:50 PM during an interview with NM #58 she stated the administering documentation is usually put in the CareVue charting system the facility uses. She had checked for documentation and it was not present. She then checked in a box that is a to do box where she would have had any previous immunizations that needed to be input in the CareVue system, There were none present for this resident. She continued to put the order in the system for the PPD to be administered to the resident. The following day she found documentation that the resident had indeed received a PPD on 03/05/24. She immediately called the physician and the pharmacist. The pharmacist informed her the resident would not be harmed by this. He also instructed her it could read as a false positive and not to read the results which involves watching the forearm where it was administered for a red swelling spot. The physician gave orders to watch for a localized rash. The resident was observed for 72 hours with no adverse reaction. All responsible parties were notified. The facility performed a house wide audit of all immunizations for system documentation. They provided education to all nursing staff. They have changed their process as to ensure this does not occur again. Rather than place documentation in a box, the nurse staff hand delivers the documentation to the Registered Nurse to enter into the system, as the Licensed Practical Nurse staff can not document under immunizations in the system. This was confirmed on 08/14/25 at 4:00 PM with the Director of Nursing. c) Resident #10 On 08/13/24 record review shows Resident #10 received a purified protein derivative test (PPD) 04/09/24. The PPD skin test is a method used to diagnose silent (latent) tuberculosis (TB) infection. According to the facility reported incident, after receiving this test, Nurse Manager (NM) #58 discovered that the resident had already received a PPD on 03/05/24. On 08/14/24 at 2:50 PM during an interview with NM #58 she stated the administering documentation is usually put in the CareVue charting system the facility uses. She had checked for documentation and it was not present. She then checked in a box that is a to do box where she would have had any previous immunizations that needed to be input in the CareVue system, There were none present for this resident. She continued to put the order in the system for the PPD to be administered to the resident. The following day she found documentation that the resident had indeed received a PPD on 03/05/24. She immediately called the physician and the pharmacist. The pharmacist informed her the resident would not be harmed by this. He also instructed her it could read as a false positive and not to read the results which involves watching the forearm where it was administered for a red swelling spot. The physician gave orders to watch for a localized rash. The resident was observed for 72 hours with no adverse reaction. All responsible parties were notified. The facility performed a house wide audit of all immunizations for system documentation. They provided education to all nursing staff. They have changed their process as to ensure this does not occur again. Rather than place documentation in a box, the nurse staff hand delivers the documentation to the Registered Nurse to enter into the system, as the Licensed Practical Nurse staff can not document under immunizations in the system. This was confirmed on 08/14/25 at 4:00 PM with the Director of Nursing. d) Resident #26 On 08/13/24 record review shows Resident #26 received a purified protein derivative test (PPD) 04/09/24. The PPD skin test is a method used to diagnose silent (latent) tuberculosis (TB) infection. According to the facility reported incident, after receiving this test, Nurse Manager (NM) #58 discovered that the resident had already received a PPD on 03/05/24. On 08/14/24 at 2:50 PM during an interview with NM #58 she stated the administering documentation is usually put in the CareVue charting system the facility uses. She had checked for documentation and it was not present. She then checked in a box that is a to do box where she would have had any previous immunizations that needed to be input in the CareVue system, There were none present for this resident. She continued to put the order in the system for the PPD to be administered to the resident. The following day she found documentation that the resident had indeed received a PPD on 03/05/24. She immediately called the physician and the pharmacist. The pharmacist informed her the resident would not be harmed by this. He also instructed her it could read as a false positive and not to read the results which involves watching the forearm where it was administered for a red swelling spot. The physician gave orders to watch for a localized rash. The resident was observed for 72 hours with no adverse reaction. All responsible parties were notified. The facility performed a house wide audit of all immunizations for system documentation. They provided education to all nursing staff. They have changed their process as to ensure this does not occur again. Rather than place documentation in a box, the nurse staff hand delivers the documentation to the Registered Nurse to enter into the system, as the Licensed Practical Nurse staff can not document under immunizations in the system. This was confirmed on 08/14/25 at 4:00 PM with the Director of Nursing. e) Resident #31 On 08/13/24 record review shows Resident #31 received a purified protein derivative test (PPD) 04/09/24. The PPD skin test is a method used to diagnose silent (latent) tuberculosis (TB) infection. According to the facility reported incident, after receiving this test, Nurse Manager (NM) #58 discovered that the resident had already received a PPD on 03/05/24. On 08/14/24 at 2:50 PM during an interview with NM #58 she stated the administering documentation is usually put in the CareVue charting system the facility uses. She had checked for documentation and it was not present. She then checked in a box that is a to do box where she would have had any previous immunizations that needed to be input in the CareVue system, There were none present for this resident. She continued to put the order in the system for the PPD to be administered to the resident. The following day she found documentation that the resident had indeed received a PPD on 03/05/24. She immediately called the physician and the pharmacist. The pharmacist informed her the resident would not be harmed by this. He also instructed her it could read as a false positive and not to read the results which involves watching the forearm where it was administered for a red swelling spot. The physician gave orders to watch for a localized rash. The resident was observed for 72 hours with no adverse reaction. All responsible parties were notified. The facility performed a house wide audit of all immunizations for system documentation. They provided education to all nursing staff. They have changed their process as to ensure this does not occur again. Rather than place documentation in a box, the nurse staff hand delivers the documentation to the Registered Nurse to enter into the system, as the Licensed Practical Nurse staff can not document under immunizations in the system. This was confirmed on 08/14/25 at 4:00 PM with the Director of Nursing.

Based on observation, record review, and staff interview, the facility failed to ensure each resident was free from abuse and neglect by leaving Resident #48 visibly soiled for an extended period of time. This was a random opportunity for discovery. Resident identifier: 48. Facility census: 51. Findings included: a) Resident #48 At approximately 9:15 AM on 08/13/24, this surveyor entered the dining room on unit 3-C of the facility, where Resident #48 was parked in a geri chair. Resident #48 was noted to be in the geri chair, with the lap tray down, and his pants visibly soiled/wet in the groin area. At approximately 9:21 AM, Resident #48 attempted to stand up from the geri chair but was unable to due to the lap tray. At this time, Resident #48's right leg began to bounce up and down, anxiously. The resident attempted to stand again, unsuccessfully, at which time his right leg began to bounce up and down at a faster pace. Resident #48 attempted to stand a third time and was unsuccessful, at which time his leg bounced up and down faster. At this time, Resident #48 attempted to stand up from the geri chair a fourth time, again, unsuccessfully. At this time, the resident's right leg was bouncing, furiously, up and down, along with his left hand. The resident seemed visibly agitated and anxious at this time. The resident eventually calmed down after approximately five (5) minutes and fell asleep in his chair. At approximately 9:37 AM, Nurse Aide (NA) #8 entered the dining room and began speaking with another resident who was falling asleep in his wheelchair. NA #8 asked the resident if he wanted to go back to his room to go to sleep, at which time she took the resident back to his room. NA #8 did not interact with Resident #48, nor check on him for proper positioning of himself or the lap tray, nor did she notice he was visibly soiled. NA #8 entered the dining room again at approximately 9:40 AM and removed a clothing protector from breakfast from a female resident, then removed the resident from the dining room. NA #8 did not interact with Resident #48 at this time, nor did she notice he was visibly soiled. At approximately 9:46 AM, NA #8 escorted a new resident into the dining room and placed them at the table to the direct right of Resident #48. At this time, there was no interaction with Resident #48 to check positioning of him, the lap tray, or to notice he was visibly soiled. At approximately 9:47 AM, NA #57 entered the dining room with another new resident, placed the resident at the table next to Resident #48. NA #57 did not notice Resident #48 was soiled, nor did they check for proper positioning of the resident or lap tray. At approximately 9:49 AM, Recreation Specialist (RS) #69, entered the dining room to escort residents to an activity taking place at the time. As RS #69 approached Resident #48, she stated Oh, he's wet, at which point, she backed away from Resident #48, gathered other residents, and left the dining room. RS #69 did not ask Resident #48 if he needed assistance, nor did she check to see if the lap tray, or Resident #48, was properly positioned. At approximately 9:51 AM, NA #8 entered the dining room again. NA #8 walked over to a resident sitting beside Resident #48, spoke with resident, turned around, used the hand sanitizer dispenser, and left the dining room. NA #8 did not check on Resident #48, despite him being visibly soiled, for proper positioning of him or the lap tray. At approximately 10:06 AM, Resident #48 attempted to stand up from the geri chair, however, he was unsuccessful due to the lap tray. At this time, the resident started bouncing his legs up and down, anxiously. The resident attempted to reposition himself in the geri chair at this time. Resident's legs now are bouncing faster and harder. Resident #48 attempted to stand out of the chair one more time, unsuccessfully. At this time, the resident's legs were bouncing faster. At approximately 10:15 AM, NA #57 entered the dining room and asked two other residents if they wanted to go to the social and listen to some music. The residents stated they did, at which time, she escorted them past Resident #48, out the door and to the activity room. NA #57 did not check on Resident #48 during this trip to the dining room, leaving him still, visibly soiled, and the positioning of him and the lap tray in question. At this time, Resident #48 remained the only resident in the dining room. At approximately 10:21 AM, NA #8 and NA #57 entered the dining room. NA #8 stated He's wet. NAs began to escort resident out of the dining room, at which point, this surveyor asked them if RS #69 had come to inform them Resident #48 was soiled after she left the dining room at approximately 9:49 AM. Both NAs stated no. At approximately 10:45 AM on 08/13/24, the Administrator of the facility was notified of Resident #48 being visibly soiled at approximately 9:15 AM, RS #69 entering the dining room and stating Oh, he's wet and leaving, without alerting staff, resulting in Resident #48 not being changed until approximately 10:21 AM. The administrator asked how long the resident was sitting in the dining room soiled. This surveyor stated, From about 9:15 AM until about 10:21 AM when the aides came to get him. However, he was already wet, so he may have been way for a longer period of time. At this time, the administrator stated the facility would report and investigate the claim of neglect. The facility completed its investigation and substantiated the allegation of neglect due to RS #69 stating she forgot to notify anyone of Resident #48's needs.

Based on observation and staff interview, the facility failed to provide Actiity of Daily Living (ADL) care for dependent residents, by leaving Resident #48 soiled for an extended period of time. This was a random opportunity for discovery. Resident identifier: 48. Facility census: 51. Findings include: A) Resident #48 At approximately 9:15 AM on 08/13/2024, this surveyor entered the dining room on unit 3-C of the facility, where Resident #48 was parked in the geri chair. Resident #48 was noted to be in the geri chair, with the lap tray down, and his pants visibly soiled in the groin area. At approximately 9:21 AM, Resident #48 attempted to stand up from the geri chair but was unable to due to the lap tray. At this time, Resident #48 ' s right leg began to bounce up and down, anxiously. The resident attempted to stand again, unsuccessfully, at which time his right leg began to bounce up and down at a faster pace. Resident #48 attempted to stand a third time and was unsuccessful, at which time his leg bounced up and down faster. At this time, Resident #48 attempted to stand up from the geri chair a fourth time, again, unsuccessfully. At this time, the resident ' s right leg was bouncing, furiously, up and down, along with his left hand. The resident seemed visibly agitated and anxious at this time. The resident eventually calmed down after approximately five (5) minutes and fell asleep in his chair. At approximately 9:37 Nurse Aide (NA) #8 entered the dining room and began speaking with another resident that was falling asleep in his wheelchair. NA #8 asked the resident if he wanted to go back to his room to go to sleep, at which time she took the resident back to his room. NA #8 did not interact with Resident #48, nor check on him for proper positioning of himself or the lap tray, nor did she notice he was visibly soiled. NA #8 entered the dining room again at approximately 9:40 AM and removed a clothing protector from breakfast from a female resident, then removed the resident from the dining room. NA #8 did not interact with Resident #48 at this time, nor did she notice he was visibly soiled. At approximately 9:46 AM, NA #8 escorted a new resident into the dining room and placed them at the table to the direct right of Resident #48. At this time, there was no interaction with Resident #48 to check positioning of him, the lap tray, or to notice that he was visibly soiled. At approximately 9:47 AM, NA #57 entered the dining room with another new resident, placed the at the table next to Resident #48. NA #57 did not notice Resident #48 was soiled, nor did they check for proper positioning of the resident or lap tray. At approximately 9:49 AM, Recreation Specialist (RS) #69, entered the dining room to escort residents to an activity taking place at the time. As RS #69 approached Resident #48, she stated Oh, he ' s wet, at which point, she backed away from Resident #48, gathered other residents, and left the dining room. RS #69 did not ask Resident #48 if he needed assistance, nor did she check to see if the lap tray, or Resident #48, was properly positioned. At approximately 9:51 AM, NA #8 entered the dining room again. NA #8 walked over to a resident sitting beside Resident #48, spoke with that resident, turned around, used the hand sanitizer dispenser, and left the dining room. NA #8 did not check on Resident #48, despite him being visibly soiled, for proper positioning of him or the lap tray. At approximately 10:06 AM, Resident #48 attempted to stand up from the geri chair, however, he was unsuccessful due to the lap tray. At this time, the resident started bouncing his legs up and down, anxiously. The resident attempted to reposition himself in the geri chair at this time. Resident ' s legs now are bouncing faster and harder and the resident looks uncomfortable, by the look on his face. Resident #48 attempted to stand out of the chair one more time, unsuccessfully. At this time, the resident ' s legs were bouncing faster. At approximately 10:15 AM, NA #57 entered the dining room and asked two other residents if they wanted to go to the social and listen to some music. The residents stated they did, at which time, she escorted them past Resident #48, out the door and to the activity room. NA #57 did not check on Resident #48 during this trip to the dining room, leaving him still, visibly soiled, and the positioning of him and the lap tray in question. At this time, Resident #48 remained the only resident in the dining room. At approximately 10:21 AM, NA #8 and NA #57 entered the dining room. NA #8 stated He ' s wet. NAs began to escort resident out of the dining room, at which point, this surveyor asked them if RS #69 had come to inform them Resident #48 was soiled after she left the dining room at approximately 9:49 AM. Both NAs stated no. At approximately 10:45 AM on 08/13/2024, the Administrator of the facility was notified of Resident #48 being visibly soiled at approximately 9:15 AM, RS #69 entering the dining room and stating Oh, he ' s wet and leaving, without alerting staff, resulting in Resident #48 not being changed until approximately 10:21 AM. The administrator asked how long the resident was sitting in the dining room soiled. This surveyor stated, From about 9:15 until about 10:21 when the aides came to get him. However, he was already wet, so he may have been that way for a longer period of time. At this time, the administrator stated the facility would report and investigate the claim of neglect. The facility completed its investigation and substantiated the allegation of neglect due to RS #69 stating she forgot to notify anyone of Resident #48 ' s needs.

Based on resident interview, staff interview and observation, the facility failed to update and implement a person-centered comprehensive care plan to meet the resident preferences and goals, and address the resident's medical, physical, mental and psychosocial needs. Resident identifiers: Resident #26 and Resident #48. Facility Census: 51. Findings include: a) Resident #26 On 08/12/24 at 10:18 AM, an observation and interview was conducted with Resident #26 which revealed Resident #26 had whiskers on his face, hair was unkempt and clothing was stained. In addition, this Surveyor smelled a strong odor. Upon entering the room, Resident #26 stated I need a hair cut, shave and I shit. I need a shower too. On 08/13/24 at 11:25 AM, a record review for Resident #26 was conducted revealing a shower schedule for every Wednesday and Saturday, evening shift. In addition, Resident #26 is noted to be an assist of 1 (one) person for bathing. Upon reviewing the Nurse Assistant (NA) documentation for the month of July 2024, multiple refusals by Resident #26 were noted to be documented, the following dates are as follows: 1. 07/03/24 2. 07/17/24 3. 07/24/24 4. 07/31/24 At this time, Resident #26's care plan was reviewed, revealing no care plan or interventions for refusal of care. On 08/14/24 at 1:20 PM, a review of the policy and procedure entitled, Requesting, Refusing and/or Discontinuing Care or Treatment was conducted, which states that if a resident refuses care, it will be documented in the resident's record and appropriate changes will be made to the resident's care plan. An interview was conducted with the Director of Nursing (DON) at 1:30 PM, in which the DON acknowledged Resident #26 was not care planned for refusal of care. B) Resident #48 Upon review of Resident #48's record, it was determined the resident was in a geri chair with a hard lap tray across it, preventing the resident from standing. The resident has an intervention on his care plan which reads as follows: When OOB (Out of Bed): GERICHAIR BILAT HIPSTERS & LAP TRAY FOR SAFETY. CHECK RES (Resident) Q30 MIN (Every 30 minutes) FOR PROPER POSITIONING OF RES & LAP TRAY Q2 HOURS & PRN FOR EXERCISE, REST, TOILETING & HYGIENE NEEDS. At approximately 9:15 AM on 08/13/24, this surveyor entered the dining room on unit 3-C of the facility, where Resident #48 was parked in the geri chair. Resident #48 was noted to be in the geri chair, with the lap tray down, and his pants visibly soiled in the groin area. At approximately 9:21 AM, Resident #48 attempted to stand up from the geri chair but was unable to due to the lap tray. At this time, Resident #48's right leg began to bounce up and down, anxiously. The resident attempted to stand again, unsuccessfully, at which time his right leg began to bounce up and down at a faster pace. Resident #48 attempted to stand a third time and was unsuccessful, at which time his leg bounced up and down faster. At this time, Resident #48 attempted to stand up from the geri chair a fourth time, again, unsuccessfully. At this time, the resident's right leg was bouncing, furiously, up and down, along with his left hand. The resident seemed visibly agitated and anxious at this time. The resident eventually calmed down after approximately five (5) minutes and fell asleep in his chair. At approximately 9:37AM Nurse Aide (NA) #8 entered the dining room and began speaking with another resident which was falling asleep in his wheelchair. NA #8 asked the resident if he wanted to go back to his room to go to sleep, at which time she took the resident back to his room. NA #8 did not interact with Resident #48, nor check on him for proper positioning of himself or the lap tray, nor did she notice he was visibly soiled. NA #8 entered the dining room again at approximately 9:40 AM and removed a clothing protector from breakfast from a female resident, then removed the resident from the dining room. NA #8 did not interact with Resident #48 at this time, nor did she notice he was visibly soiled. At approximately 9:46 AM, NA #8 escorted a new resident into the dining room and placed them at the table to the direct right of Resident #48. At this time, there was no interaction with Resident #48 to check positioning of him, the lap tray, or to notice that he was visibly soiled. At approximately 9:47 AM, NA #57 entered the dining room with another new resident, placed them at the table next to Resident #48. NA #57 did not notice Resident #48 was soiled, nor did they check for proper positioning of the resident or lap tray. At approximately 9:49 AM, Recreation Specialist (RS) #69, entered the dining room to escort residents to an activity taking place at the time. As RS #69 approached Resident #48, she stated Oh, he's wet, at which point, she backed away from Resident #48, gathered other residents, and left the dining room. RS #69 did not ask Resident #48 if he needed assistance, nor did she check to see if the lap tray, or Resident #48, was properly positioned. At approximately 9:51 AM, NA #8 entered the dining room again. NA #8 walked over to a resident sitting beside Resident #48, spoke with that resident, turned around, used the hand sanitizer dispenser, and left the dining room. NA #8 did not check on Resident #48, despite him being visibly soiled, for proper positioning of him or the lap tray. At approximately 10:06 AM, Resident #48 attempted to stand up from the geri chair, however, he was unsuccessful due to the lap tray. At this time, the resident started bouncing his legs up and down, anxiously. The resident attempted to reposition himself in the geri chair at this time. Resident's legs now are bouncing faster and harder and the resident looks uncomfortable, by the look on his face. Resident #48 attempted to stand out of the chair one more time, unsuccessfully. At this time, the resident's legs were bouncing faster. At approximately 10:15 AM, NA #57 entered the dining room and asked two other residents if they wanted to go to the social and listen to some music. The residents stated they did, at which time, she escorted them past Resident #48, out the door and to the activity room. NA #57 did not check on Resident #48 during this trip to the dining room, leaving him still, visibly soiled, and the positioning of him and the lap tray in question. At this time, Resident #48 remained the only resident in the dining room. At approximately 10:21 AM, NA #8 and NA #57 entered the dining room. NA #8 stated He's wet. NAs began to escort resident out of the dining room, at which point, this surveyor asked them if RS #69 had come to inform them Resident #48 was soiled after she left the dining room at approximately 9:49 AM. Both NAs stated no. At approximately 10:45 AM on 08/13/2024, the Administrator of the facility was notified of Resident #48 being visibly soiled at approximately 9:15 AM, RS #69 entering the dining room and stating Oh, he's wet and leaving, without alerting staff, resulting in Resident #48 not being changed until approximately 10:21 AM. The administrator asked how long the resident was sitting in the dining room soiled. This surveyor stated, From about 9:15 until about 10:21 when the aides came to get him. However, he was already wet, so he may have been that way for a longer period of time. The Administrator was notified that staff did not check on the resident or lap tray, per his care plan during this timeframe. At this time, the administrator stated the facility would report and investigate the claim of neglect. The facility completed its investigation and substantiated the allegation of neglect due to RS #69 stating she forgot to notify anyone of Resident #48's needs. 50552

Based on record review and staff interview, the facility failed to ensure a resident did not have an Activities of Daily Living (ADL) decline unless unavoidable, due to Resident #48 being physically restrained in a geri chair with a lap tray. This was true for one (1) of one (1) residents reviewed for ADL decline during the survey process. Resident identifier: 48. Facility census: 51. Findings include: A) Resident #48 At approximately 12:00 PM on 08/12/24, during review of the resident matrix (resident census and conditions of residents) provided by the facility, it was determined the facility had Resident #48 marked as being in physical restraints. Upon review of Resident #48's record, it was determined the resident was in a geri chair with a hard lap tray across it, preventing the resident from standing. The order for the restraint reads as follows: When OOB (Out of Bed): GERICHAIR BILAT HIPSTERS & LAP TRAY FOR SAFETY. CHECK RES (Resident) Q30 MIN (Every 30 minutes) FOR PROPER POSITIONING OF RES & LAP TRAY Q2 HOURS & PRN FOR EXERCISE, REST, TOILETING & HYGIENE NEEDS. At approximately 1:30 PM on 08/12/24, an interview was conducted with Licensed Practical Nurse (LPN) #103 regarding the geri chair and lap tray for Resident #48. LPN #103, regarding the lap tray, stated, I've been here since he first got here. When he got here he would walk around all the time, but he had some falls so they put him in the chair and put the tray on it so he couldn't get up and walk. LPN #103 was asked if Resident #48 was able to release the lap tray from the chair on command, in the event of an emergency, to which she stated No, he can't release it. But he can probably yell out if he needs help. At approximately 12:00 PM on 08/14/24, an interview was conducted with the DON, in which she was asked to supply incident reports pertaining to the falls suffered by Resident #48 and how they led to him being physically restrained in the geri chair. The DON stated the resident had a number of falls and the facility was concerned about his safety. The DON was asked if the facility ever considered less restrictive measures before they restrained Resident #48 in the geri chair, such as a wheelchair. The DON stated We didn't believe a wheelchair was appropriate for him, so no, I don't believe we did evaluate him for one, but I would have to check to make sure. The DON stated she did not believe the resident could propel a wheelchair now, stating He probably could have before, but not now. Review of the Minimum Data Set (MDS) Assessments For Resident #48 revealed the following: For the MDS dated [DATE], Section G0300 reveals the resident was Steady at all times while walking. The resident was independently walking distances of ten (10) feet on uneven surfaces and with picking up objects. The MDS showed the resident required partial to moderate assistance, or supervision for Activities of Daily Living (ADLs) The MDS also revealed the resident received no restorative services at this time. The MDS indicated the resident exhibited wandering behaviors every day. After the initial order for the physical restraint on 06/16/24, the MDS dated [DATE] revealed the resident remained independent with the same tasks as in the MDS in May 2023. The MDS states the resident exhibits wandering behaviors daily. In a significant change MDS, dated [DATE], the resident was not noted to have any impairment of lower or upper extremity. However, walking was no longer attempted, due to a medical or safety concern, and the resident was now totally dependent for all ADLs. The resident still, according to the MDS, exhibited wandering behavior daily. Each MDS which was submitted following the significant change in August 2023, up to and including the annual MDS dated [DATE], now shows the resident completely dependent for all ADLs, walking not being attempted due to a medical or safety concerning, and exhibiting wandering behavior daily, despite being restrained in the geri chair with a lap tray. At approximately 1:00 PM on 08/14/24, an interview was conducted the the MDS Coordinator and the DON. The MDS coordinator was asked about the resident exhibiting wandering behavior daily if he was in the chair. The MDS Coordinator stated When they release him from the chair he will stand up and walk. He will stand up and walk if he isn't watched. The DON was asked if the resident was able to walk if he would be able to propel a wheelchair on his own, despite her saying she did not feel he could in an earlier interview. The DON stated Some days he can walk and some days he can't. We thought he would slide out of a wheelchair if we put him in one. The DON and MDS Coordinator both stated Resident #48 was able to ambulate independently up until the point of being ordered the geri chair with the lap tray. The DON confirmed at this time the facility did not assess Resident #48 for a wheelchair due to them believing he would slide out of it.

Based on observation and staff interview the facility failed to ensure the residents were provided a safe, clean, comfortable and homelike environment. A wall was in poor repair in a residents room. This was a random opportunity for discovery during the long term care survey process. Identifier: Room C 316. Facility census: 51. Findings included: a) Room C 316 During a tour of the facility, Room C 316 was observed to have an area on the wall under the air conditioner which was approximately two (2) feet by two (2) feet in size which was not covered by paint and exposed the white wall plaster underneath. This area was extremely rough in texture and some of the wall plaster was missing. On 08/13/24 at 12:53 PM, during an interview with Certified Nursing Assistant #8, she agreed the wall area was not a pleasant homelike environment and stated she would let maintenance know. During an interview with the Director of Nursing (DON) on 08/13/24 at 1:03 PM the DON stated she would also make maintenance aware of the wall condition.

Based on record review and staff interview, the facility failed to properly investigate an allegation of injury of unknown origin. This was a discovered during an investigation of a facility reported incident. Resident identifier: #55. Facility census: 51. Findings include: a) Resident #55 On [DATE] 8:24 AM, a review of care plan revealed the following: -Resident exhibits behaviors of refusing showers, treatments and/or medications. Her guardian has reported this is a lifelong issue. Resident will also make false accusations against staff. Resident has stated on several occasions staff pull her up by her arms and upon further investigation will identify someone has not worked in the facility for a long period of time. Effective [DATE] -Resident is at risk for cognitive loss, alteration in thought process related to diagnosis of Affective Psychosis, Mild Cognitive Disorder, Dementia, Bipolar Disorder and recurrent depression. Effective [DATE] -Resident's community history involves surviving a rape, house fire and breast cancer. -Resident has unclear speech due to history of cerebrovascular accident (resident can nod yes or no, board or pen and paper for communication). Effective [DATE] -Resident has persistent episodes of anger manifested by not getting what she wants. Resident will pinch, slap, punch, bite, pull other's hair, make false accusations, refusing care and scratch employees and residents. Effective [DATE]. -Potential for increasing confusion secondary to dementia and schizophrenia. Effective [DATE] -Needs to be kept comfortable. Has no cardiopulmonary resuscitation (CPR) request. Do not resuscitate (DNR)/Comfort measures. No labs, no weights, no intubation, no tube feeding, no dialysis, no antibiotics, no intravenous (iv) fluid, no feeding tube. May use oxygen via non-rebreather as needed for comfort. May use suction and manual treatment of airway obstruction as needed for comfort. Do not transfer to hospital unless comfort needs can not be met in the facility. Effective [DATE]. - Resident is comfort care. Effective [DATE]. On [DATE] at 9:03 AM, a review of resident's diagnosis list at time of death: -Vascular Dementia without behavioral disturbance -Essential hypertension -Type 1 (one) diabetes mellitus without complications -Hyperlipidemia, unspecified -Schizoaffective disorder, unspecified -Bipolar Disorder, unspecified -Major depressive Disorder, recurrent, unspecified -Cerebral Infarction, unspecified -Malignant neoplasm of endometrium -Chronic Obstruction Pulmonary Disease, unspecified -Atherosclerotic Heart Disease of Native coronary artery without angina pectoris -Acute embolism and thrombosis of unspecified deep veins of unspecified lower extremity -Gastro-esophageal reflux disease with esophagitis -Personal History of other diseases of the digestive system On [DATE] at 10:00 AM, a review of incident reported for Resident #55 dated for [DATE] revealed the resident was found with an injury of unknown origin. Resident is nonverbal and communicated with nods, pointing, and a dry erase boards. Resident also has a history of making false allegations against staff. On the date of the incident, staff inquired as to how she obtained the bruise on her arm and resident nodded yes when asked if it was caused by staff trying to pull her up. Interviews were conducted with (three) 3 staff who were on shift during time who denied witnessing anyone, or they themselves, had pulled resident's arm. Resident's orders were to be lifted using a lift. She could not name or describe the alleged perpetrator. The investigation contained no statements from other residents and no body audits of other residents residing on the same hall as Resident #55. On [DATE] at 11:45 AM, an Interview with the Social Services Director #63 who reported the facilities normal process for investigating an allegation of abuse would be to interview staff involved or on shift as well as all residents and complete body audits on those who could not be interviewed. She stated no other resident's aside from the alleged victim was interviewed and only three (3) staff members. Social Services Director #63 stated, she was unsure as to why she did not interview any other residents or complete body audits for this investigation.

Based on record review and staff interview the facility failed to ensure the admission Preadmission Screening and Resident Review (PASSR) contained all pertinent diagnoses. This was true for one (1) of seven (7) PASSRs' reviewed during the long term care survey process. Resident Identifier: #42 Facility Census: #51 Findings Include: a) Resident #42 On 08/13/24 at 8:23 AM record review shows Resident #42 has the following medical diagnosis: Schizophrenia 12/10/19 Dementia 12/10/19 Intellectual disabilities 08/28/23 The PASSR provided by the Director of Social Work #63, which was dated 10/22/19 did not contain a dementia diagnosis. The following diagnoses were on the PASSR: mental disorders delusions Schizophrenic disorder Schizophrenia Unspecified neurocognitive disorder unspecified symptoms and signs involving cognitive functions and awareness This was confirmed with the Director of Social Work on 08/23/24 at 3:30 PM, who agreed that the dementia diagnosis should have been on the PASSR dated 10/22/19.

Based on observation, record review, and staff interview, the facility failed to ensure each resident was treated with dignity and respect. Resident #48 visibly soiled for an extended period of time in the little dining room on the third floor. This was a random opportunity for discovery. Resident identifier: #48. Facility census: 51. Findings included: a) Resident #48 At approximately 9:15 AM on 08/13/24, this surveyor entered the dining room on unit 3-C of the facility, where Resident #48 was parked in the geri chair. Resident #48 was noted to be in the geri chair, with the lap tray down, and his pants visibly soiled/wet in the groin area. At approximately 9:21 AM, Resident #48 attempted to stand up from the geri chair but was unable to due to the lap tray. At this time, Resident #48's right leg began to bounce up and down, anxiously. The resident attempted to stand again, unsuccessfully, at which time his right leg began to bounce up and down at a faster pace. Resident #48 attempted to stand a third time and was unsuccessful, at which time his leg bounced up and down faster. At this time, Resident #48 attempted to stand up from the geri chair a fourth time, again, unsuccessfully. At this time, the resident's right leg was bouncing, furiously, up and down, along with his left hand. The resident seemed visibly agitated and anxious at this time. The resident eventually calmed down after approximately five (5) minutes and fell asleep in his chair. At approximately 9:37 AM, Nurse Aide (NA) #8 entered the dining room and began speaking with another resident who was falling asleep in his wheelchair. NA #8 asked the resident if he wanted to go back to his room to go to sleep, at which time she took the resident back to his room. NA #8 did not interact with Resident #48, nor check on him for proper positioning of himself or the lap tray, nor did she notice he was visibly soiled. NA #8 entered the dining room again at approximately 9:40 AM and removed a clothing protector from breakfast from a female resident, then removed the resident from the dining room. NA #8 did not interact with Resident #48 at this time, nor did she notice he was visibly soiled. At approximately 9:46 AM, NA #8 escorted a new resident into the dining room and placed them at the table to the direct right of Resident #48. At this time, there was no interaction with Resident #48 to check positioning of him, the lap tray, or to notice he was visibly soiled. At approximately 9:47 AM, NA #57 entered the dining room with another new resident, placed the resident at the table next to Resident #48. NA #57 did not notice Resident #48 was soiled, nor did they check for proper positioning of the resident or lap tray. At approximately 9:49 AM, Recreation Specialist (RS) #69, entered the dining room to escort residents to an activity taking place at the time. As RS #69 approached Resident #48, she stated Oh, he's wet, at which point, she backed away from Resident #48, gathered other residents, and left the dining room. RS #69 did not ask Resident #48 if he needed assistance, nor did she check to see if the lap tray, or Resident #48, was properly positioned. At approximately 9:51 AM, NA #8 entered the dining room again. NA #8 walked over to a resident sitting beside Resident #48, spoke with resident, turned around, used the hand sanitizer dispenser, and left the dining room. NA #8 did not check on Resident #48, despite him being visibly soiled, for proper positioning of him or the lap tray. At approximately 10:06 AM, Resident #48 attempted to stand up from the geri chair, however, he was unsuccessful due to the lap tray. At this time, the resident started bouncing his legs up and down, anxiously. The resident attempted to reposition himself in the geri chair at this time. Resident's legs now are bouncing faster and harder. Resident #48 attempted to stand out of the chair one more time, unsuccessfully. At this time, the resident's legs were bouncing faster. At approximately 10:15 AM, NA #57 entered the dining room and asked two other residents if they wanted to go to the social and listen to some music. The residents stated they did, at which time, she escorted them past Resident #48, out the door and to the activity room. NA #57 did not check on Resident #48 during this trip to the dining room, leaving him still, visibly soiled, and the positioning of him and the lap tray in question. At this time, Resident #48 remained the only resident in the dining room. At approximately 10:21 AM, NA #8 and NA #57 entered the dining room. NA #8 stated He's wet. NAs began to escort resident out of the dining room, at which point, this surveyor asked them if RS #69 had come to inform them Resident #48 was soiled after she left the dining room at approximately 9:49 AM. Both NAs stated no. At approximately 10:45 AM on 08/13/2024, the Administrator of the facility was notified of Resident #48 being visibly soiled at approximately 9:15 AM, RS #69 entering the dining room and stating Oh, he's wet and leaving, without alerting staff, resulting in Resident #48 not being changed until approximately 10:21 AM. The administrator asked how long the resident was sitting in the dining room soiled. This surveyor stated, From about 9:15 AM until about 10:21 AM when the aides came to get him. However, he was already wet, so he may have been wet for a longer period of time. At this time, the administrator stated the facility would report and investigate the claim of neglect. The facility completed its investigation and substantiated the allegation of neglect due to RS #69 stating she forgot to notify anyone of Resident #48's needs.

45173 Based on observation and staff interview, the facility failed to provide a dignified dining experience for four (4) of 50 residents. These were random opportunities for discovery. Resident Identifiers: #8, #1, #41, #50 and #30. Facility Census: 50. Findings Included: a) Resident #8 On 08/28/23 at 12:38 PM, an observation of lunch trays being passed in dining room [ROOM NUMBER]B was made. Resident #8 was sitting at the same table as Resident #14. Resident #14 received his lunch tray first. After approximately 10 minutes, Resident #8 received her lunch tray. The lunch trays were being passed by Nurse Aide (NA) #70 and NA #88. On 08/28/23 at 1:15 PM, the Hospital Administrator Assistant #62 was notified and stated, they have been trained .I don't know why they didn't do it correctly. b) Resident #1 On 08/28/23 at 12:38 PM, an observation of lunch trays being passed in dining room [ROOM NUMBER]B was made. Resident #1 was sitting in a wheelchair at the same table as Resident #22. Resident #22 received his lunch tray first. After approximately 10 minutes, Resident #1 received his lunch tray. The lunch trays were being passed NA #70 and NA #88. On 08/28/23 at 1:15 PM, the Hospital Administrator Assistant #62 was notified and stated, they have been trained .I don't know why they didn't do it correctly. c) Resident #41 On 08/28/23 at 12:38 PM, an observation of lunch trays being passed in dining room [ROOM NUMBER]B was made. Resident #41 was sitting at the same table as Resident #21. Resident #21 received his lunch tray first. After approximately 10 minutes, Resident #41 received her lunch tray. The lunch trays were being passed by NA #70 and NA #88. On 08/28/23 at 1:15 PM, the Hospital Administrator Assistant #62 was notified and stated, they have been trained .I don't know why they didn't do it correctly. d) Resident # 30 On 08/28/23 at 12:10 PM, observation was made by this surveyor as Health Service Assistant #12 was assisting Resident #30 with her noon meal. HSA #12 and was standing while feeding the resident. This was confirmed with the Health Service Assistant and she stated I will get a chair. e) Resident #50 On 08/28/23 at 12:14 PM observation was made by this surveyor as Recreation Specialist (RS) #34 was assisting Resident #50 with her noon meal. RS #34 was standing while feeding the resident. This was confirmed with the Recreation Specialist and she stated I forgot, at which time she went to obtain a chair. Both of these incidents were also confirmed with Nurse III (#1.)

Based on review of ambient air temperatures measured by a life-safety code (LSC) surveyor from the Office of Health Facility Licensure and Certification (OHFLAC), information from the National Weather Service, review of resident body temperatures, review of the facility's 10/01/10 contingency plan entitled "Heating back up plan", review of National Institutes of Health (NIH) news release dated 01/16/09 entitled "Hypothermia: A Cold Weather Risk for Older People", review of facility documents, review of information on hypothermia from the Centers for Disease Control and Prevention (CDC), review of an article entitled "Hypothermia" (06/09/09) by the Mayo Foundation for Medical Education and Research (MFMER), medical record review, review of Appendix PP of the Centers for Medicare & Medicaid Services (CMS) State Operations Manual, and staff interview, the facility's governing body failed to obtain the necessary supplies and services to repair and/or replace this boiler system prior to the cold weather experienced in the area on 10/05/10. The facility's heating boiler system, utilized to heat the common areas and resident rooms, failed to pass inspection on and was "red-tagged" (prohibiting the use of the boiler system until defects in the system were corrected) during inspections on 08/06/10 and 08/09/10. The governing body, possessing the authority to approve and allocate funds for the maintenance of the heating system for this facility, was aware of significant problems with the heating boiler system as early as August 2009. The governing body was also aware the facility's heating boiler system failed to pass inspections in August 2010 and did not act to correct the identified problems prior to a complaint survey beginning on 10/04/10. The failure of the governing body to authorize funding for the necessary repair and/or replacement of the malfunctioning heating boiler system, or to provide for an acceptable alternate heat source, in a timely manner resulted in findings of immediate jeopardy and substandard quality of care. It was determined, on 10/06/10 at 12:15 p.m., that residents residing in this unheated facility were placed in immediate jeopardy of harm or death related to the potential for developing hypothermia or other cold-related complications. Residents were found sleeping in rooms with ambient air temperatures as low as 59 degrees Fahrenheit (F). Sixteen (16) residents, who exhibited one (1) or more risk factors for developing hypothermia, were found to have sustained a drop in their average body temperatures ranging from 0.7 degree F to 2.2 degrees F related to exposure to less than safe indoor temperatures. The governing body of this facility was ultimately responsible for the procurement, approval, and allocation of funding to maintain and ensure a safe and reliable heating system for this facility, as this entity alone possessed the authority to approve necessary repairs and/or replacement of this malfunctioning heating system. This practice affected sixteen (16) of eighty-one (81) residents currently residing in the facility. Resident identifiers: #50, #37, #47, #75, #42, #82, #49, #52, #83, #44, #11, #68, #39, #41, #64, and #15. Findings include: a) Residents #50, #37, #47, #75, #42, #82, #49, #52, #83, #44, #11, #68, #39, #41, #64, and #15 Interview with the facility's administrator and the maintenance director, on 10/04/10 at approximately 1:40 p.m., revealed the facility's heating boiler system was in need of repair. The boilers intended to heat the resident rooms and common areas had been inspected by a boiler inspector and were "red tagged" as not operational (prohibiting the use of the boiler system until defects in the system were corrected) during inspections dated 08/06/10 and 08/09/10. According to the National Weather Service, the minimum outdoor temperature in the Beckley, WV area on 10/04/10, measured at 3:35 a.m., was 43 degrees F. Ambient air temperatures of resident rooms were taken by the LSC surveyor, accompanied by a licensed practical nurse (LPN - Employee #158), between the hours of 5:30 a.m. to 6:35 a.m. on 10/05/10. Fifty-eight (58) of sixty-five (65) occupied resident rooms were found to be below 70 degrees F, and nineteen (19) of sixty-five (65) occupied resident room were found to be below 65 degrees F, which is below the temperature range of 71 to 81 degrees for safety and comfort established at 42 CFR 483.15(h)(6). (Note the outside ambient air temperature during this testing of resident room temperatures was 49 degrees F. Review of the Guidance to Surveyors for 42 CFR 483.15(h)(6), found in Appendix PP of the CMS State Operations Manual, revealed, "'Comfortable and safe temperature levels' means that the ambient temperature should be in a relatively narrow range that minimizes residents' susceptibility to loss of body heat and risk of hypothermia or susceptibility to respiratory ailments and colds. ... For facilities certified after October 1, 1990, ... the temperatures may fall below 71 (symbol for degrees) F for facilities in areas of the country where that temperature is exceeded only during brief episodes of unseasonably cold weather (minimum temperature must still be maintained at a sufficient level to minimize risk of hypothermia and susceptibility to loss of body heat, respiratory ailments and cold). ..." This determination resulted in a finding of substandard quality of care for a failure to provide comfortable and safe temperature levels facility-wide. (See citation at F257 for additional details.) This health facility nurse surveyor was brought in on the morning of 10/05/10, to assist the LSC surveyor in conducting a partial extended survey. - Upon arrival on 10/05/10 at 10:05 a.m., the nurse surveyor observed the hallways and resident rooms on the first floor to be uncomfortably chilly. According to the National Weather Service, the minimum outdoor temperature in the Beckley, WV area on 10/05/10, measured at 11:59 p.m., was 41 degrees F. An interview with the LSC surveyor revealed the ambient air temperature in resident rooms on the first and other occupied floors was registering below 65 degrees F. Resident room ambient air temperatures, taken between the hours of 8:30 a.m. to 9:15 a.m. on 10/06/10, found forty-four (44) of forty-eight (48) occupied resident rooms tested were found below 70 degrees F, and twenty (20) of forty-eight (48) occupied resident rooms were below 65 degrees F. (Note the outside ambient air temperature during this testing of resident room temperatures was 46 degrees F.) The administrator (Employee #10) was present. When asked if staff was taking residents' body temperatures and assessing for signs and symptoms of hypothermia due to the excessively cool temperatures, the administrator stated staff was not taking residents' body temperatures. At this time, the nurse surveyor requested of the administrator that all residents' body temperatures be taken. Review of the residents' body temperatures, as measured by facility staff, found three (3) residents with temperatures below 97 degrees F. A review of the past history of body temperatures for these three (3) residents (Residents #12, #36, and #6) found this was not unusual for these residents. The administrator stated the facility had purchased portable electric space heaters to place throughout the facility and extra blankets for resident use. It was not found that residents were in danger of suffering from hypothermia or other cold-related complications at this time. -- The NIH warns in their 01/15/09 newsletter: "... Older people also are as risk for hypothermia because their body's response to cold can be diminished by certain illnesses such as diabetes and some medicines, including over-the-counter cold remedies. In addition, older adults may be less active and generate less body heat. As a result, they can develop hypothermia even after exposure to relatively mild cold weather or a small drop in temperature... take his or her temperature. If it's 96 degrees or lower, call 911... Even mildly cool homes with temperatures from 60 to 65 degrees can trigger hypothermia in older people." The CDC states, "Hypothermia occurs when the body temperature is less than 95 degrees. If persons exposed to excessive cold are unable to generate enough heat (e.g., through shivering) to maintain a body temperature of 98.6 degrees their organs (e.g., brain heart or kidneys) can malfunction." An article by the MFMER titled "Hypothermia" (06/09/09) (<http://www.mayoclinic.com/health/hypothermia/DS /DSECTION=risk-factors>) noted, "Hypothermia isn't always the result of exposure to extremely cold outdoor temperatures. An older person may develop mild hypothermia after prolonged exposure to indoor temperatures that would be tolerable to a younger or healthier adult - for example, temperatures in a poorly heated home or in an air-conditioned home." The MFMER article also identifies the following risk factors associated with developing hypothermia: "- Older age. People age 65 and older are more vulnerable to hypothermia for a number of reasons. The body's ability to regulate temperature and to sense cold may lessen with age. Older people are also more likely to have a medical condition that affects temperature regulation. Some older adults may not be able to communicate when they are cold or may not be mobile enough to get to a warm location. ... "- Mental impairment. People with a mental illness, dementia or another condition that impairs judgment may not dress appropriately for the weather or understand the risk of cold weather. People with dementia may wander from home or get lost easily, making them more likely to be stranded outside in cold or wet weather. ... "- Certain medical conditions. Some health disorders affect your body's ability to regulate body temperature. Examples include underactive [MEDICAL CONDITION] [MEDICAL CONDITION], stroke, severe arthritis, [MEDICAL CONDITION], trauma, spinal cord injuries, burns, disorders that affect sensation in your extremities (for example, nerve damage in the feet of people with diabetes), dehydration and any condition that limits activity or restrains the normal flow of blood. ... "- Medications. A number of antipsychotic drugs and sedatives can impair the body's ability to regulate its temperature." -- Upon return to the facility at 8:45 a.m. on 10/06/10, a request was again made for assessments of each resident's body temperature. Upon review of the body temperatures and conference with the LSC surveyor, it was found that residents had slept in rooms as cold as 59 degrees F, and sixteen (16) cognitively and/or physically impaired residents sustained a reduction in their body temperatures as much as 2.2 degrees F (Residents #50, #37, #47, #75, #42, #82, #49, #52, #83, #44, #11, #68, #39, #41, and #64). The director of nursing (DON - Employee #87) was asked to provide a three-month summary of the body temperatures of these sixteen (16) residents to establish an average baseline body temperature for each individual. A tour of the facility found portable electric space heaters had been placed in the resident hallways, and the corridor doors to the residents' rooms were left open. However, the facility had not purchased enough portable electric space heaters to place one (1) in each of the occupied resident rooms, to assure the ambient air temperature remained at a safe level while residents were sleeping. A random check with the LSC surveyor found the temperatures of resident rooms to be 59 degrees F, 61 degrees F, 62 degrees F, and 64 degrees F. A review of the residents' body temperatures, taken on the morning of 10/06/10 and compared with their average baseline body temperatures over the preceding three-month period, found the following: 1. Resident #50 Resident #50's average body temperature was 98.7 degrees F. His body temperature, on the morning of 10/06/10, had dropped to 96.5 degrees F, a difference of 2.2 degrees F. His ambient room temperature was 62 degrees F. Resident #50's most recent minimum data set (MDS), an abbreviated quarterly assessment with an assessment reference date (ARD) of 07/12/10, revealed this [AGE] year old male's [DIAGNOSES REDACTED]. 2. Resident #37 Resident #37's average body temperature was 98.2 degrees F. Her body temperature, on the morning of 10/06/10, was determined to be 96.1 degrees F, a reduction of 2.1 degrees F. Her ambient room temperature was 64 degrees F. Her most recent MDS, a quarterly with an ARD of 08/02/10, revealed this [AGE] year old female's [DIAGNOSES REDACTED]. Her cognitive skills for daily decision-making were severely impaired, she required extensive physical assistance with bed mobility, was totally dependent on staff for transferring, and she did not ambulate during the assessment reference period. 3. Resident #47 Resident #47's average body temperature was 98.3 degrees F. His body temperature, on the morning of 10/06/10, was 96.9 degrees F, a reduction of 1.3 degrees F. The ambient air temperature in his room was 61 degrees F. His most recent MDS, a comprehensive annual assessment with an ARD of 07/26/10, revealed this [AGE] year old male's [DIAGNOSES REDACTED]. His cognitive skills for daily decision-making were moderately impaired, he required limited physical assistance with bed mobility and extensive physical assistance with transferring, and he did not ambulate during the assessment reference period. He was also receiving antipsychotics. 4. Resident #75 Resident #75's average body temperature was 97.9 degrees F. His body temperature, on the morning of 10/06/10, was 96.5 degrees F, a reduction of 1.4 degrees F. The ambient air temperature in his room was 59 degrees F. His most recent MDS, an annual with an ARD of 07/19/10, revealed this [AGE] year old male's [DIAGNOSES REDACTED]. His cognitive skills for daily decision-making were moderately impaired, he required limited physical assistance with bed mobility, he was totally dependent on staff for transferring, and he did not ambulate during the assessment reference period. He was also receiving antipsychotics and antidepressants daily. 5. Resident #42 Resident #42's average body temperature was 98.7 degrees F. Her body temperature, on the morning of 10/06/10, was 96.8 degrees F, a reduction of 1.9 degrees F. The ambient air temperature of her room was 62 degrees F. Her most recent MDS, a quarterly with an ARD of 08/09/10, revealed this [AGE] year old female's [DIAGNOSES REDACTED]. Her cognitive skills for daily decision-making were severely impaired, she required extensive physical assistance with bed mobility, she was totally dependent on staff for transferring, and she did not ambulate during the assessment reference period. 6. Resident #82 Resident #82's average body temperature was 98.6 degrees F. Her body temperature, on the morning of 10/06/10, was 96.7 degrees F, a reduction of 1.9 degrees F. The ambient air temperature of her room was 63 degrees F. Her most recent MDS, a quarterly with an ARD of 08/30/10, revealed this [AGE] year old female's [DIAGNOSES REDACTED]. Her cognitive skills for daily decision-making were severely impaired, she required limited physical assistance with bed mobility and extensive physical assistance with transferring, and she did not ambulate during the assessment reference period. She was also receiving antipsychotics, anxiolytics, and antidepressants daily. 7. Resident #49 Resident #49's average body temperature was 98.3 degrees F. His body temperature, on the morning of 10/06/10, was 96.4 degrees F, a reduction of 1.9 degrees F. The ambient air temperature of his room was 66 degrees F. Resident #49's most recent MDS, a quarterly with an ARD of 08/08/10, revealed this [AGE] year old male's [DIAGNOSES REDACTED]. His cognitive skills for daily decision-making were severely impaired, he was totally dependent on staff for bed mobility and transferring, and he did not ambulate during the assessment reference period. 8. Resident #52 Resident #52's average body temperature was 98.4 degrees F. Her body temperature, on the morning of 10/06/10, was 96.6 degrees F, a reduction of 1.8 degrees F. The ambient air temperature in her room was 67 degrees F. Her most recent MDS, a quarterly with an ARD of 09/10/10, revealed this [AGE] year old female's [DIAGNOSES REDACTED]. Her cognitive skills for daily decision-making were moderately impaired, she required extensive physical assistance with bed mobility, she was totally dependent on staff for transferring, and she did not ambulate during the assessment reference period. She was also receiving antipsychotics daily. 9. Resident #83 Resident #83's average body temperature was 98.2 degrees F. His body temperature, on the morning of 10/06/10, was 96.5 degrees F, a reduction of 1.7 degrees F. The ambient air temperature in his room was 66 degrees F. His most recent MDS, a quarterly with an ARD of 09/12/10, revealed this [AGE] year old male's [DIAGNOSES REDACTED]. His cognitive skills for daily decision-making were moderately impaired, he required extensive physical assistance with bed mobility, he was totally dependent on staff for transferring, and he did not ambulate during the assessment reference period. 10. Resident #44 Resident #44's average body temperature was 98.3 degrees F. Her body temperature, on the morning of 10/06/10, was 96.7 degrees F, a reduction of 1.7 degrees F. The ambient air temperature in her room was 67 degrees F. Her most recent MDS, a quarterly with an ARD of 09/20/10, revealed this [AGE] year old female's [DIAGNOSES REDACTED]. 11. Resident #11 Resident #11's average body temperature was 98.3 degrees F. Her body temperature, on the morning of 10/06/10, was 96.8 degrees F, a reduction of 1.5 degrees F. Her ambient room temperature was 61 degrees F. Her most recent MDS, a comprehensive significant change in status assessment with an ARD of 07/26/10, revealed this [AGE] year old female's [DIAGNOSES REDACTED]. Her cognitive skills for daily decision-making were moderately impaired, she required extensive physical assistance with bed mobility, she was totally dependent on staff for transferring, and she did not ambulate during the assessment reference period. She was also receiving antipsychotics, anxiolytics, and antidepressants daily. 12. Resident #68 Resident #68's average body temperature was 97.3 degrees F. Her body temperature, on the morning of 10/06/10, was 95.8 degrees F, a reduction of 1.5 degrees F. Her ambient room temperature was 69 degrees F. Her most recent MDS, an annual with an ARD of 07/26/10, revealed this [AGE] year old female's [DIAGNOSES REDACTED]. She was also receiving anxiolytics and antidepressants daily. 13. Resident #39 Resident #39's average body temperature was 98.2 degrees F. His body temperature, on the morning of 10/06/10, was 96.9 degrees F, a reduction of 1.3 degrees F. The ambient air temperature of his room was 67 degrees F. His most recent MDS, a quarterly with an ARD of 07/12/10, revealed this [AGE] year old male's [DIAGNOSES REDACTED]. He was also receiving antipsychotics, antidepressants, and anxiolytics daily. 14. Resident #41 Resident #41's average body temperature was 97.5 degrees F. Her body temperature, on the morning of 10/06/10, was 96.4 degrees F, a reduction of 1.1 degrees F. The ambient air temperature of her room was 64 degrees F. Her most recent MDS, an annual with an ARD of 08/16/10, revealed this [AGE] year old female's [DIAGNOSES REDACTED]. Her cognitive skills for daily decision-making were severely impaired, she was totally dependent on staff for bed mobility and transferring, and she did not ambulate during the assessment reference period. 15. Resident #64 Resident #64's average body temperature was 97.9 degrees F. His body temperature, on the morning of 10/06/10, was 96.8 degrees F, a reduction of 1.1 degrees F. The ambient air temperature of his room was 68 degrees F. His most recent MDS, a quarterly with an ARD of 08/23/10, revealed this [AGE] year old male's [DIAGNOSES REDACTED]. His cognitive skills for daily decision-making were severely impaired, he required extensive physical assistance with transferring, and he did not ambulate during the assessment reference period. He was also receiving antipsychotics, antidepressants, and anxiolytics daily. 16. Resident #15 Resident #15's average body temperature was 97.4 degrees F. Her body temperature, on the morning of 10/06/10, was 96.7 degrees F, a reduction of 0.7 degree F. Her ambient room temperature was 66 degrees F. Her most recent MDS, a quarterly with an ARD of 09/23/10, revealed this [AGE] year old female's [DIAGNOSES REDACTED]. She was also receiving antipsychotics daily. -- Following the analysis of residents' body temperatures, review of ambient air temperatures, and conference with the LSC surveyor and program manager, it was determined the facility's failure to obtain the necessary repairs and/or replacement of the boiler heating system serving the resident rooms and common areas, failure to obtain sufficient portable electric space heaters to keep resident sleeping areas at safe temperatures, and failure to assure the residents' body temperatures remained at normal levels constituted an immediate threat to the life and health of more than an isolated number of residents living in the facility. The immediate jeopardy was abated at 8:35 p.m. on 10/06/10, following the purchase and placement of an adequate supply of portable electric space heaters to serve each resident rooms and the common areas, the development and implementation of a monitoring system to assess ambient air temperature and resident body temperatures, and the transfer of some of the residents from an unheated floor to a floor supplied by heat. It was determined that a deficient practice remained with the potential of more than minimal harm to more than an isolated number of residents until such time as the facility obtained a safe and reliable heating system. -- b) Review of facility documents found a request from the facility, dated 08/24/09, to replace a boiler which had been in operation since 10/94. The document from the governing body stated the funds were available and were awaiting "your okay". On 08/25/09, the chief operations officer (COO) of the governing body replied, "I don't see anything happening with this project until next summer so we would need to be able to fire the old boiler one more winter..." The facility replied, on 08/26/09, with, "Yes sir, to be honest I was afraid that we were not going to make it last winter and we almost did not, this boiler blew tubes and went down at least ten times last winter, every time we blow a tube the steam fills the boiler and then is followed by the cold water supplying the boiler... I do not believe that this boiler will last through the winter if we were able to get all of this repair work completed before cold sets in, I honestly believe that at this point we need to try to get a new boiler just like this one and switch them out..." As of the immediate jeopardy and substandard quality of care finding on 10/06/10, there was no indication the governing body had made any arrangements for the replacement of the boiler system, or the acquisition of an acceptable alternate heat source, to ensure residents were provided a safe and comfortable environment for the winter of 2010. .

Based on review of ambient air temperatures measured by a life-safety code (LSC) surveyor from the Office of Health Facility Licensure and Certification (OHFLAC), information from the National Weather Service, review of resident body temperatures, review of the facility's 10/01/10 contingency plan entitled "Heating back up plan", review of National Institutes of Health (NIH) news release dated 01/16/09 entitled "Hypothermia: A Cold Weather Risk for Older People", review of facility documents, review of information on hypothermia from the Centers for Disease Control and Prevention (CDC), review of an article entitled "Hypothermia" (06/09/09) by the Mayo Foundation for Medical Education and Research (MFMER), medical record review, review of Appendix PP of the Centers for Medicare & Medicaid Services (CMS) State Operations Manual, and staff interview, the facility failed to provide goods and services to avoid physical harm, by failing to provide a reliable source of heat to maintain safe indoor temperatures and ensure residents were safe from developing hypothermia. The facility's heating boiler system, utilized to heat the common areas and resident rooms, failed to pass inspection on and was "red-tagged" (prohibiting the use of the boiler system until defects in the system were corrected) during inspections on 08/06/10 and 08/09/10. The facility's governing body failed to obtain the necessary supplies and services to repair and/or replace this boiler system prior to the cold weather experienced in the area on 10/05/10. The facility's contingency plan entitled "Heating back up plan" found the plan consisted of purchasing twenty (20) portable space heaters; this number was not sufficient to supply heat to sixty-five (65) unheated rooms occupied by eighty-one (81) residents currently in the facility. The contingency plan was inadequate to ensure the residents' environment remained at safe and comfortable temperature levels. This failure resulted in the ambient air temperatures in resident rooms falling to unacceptably low levels, placing sixteen (16) of eighty-one (81) facility residents in immediate jeopardy of injury or death from hypothermia or other cold-related complications. The NIH warns in their 01/15/09 newsletter: "... Older people also are at risk for hypothermia because their body's response to cold can be diminished by certain illnesses such as diabetes and some medicines, including over-the-counter cold remedies. In addition, older adults may be less active and generate less body heat. As a result, they can develop hypothermia even after exposure to relatively mild cold weather or a small drop in temperature... take his or her temperature. If it's 96 degrees or lower, call 911... Even mildly cool homes with temperatures from 60 to 65 degrees can trigger hypothermia in older people." An article by the MFMER dated 06/09/09 and entitled "Hypothermia", states, "Hypothermia isn't always the result of exposure to extremely cold outdoor temperatures. An older person may develop mild hypothermia after prolonged exposure to indoor temperatures that would be tolerable to a younger or healthier adult - for example, temperatures in a poorly heated home or in an air-conditioned home." The MFMER article identified risk factors associated with developing hypothermia to include age [AGE] years or older, mental impairment, certain medical conditions (e.g., [MEDICAL CONDITIONS] ([MEDICAL CONDITION]), severe arthritis, Parkinson ' s disease, spinal cord injuries, disorders that affect sensation in the extremities (including [MEDICAL CONDITION] in diabetics), dehydration, and any condition that limits activity or restrains the normal flow of blood), and the use of certain medications (e.g., antipsychotics). On 10/06/10 at 12:15 p.m., it was determined that residents had been sleeping in rooms with an ambient air temperature as low as 59 degrees Fahrenheit (F). Sixteen (16) facility residents, who were positive for one (1) or more risk factors for hypothermia and who had extended exposure to these unsafe temperatures, were determined to have sustained a drop in their average body temperatures ranging from 0.7 degree F to 2.2 degrees F. The facility assessed these sixteen (16) residents as having body temperatures as low as 95.8 degrees F, placing them at risk for hypothermia. Information on hypothermia from CDC states: "Hypothermia occurs when the body temperature is less than 95 degrees. If persons exposed to excessive cold are unable to generate enough heat (e.g., through shivering) to maintain a body temperature of 98.6 degrees their organs (e.g., brain heart or kidneys) can malfunction." The administrator was informed, at 12:15 p.m. on 10/06/10, that the facility's failure to provide a reliable source of heat to resident rooms placed more than an isolated number of residents in immediate jeopardy of injury or death, due to the potential for developing hypothermia. The immediate jeopardy was abated at 8:35 p.m. on 10/06/10, following the purchase and placement of an adequate supply of portable electric space heaters to serve all occupied resident rooms, the development and implementation of a monitoring system to assess ambient air temperature and resident body temperatures, and the transfer of some of the residents from an unheated floor to a floor supplied by heat. Upon removal of the immediate jeopardy, a deficient practice remained with the potential of more than minimal harm to more than an isolated number of residents until such time as the facility obtained a safe and reliable heating system without the use of portable electric space heaters. Resident identifiers: #50, #37, #47, #75, #42, #82, #49, #52, #83, #44, #11, #68, #39, #41, #64, and #15. Facility census: 81. Findings include: a) Residents #50, #37, #47, #75, #42, #82, #49, #52, #83, #44, #11, #68, #39, #41, #64, and #15 Interview with the facility's administrator and the maintenance director, on 10/04/10 at approximately 1:40 p.m., revealed the facility's heating boiler system was in need of repair. The boilers intended to heat the resident rooms and common areas had been inspected by a boiler inspector and were "red tagged" as not operational (prohibiting the use of the boiler system until defects in the system were corrected) during inspections dated 08/06/10 and 08/09/10. According to the National Weather Service, the minimum outdoor temperature in the Beckley, WV area on 10/04/10, measured at 3:35 a.m., was 43 degrees F. Ambient air temperatures of resident rooms were taken by the LSC surveyor, accompanied by a licensed practical nurse (LPN - Employee #158), between the hours of 5:30 a.m. to 6:35 a.m. on 10/05/10. Fifty-eight (58) of sixty-five (65) occupied resident rooms were found to be below 70 degrees F, and nineteen (19) of sixty-five (65) occupied resident room were found to be below 65 degrees F, which is below the temperature range of 71 to 81 degrees for safety and comfort established at 42 CFR 483.15(h)(6). (Note the outside ambient air temperature during this testing of resident room temperatures was 49 degrees F. Review of the Guidance to Surveyors for 42 CFR 483.15(h)(6), found in Appendix PP of the CMS State Operations Manual, revealed, "'Comfortable and safe temperature levels' means that the ambient temperature should be in a relatively narrow range that minimizes residents' susceptibility to loss of body heat and risk of hypothermia or susceptibility to respiratory ailments and colds. ... For facilities certified after October 1, 1990, ... the temperatures may fall below 71 (symbol for degrees) F for facilities in areas of the country where that temperature is exceeded only during brief episodes of unseasonably cold weather (minimum temperature must still be maintained at a sufficient level to minimize risk of hypothermia and susceptibility to loss of body heat, respiratory ailments and cold). ..." This determination resulted in a finding of substandard quality of care for a failure to provide comfortable and safe temperature levels facility-wide. (See citation at F257 for additional details.) This health facility nurse surveyor was brought in on the morning of 10/05/10, to assist the LSC surveyor in conducting a partial extended survey. - Upon arrival on 10/05/10 at 10:05 a.m., the nurse surveyor observed the hallways and resident rooms on the first floor to be uncomfortably chilly. According to the National Weather Service, the minimum outdoor temperature in the Beckley, WV area on 10/05/10, measured at 11:59 p.m., was 41 degrees F. An interview with the LSC surveyor revealed the ambient air temperature in resident rooms on the first and other occupied floors was registering below 65 degrees F. Resident room ambient air temperatures, taken between the hours of 8:30 a.m. to 9:15 a.m. on 10/06/10, found forty-four (44) of forty-eight (48) occupied resident rooms tested were found below 70 degrees F, and twenty (20) of forty-eight (48) occupied resident rooms were below 65 degrees F. (Note the outside ambient air temperature during this testing of resident room temperatures was 46 degrees F.) The administrator (Employee #10) was present. When asked if staff was taking residents' body temperatures and assessing for signs and symptoms of hypothermia due to the excessively cool temperatures, the administrator stated staff was not taking residents' body temperatures. At this time, the nurse surveyor requested of the administrator that all residents' body temperatures be taken. Review of the residents' body temperatures, as measured by facility staff, found three (3) residents with temperatures below 97 degrees F. A review of the past history of body temperatures for these three (3) residents (Residents #12, #36, and #6) found this was not unusual for these residents. The administrator stated the facility had purchased portable electric space heaters to place throughout the facility and extra blankets for resident use. It was not found that residents were in danger of suffering from hypothermia or other cold-related complications at this time. -- The NIH warns in their 01/15/09 newsletter: "... Older people also are as risk for hypothermia because their body's response to cold can be diminished by certain illnesses such as diabetes and some medicines, including over-the-counter cold remedies. In addition, older adults may be less active and generate less body heat. As a result, they can develop hypothermia even after exposure to relatively mild cold weather or a small drop in temperature... take his or her temperature. If it's 96 degrees or lower, call 911... Even mildly cool homes with temperatures from 60 to 65 degrees can trigger hypothermia in older people." The CDC states, "Hypothermia occurs when the body temperature is less than 95 degrees. If persons exposed to excessive cold are unable to generate enough heat (e.g., through shivering) to maintain a body temperature of 98.6 degrees their organs (e.g., brain heart or kidneys) can malfunction." An article by the MFMER titled "Hypothermia" (06/09/09) (<http://www.mayoclinic.com/health/hypothermia/DS /DSECTION=risk-factors>) noted, "Hypothermia isn't always the result of exposure to extremely cold outdoor temperatures. An older person may develop mild hypothermia after prolonged exposure to indoor temperatures that would be tolerable to a younger or healthier adult - for example, temperatures in a poorly heated home or in an air-conditioned home." The MFMER article also identifies the following risk factors associated with developing hypothermia: "- Older age. People age 65 and older are more vulnerable to hypothermia for a number of reasons. The body's ability to regulate temperature and to sense cold may lessen with age. Older people are also more likely to have a medical condition that affects temperature regulation. Some older adults may not be able to communicate when they are cold or may not be mobile enough to get to a warm location. ... "- Mental impairment. People with a mental illness, dementia or another condition that impairs judgment may not dress appropriately for the weather or understand the risk of cold weather. People with dementia may wander from home or get lost easily, making them more likely to be stranded outside in cold or wet weather. ... "- Certain medical conditions. Some health disorders affect your body's ability to regulate body temperature. Examples include underactive [MEDICAL CONDITION] [MEDICAL CONDITION], stroke, severe arthritis, [MEDICAL CONDITION], trauma, spinal cord injuries, burns, disorders that affect sensation in your extremities (for example, nerve damage in the feet of people with diabetes), dehydration and any condition that limits activity or restrains the normal flow of blood. ... "- Medications. A number of antipsychotic drugs and sedatives can impair the body's ability to regulate its temperature." -- Upon return to the facility at 8:45 a.m. on 10/06/10, a request was again made for assessments of each resident's body temperature. Upon review of the body temperatures and conference with the LSC surveyor, it was found that residents had slept in rooms as cold as 59 degrees F, and sixteen (16) cognitively and/or physically impaired residents sustained a reduction in their body temperatures as much as 2.2 degrees F (Residents #50, #37, #47, #75, #42, #82, #49, #52, #83, #44, #11, #68, #39, #41, and #64). The director of nursing (DON - Employee #87) was asked to provide a three-month summary of the body temperatures of these sixteen (16) residents to establish an average baseline body temperature for each individual. A tour of the facility found portable electric space heaters had been placed in the resident hallways, and the corridor doors to the residents' rooms were left open. However, the facility had not purchased enough portable electric space heaters to place one (1) in each of the occupied resident rooms, to assure the ambient air temperature remained at a safe level while residents were sleeping. A random check with the LSC surveyor found the temperatures of resident rooms to be 59 degrees F, 61 degrees F, 62 degrees F, and 64 degrees F. A review of the residents' body temperatures, taken on the morning of 10/06/10 and compared with their average baseline body temperatures over the preceding three-month period, found the following: 1. Resident #50 Resident #50's average body temperature was 98.7 degrees F. His body temperature, on the morning of 10/06/10, had dropped to 96.5 degrees F, a difference of 2.2 degrees F. His ambient room temperature was 62 degrees F. Resident #50's most recent minimum data set (MDS), an abbreviated quarterly assessment with an assessment reference date (ARD) of 07/12/10, revealed this [AGE] year old male's [DIAGNOSES REDACTED]. 2. Resident #37 Resident #37's average body temperature was 98.2 degrees F. Her body temperature, on the morning of 10/06/10, was determined to be 96.1 degrees F, a reduction of 2.1 degrees F. Her ambient room temperature was 64 degrees F. Her most recent MDS, a quarterly with an ARD of 08/02/10, revealed this [AGE] year old female's [DIAGNOSES REDACTED]. Her cognitive skills for daily decision-making were severely impaired, she required extensive physical assistance with bed mobility, was totally dependent on staff for transferring, and she did not ambulate during the assessment reference period. 3. Resident #47 Resident #47's average body temperature was 98.3 degrees F. His body temperature, on the morning of 10/06/10, was 96.9 degrees F, a reduction of 1.3 degrees F. The ambient air temperature in his room was 61 degrees F. His most recent MDS, a comprehensive annual assessment with an ARD of 07/26/10, revealed this [AGE] year old male's [DIAGNOSES REDACTED]. His cognitive skills for daily decision-making were moderately impaired, he required limited physical assistance with bed mobility and extensive physical assistance with transferring, and he did not ambulate during the assessment reference period. He was also receiving antipsychotics. 4. Resident #75 Resident #75's average body temperature was 97.9 degrees F. His body temperature, on the morning of 10/06/10, was 96.5 degrees F, a reduction of 1.4 degrees F. The ambient air temperature in his room was 59 degrees F. His most recent MDS, an annual with an ARD of 07/19/10, revealed this [AGE] year old male's [DIAGNOSES REDACTED]. His cognitive skills for daily decision-making were moderately impaired, he required limited physical assistance with bed mobility, he was totally dependent on staff for transferring, and he did not ambulate during the assessment reference period. He was also receiving antipsychotics and antidepressants daily. 5. Resident #42 Resident #42's average body temperature was 98.7 degrees F. Her body temperature, on the morning of 10/06/10, was 96.8 degrees F, a reduction of 1.9 degrees F. The ambient air temperature of her room was 62 degrees F. Her most recent MDS, a quarterly with an ARD of 08/09/10, revealed this [AGE] year old female's [DIAGNOSES REDACTED]. Her cognitive skills for daily decision-making were severely impaired, she required extensive physical assistance with bed mobility, she was totally dependent on staff for transferring, and she did not ambulate during the assessment reference period. 6. Resident #82 Resident #82's average body temperature was 98.6 degrees F. Her body temperature, on the morning of 10/06/10, was 96.7 degrees F, a reduction of 1.9 degrees F. The ambient air temperature of her room was 63 degrees F. Her most recent MDS, a quarterly with an ARD of 08/30/10, revealed this [AGE] year old female's [DIAGNOSES REDACTED]. Her cognitive skills for daily decision-making were severely impaired, she required limited physical assistance with bed mobility and extensive physical assistance with transferring, and she did not ambulate during the assessment reference period. She was also receiving antipsychotics, anxiolytics, and antidepressants daily. 7. Resident #49 Resident #49's average body temperature was 98.3 degrees F. His body temperature, on the morning of 10/06/10, was 96.4 degrees F, a reduction of 1.9 degrees F. The ambient air temperature of his room was 66 degrees F. Resident #49's most recent MDS, a quarterly with an ARD of 08/08/10, revealed this [AGE] year old male's [DIAGNOSES REDACTED]. His cognitive skills for daily decision-making were severely impaired, he was totally dependent on staff for bed mobility and transferring, and he did not ambulate during the assessment reference period. 8. Resident #52 Resident #52's average body temperature was 98.4 degrees F. Her body temperature, on the morning of 10/06/10, was 96.6 degrees F, a reduction of 1.8 degrees F. The ambient air temperature in her room was 67 degrees F. Her most recent MDS, a quarterly with an ARD of 09/10/10, revealed this [AGE] year old female's [DIAGNOSES REDACTED]. Her cognitive skills for daily decision-making were moderately impaired, she required extensive physical assistance with bed mobility, she was totally dependent on staff for transferring, and she did not ambulate during the assessment reference period. She was also receiving antipsychotics daily. 9. Resident #83 Resident #83's average body temperature was 98.2 degrees F. His body temperature, on the morning of 10/06/10, was 96.5 degrees F, a reduction of 1.7 degrees F. The ambient air temperature in his room was 66 degrees F. His most recent MDS, a quarterly with an ARD of 09/12/10, revealed this [AGE] year old male's [DIAGNOSES REDACTED]. His cognitive skills for daily decision-making were moderately impaired, he required extensive physical assistance with bed mobility, he was totally dependent on staff for transferring, and he did not ambulate during the assessment reference period. 10. Resident #44 Resident #44's average body temperature was 98.3 degrees F. Her body temperature, on the morning of 10/06/10, was 96.7 degrees F, a reduction of 1.7 degrees F. The ambient air temperature in her room was 67 degrees F. Her most recent MDS, a quarterly with an ARD of 09/20/10, revealed this [AGE] year old female's [DIAGNOSES REDACTED]. 11. Resident #11 Resident #11's average body temperature was 98.3 degrees F. Her body temperature, on the morning of 10/06/10, was 96.8 degrees F, a reduction of 1.5 degrees F. Her ambient room temperature was 61 degrees F. Her most recent MDS, a comprehensive significant change in status assessment with an ARD of 07/26/10, revealed this [AGE] year old female's [DIAGNOSES REDACTED]. Her cognitive skills for daily decision-making were moderately impaired, she required extensive physical assistance with bed mobility, she was totally dependent on staff for transferring, and she did not ambulate during the assessment reference period. She was also receiving antipsychotics, anxiolytics, and antidepressants daily. 12. Resident #68 Resident #68's average body temperature was 97.3 degrees F. Her body temperature, on the morning of 10/06/10, was 95.8 degrees F, a reduction of 1.5 degrees F. Her ambient room temperature was 69 degrees F. Her most recent MDS, an annual with an ARD of 07/26/10, revealed this [AGE] year old female's [DIAGNOSES REDACTED]. She was also receiving anxiolytics and antidepressants daily. 13. Resident #39 Resident #39's average body temperature was 98.2 degrees F. His body temperature, on the morning of 10/06/10, was 96.9 degrees F, a reduction of 1.3 degrees F. The ambient air temperature of his room was 67 degrees F. His most recent MDS, a quarterly with an ARD of 07/12/10, revealed this [AGE] year old male's [DIAGNOSES REDACTED]. He was also receiving antipsychotics, antidepressants, and anxiolytics daily. 14. Resident #41 Resident #41's average body temperature was 97.5 degrees F. Her body temperature, on the morning of 10/06/10, was 96.4 degrees F, a reduction of 1.1 degrees F. The ambient air temperature of her room was 64 degrees F. Her most recent MDS, an annual with an ARD of 08/16/10, revealed this [AGE] year old female's [DIAGNOSES REDACTED]. Her cognitive skills for daily decision-making were severely impaired, she was totally dependent on staff for bed mobility and transferring, and she did not ambulate during the assessment reference period. 15. Resident #64 Resident #64's average body temperature was 97.9 degrees F. His body temperature, on the morning of 10/06/10, was 96.8 degrees F, a reduction of 1.1 degrees F. The ambient air temperature of his room was 68 degrees F. His most recent MDS, a quarterly with an ARD of 08/23/10, revealed this [AGE] year old male's [DIAGNOSES REDACTED]. His cognitive skills for daily decision-making were severely impaired, he required extensive physical assistance with transferring, and he did not ambulate during the assessment reference period. He was also receiving antipsychotics, antidepressants, and anxiolytics daily. 16. Resident #15 Resident #15's average body temperature was 97.4 degrees F. Her body temperature, on the morning of 10/06/10, was 96.7 degrees F, a reduction of 0.7 degree F. Her ambient room temperature was 66 degrees F. Her most recent MDS, a quarterly with an ARD of 09/23/10, revealed this [AGE] year old female's [DIAGNOSES REDACTED]. She was also receiving antipsychotics daily. -- Following the analysis of residents' body temperatures, review of ambient air temperatures, and conference with the LSC surveyor and program manager, it was determined the facility's failure to obtain the necessary repairs and/or replacement of the boiler heating system serving the resident rooms and common areas, failure to obtain sufficient portable electric space heaters to keep resident sleeping areas at safe temperatures, and failure to assure the residents' body temperatures remained at normal levels constituted an immediate threat to the life and health of more than an isolated number of residents living in the facility. The immediate jeopardy was abated at 8:35 p.m. on 10/06/10, following the purchase and placement of an adequate supply of portable electric space heaters to serve each resident rooms and the common areas, the development and implementation of a monitoring system to assess ambient air temperature and resident body temperatures, and the transfer of some of the residents from an unheated floor to a floor supplied by heat. It was determined that a deficient practice remained with the potential of more than minimal harm to more than an isolated number of residents until such time as the facility obtained a safe and reliable heating system. .